my therapist, my psychiatrist, my plan, my meds…

Posted on Thursday 7 February 2013

I don’t usually do this – republish someone else’s complete blog post. I try to pull out the parts I want to say something about or emphasize, then link the source in case you want to read the whole thing. But I could find nothing I wanted to take out of this post by Dr. Healy [I reformatted it for space and I think his original is much easier to read]. I just thought every word needed emphasis:
Prozac and SSRIs: Twenty-fifth Anniversary
Dr. David Healy
06 Feb 2013

One Prescription for Every Man, Woman and Child
Prozac was approved in 1987 in the US, and launched in early 1988, followed by a clutch of other SSRIs. Twenty-five years later, we now have one prescription for an antidepressant for every single person in the West per year. Twenty-five years before Prozac, 1 in 10,000 of us per year was admitted for severe depressive disorder – melancholia. Today at any one point in time 1 in 10 of us are supposedly depressed and between 1 in 2 and 1 in 5 of us will be depressed over a lifetime. Around 1 in 10 pregnant women are on an antidepressant. No one knows how many new cases of depression there are per year partly because modern depression is a creation of the marketing of Prozac. Until recently what is now called depression was called anxiety, nerves or a nervous breakdown. SSRIs can help some cases of nerves but they are of no use for depression proper – melancholia. But the money for companies lies in treating nerves not melancholia – and as a result any of us with severe depression is likely to get worse treatment now than we once did.  We’ve gone backwards.

How Many Hooked?
By 1999 the number of us taking SSRIs chronically equaled the number starting an SSRI each year. By 2003, over 6 million Americans were taking an antidepressant semi-permanently – along with over 6 million Europeans. The number of prescriptions for antidepressants is increasing by 5-10% each year, while the figure for people starting each year remains the same. This means that there is an increase of 5% to 10% in the number of people hooked to antidepressants each year.

Lives Lost
There is no research evidence to suggest that anyone’s life is saved by taking an antidepressant but if there are lives saved the research makes it clear that for every life saved there must be another lost. There are probably something between 1000-1500 extra suicides in the US each year, triggered by an antidepressant – an extra 2000-2500 in Europe. The data is similar for violence. There are probably between 1000-1500 extra episodes of violence in the US each year that would not have happened without antidepressant input and between 2000-2500 extra episodes in Europe.  Some of these will include school or other mass shootings which were unheard of twenty-five years ago.

Aborted Families
About 4000 families in the US have children born with major birth defects each year because of antidepressants taken in pregnancy. Up to 20,000 women per year have a miscarriage because of these drugs and a large number have voluntary terminations linked to antidepressants. Miscarriages are among the biggest single predictors of later mental illness and substance misuse in women.  In Europe these figures likely run at an extra 6000+ birth defects, 30,000+ miscarriages, and who knows how many extra voluntary terminations. Most children born to mothers who have been on these drugs do not have obvious birth defects. But it increasingly looks as though these children may show cognitive delay and other autistic spectrum features.

The Dead Doctor Sketch
Perhaps the greatest casualty of Prozac has been holistic medicine. Imagine you have numbness in an arm or pain in a shoulder. If referred to an orthopedic or neurology department you will have every conceivable scan or test to pinpoint the problem. Chances are the clinic will find abnormalities and attempt to put things right – abnormalities that are not the source of your problem. A good generalist, who knows your circumstances, relationships, difficulties at work and the community from which you come, can spot when aches and numbness stem from strain or tension – they see you rather than bits of you. Prozac has killed Generalism. It did so by focusing attention on mood in the way neurologists hyper-focus on nerves. Psychiatrists have become the doctors who deal in heroic combinations and doses of pills rather than doctors who, like generalists, step back and take a broader view. Prozac has also killed therapy – just like Prozac CBT has a hyper-focus on thoughts rather than the big picture. CBT has also become a conduit into antidepressant prescribing as therapists regularly suggest softening up a depression with pills.

Psychiatry leads the Way
Many see or saw psychiatry as a medical backwater with grim, overcrowded hospitals, and a dim understanding of the disorders it treats. In fact it was the first branch of medicine to have specialist hospitals and journals, the first to discover the bases for and eliminate several serious disorders, the first to adopt rating scales and controlled trials. And with Freud’s son-in-law, Edward Bernays, it was the first to step into public relations. Twenty-five years ago, no one could have imagined that the bulk of the treatment literature would be ghostwritten, that negative trials could be portrayed as glowingly positive studies of a drug, that controlled trials could have been transformed into a gold-standard method to hide adverse events, or that dead bodies could have been hidden from medical academics so easily.  Twenty-five years ago no one would have believed that a drug less effective for nerves or melancholia than heroin, alcohol or older and cheaper antidepressants could have been brought on the market and that almost as a matter of national policy people would be encouraged to take it for life.
I came at this from such a different angle from Dr. Healy. In my early thirties, I had made a mid-course correction in my career as an Internist and retrained in psychiatry – interested in psychotherapy. For me, the nodal point in that second career was the publication of the DSM-III in 1980. At the time, I was in psychoanalytic training and directing a psychiatric residency. By the time Prozac came out, I had either left or been extruded from academia [actually both] and was starting my private practice. The coming of Prozac was just a blip on the radar screen already covered with other bogies. In contrast, Dr. Healy was a young and upcoming biological psychiatrists who caught on to the toxicity of the drug early on and pursued it when most others were denying it. So our perspectives were very different. When Prozac came, I was in a practice with like-minded colleagues, involved in our analytic institute and an academic program at our college. I had no connection with the Psychiatry Department though I was on the clinical faculty.

