Wednesday, January 16, 2008

This is Why You Need A Psychiatrist

From today's Wall Street Journal, an article on how antidepressants aren't all they were cracked up to be: Antidepressants Under Scrutiny Over Efficacy. David Armstrong and Keith Winstein write,
"Since the overwhelming amount of published data on the drugs show they are effective, doctors unaware of the unpublished data are making inappropriate prescribing decisions that aren't in the best interest of their patients, according to researchers led by Erick Turner, a psychiatrist at Oregon Health & Science University. Sales of antidepressants total about $21 billion a year, according to IMS Health."

Actually, the issue at hand is that the pharmaceutical companies don't publish or make public the studies that don't show the results that will sell their meds. It's not a news release that we've suddenly realized that antidepressants don't always work. These are two separate issues. The WSJ article is based on a report in the New England Journal of Medicine, Selective Publication of Antidepressant and Its Influence on Apparent Efficacy, and it uses data on antidepressant studies to make this point. Okay, it's also about how antidepressants aren't as effective as the drug companies say they are, but this just doesn't surprise me. The WSJ article goes on to say,

"There is a view that these drugs are effective all the time," he (Dr. Turner) said. "I would say they only work 40% to 50% of the time," based on his reviews of the research at the FDA, "and they would say, 'What are you talking about? I have never seen a negative study.'" Dr. Turner, said he knew from his time with the agency that there were negative studies that hadn't been published.

There's someone out there who thought antidepressants work all the time? This is why people need psychiatrists, not primary care docs, managing their psych meds:

1) Even at high enough doses given for long enough (6 weeks), any given antidepressant may not work on any given patient. Or it may help with some symptoms and not others.

2) If one antidepressant doesn't work, another might.

3) If one antidepressant doesn't work, augmenting with a second medication may work.

4) As a patient suffering from Bipolar Disorder, depressed, moderate in severity, recurrent, said to me recently, "I think the therapy helps as much as the medicine."

I don't think it's news that a) anyone can write a prescription for Prozac and the patient may not get better, or b) this is complicated stuff.

The issue of the pharmaceutical agencies hiding their negative data is also not news. Personally, I think the legal penalties for withholding this information should be stiff enough to stand as a deterrent. You just don't hear of drug company CEO's in the cell next to Martha Stewart.


Anonymous said...

Good day to you!

I am very much interested in reading blogs about nursing and medicine. I have a blog and I made a link to your site. If possible, please link to my site. May you have a productive year this 2008.

Yours truly,
Jay of Philippine Nurse

Dr. Smak said...

Please don't confuse some idiot who thinks SSRIs always work with the thousands of us primary care docs who treat the vast majority of uncomplicated mental disease.

My residency program hammered your four numbered points into us. The most important skill of a primary care doc is knowing when to refer to a specialist. But, I take great exception to your assertion that everyone who needs a therapist or an SSRI needs a psychiatrist. And there aren't nearly enough of you to take on the burden, anyway.

Anonymous said...

As a patient suffering from Bipolar Disorder, depressed, moderate in severity, recurrent, said to me recently, "I think the therapy helps as much as the medicine."

Absolutely true. This is why psychiatrists need to be talented in both pharmacology and in psychotherapy.

But while we're on the subject, remember this comment by ClinkShrink back in November?

...I didn't become a psychiatrist because I wanted to be a therapist. I had no interest in psychotherapy and I honestly still don't.

So I guess a 40-50% success rate is good enough for prison.

Anonymous said...

"As a patient suffering from Bipolar Disorder, depressed, moderate in severity, recurrent, said to me recently, 'I think the therapy helps as much as the medicine.'"

Ditto. But I actually think the therapy helps me control the bipolar disorder better than the meds. The stress managment and coping skills I've learned in therapy are priceless. It helps me to head off a lot of triggers before they turn into an episode. Plus it doesn't have all the unpleasant side effects:).

The Shrink said...

