reflections on a doodle…

Posted on Wednesday 14 October 2015

I was looking at my old patent-life graph I used in a reset button…, and was updating it while I watched the debates on television. It didn’t take very long, and I found myself doodling a frequency distribution on the back of a nearby envelope. It looked kind of interesting, so I made an accurate version [it looked like the-rise-and-fall-of something]. While I realize that there have been a few new drugs in each class that aren’t represented here, these are the major players. There were several things I thought about looking at the frequency distribution of my major-psych-drugs-in-patent-timeline.

There’s the obvious thing [forgetting about the late-comers and me-toos for the moment]. We’re beyond the "pipeline" days when the detail-reps and KOLs were paid to go from place to place pushing these drugs. There’s also some relief from the horrible Direct-To-Consumer ads, so I’ve essentially stopped talking back to the television set. I would hope that this is a time when we can properly evaluate each of these classes and its members without the roar from advertising, ideologues, and tainted KOLs. And since the majority of the prescriptions are being written by primary care physicians, it behooves us to clarify the efficacy, toxicity, and rational indications for every one of  these drugs. Some think they’re inert. Some think they’re poison. Some think they are the great leap forward. Those are scientific, not ideological, issues, and the real answer is more elusive than it ought to be at this point.

But even without the pressure from PHARMA and an empty pipeline, these drugs are selling like hot-cakes, and the consensus is that they are still way over-prescribed [at least my consensus]. With the increasingly large databases from healthcare plans and the government, we ought to be able to figure out why. And we need to know how many stay on the drugs just to avoid withdrawal symptoms, and figure out how to help them safely get off. Many of the problem come with long term use, and a lot of patients and doctors continue them as "preventive insurance" or something like that in inproven situations. Also, it appears that the generic drug makers are jumping on the high price band-wagon along with the patent-holders, so somebody needs to curb that trend. And I suspect that PHARMA isn’t the only industry pushing these medications. Managed Care and other third party payers like the drugs because in spite of their high cost, they are still cheaper than other interventions and they get a checkmark in the treatment box [an analogy to deinstitutionalization comes to mind].

Finally, one wonders if some of this almost reflexive drug treatment is continuing because people don’t know  what else to do for their patients other than prescribe drugs [particularly after the thirty years we’ve just lived through]. And that’s not just about psychiatrists. Many practicing therapists make a referral for a med-consult during their first session. Physicians who receive these consults feel obligated to respond with a prescription. So this is a time when training programs, supervisors, and CME programs in multiple specialties would do well to focus on something like Back to Basics [meaning all sorts of forgotten or unlearned skills]. A strong reason for fighting for mental health parity is to give clinicians of all sorts the time to do their jobs [for the moment, I’ll forgo my recurrent ranting about Collaborative Care]. One can expect Managed Care to oppose any such a suggestion. In fact, when we talk about Conflicts of Interest, we ought to apply some of the indictment to the motives of Managed Care, who’ve had a field day chopping up mental health coverage…
  1.  
    Cate Mullen
    October 14, 2015 | 9:55 AM
     

    Excellent commentary! Does anyone remember the phrase”continuum of care”?I
    In the early eighties it seemed as if treatment were going to be based with several different types of care and treatment. Somehow that philosophy of treatment was totally disavowed by the powers that be.
    This also happened with the phrase “Therapeutic Milieu.”Fritz Redl wrote a great book “When we deal with Children” it is no long in print and if you Wiki Fritz the entry is all in German.
    I remember going to a DC/Baltimore Child Psychoanalytic Seminar and as a grad student in Social Work being so impressed with the presenters. They were not only (two white older males) very intelligent but they emanated a sense of caring and respect for children that impressed me to this day.
    I come from a very medical family and as I worked on medical units and psych units and ect. I really sensed that something was going wrong. The care and concern and respect towards patients kept slowly sliding down hill.

    I saw this not only in the medical profession but in all professions including my own. This correlated with the rise of Managed Care, and as we all know the rise of Pharma and the rise of Wall Street.
    Well we are all the frog in the boiling hot water now.
    Thanks for all of your work and thoughts. We all do what we can. It is , at times,, small but one hopes someday something will tip for the better.

