Wednesday, March 05, 2008

Paging Doctor Jack Daniel

I know many of you are hoping for some further insights into the housing bubble's technicolor bursting (more on that tomorrow), but let's look deeper into our society's dependency on mood-altering drugs.

I recommend this article The Medicated Americans: Antidepressant Prescriptions on the Rise from the Scientific American website.

If you don't have time to read the entire piece and the reader comments, here are the important points:

1. We are essentially self-medicating ourselves. Some 11% of American women and 5% of American men are taking prescription anti-depressants. Disturbingly, these drugs are often prescribed in response to patient requests--after they'd seen pharmaceutical advertising:
(excerpts in quotes)

"If statistics serve, we know a number of things about the Medicated American. We know there is a very good chance she has no psychiatric diagnosis. A study of antidepressant use in private health insurance plans by the New England Research Institute found that 43 percent of those who had been prescribed antidepressants had no psychiatric diagnosis or any mental health care beyond the prescription of the drug.

We know she is probably female: twice as many psychiatric drugs are prescribed for women than for men, reported a 1991 study in the British Journal of Psychiatry. Remarkably, in 2002 more than one in three doctor’s office visits by women involved the prescription of an antidepressant, either for the writing of a new prescription or for the maintenance of an existing one, according to the ­Centers for Disease Control and Prevention.

We know that Julie in Iowa was far more likely to ask her doctor for an antidepressant after having seen it advertised on TV or in print; one fifth of Americans have asked their doctor for a drug after they have seen it advertised. And when Julie asked for her antidepressant, her doctor was likely to comply with the request, even if he or she felt ambivalent about the choice of drug or diagnosis.

It is unlikely that the doctor spent much time talking to Julie about the nature of the drugs, the common side-effect profiles and the remote but potentially dangerous side effects. Based on taped sessions, a 2006 study at the University of California, Los Angeles, showed that when prescribing a new medicine, two thirds of doctors said nothing to the patient about how long to take the medication, and almost half did not indicate the dosage amount and frequency. Only about a third of the time did doctors talk about adverse side effects."

In other words, doctors who are not mental health professionals are providing prescriptions at the patients' request, and not providing them with the potential downsides of taking such powerful drugs. This is essentially self-medication.

2. The general public is not being informed about the possible adverse effects of these drugs or being offered psychotherapy/cognitive therapy in conjunction with, or as an alternative to, anti-depressants.

"In the case of antidepressants, failure to review possible side effects and to monitor the patient’s progress in the weeks and months after starting the drugs is deeply irresponsible. A 2004 study in the Journal of the American Medical Association stated that "the risk of suicidal behavior is increased in the first month after starting antidepressants, especially during the first one to nine days." Worse, there is no longer any need to deal with an actual physician: all these drugs are readily available, with a few clicks and a credit card.

We further know that Julie’s managed care insurance was more than happy to cover the prescription, especially if it meant that the company did not have to pay for therapy, which Julie is less and less likely, and less and less able, to pursue—an unsurprising fact given that there are only about 40,000 psychiatrists in the country.

As a result, after starting antidepressants and taking them for three months, three quarters of adults and more than half of children do not see a doctor or therapist specifically for mental heath care, found a study by Medco Health Solutions. Another report, referenced in the New York Times, reported that only 20 percent of people who take antidepressants have any kind of follow-up appointment to monitor the medication.

Between 1987 and 1997, while the rate of pharmacological treatment for depression doubled, the number of psychotherapy visits for depression decreased, as cited in a study in the January 9, 2002, issue of the Journal of the American Medical Association. These days only about 3 percent of the population receives therapy from a psychiatrist, psychologist or social worker, according to a 2006 study in Archives of General Psychiatry.

