Only Severely Depressed Benefit From Antidepressants

And while I am writing about antidepressants today and the treatment of depression, let me mention here that antidepressants, while a great revenue enhancer for the pharmaceutical companies, don't seem to work beyond what one would expect from the placebo effect.

Reuters HealthDay reported on March 1, 2008 on a study which appears in the on-line journal, PLoS Medicine, on February 25, 2008 which found that antidepressants only helped in severe depression. They did not seem to have much of an effect beyond the placebo effect for mild and moderate depression.

Again, these are not new findings. Most of us in the mental health field have known this for years. Primary Care Physicians continue to prescribe antidepressants because it is an easy, quick way to respond to patient's complaints, and the pharmaceutical companies have plied Primary Care Phsysicians with plenty of free samples to give the physician and patient the illusion that there is a quick fix in popping a pill. Here's a snippet from the Reuters article:

While popular antidepressants such as Prozac are widely prescribed for people with varying degrees of depression, the drugs are only effective for those with the most severe depression, a new study suggests.

"Although patients get better when they take antidepressants, they also get better when they take a placebo, and the difference in improvement is not very great," lead researcher Irving Kirsch, a professor of psychology at the University of Hull in Great Britain, said in a prepared statement. "This means that depressed people can improve without chemical treatments," he added.

In the study, Kirsch and his colleagues collected data on 35 clinical trials of antidepressant drugs whose results had been submitted to the U.S. Food and Drug Administration. The antidepressants included in the trials were fluoxetine (Prozac), venlafaxine (Effexor), nefazodone (Serzone), and paroxetine (Seroxat/Paxil).

An analysis of the data showed that patients taking antidepressants fared no better than patients receiving a placebo. This appeared to be the case whether the patients were mildly or moderately depressed.

The drugs only seemed to benefit a small group of patients -- those with the severest depression when the study began.

Based on these results, there appears to be little reason to prescribe these antidepressants to anyone but the most severely depressed patients, the study authors concluded.

The findings were published online Feb. 25 in the journal PLoS Medicine.

Psychotherapy_2 Brief cognitive behaviorally oriented psychotherapy is treatment of choice for mild to moderate forms of depression, and has been shown to be very helpful with medications and other treatments with severely depressed patients as well.

Link: MedlinePlus: Only Severely Depressed Benefit From Antidepressants: Study.

Psychotherapy helps for Depressed Teens

Depressed_teen Reuters HealthDay reported on February 26, 2008 on a study published in the February 27, 2008 issue of JAMA, the Journal of the American Medical Association, that if adolescent depression doesn't lift after treatment with an antidepressant, guess what, psychotherapy helps and/or maybe another antidepressant.

While the Reuters article headline is "New Hope for depressed teens", this is old news and mental health professionals, I hope, have known this for years. Most careful research has found that psychotherapy is the treatment of choice especially for adolescent depression, and sometimes, medication can help. Of course, it is much easier for Primary Care Physicians to write out a prescription or give the teen pharmaceutical samples than it is to actually listen to the kid's troubles.

At any rate, it is validating to see some research which finds what I and most of my collegaues already know and that is, psychotherapy is helpful.

Link: MedlinePlus: New Hope for Depressed Teens.

College students have more psychiatric problems than ever straining college counseling centers

College_mental_health According to an article in Inside Higher Ed on March 18, 2008 more students in college these days have psychiatric problems requiring treatment.

In last year’s annual survey of counseling center directors sponsored by the American College Counseling Association, fully 91.5 percent reported observing the “recent trend toward greater number of students with severe psychological problems” on their campuses, while 87.5 percent said they noticed a growing number of students arriving on campus already on medication. They reported that 23.3 percent of “clients” at counseling centers are on psychiatric medication, up from 20 percent in 2003 and 17 percent in 2000. In 1994, the number was even lower, at 9 percent.

Link: The Mental Health Squeeze :: Inside Higher Ed :: Higher Education's Source for News, and Views and Jobs.

Socially connected people do better after surgery

Hospital_visit To us Social Workers the findings in a study published in the February, 2008 issue of the Journal of the American College of Sugeons and reported by Reuters on 02/21/08 comes as no surprise. People with good social support do better in outcomes after surgery than those without good social support. Here's a brief snippet from the Reuter's article:

People who have a strong social network feel less pain and anxiety before having surgery than their more isolated peers, according to a new study in VA patients. This translates to less pain and anxiety after the operation, less use of pain medication, and fewer days spent in the hospital, researchers report.

"Our hope is to try to put a spotlight on this for surgeons," Dr. Daniel B. Hinshaw told Reuters Health. The findings make it clear, he explained, that surgeons should ask patients about their level of social support, and anticipate that people with less support may fare worse.

"The old John Donne reference 'no man is an island' is extremely relevant to our health," he commented.

Link: MedlinePlus: Socially connected people do better after surgery.

