{"id":12714,"date":"2011-08-31T20:03:37","date_gmt":"2011-09-01T00:03:37","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=12714"},"modified":"2011-08-31T21:03:33","modified_gmt":"2011-09-01T01:03:33","slug":"stahls-first-question","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/08\/31\/stahls-first-question\/","title":{"rendered":"Stahl’s first question…"},"content":{"rendered":"
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In my last post, a minimalistic formulary of generic medications rolled off my tongue. A friend read it and asked, "Do you keep score?" No, I don’t keep score, but I do keep up. In the adult clinic, we see only indigent and uninsured people. We have a pharmacy with donated drugs, a few purchased, and the capacity to apply for drugs through companies’ hardship programs. In the Child and Adolescent Clinic, most of the kids are on Medicade, meaning their medications [generics if available] are covered. For some drugs [left above] the medications are available as $4.00\/month or $10.00\/3·month prescriptions in local pharmacies [Kroger shown]. On the right are the prices for other generics. We do stock Depakote 250MG [Divalproex] and Risperidone 0.5MG and 1MG [Risperdal] when we can. But, there are a very small number of people on either of one of those medications. But I keep up because cost, for these patients, is a limiting factor. <\/p>\n

When I watch the direct-to-consumer ads on television or see the glossy displays in the Journals for the more recent versions of these medications, I sometimes wonder if the people taking them are any better served and have better results than the patients I see in our little rural clinic. I don’t really know the answer – having little experience with those drugs that we hear so much about. That list up there is only a baker’s dozen [2 anti-anxiety agents, 2 "mood stabilizers," 2 anti-psychotics, 6 anti-depressants, and 1 stimulant]. If we added in all the in-patent non-generic drugs available in psychiatry, the count in each category would rise, but the number of categories would be close to the same. <\/p>\n

I’m rambling on about this because Dr. Stahl’s question haunts me: "<\/font><\/strong>Were the last 25 years of mental health treatment discoveries so worthless as to discard these efforts for the future?"<\/font><\/strong> The two groups of drugs on the list not yet in use back in 1987 were the SSRIs [introduced that year] and the Atypical Anti-psychotics [derivatives of Clozaril, introduced in the 1970s]. Most of the changes in the last 25 years weren’t exactly "mental health treatment discoveries"<\/font><\/strong> in the meaning of the word dis·cover<\/font><\/strong> – to find something new. They were more like re·fine·ments<\/font><\/strong> – variations on known themes. While that’s a perfectly legitimate direction for the pharmaceutical R&D departments to take, certainly not "worthless," Stahl’s question implies something that’s not quite right. He’s what the Red Guard under Mao called a "roader" – going down a different road. He’s mostly talking about the fate of the US and UK CNS pharmaceutical industry which is apparently not faring very well at the moment [in spite of big numbers on their quarterly reports – even with their settlement losses and lawyer’s fees in the debit column].<\/p>\n

Rereading his polemic, it’s largely about pharmaceutical industry. In fact, Stahl’s first question<\/strong> is spoken from an industrial<\/font><\/strong> point of view, "If you were in the Pharma business, would you work with psychiatry anymore?"<\/font><\/strong> I guess I misread it the first time through. I took "psychiatry" to mean something like "the domain Psychiatry" – the medical specialty. That didn’t make any sense to me at all. My perception is that the field of psychiatry has embraced psychopharmacology with a passion, almost merging at times with the pharmaceutical industry. But I think he meant "the domain Mental Illness" – the area of medicine where psychiatrists spend their time [the drug companies call it CNS medicine]. And why wouldn’t the Pharma business want to work in this area anymore? He thinks it’s because of the people he thinks are hell-bent on destroying them, are suing them all the time, are bad-mouthing them:<\/div>\n