[News item] Why Big Pharma is not addressing the failure of antidepressants

Why Big Pharma is not addressing the failure of antidepressants.

From the 14 May 2015 post at The Conversation

Around a quarter of people experience depression at some point in their lives, two-thirds of whom are women. Each year more than 11m working days are lost in the UK to stress, depression or anxiety and there are more than 6,000 suicides. The impact of depression on individuals, families, society and the economy is enormous.

Front-line therapies usually include medication. All the commonly prescribed antidepressants are based on “the monoamine hypothesis”. This holds that depression is caused by a shortage of serotonin and noradrenaline in the brain. Existing antidepressants are designed to increase the levels of these chemicals.

The first generation of antidepressants were developed in the 1950s and a second generation came in the 1980s. Products such as Prozac and Seroxat were hailed as “wonder drugs” when they first came onto the market.

In the roughly 30 years since, these kinds of drugs have come to look tired and jaded. Patents have expired and there are doubts about their efficacy. Some scientists even argue the drugs do more harm than good.

Broken model

There has been no third generation of antidepressants. This is despite there having been moon-landing levels of investment in research. The antidepressant discovery process that gave rise to the earlier drugs is clearly broken. It is also apparent that this process had never worked that well, since the only real improvements over the previous 60 years were a reduction of side-effects.

By the mid-2000s the major pharmaceutical companies started disinvesting in this area. Government funding for basic research into depression and charitable funding followed a similar pattern. In 2010 GSK, AstraZeneca, Pfizer, Merck and Sanofi all announced that they had stopped looking for new antidepressants altogether. Professor David Nutt, the former government drug advisor, declared this to be the “annus horribilis” for psychiatric drug research. The likelihood now is that there will be no new antidepressants for decades.

However, there continues to be an urgent and pressing need for more effective treatments. The question the drug companies now need to ask themselves is, did they fail because the task was impossible, or did they fail simply because they got things wrong? Our view is that there was a systems failure.

…..

[Press release] What makes some women able to resist or recover psychologically from assault-related trauma?

Regions of the brain affected by PTSD and stress. (Photo credit: Wikipedia)

 

From the 2 March 2015 press release

In a study of 159 women who had been exposed to at least one assault-related potentially traumatic event, 30% developed major depressive disorder, which may be attributed to self-blame common to survivors of assault. Fewer women (21%) developed chronic posttraumatic stress disorder.

Mastery–the degree to which an individual perceives control and influence over life circumstances–and social support were most prevalent in women who did not develop a trauma-related psychiatric disorder after assault exposure, while mastery and posttraumatic growth were related to psychiatric recovery. These factors were less established in women with a current psychiatric disorder.

The Brain and Behavior findings have significance for the health and wellbeing of women, and for identifying individuals who are most in need of resilience-promoting interventions. “Women exposed to assault may present with post-trauma depression in lieu of posttraumatic stress disorder. Resilience factors like mastery and social support may attenuate the deleterious effects of an assault,” said lead author Heather L. Rusch. “The next step is to determine the extent that these factors may be fostered through clinical intervention.”

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[Press release] Losing a family member in childhood associated with psychotic illness

From the 21 January 2014 press release

Highest risk seen in children who experience suicide in close family members

Experiencing a family death in childhood is associated with a small but significant increase in risk of psychosis, suggests a paper published today on bmj.com.

The researchers say that the risks are highest for children who have experienced a suicide in the ‘nuclear family’ (brothers, sisters, parents).

Previous studies have concluded that the risk of adult disease can be influenced by genetics, lifestyle and environmental experience. There is also evidence that maternal psychological stress adversely affects the development of the fetus.

Population studies have so far provided weak support for an association between prenatal maternal psychological stress and later psychosis. Researchers from the UK, US and Sweden therefore set out to examine the association between deaths in the family as a form of severe stress to the individual and subsequent psychosis. Data were taken from Statistics Sweden and the Swedish National Board of Health and Welfare and children born between 1973 and 1985 in Sweden.

Definitions of psychosis were: non-affective psychosis (including schizophrenia) and affective psychosis (bipolar disorder with psychosis and unipolar depression with psychosis).