Chantix May Raise Suicide Risk but smoking is still the far greater health risk

Smoking Reuters HealthDay reported on February 1, 2008 that the FDA has warned that the anti-smoking drug, Chantix, might contribute to suicidal ideas and behavior.

There's increasing evidence that the smoking-cessation drug Chantix is linked to serious "neuropsychiatric" side effects, including agitation, depressed mood and even suicide, U.S. health officials said Friday.

The U.S. Food and Drug Administration has asked Chantix's manufacturer, Pfizer Inc., to make the warning about these potential problems more prominent on prescribing information and on the drug's label. The agency is also working with Pfizer to produce a Medication Guide for patients, officials said.

"We have become increasingly concerned as we have seen a number of compelling cases that truly look as if they are the result of exposure to the drug and not to other causes," Dr. Bob Rappaport, director of the FDA's Division of Anesthesia, Analgesia and Rheumatology Products, said during an afternoon teleconference.

"These cases involve abnormal behaviors, changes in mood, and suicidal ideation and suicide," Rappaport said.

The FDA knows of 491 cases of suicidal behavior associated with Chantix, said Dr. Celia Winchell, a team leader in the FDA's Division of Anesthesia, Analgesia and Rheumatology Products.

"Of these, 420 are from the United States," Winchell said. "There are 39 that involve completed suicides, 34 in the United States."

According to Pfizer, 5 million patients have taken Chantix, whose generic name is varenicline.

Friday's warning follows a Nov. 20 FDA statement that the agency was "evaluating post-marketing adverse event reports on Chantix related to changes in behavior, agitation, depressed mood, suicidal ideation, and actual suicidal behavior."

At that time, Pfizer said there had never been a cause-and-effect relationship shown between Chantix and these symptoms. The company also said that part of the problem may be due to nicotine withdrawal.

Pifzer who manufactures and markets Chantix says that part of the agitation and suicidal ideas might be linked to nicotine withdrawal. One thing seems clear, and cigarettes are a huge risk factor for premature death so stopping smoking, even with the use of Chantix, is well worth any minimal risk.

Link: MedlinePlus: Quit-Smoking Drug May Raise Suicide Risk.

Life on the Mental Health Front lines

Rounds This fall, 2008, I will have been in the Mental Health field for 40 years. In addition I have raised 9 children of my own with my wife, and now I have 10 grandchildren.
I feel over the hill in some ways working in my private practice, being an agency executive, and teaching undergraduate social workers. Recently though, for the first time in a long time, I agreed to accompany a 16 year old client and his mother to an IEP meeting at his high school. The meeting was called to discuss his returning from a special ed 12:1:1 classroom to normal programming. I was appalled at the arrogance of the Principal who lectured the mother and the student about his zero tolerance policy for misbehavior and seriously questioned whether the student was prepared to function in this "higher expectation" environment. The mother started crying and said to him, "It seems that you are expecting and waiting for my son to fail!" at which point he demurred saying that he was not making a judgment only issuing a warning of what was expected. I thought to myself, "What an asshole!"
After he left the meeting the chairperson of the meeting, the Director of Pupil Personnel Services, tried to minimize his behavior saying that they like to play "good cop", "bad cop."
My wife and I wound up homeschooling our kids and most of my grandchildren are now homeschooled by their parents thank god. I am reminded of Pink Floyd's song, "We don't need no education. We don't need no thought control! Teachers!!!!!! Leave those kids alone!!
Schools blame parents all the time in the U.S. as well as policy makers for their children's poor functioning and misbehavior. It's outrageous really. In the U.S. there is very little parental support of any kind unlike in U.K. and Europe. Parents are left to struggle and when they lack the resources to respond to their children's problems there is an intimation that they are bad parents.
Today, I came from a meeting with a psychiatrist and a family intervention team trying to keep a 16 year old young female out of placement. The Psychiatrist kept saying every time concerns were raised about her behavior, "You have to understand, she's very sick. Her brain is not working right." She was trying to refer the father to NAMI support groups so he could learn more about mental illness. Under my breath, I am whistling, "I can't believe this shit!"
It's been a long time since I was on the front lines in this way, and it is appalling at the lack of compassion and inability of the systems we have created to respond in my human, respectful, and dignified ways. Now days it seems to be all about the money and the regulations requiring compliance with certain standards. Service providers are no longer working with clients and families but for some invisible agenda setters whom the service recipients never see and probably are not even aware of who are calling the shots.
In case you're wondering about the High School Principal, he said was an interim principal whom the school board had brought in from retirement to "clean things up", and the Psychiatrist is the director of a clinical research program hired to run drug trials. So the hidden agendas are veiled, but lurking behind the scenes, and students, patients, and their families are mystified as to why they are reduced to tears and sent off to support groups to learn that "mental illness" is caused by bad chemicals which can be rectified with phamaceuticals from Big Pharma.

Antidepressant Effectiveness Probably Overstated

Celexa Reuters HealthDay reported on January 16, 2008 on an article in the January 17, 2008 issue of the New England Journal of Medicine which found that the effectiveness of antidepressants is overstated and misrepresented.