  2.  
    Bernard Carroll
    October 14, 2015 | 10:39 AM
     

    Before Prozac arrived, we had the tricyclic antidepressants (TCAs) like Tofranil and Elavil. These were recognized as efficacious for depression mainly through trials in severely depressed patients (the great majority were inpatients). They were promoted for use in primary care patients with depression of lesser severity mainly on the ground that, if they worked for the severe cases, then they should help milder cases, too. The clinical exercise then became one of weighing potential benefit against possible toxicity, which had to be taken seriously. In practice, primary care physicians mostly prescribed very low doses of the TCAs, so the ecological effectiveness of those drugs in primary care was dubious at best.

    With the new generation of SSRI antidepressants, we have the reverse situation. These were trialed mostly in outpatient populations, and increasingly in subjects recruited through contract research organizations, either commercial or academic. The established efficacy of SSRIs does not compare to that of the TCAs (Number Needed to Treat of around 10 versus around 3). They are used widely (selling like hot-cakes, as Dr. Mickey put it), and in full dosage, in primary care because of their low toxicity but there is little evidence that they are useful in classic, severe depression of the melancholic or bipolar or psychotic varieties. In effect, we impute efficacy of SSRIs in such cases from their weak efficacy in milder depressions. Once again, the ecological effectiveness of these drugs across the board is dubious at best, despite the marketing. The current focus on treatment resistant depression bears testament to that. STAR*D taught us that much, at least.

  3.  
    James O'Brien, M.D.
    October 14, 2015 | 11:41 AM
     

    I have been baffled for a while at the popularity of Abilify and Seroquel. Sadly, I have concluded that these are being prescribed at high rates because physicians view them the way diplomats operated the Middle East in the movie Syriana…choosing the least bad terrible option. Probably because Powerpoint has convinced them the risk of TD is minimal with SGAs.

    I’m glad you’re pointing out the mangled care COI, which in practice on a daily basis is a much bigger problem that pharma COI. Actually I think Big Mangle and Big Journo is a much more serious problem than Big Pharma. In fact for the working physician BIg Pharma Benefit Manager is a much bigger problem than Big Pharma.

  4.  
    EastCoaster
    October 14, 2015 | 10:13 PM
     

    I’m a little confused about why Clozaril isn’t on there.

  5.  
    October 14, 2015 | 10:31 PM
     

    EastCoaster,

    Those on the list are the in-patent drugs. Clozaril was in-patent in the 1960s but withdrawn because of fatal cases of Agranulocytos.. It was released again in 1989 for limited use in treatment resistant cases with obligatory monitoring of blood counts. So I assumed it was long off-patent in the interval shown in this graph. But my bad, You’re right and I’m wrong. It was apparently in-patent from the 1989 re-release until 1998. I’ll update it…

    Thanks,

  6.  
    October 14, 2015 | 11:40 PM
     

    I think ongoing increase in large part as “chemical imbalance” myths are POWERFUL!!! Pharma leads its advertising to public AND PROFESSIONALS with these myths (doctors believe…), not for no reason. Professionals believing there’s a deficiency, feel negligent in not prescribing the topper upper. And “augmenters” same stuff. It’s sophisticated shaping of prescribing behavior, and it is working, to the harm of thousands worldwide.

  7.  
    Catalyzt
    October 15, 2015 | 1:29 PM
     

    Unfortunately, automatic “med consults” wind up being part of private practice for many MFTs, Social Workers and PsyDs as well. I think the problem starts in internship or clinical training, because med consults are, or were, pretty much mandated for certain diagnoses at many clinics. (“You can’t treat an unmedicated bipolar/depressed client, but if they are on medication, you can work with them as an MFTI, psych assistant, etc.”) Since “depression” can mean almost anything, certainly in the DSM V and even in the DSM IV, this policy leads many interns and trainees to make lots of psych referrals.

    Since this has been going on for decades, we can sometimes wind up with a very bad situation in private practice as well.

    Imagine the following scenario– I’ve heard several variations on this theme, maybe you have, too. Let’s say that early in your training, before you know any better, a friend asks you for a referral to a therapist. Let’s say your friend has PTSD or severe GAD, and you send them to a therapist recommended by a supervisor or professor. This therapist has a well-established private practice, a great reputation, and works from the old med-referral-mental-disease model and– unfortunately– it turns out that he or she routinely does psych referrals for meds.

