{"id":37119,"date":"2013-06-07T07:23:14","date_gmt":"2013-06-07T11:23:14","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=37119"},"modified":"2013-06-07T08:08:52","modified_gmt":"2013-06-07T12:08:52","slug":"objectively","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/06\/07\/objectively\/","title":{"rendered":"objectively&#8230;"},"content":{"rendered":"\n<div align=\"justify\"><sup><strong><em>Depression and bipolar illness in the workplace impair productivity and are dearly expensive, as multiple studies have documented for decades. One would assume that such reports would have fueled widespread concern and action, but they have not, despite huge potential payoffs.<\/em><\/strong><\/sup>   <\/div>\n<div align=\"right\"><sup><strong><a target=\"_blank\" href=\"http:\/\/ajp.psychiatryonline.org\/article.aspx?articleID=1694213\">Workplace Depression: Personalize, Partner, or Pay the Price<\/a> by John F. Greden, M.D.<\/strong><\/sup><\/div>\n<p>     <\/p>\n<div align=\"justify\">I wouldn&#8217;t bother with the article discussed below if the <strong><font color=\"#004400\">American Journal of Psychiatry<\/font><\/strong> hadn&#8217;t made such a big deal of it and presented it so bizarrely. It&#8217;s this month&#8217;s cover story &#8211; illustrated by everyone&#8217;s favorite Mexican Communist Muralist &#8211; <a target=\"_blank\" href=\"http:\/\/en.wikipedia.org\/wiki\/Diego_Rivera\">Diego Rivera<\/a>. They say of the cover:<\/div>\n<div align=\"justify\">\n<ul>\n<div><sup><strong>The murals caused an outcry, because Rivera,  a former member of the Mexican Communist Party and a self-proclaimed  painter of the oppressed working class, was deemed unsuitable to  celebrate the capitalist ascendancy of Detroit. There were threats to  whitewash the freshly frescoed walls until Edsel Ford approved the  murals and the Detroit public followed suit. Indeed, Rivera, for all his communist  notoriety, said that &ldquo;Henry Ford [is] a true poet and artist, one of the  greatest in the world&rdquo; and proclaimed that Detroit embodied the best  expression of American art&mdash;the factory. Yet while the murals celebrate hard work and  productivity, their dark, eerie light and the forlorn&mdash;or at best,  flat&mdash;faces of its factory workers suggest the oppressive aspect of  capitalism. Work, in Rivera&rsquo;s depiction, is admirable. Productivity,  more so. But an accompanying <em>op<\/em>pression and <em>de<\/em>pression  seem inextricable in these murals and in the minds of Americans, and  Detroiters in particular, during the Great Depression. One wonders,  looking at these murals, how productive the oppressed worker can be. <font color=\"#990000\">In  this issue, new research by Trivedi et al. assesses how productivity  suffers for depressed workers.<\/font><\/strong><\/sup><\/div>\n<\/ul><\/div>\n<div align=\"justify\"><img decoding=\"async\" width=\"170\" vspace=\"2\" hspace=\"4\" border=\"1\" align=\"right\" src=\"http:\/\/1boringoldman.com\/images\/trivedi-work.jpg\" \/>[Somehow, that last sentence didn&#8217;t quite fit the flow of things]. Next came the editorial [<strong><a target=\"_blank\" href=\"http:\/\/ajp.psychiatryonline.org\/article.aspx?articleID=1694213\">Workplace Depression: Personalize, Partner, or Pay the Price<\/a><\/strong>] with the opening lines I quoted above [I can pretty much guarantee you that Diego Rivera would rise from the grave if he could and denounce this editorial, throwing red paint on as many copies as he could get his hands on]. The editorial ends with:<\/div>\n<div align=\"justify\">\n<ul>\n<div><sup><strong>&quot;<em>Business leaders, insurance companies, and anyone who bemoans high  health care costs will need to respond to data showing that wellness is a  better cost-reducer and productivity-improver than treatment  restrictions. The findings by Trivedi et al. in this issue  addressed only productivity gains, but in doing so, the authors provide  a tantalizing peek at a promising vision. Full-scale workplace  initiatives, network partnerships, personalized treatment development,  and prevention programs will promote profitability rather than raising  costs. This vision is attainable.