When Dr. Healy says that "Twenty-five years ago, no one could have imagined that…" he is completely correct. But from my perspective, twenty-five years ago I couldn’t even imagine what had already happened in psychiatry and was once again personally making another mid-course correction. The part of Dr. Healy’s post that I relate to the most is The Dead Doctor Sketch. I had come to psychiatry from Internal Medicine because I realized that many of the people I saw were primarily in need of help with their lives and matters mental, and I had become dissatisfied with just dealing with the physical part. When psychiatry medicalized in the early 1980s, it went off and left me and the whole reason I was there in the first place. So the way I see it, Prozac didn’t cause the things he mentions. It was the drug the newly revised psychiatry had been waiting for – a biological messiah fulfilling the prophesy of the neoKraepelinians, and it was followed by a series of latter-day saints.

In The Dead Doctor Sketch, Dr. Healy mentions CBT – Cognitive Behavior Therapy. Aaron Beck, its founder, was dissatisfied with the psychoanalysis of his training and came up with a therapy based on his observation that depressed people think depressively, dream depressively, and live depressively. He proposed seeing their depressive cognition as a behavior and applying the principles of behavioral therapy to their depressive cognition, and later to other cognitive styles. He was right about that kind of thinking and had some measurable success in changing it. Now, everyone is a cognitive behavior therapist, primarily because it is sanctioned as an "evidence-based" therapy. What Dr. Healy says is exactly right. Mental Health practitioners send their clients to psychiatrists for "meds" and then do counseling of various kinds. For all the talk about CBT, I haven’t run into many people who actually do formal CBT. I’m sure they’re out there, but I think it’s more something fresh graduates do until they find a style of their own. But no matter what they end up doing, they sure send their clients for "meds," and the psychiatrists sure prescribe them. In the US, there’s a third party involved – the insurance carrier. So patients now talk about a number of things: my therapist, my psychiatrist, and my plan – the latter being a major ingredient. All three forces point to the fourth thing – my meds. I couldn’t have imagined that set-up twenty-five years ago either.

Among the many points Dr. Healy makes in this post, none is more insightful than this:
A good generalist, who knows your circumstances, relationships, difficulties at work and the community from which you come, can spot when aches and numbness stem from strain or tension – they see you rather than bits of you. Prozac has killed Generalism. It did so by focusing attention on mood in the way neurologists hyper-focus on nerves.
While I would quibble that it wasn’t only Prozac that killed Generalism, there’s little question that Prozac was an essential link in the tragedy that Dr. Healy so eloquently lays on the table…
    February 7, 2013 | 5:11 PM

    Agree with most of Dr. Healy’s post, but the following part really bugs me:

    “There are probably something between 1000-1500 extra suicides in the US each year, triggered by an antidepressant…There are probably between 1000-1500 extra episodes of violence in the US each year that would not have happened without antidepressant input…”

    The phrase “there are probably” does not inspire much confidence in his data. Any idea where he got those numbers from?

    February 7, 2013 | 5:54 PM

    I wondered too. I actually went looking for my copy of Pharmaggedon to see if the numbers were in there after I read the post, but it’s loaned out. I don’t question the fact of the violence, but I don’t know how he quantified it. On the other hand, I retired to a very sparsely populated rural place and I know of two sure thing SSRI related suicides in this last year.

    berit bj
    February 7, 2013 | 7:15 PM

    One place to look for data is
    Another is according to which less than 5% of serious adverse events are reported.
    The Medication Guide on antidepressants, approved by the FDA in 2008, reads like one, long warning issued all these years too late, after massive harm to thousands, after tapping billions of dollars from private and public purses to shareholders and CEOs paid salaries in tens of millions.

    Rob Purssey
    February 7, 2013 | 7:47 PM

    I suggest post the questions on Healy’s blog, await his explanation.

    berit bj
    February 7, 2013 | 9:28 PM
  is by dr Healy, and a team, inviting readers to report adverse drug reactions, building an independent database, as patient-stories in media and on http://www.ssristories are brushed aside as merely “anecdotal” by the industrialists, as neither the FDA nor the prescribers experience the adverse drug events real people and unborn babies are victims of, as RCTs have been designed to hide the bodies, suicides of medicated patients ascribed to “the illness”, protecting the business.

    February 9, 2013 | 12:14 PM

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