Exposure periods were divided into ‘any exposure’ (all pre and postnatal); ‘any prenatal’ (prior to birth) and ‘any postnatal’ (birth up to 13 years of age) and further subdivided by trimester (first, second, third) and by three year periods in childhood between birth and 13 years of age (0-2.9 years; 3-6.9 years and 7-12.9 years). If more than one exposure occurred during the study period, priority was given to the earliest exposure.

Death was categorised into suicide, fatal injury / accident and others (such as cancers and cardiac arrests).

Models were adjusted for year of birth, child sex, maternal and paternal age, maternal and paternal nationality, parental socioeconomic status and history of any psychiatric illness in the family.

The final number of children included in the study was 946,994. Altogether, 321,249 (33%) children were exposed to a family death before the age of 13. Of individuals exposed to any death during the study period, 1323 (0.4%) developed a non-affective psychosis while 556 (0.17%) developed an effective psychosis. 11,117 children were exposed to death from suicide, 15,189 from accidents and the majority, 280,172 to deaths due to natural causes.

No increased risk of psychosis was seen following exposure in any prenatal period. Postnatally, an increased risk of ‘all psychosis’ was associated with deaths in the nuclear family and risk increased the earlier in childhood the death occurred.

Risks associated with exposure to suicide were higher compared with exposure to deaths from accidents which in turn were higher than risks associated with other deaths from natural causes.

The largest risk was seen in children exposed ages 0-3 years and risks reduced as age of exposure increased.

Professor Kathryn Abel, from the Centre for Women’s Mental Health at The University of Manchester, said: “Our research shows childhood exposure to death of a parent or sibling is associated with excess risk of developing a psychotic illness later in life. This is particularly associated with early childhood exposure. Further investigation is now required and future studies should consider “the broader contexts of parental suicide and parental loss in non-western, ethnically diverse populations.”

 

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Research: Severe bereavement stress during the prenatal and childhood periods and risk of psychosis in later life: population based cohort study

 

 

Preventing disease is a problem for the health industry

By ROB LAMBERTS, MD | PHYSICIAN | OCTOBER 3, 2013, at KevinMD.com

……

People come to me for answers, and my profession pitches doctors as the ones with answers.  We fix problems.

This, of course, is not true — a fact that I have come to see as a core problem in the practice of medicine in America, and a reality that (as everything seems to do) comes largely from the way we pay for medicine.  We are paid to fix problems.  How do we fix problems?  With procedures.

The best evidence for this are the things at the heart of health care: codes.   There are three types of codes that dominate the financial and clinical lives of anyone in health care:

• ICD codes: codes for medical problems
• CPT codes: codes for medical procedures
• E/M codes: codes used by doctors who don’t do procedures so they can get paid for office visits

What this encourages from the medical profession is predictable: lots of problems treated by lots of procedures.  This is good for doctors who do procedures, especially ones that are cutting-edge (like robotic surgery) or ones that seem particularly dramatic and/or heroic (open heart surgery, heart stents).  These are the things the headline consuming public is most hungry for.  Just like it grabs more headlines to catch a terrorist plot just before it has its horrible effect than to prevent it early in the process, it’s a lot sexier to do a procedure to treat heart disease than to simply prevent the disease in the first place.  Which is the better outcome?  Preventing heart disease.  Which is paid more?  Not even close.

The problem with problems

A more subtle (and perhaps more significant) effect of this mindset is the way in which everything is labeled as “problems” or “diseases.”  A recent ruling of the AMA that obesity is a “disease” stirred up quite a bit of controversy. The AMA ruling does nothing to change the nature of obesity, and clearly is more a discussion of semantics, politics, and funding, than it is a true medical question.  In reality, I used to not be able to bill the ICD-9 code for obesity and get paid, but now I guess I could (if I did that kind of thing any more).  I suspect this opens the door for more procedures to be paid for by insurers, as the response to any problem is always a procedure in our system.