For a drug company to have 2 trials failing to show efficacy, then concealing that, is unethical.

Sure, they're not charities and advertise/publicise themselves in excessively positive ways, but this really was very bad form.

The Shrink said...

For a drug company to have 2 trials failing to show efficacy, then concealing that, is unethical.

Sure, they're not charities and advertise/publicise themselves in excessively positive ways, but this really was very bad form.

Rach said...

Totally just hit on these points from a patient's POV on my blog (yesterday actually).

Very timely and appropriate. you can't blanket the population with the SSRI du jour just because it's the 'in' thing to do.

Ladyk73 said...

I think the flip side is important too. During my slide into depression hell, I was on an Effexor, but increasing the dose didn't help. I was suicidal and having a nervous breakdown. Instead of a psychiatrist, I was referred to a therpist. After a month of this hell, he refered me to a psychiatrist. And I finally got on Lamictal. It was a proper process....but it took two months.

During my recovery, when I had severe symptoms, I would request a medicine change. I was told to talk to my therpist. My therpist told me to talk to my psych NP (who was a bitch, by the way).

Anyways, after a couple of hospital stays, and a new psychiatrist, I was finally put on a medicine that helped, seroquel.

So...I think both are valuable.

I think when patients ask for a med change, they may be correct.

Roy said...

I agree with Dr Smak that most PCPs can manage uncomplicated depression (though I find that many do not manage it so well... eg, first follow-up appt after starting an antidepressant is often 1 month, but should be 1 week; also, I often see a failure to titrate up to maximum dose prior to moving on to another drug; finally, I still see Xanax or Ativan being prescribed for Depression).

Also agree that there are not enough psychiatrists to go around. I think more psychiatrists need to be willing to take on a consultant role, seeing the pt and sending them back to the PCP to manage. This model would allow us to treat many more people. Of course, this would require psychotherapy to take a back seat for these psychiatric consultants.

[Dinah, I did change "idiot" to "anyone" to remove the erroneous impression that we were calling all PCPs and NPs idiots. If you think it important, please add it back in.]

Aqua said...

I think it is completely unethical for the drug companies not to publish ALL studies about their medications. It is also unethical for the government's drug regulators to allow this to continue.

I know there are lots of primary care physicians who can recognize and treat uncomplicated depression, unfortunately I didn't meet one of those until I had what I now recognize as numerous major depressive episodes over a period of 18 years. I wish I had been referred to a psychiatrist when I was 18 instead of 36

Due to a chronic MDE over the past 6.5 years I have tried (in combinations and alone) all the SSRI's, SNRI's, an MAOI, 3 trycilics, a couple other ant-d's I can't think of, 3 different antipsychotics, 5 different mood stabilizers, benzodiazepines, stimulants, 8 ECT treatments and weekly therapy. Nothing has worked or helped except ECT, Lithium and Prozac each seemed to help for a few weeks.

What has kept me alive is therapy with my pdoc. Without that type of support from him I would never have been able to keep trying.

Dinah said...

Jay-- Welcome!

Dr. Smak-- I absolutely don't think every case of depression needs a psychiatrist. Probably every case of treatment-resistant depression (failure of 2 antidepressants) needs a psychiatrist.

Roy-- fine to take out my "idiot" reference.


The Shrink: agreed.

Rach, Michelle, Aqua, and LadyAK47: thanks for your insights as to what therapy can do.

ClinkShrink said...

Anon: That's why prisons have psychologists. The split treatment model is the standard of care in the public mental health system, both inside and outside of prison. And I'm reluctant to characterize every person with bipolar disorder as someone who needs (and wants) psychotherapy.

NeoNurseChic said...

