C’mon, get happy
This week PostScript noted a flurry of reports, posts, and stories on the topic of happiness asking all sorts of things: How achievable is it, how sellable is it, do we stand to lose something human when we lose the blues, and at what cost?
At top, a meta-analysis in the New England Journal of Medicine that found a third of company-sponsored clinical trials on anti-depressants Prozac and Paxil went unpublished, effectively tilting the body of accepted wisdom on these popular drugs in favor of their efficacy. The NEJM study looked at 74 trials of 12 drugs, and found that using the published studies demonstrated significant improvements in depression levels over placebos. Once the unpublished ones are folded into the mix, the difference between pharmaceutical and placebo becomes modest.
The punch-line? According to the New York Times, “while 94 percent of the positive studies found their way into print, just 14 percent of those with disappointing or uncertain results did.” To the SSRI manufacturers, it seems that no news was good news – or at least better news.
“’This is a very important study for two reasons,’” NEJM editor Dr. Jeffrey M. Drazen told the Times. “One is that when you prescribe drugs, you want to make sure you’re working with best data possible; you wouldn’t buy a stock if you only knew a third of the truth about it.” Second, Dr. Drazen continued, ‘we need to show respect for the people who enter a trial.’”
We take Drazen’s point – human participation in clinical trials is predicated, in part, on trust that those trials will be conducted fairly and reported accurately – but certainly reported.
Yet Drazen’s comments themselves are a strange one-two, and read like he’s comparing the health of trial participants to shares in a publicly traded company – a linguistic slip, perhaps, but one that’s disturbing as it is telling about the trouble with clinical trials disclosure and pharmaceutical company forthrightness: It’s about the shareholders, stupid.
And that harsh reality underscores the need for all clinical trials to be registered publicly before they are begun, a federal law that awaits implementation.
Over at Carlat Psychiatry Blog, Dr. Carlat points to a Furious Seasons post about how much depression psychiatrists should aim to relieve in their patients – and how many drugs that should take. According to Carlat, remission has replaced response (a 50 percent improvement) as the grail of psychiatrists, a shift that both he and Dawdy argue maybe at best industry-inspired and misguided, and at worst harmful, as polypharmacy becomes an ever-more common next step when a single-therapy regimen doesn’t do the trick. And what ever happened to psychotherapy?
Dawdy, who blogs as a patient in the mental health care system, writes, “I’ve noted previously how obsessed the psych world is with complete symptom remission in all forms of mental illness and how useless such a goal is for patients. Yes, it’s a laudable public health goal, but within the limits of current technologies and practices does not seem to be achievable for many patients. If complete symptom remission is your polestar, then that could spell all sorts of practical problems for patients.” Especially if the studies patients rely on to gauge their chances for improvement aren’t the whole picture.
Last month, the New York Review of Books pondered these same questions in its pages. Frederick Crew’s “Talking Back to Prozac” is an insightful look at three new books on sadness and its salves that ask important questions about how and how much we are treating the blues. Like many good reviews, his analysis asks more questions than it answers, and frames each of these books as part of the bigger conversation about our shifting views of psychopharmacology – views that are sure to shift again in light of the new NEJM study.
If you’re looking for something a little lighter, then this Boston Globe piece is the way to go. It leads with Tom Brady and ends with Ogden Nash and doesn’t get much deeper in the middle.
The Globe piece is all over the place, but it mentions Eric Wilson’s book, “Against Happiness: In Praise of Melancholy,” which has been adapted into an essay for the Chronicle of Higher Education online review. Wilson, a professor of English at Wake Forest University, has just written a book on how good the doldrums are for art and literature.
Wilson’s basic argument – we think – is that our culture is fighting melancholy (that’s English major for depression) and in doing so, chucking our potential to make good, sad art out the window.
“To foster a society of total happiness is to concoct a culture of fear,” Wilson writes. One expects such a big claim to be followed by examples, or at least a map of how he got there. But instead of explaining, Wilson just bowls on through. “Do we really want to give away our courage for mere mirth?”
Huh?
This may be the problem with adapting books into one-page essays – each sentence is a chapter gone unexplained and undefended. But why would a professor of English take it upon himself to draw this diagnostic line in the sand:
“Obviously, those suffering severe depression — suicidal and bordering on psychosis — require serious medications. But what of those who possess mild to moderate depression? Should these potential visionaries and innovators eradicate their melancholia with the help of a pill?”
Wilson’s outlandish assumption of clinical power to deem some depressed and others artists is one of the more egregious examples of academic arm-chair quarterbacking we’ve seen in awhile.
But if the melancholy Wilson favors is as unsavory as he makes it sound – “an almost infinite sounding of the exquisite riddles of Being” – PostScript can hardly blame those who believe we can and ought to treat that, or at least tone down all those chronic riddles for those to whom they are deafening.
Wilson doesn’t seem to have had the same problems getting published as some of those antidepressant studies did. And maybe that’s the most depressing thing of all.
January 21st, 2008 at 2:04 am
Thank you for this article.
I’m not in the medical industry; I am merely a patient of it.
I’ve experienced depression (always from clear and obvious causes like infertility issues or other stress, not from brain chemistry problems) but never been medicated for it. I credit my ability to write fiction that makes other people cry to the fact that I’ve muddled through my own pain and then found catharsis in releasing it upon my poor, unsuspecting characters.
The very idea of taking a happy pill to turn real-life anguish into a tiptoe through the tulips is frightening to me. I can’t imagine what I would have lost.