There is pressure now to respond to each “problem” with a procedure, or at least a thing to eliminate it as a problem.  Examples:

• Sinus infections are routinely treated with antibiotics despite no evidence that it actually helps.  Having marketed our profession as problem-fixers, we are met with patients expecting a fix to their problem.  They are disappointed (and even angry) when we don’t “do something” for a “problem” that will resolve on its own, even if the intervention probably causes more harm than benefit.  Problem: sinusitis.  Procedure: antibiotic.  Check.
• Cholesterol treatment is another example of this.  High cholesterol, be it LDL, total, or triglyceride is seen as a “problem,” even in people who are not at risk for heart disease.  I’ve seen many low-risk patients come to my practice on cholesterol medication that does little more than improve their numbers.  The evidence shows that certain high-risk people benefit from being on certain medications which lower the cholesterol.  For folks outside of those high-risk groups, the medications simply make numbers look better (at best) and potentially harm them (at worst).  Problem: High cholesterol.  Procedure: cholesterol drug.  Check.
• Depression and anxiety are normal emotions.  Life is painful and unsure.  There only are two ways to avoid these emotions: die or get stoned.  My personal experience (some fairly recent) is that the times of life most marked by anxiety and depression are accompanied by significant personal growth.  Before everyone gets mad at me for saying these aren’t diseases, I must add that there are cases of both of these emotions that are terribly destructive and potentially fatal if not treated.  But we physicians have lowered the price of admission to treatment, including people going through hard times as those who have clinical depression.  Responding to TV ads about “that pill that will make me happy,” we are met with patients expecting us to “fix their problem” — a problem that is not really a problem; it’s life.  Problem: anxious and depressed people.  Procedure: medication.  Check.

A better way

I think there’s a better way to look at things.  I’ve said this before, but I am coming to grasp just how radical this approach is and just how much it undermines our health care system.  There is something far more important than problems:

Risk.

When someone comes to my office with chest pain, my thoughts do not go to the question: “what is going on?”  A more important problem comes first: “is this a dangerous situation?”  I want to know if the person is ready to die from a heart attack or other serious problem.  This is true in nearly every decision I make as a doctor when faced with a condition.  Could that cough be latent lung cancer?  Could that headache be a brain tumor?  Could the depressed man kill himself?

Risk reduction also rules how I approach disease.  I treat cholesterol and hypertension, not because they themselves are problems, but because they can lead to heart disease, stroke, and other problems.  High cholesterol is not, in my opinion, a “disease” for most people; it is a risk factor.  I treat diabetes mainly to prevent the complications.  Do I care if a 90-year-old has an A1c of 8?  No way.  It doesn’t increase their risk enough to matter.

This does not mean we approach “prevention” like the system presently does: throwing procedures at it.  The health care system doesn’t reward having healthy patients, it rewards doing procedures reported to prevent problems.  Yet the system is not addressing the true goal of prevention: risk reduction. We are “rewarded” by ordering tests, whether or not they reduce risk.  PSA testing is a perfect example of this, as are many other misguided attempts to treat prevention as another problem to  fix with a procedure.

The problem with this, of course, is that it far more to the financial benefit of doctors (and drug companies) for us to address every problem and show we are giving “good care” by checking off the box next to each problem.  In the bigger picture, risk reduction makes the jobs of future cardiovascular surgeons (and drug companies) much less secure.  It attacks the revenue stream of most doctors and hospitals (and drug companies) right where it counts: you can’t make nearly as much money off of healthy people as you can people with “problems.”

This is why, I believe, any system that profits more from people with “problems” than those without is destined to collapse.  Our system is opposed to the goal of every person I see: to stay healthy and stay on as few drugs, have as few procedures, and avoid as many doctors (and drug companies) as possible.

What would happen if we prevented disease?  What would happen if people didn’t have medical problems?  For society it would be great.  For the health care industry it would be a huge problem.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

Read the entire article here

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The Medicalization of Modern Life

Pinocchio DSM 5 (Photo credit: Leonard John Matthews)

From the 12 December 2012 article by Allen Frances, MD at The Health Care Blog

…This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry.

The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.

Just ignore the ten changes that make no sense….

…DSM 5 has neither been able to self correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis. Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably ‘psychosis risk’, mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, ‘hebephilia’, cumbersomepersonality ratings, and sharply lowered thresholds for many existing disorders). But APA stubbornly refused to sponsor any independent review and has given final approval to the ten reckless and untested ideas that are summarized below….