As a result, a good number of Americans are now taking SSRIs (anti-depressants) for non-FDA-approved uses, termed "off label" prescriptions. A 2006 study found that three quarters of people prescribed antidepressant drugs receive the medications for a reason not approved by the FDA. 3. "

Depression has become the "diagnosis" of choice for normal human responses to crisis, trauma and loss. Meanwhile, actual serious mental disorders are going untreated because, well, there's no money in it, while it's obviously profitable to advertise /troll for millions of prescriptions for anti-depressants.

"Depression, once considered a rare disease usually associated with elderly women, is overwhelmingly the mental health diagnosis of choice of our time. Martin E. P. Seligman of the University of Pennsylvania, perhaps America’s most influential academic psychologist, has stated: "If you’re born around World War I, in your lifetime the prevalence of depression, severe depression, is about 1 percent. If you’re born around World War II, the lifetime prevalence of depression seemed to be about 5 percent. If you were born starting in the 1960s, the lifetime prevalence seemed to be between 10 and 15 percent, and this is with lives incomplete."

What modern psychiatry has done, I am convinced, is to conflate and confuse the two, Depression and depression. David Healy, in Let Them Eat Prozac (NYU Press, 2004), calls it "a creation of depression on so extraordinary and unwarranted a scale as to raise questions about whether pharmaceutical and other health care companies are more wedded to making profits from health than contributing to it."

In contrast, large percentages of people with severe and persistent mental illness get no care whatsoever. "The majority of those with a diagnosable mental disorder [are] not receiving treatment," wrote the U.S. surgeon general in a 1999 report. Studies published in 1985, 2000 and 2001 found that 50, 42 and 46 percent, respectively, of people with serious mental illness were receiving no treatment for their conditions.

A massive study in the early 2000s on the prevalence of mental illness led by health care policy researcher Ronald C. Kessler of Harvard Medical School, in collaboration with the World Health Organization, revealed that in developed countries 35 to 50 percent of people with serious cases had not been treated in the previous year; in poor countries the figure was 80 percent.

I think we have got to get beyond the absurd vapidity of disorder categories such as "phase of life problem" and "sibling relational problem." We should get a little more specific about Julie’s angst. Let us take the daring step of calling life problems what they are and what they were up until about 20 years ago: life problems."

4. The social, financial and political structures which create such large-scale "depression" are ignored in favor of treatment of symptoms. The general mindset is, yes, our lifestyle is stressful and it's simply the result of "modern times." But if you think this through, it becomes less a truism than an article of faith--an article of faith which lets our fundamentally sick social system off the hook. How convenient for those in charge of those structures.

Is this really the only way to live in a First World nation? To answer "yes" is to be blind to the causal factors which are cultural and political. For instance: losing your healthcare when you get laid off or switch jobs is a truly insane system which creates massive waste and needless stress. Being unable to clear your debts via bankruptcy, though businesses have no problem doing so, is needlessly stressful, too. (If you simply incorporated, your debt could be disappeared in nothing flat.)

Since there's no affordable housing in the city close to your job, then you spend huge amounts of time commuting rather than spending it with your family, or walking or biking to work as many do in other First World countries. These are political structures which are not intrinsic to a harried, stressful "modern life." They are not unbreakable natural forces like gravity. They are policy-driven and could be changed politically. They have mental health consequences which are brushed under the carpet or self-medicated.

Here is how one Scientific American reader identified the underlying issues:

"Another thought is an observation that I made as an executive because of my reading in neurophysiology. There is a phenomenon in which hippocampus die-off occurs in people under stress for years on end. I began to nickname this executive syndrome because I noticed that these guys who were hard-charging for years that finally made it to the executive suite mostly exhibited signs of hippocampus damage.

Some of them I would call florid in their sometimes bizarre behavior rooted in just not taking things in. Their memories weren't so good, they would have trouble taking in new information, they would make decisions that weren't warrented by the data. Notably, hippocampus damage also primes people for depression if things don't go well, and I can tell you that there is a lot of depression in the executive ranks, but it's mostly secret.