Not that I revel in the pain…I’m quite happy to have sad times end and be replaced with happy ones, but isn’t that also the point? Aren’t happy times richer for knowing sadness before?
Two weeks ago I saw a PBS Frontline show about giving anti-depressants and anti-psychotics to kids as young as two. Since then, whenever our precocious two-year-old tells us that, “Sharing makes me sad,” or “I am angry!” my husband and I joke (out of earshot of the toddler) that regardless of her well-articulated emotions, clearly by US standards she should be medicated into bliss. Happy, quiet, tantrum-free bliss. She should not have to learn to deal with hard emotions when a pill can make it all better, right! Grr.
I sincerely hope more doctors and society as a whole start to learn from the information you’ve posted here before our poor kid reaches school and some teacher tries to medicate her into submission. I’d say that thought depresses me, but then I’d have to take a pill…
June 5th, 2008 at 5:23 pm
Current Depression Medications: Do The Benefits Outweigh the Harm?
Presently, for the treatment of depression and other what some claim are mental disorders, as they are questionable, selective serotonin reuptake inhibitors are the drugs of choice by most prescribers. Such meds, meds that affect the mind, are called psychotropic medications. SSRIs also include a few meds in this class with the addition of a norepinephrine uptake inhibitor added to the SSRI, and these are referred to SNRI medications. Examples of SNRIs are Cymbalta and Effexor. Some consider these classes of meds a next generation after benzodiazepines, as there are similarities regarding their intake by others, yet the mechanisms of action are clearly different, but not their continued use and popularity by others.
Some Definitions:
Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrist’s bible, which is the DSM, states that the definite etiology of depression remains a mystery and is unknown. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected with limited scientific evidence. In fact, diagnosing diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.
Norepinephrine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med.
And depression is only one of those mood disorders that may exist, yet possibly the most devastating one. An accurate diagnosis of these mood conditions lack complete accuracy, as they can only be defined conceptually, so the diagnosis is dependent on subjective criteria, such as questionnaires. There is no objective diagnostic testing for depression. Yet the diagnosis of depression in patients has increased quite a bit over the decades. Also, few would argue that depression does not exist in other people. Yet, one may contemplate, actually how many other people are really depressed?
Several decades ago, less than 1 percent of the U.S. populations were thought to have depression. Today, it is believed that about 10 percent of the populations have depression at some time in their lives. Why this great increase in the growth of this condition remains unknown and is subject to speculation. What is known is that the psychiatry specialty is the one specialty most paid to by certain pharmaceutical companies for ultimately and eventual support of their psychotropic meds, as this industry clearly desires market growth of these products. Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders are suspected by a health care provider. Yet these meds discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related disease states.
Over 30 million scripts of these types of meds are written annually, and the franchise is around 20 billion dollars a year, with some of the meds costing over 3 dollars per tablet. There are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to being promoted for treatment for menopause. The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.
Furthermore, these meds have received additional indications besides depression for some really questionable conditions, such as social phobia and premenstrual syndrome. With the latter, I find it hard to believe that a natural female experience can be considered a treatable disease. Social phobia is a personality trait, in my opinion, which has been called shyness or perhaps a term coined by Dr. Carl Jung, which is introversion, so this probably should not be labeled a treatable disease as well. There are other indications for certain behavioral manifestations as well with the different SSRIs or SRNIs. So the market continues to grow with these meds. Yet, it is believed that these meds are effective in only about half of those who take them, so they are not going to be beneficial for those suspected of having certain medical illnesses treated by such meds. The makers of such meds seemed to have created such conditions besides depression for additional utilization of these types of medications, and are active and have been active in forming symbiotic relationships with related disease- specific support groups, such as providing financial support for screenings for the indicated conditions of their meds- screening of children and adolescents in particular, I understand, and as a layperson, I consider such activities dangerous and inappropriate for several reasons.
Danger and concerns by others primarily involves the adverse effects associated with these types of meds, which include suicidal thoughts and actions, violence, including acts of homicide, and aggression, among others, and the makers of such drugs are suspected to have known about these effects and did not share them with the public in a timely and critical manner. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others, such as those in the medical profession as well as citizen watchdog groups. The reasons for this attention are due to the potential off-label use of these meds in this population, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, including the decreased efficacy of SSRIs in general, which is believed to be less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding such important information- Elliot Spitzer specifically, as I recall.
And there are very serious questions about the use of SSRIs in children and adolescents regarding the effects of these meds on them. For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect could cause harm rather than benefit? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring in their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist. It is observed in some who take such meds, but not all who take these meds. Yet health care providers possibly should be much more aware of these possibilities
Finally, if SSRIs are discontinued, immediately in particular instead of a gradual discontinuation, withdrawals are believed to be quite brutal, and may be a catalyst for suicide in itself, as not only are these meds habit forming, but discontinuing these meds, I understand, leaves the brain in a state of neurochemical instability, as the neurons are recalibrating upon discontinuation of the SSRI that altered the brain of the consumer of this type of med. This occurs to some degree with any psychotropic med, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs, it is believed.
SSRIs and SRNIs have been claimed by doctors and patients to be extremely beneficial for the patient’s well -being regarding the patient’s mental issues where these types of meds are used, yet the risk factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug. Considering the lack of efficacy that has been demonstrated objectively, along with the deadly adverse events with these meds only recently brought to the attention of others, other treatment options should probably be considered, but that is up to the discretion of the prescriber.
“I use to care, but now I take a pill for that.” — Author unknown
Dan Abshear