…

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase inchildhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates– 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8 ) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment.

Related articles

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• An Interview with Allen Frances M.D.: Making the DSM-5 WORSE? (educationviews.org)
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• Gender Identity Disorder Officially Removed From DSM-5 (lezgetreal.com)
• The DSM-5 has been finalised (mindhacks.com)
• The DSM-5: Anachronistic Before Its Time – Boycott the DSM-5 (madinamerica.com)
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• New additions to Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (casesblog.blogspot.com)
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Patients Tell How Magnetic Therapy Lifted Their Depression

TMS (Photo credit: jeanbaptisteparis)

 

From the 15 October 2012 article at Science Daily

 

Three patients who have suffered periodic major depression throughout their adult lives told an audience attending a Loyola Grand Rounds presentation how their lives have been transformed by a new magnetic therapy.

The treatment, called transcranial magnetic stimulation (TMS), sends short pulses of magnetic fields to the brain.

“I feel better now than I have in a very long time,” said patient Jannel Jump. “I’m living a life now, rather than hiding from it.”

Another patient said TMS brought him out of a depression so severe he couldn’t get out of bed.

And a third patient said TMS “has helped me to have a glass-is-half-full outlook. I’m in a much better spot today.”

The Food and Drug Administration approved TMS in 2009 for patients who have major depression and have tried and failed at least one antidepressant. The FDA has approved one TMS system, NeuroStar®, made by Neuronetics, said Dr. Murali Rao, MD, DFAPA, FAPM, Chairman of the Department of Psychiatry and Behavioral Neurosciences at Loyola University Chicago Stritch School of Medicine….

 

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How A Parent’s Education Can Affect The Mental Health Of Their Offspring

How A Parent’s Education Can Affect The Mental Health Of Their Offspring

From the 29 January 2012 article at ScienceNews Today

New research sheds light on cycle of low socioeconomic status and depression Could depression in adulthood be tied to a parent’s level of education? A new study led by Amélie Quesnel-Vallée, a medical sociologist from McGill University, suggests this is the case…

 

…

The team found that higher levels of parental education meant fewer mental health issues for their adult children. “However, we also found much of that association may be due to the fact that parents with more education tend to have children with more education and better paying jobs themselves,” explained Quesnel-Vallée. “What this means is that the whole process of climbing up the social ladder that is rooted in a parent’s education is a crucial pathway for the mental health of adult children.”

These findings suggest that policies aimed at increasing educational opportunities for all, regardless of social background, may help break the intergenerational cycle of low socioeconomic status and poor mental health. “Children don’t get to choose where they come from. I think we have a responsibility to address health inequalities borne out of the conditions of early childhood,” said Quesnel-Vallée.

Related articles

• How A Parent’s Education Can Affect The Mental Health Of Their Offspring (medicalnewstoday.com)
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Link Found Between Major Depression and Social Conditions

Blue- High income

Green- Upper middle income

Purple- Lower middle income

Red- Low income

http://commons.wikimedia.org/wiki/File:World_Bank_income_groups.svg

From a 27 July posting by dal22 in Research Now

Major depression is a serious condition, and can lead to a decline in function and quality of life. A new study published in the most recent issue of BMC Medicine reports on a survey of 89,037 adults from 18 high- and low-middle-income countries. Through face to face interviews, data were collected on prevalence, impairment, and demographic factors associated with depression.

Results showed that the average age of onset was 25.7 years in 10 high-income countries and 24.0 years in 8 low-middle-income countries. The ratio of females to males with major depression was

Countries based on World Bank income groupings for 2006 (calculated by GNI per capita, Atlas method).    High income    Upper-middle income    Lower-middle income    Low income

approximately 2:1. Major depression was associated with a younger age in high-income countries, while older age showed greater prevalence in several low-middle-income countries. Separation was found to be the most significant demographic factor in high income countries, while being divorced or widowed was most significant in low-middle-income countries.

According to the authors, major depression is a worldwide threat to public health and is strongly associated with social conditions. Further research will be needed for evaluation of risk factors contributing to occurrence of major depressive episodes.

Read the complete article.

Related articles

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