So recently I read that Prozac stimulates nerve growth in the hippocampus. That made me think that maybe a segment of the population that should be taking Prozac or some other hippocampus restoration drug is people in the executive suite. Maybe we should be getting it to them more than the kids who are mostly just dealing with major hormones. Personally, I think most of the drugging of children and teens is for the convenience of parents.

Last, I think that modern lives are much more stressful mentally than the lives people lived 100 years ago. The modern USA has had a near complete breakdown of community. Marriages don't last. Social rules are unclear. Entire professions bloom and then nearly disappear. Professional knowledge is measured in half-life years. Our parents expected to work for the same place for a lifetime. Who thinks that now except federal government employees? (And maybe not even them.)

So I think we are under much more stress now than our parents, and certainly our grandparents. Our stresses are continuous, angst generating, and we face the world alone, or at best in a mated pair. This is not how our ancestors lived."

Another reader missed the point of the article--the rise of self-medication--but made a defense of SSRIs as a "cure". If a user is seriously, clinically depressed, this may well be true; I have seen many near-miraculous cures of severe depression via medication. But we still must ask: is being stressed out the same as being clinically depressed?

"I am a 7th year pharmacy student from Portland, Oregon. We understand that after about 2 years of continual SSRi therapy, a process known as neuronal sprouting begins. This term describes a process in which serotonergic neurons regrow in particular areas of the brain which display transmission deficits in depressed people. Americans, like everyone else, find themselves functioning in an increasingly demanding and stressful world. Cortisol is produced in response to stress and it is responsible for destroying seritonergic nerve endings in these critical areas of the brain that are dysfunctional in a person with depression. Decreased neuronal transmission is the physiological cause of depression in a vast majority of people. Therefore, SSRi's represent an actual physical cure for depression."

Astute reader Trey S. sent in this link to a article by author Peter D. Cramer, who wrote Listening to Prozac.

"The issue that Barber addresses, distinguishing the treatment of disease from what I have called "cosmetic psychopharmacology," remains important. And it's not that Barber is wrong about the culture. Big Pharma wields too much influence. Soft technologies like psychotherapy get short shrift. The world is too much with us; late and soon, getting and spending, we lay waste our powers. But there is a danger in taking a narrow viewpoint—making our time and place out as exceptional and so finding constant crises.

Likewise, there is risk in answering questions prematurely. Finally, how antidepressants interact with capitalism remains uncertain. We may—this concern was at the core of Listening to Prozac—be using medication to achieve the assertiveness and confidence that our society demands. Or, as Barber suggests, we may be numbing ourselves. But two other possibilities remain on the table. We may be doing pretty well with the imperfect medicines we have. Or we may still be failing to reach numbers of people with substantial mental illness."

5. Are men only half as likely to be depressed, or do they simply self-medicate with other mind-altering substances? If you were wondering when the "paging Doctor Jack Daniel" connection would be made, here it is: though I have no studies to support this thesis, I suspect men self-medicate more often with alcohol and marijuana than women. If we included heavy users of alcohol and marijuana, I suspect some 15% of the population, men and women alike, are self-medicating either with prescription drugs or other substances.

Men tend to be "stoners," i.e. habitual users of marijuana, more than women, in my experience, though again, statistics are hard to come by. And if you can't afford Mary Jane, or don't want the risks of buying and using an illegal substance, then you turn to Doctor Jack Daniel (or Dr. Merlot or Dr. Sam Adams, etc.)

Whether we're turning to our family doctor for a prescription to an anti-depressant or seeking the solace of Dr. Daniel, we are basically accepting the politically convenient truism that our depression and stress are the result of our own weaknesses, rather than the result of inherently sick social, physical and political structures.

That's the conclusion we're supposed to reach, and I am therefore deeply skeptical of the entire truism that massive depression, unhappiness and stress are the "natural order of the American universe." I distrust the politically convenient.

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