    Weirdly, he/she refers to a psychiatrist who prescribes an SSRI for this client– maybe Celexa or Lexapro, which is supposed to stop people from “obsessing.” This is probably the psychiatrist this therapist always uses, and it’s probably a drug they use frequently. You are very upset by this, because you are learning that SSRIs rarely work for depression.

    Flash forward four or five years. Guess what? The client isn’t doing much better, and might even be doing worse. When you see the client– maybe he’s a classmate, or a co worker, or someone you play golf with– all he does is talk about how wrapped up he is in his anxiety and his symptoms.

    And– big surprise– he’s still seeing his therapist. Once a week, sometimes more in crisis, and this has been going on for FIVE YEARS. Of course, it’s one thing if the client is doing psychoanalysis, which, by the way, I completely believe in, because I feel it has a very different sort of treatment goal. But no– it sounds like they’re doing CBT and breathing exercises and kind of wallowing in trauma and anxiety. And even though you made the referral (through a supervisor or professor), there’s not a lot you can do, because the client really loves their therapist.

    It’s an ethical violation for you to give your friend direct advice about his medication for about thirteen different reasons. You can express concern as a friend about side effects, you can strongly encourage them to seek out additional sources of information, but you can’t do anything that looks like practicing psychotherapy with someone you know personally, and you can’t advise them about whether or not to take meds. When you do express concern, your friend says, “Look, I do what my doctor tells me to.”

    You wonder if your friend’s range of affect is narrowing. You wonder if their ability to make good decisions about their own care has been compromised.

    I do not think a therapist who makes this kind of med referral consciously decides, “I’m just going to strap on the feed-bag here, keep my client stuck, and not have to bother bringing in new business.” But I can’t help wondering if, tacitly, that’s kind of what’s happening, And wondering what outcome might have resulting if the therapist had crafted a treatment plan without medication.

    By the way, it’s time for my quarterly self-identification, where I post my actual name– something I avoid doing in my screen ID for security purposes, and because I’m not much of a social media person.

    And time for me to offer a hearty thanks to everyone here for helping me keep my sanity while I studied for my exam, particularly the bit on the DSM V. You guys really helped me keep my sense of humor, and keep things in perspective.

    Matthew Jansky, MA
    Licensed Marriage and Family Therapist

  8.  
    October 16, 2015 | 1:13 AM
     

    Reading about this overfocus on mostly ineffective pills makes me so glad that I titrated myself off pills (against my psychiatrist’s wishes), sought long-term psychotherapy, which proved so much more effective than any drug, and became able to work and have relationships rather than becoming a chronic mental patient.

  9.  
    October 16, 2015 | 9:40 AM
     

    Your last paragraph is basically my epitaph for my blog, I completely agree with you, “Finally, one wonders if some of this almost reflexive drug treatment is continuing because people don’t know what else to do for their patients other than prescribe drugs [particularly after the thirty years we’ve just lived through]. And that’s not just about psychiatrists. Many practicing therapists make a referral for a med-consult during their first session. Physicians who receive these consults feel obligated to respond with a prescription.”

    It is just so old and pathetic no one really gives a damn about an honest and true standard of care anymore. Me, I am just going to stick with doing Locum work for now, until my board certification comes due end of 2018, and then find something else to do with my life outside psychiatry, as who will employ me without board certification?

    My reply to that is simply this: “why do you employ those who are bound to the APA and American Board of Psychiatry these days?!”

    I’m sticking to my hypothesis, antisocial agendas are prevalent and pervasive, and society is going through hideous assimilation.

    Be safe, be well, be wise!

  10.  
    October 16, 2015 | 8:10 PM
     

    As Mickey wrote: “And we need to know how many stay on the drugs just to avoid withdrawal symptoms, and figure out how to help them safely get off.”

    Amen! This should not be left to patient-run Web sites. Physicians truly need to come to grips with this. Millions of people are stranded on the drugs because when they reduce the dosage, they get terrible withdrawal symptoms.

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