A systematic review of studies on antidepressants concludes that the positive effects of these drugs are probably overstated in the medical literature.

But it's not clear if the bias comes from a reluctance to submit negative manuscripts or decisions by journals not to publish them, or a combination of both, according to Oregon Health and Science University researchers, whose report is published in the Jan. 17 issue of the New England Journal of Medicine.

The researchers compared drug efficacy inferred from published studies with drug efficacy reported to a mandatory U.S. government registry of clinical trials, in which all results, including raw data, must be included.

Only 51 percent of studies in the U.S. Food and Drug Administration registry were considered by the agency to have positive results.

In the published medical literature, however, 94 percent of studies appeared positive.

The increase in the effectiveness of the drug ranged from 11 percent to 69 percent for individual drugs, and was 32 percent overall. The antidepressant Wellbutrin appeared to show a high level of bias.

The authors also noted that studies that were not positive were often published with a slant that made them seem positive

This is really not new information for us in the field. It appears that the biggest postive effect of antidepressants can be attributed to the placebo effect. After that there is little evidence that a positive effect is due to a pharmocological influence.

Other evidence indicates that psychotherapy and exercise has a positive effect on depression.

Having said that, I know many patients who benefit from antidepressants and I, myself, take Celexa which I believe helps me. I also go for psychotherapy at least once per month and sometimes two times per month.

Link: MedlinePlus: Antidepressant Effectiveness Probably Overstated: Report.

Supreme Court to consider shield for drug, cigarette firms

Cigarette_warning_label The LA Times reported on January 19, 2008 that the Supreme Court may hear a case in which cigarette companies and drug companies argue that they cannot be sued in state court because the Feds already approved their consumer warnings.

I am reminded in reading this about the joke: "What's the three biggest lies ever told?"

"I'll still love you in the morning. The check is in the mail. I'm from the government and I'm here to help you."

The Supreme Court signaled Friday that it may be ready to shield drug companies and cigarette makers from lawsuits from consumers who say they were not fully warned of the dangers of the product. The justices voted to hear a pair of appeals from industry lawyers that, if upheld, would erect a new barrier to lawsuits. Related -Supreme Court of the United States Related Stories -Ruling limits reach of investor suits -Justices uphold ban on test drugs for the dying -High court to hear TV judge's case -Justices to decide whether murder victims' prior statements are admissible For many years, lawyers for the pharmaceutical industry and cigarette makers have argued that their products should be shielded from suits if they have been approved for use by a federal agency -- such as the Food and Drug Administration -- and a warning label is included. For example, most prescription drugs come with labels that indicate they may be safely used under certain conditions. Consumers are also warned against overdosing or using the drug for other purposes. Industry lawyers say these federally approved warning labels should "preempt" or block lawsuits in state courts from consumers who say they used the drug as prescribed but were badly hurt by it. They say the FDA, and not jurors, should have the role of deciding when drugs can be used safely.

Link: Supreme Court to consider shield for drug, cigarette firms - Los Angeles Times.

Most Free Drug Samples Go to Wealthy and Insured

Drug_sample Reuters HealthDay reported on January 2, 2008 on an article which will appear in the February, 2008 issue of the American Journal Of Public Health which found that most free drug samples go to the wealthy and insured not to the poor and uninsured.

Most free drug samples go to wealthy and insured patients, not to the poor and uninsured who may need them most, Harvard researchers report. In fact, more than four-fifths of those who receive samples are insured, while less than one-fifth are uninsured and less than one-third have low incomes (below $37,000 for a family of four), the researchers found. "Free drug samples influence prescribing and also introduce potential safety problems," said lead researcher Dr. Sarah Cutrona, a physician with the Cambridge Health Alliance and an instructor of medicine at the Harvard Medical School. "Despite these problems, many doctors support the program because [they say] free samples 'allow us to get free medications to our neediest patients,' " she said. However, most free samples don't go to the neediest patients, Cutrona's group found. In the study, Cutrona's team collected data on almost 33,000 people who participate in the annual Medical Expenditure Panel Survey. The researchers reported their findings in the February issue of the American Journal of Public Health.

Of course, if you think about this a minute it makes a lot of sense. Who goes to doctors offices? People who have insurance and can pay for care. Uninsured and poor people go to clinics and emergency rooms.

And who is more likely to buy drugs that the pharmaceutical companies are marketing to? People with money and a prescription rider on their health insurance plan.

Link: MedlinePlus: Most Free Drug Samples Go to Wealthy and Insured.

Bipolar moms-to-be who stop meds risk relapse

Pregnant_woman Reuters reported on January 1, 2008 on a study in the December, 2007 issue of the American Journal Of Psychiatry that pregnant woman with a history of bi-polar illness might be better to stay on their meds during their pregnancies rather than to discontinue them to avoid relapse.

Link: MedlinePlus: Bipolar moms-to-be who stop meds risk relapse.