Sometimes even, the best treatment for depression is the treatment of anxiety for some people. This worked for me, so far. When I discussed medication with my psychiatrist due to persistent depression and suicidal thoughts that were getting really troublesome, he thought about it and decided to start with BuSpar to see if we could get the anxiety under control some and then hopefully it would impact the depression. This has actually helped some. Having my anxiety reduced to a degree (not the crazy out-of-control anxiety I get, but some of the daily anxiety that blocks me from functioning normally) has given me more confidence, and having more confidence has made me less depressed. Indirectly, the BuSpar helped my depression and I believe it even lessened my suicidal thoughts - unless my suicidal thoughts just are taking a temporary LOA, but I'll take it any way I can get it. It wasn't a sudden change, but more of a gradual one, and then one day I thought to myself, "Hey I haven't felt suicidal in awhile.... That's a relief."

Of course, the therapy has helped tremendously, but I still had suicidal thoughts in spite of the therapy and some very significant depression and anxiety. Adding the med has allowed me to take back some of the control of my own life that the anxiety was running. I'm talking about some simple stuff that to me was absolutely overwhelming - such as making phone calls, managing finances, and other things that I am now much more proactive at doing now that I am not so afraid, depressed, and overwhelmed by all these things.

It didn't take all the anxiety away - last night I balanced my checkbook and paid bills before bed, then got into looking at flex spending account stuff (this has been a recent disaster), and I got myself so worked up that I couldn't go to bed for quite some time. However, I think some of the generalized underlying anxiety has lessened, and this has been a tremendous help.

Just my .02 :)

Take care,
Carrie :)

a psychiatrist who learned from veterans said...

Pardon me, but I don't think we need to make a crusade about this. With regard to negative studies, many years ago Sandoz had a drug called fluotracen. They stopped studying it after Phase II. One of the people in possession of the data wrote it up and submitted it for publication; not accepted. Sandoz never evidenced the slightest displeasure in the pursuit of publication at any stage. Roboxetine looked like it would be a good NE reuptake inhibitor but the criteria for entry into the study was set at 'not very depressed;' so (perhaps) the studies weren't positive enough. You've got to show separation. The company had a limited budget and time to pursue this; so it was dropped. We thus miss a NE reuptake inhibitor that would be safer than desipramine in overdose. With regard to Bipolar Disorder, depressed, the 'antidepressants' don't have an indication for that condition, i.e. there is insufficient data supporting their use there. This is, IMHO, a much bigger issue and it's no secret.

Suicide Malpractice said...

The study has no credibility coming from a left wing propaganda organ, the New England Journal of Medicine. N Engl J Med. 2008;358:252-60. An author is from Harvard, invalidating the review. These are biased left wing ideologues, clinician haters, seeking the destruction of corporate America.

These ideologues forgot something. The more severe the depression, the more likely and the greater the response to anti-depressant medication. That has been known for 50 years. The imipramine responder resembles the Parkinson patient. There is a lot of overlap between the two conditions. Many patients with Parkinson Disease are depressed. The severely depressed are slowed down, mute, have pseudo-dementia. The other feature of severe depression is, of course, intense suicidal urges. Patients with such strong biological symptoms are less likely to respond to placebo, when compared to patients with mild depression or even stress and normal sadness from loss.

The intensifying fear of litigation has caused severely depressed, and suicidal patients to get excluded from clinical trials. A patient suicide may end the clinical trial because of sanctions by the biased FDA and lawsuits. The patients who would cause the largest separation between drug and placebo have been progressively excluded.

Left wing ideologues like these biased, misleading, Harvard twits have intimidated companies into excluding severe patients. They caused the progressive failure of separation of drug from placebo responses. Then these clinical care haters complain that studies fail to separate drug from placebo responses.

As to any notion primary doctors can not or should not treat depression, I find that misleading, false, and self-serving. And I am a psychiatrist.

In areas where they do, after encouragement by authorities, the suicide rate drops. When they are deterred, as by a bogus, false, black box warning from irresponsible and appalling FDA Psychopharmacology Committees, the suicide rate increases in the targeted patient group.

When we psychiatrists make alarmist claims to increase our specialist referrals, the public may just ignore them, as self-serving garbage.