<\/em>&quot;<\/strong><\/sup><\/div>\n<\/ul><\/div>\n<div align=\"justify\">[Don&#8217;t miss reading the whole editorial]. And then we move on to the paper by Trivedi et al. Wouldn&#8217;t you know that it was a STAR*D study, based on the responses to the WPAI [<strong><font color=\"#200020\">Work Productivity and Activity Impairment<\/font><\/strong> scale] gathered by a voice activated telephone system at nodal points along the way. Here are the questions they analyzed [I couldn&#8217;t find the version for Depression, so use your imagination]:            <\/div>\n<p align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"400\" height=\"400\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/trivedi-work-0.gif\" \/><br \/>                       <sup><strong>[WPAI: example from Irritable Bowel Syndrome]<\/strong><\/sup><\/p>\n<div>And finally, here&#8217;s the article:<\/div>\n<blockquote>\n<div align=\"center\"><a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/23558394\">Increase in Work Productivity of Depressed Individuals With Improvement in Depressive Symptom Severity<\/a><br \/>                            <sup><strong>by Madhukar H. Trivedi, M.D.; David W. Morris, Ph.D.; Stephen R. Wisniewski, Ph.D.; Ira Lesser, M.D.; Andrew A. Nierenberg, M.D.; Ella Daly, M.B., M.R.C.Psych.; Benji T. Kurian, M.D., M.P.H.; Bradley N. Gaynes, M.D.; G.K. Balasubramani, Ph.D.; and A. John Rush, M.D.<\/strong><\/sup><br \/>                            <strong><font color=\"#004400\">American Journal of Psychiatry<\/font><\/strong> 2013 170:633&ndash;641.<\/div>\n<p>                           <\/p>\n<div align=\"justify\"><sup><strong><\/p>\n<div><u><font color=\"#200020\">Objective<\/font><\/u>: The authors sought to identify baseline clinical and sociodemographic characteristics associated with work pro- ductivity in depressed outpatients and to assess the effect of treatment on work productivity.<\/div>\n<div><u><font color=\"#200020\">Method<\/font><\/u>: Employed depressed outpatients 18 &ndash; 75 years old who completed the Work Productivity and Activity Impairment scale [N=1,928] were treated with citalopram [20 &ndash; 40 mg\/day] in the Sequenced Treatment Alternatives to Relieve Depression study. For patients who did not remit after an initial adequate antidepressant trial [level 1], either a switch to sertraline, sustained-release bupropion, or extended-release venlafaxine or an augmentation with sustained-release bupropion or buspirone was provided [level 2]. Participants&rsquo; clinical and demographic characteristics and treatment outcomes were analyzed for associations with baseline work productivity and change in productivity over time.<\/div>\n<div> <u><font color=\"#200020\">Results<\/font><\/u>: Education, baseline depression severity, and melancholic, atypical, and recurrent depression subtypes were all in- dependently associated with lower benefit to work productivity domains. During level 1 treatment, work productivity in several domains improved with reductions in depressive symptom severity. However, these findings did not hold true for level 2 outcomes; there was no significant association between treatment response and reduction in work impairment. Results were largely confirmed when multiple imputations were employed to address missing data. During this additional analysis, an association was also observed between greater impairment in work productivity and higher levels of anxious depression.<\/div>\n<div> <u><font color=\"#200020\">Conclusions<\/font><\/u>: Patients with clinically significant reductions in symptom severity during initial treatment were more likely than nonresponders to experience significant improvements in work productivity. In contrast, patients who achieved symptom remission in second-step treatment continued to have impairment at work. Patients who have demonstrated some degree of treatment resistance are more prone to persistent impairment in occupational productivity, implying a need for additional, possibly novel, treatments.<\/div>\n<p><\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">So the first thing we learn [omitted from the abstract] is the answer to Question 1, &quot;<em>Are you currently employed [working for pay]?<\/em><\/div>\n<div align=\"justify\">\n<ul>\n<div><sup><strong>&quot;Of the 4041 participants enrolled in STAR*D, 2311 were employed, and of these, 1928 reported impairment in work productivity or activity at baseline. Of these, 1100 provided complete data regarding work productivity at exit from the initial treatment with citalopram&quot;&#8230;<\/strong><\/sup><\/div>\n<\/ul><\/div>\n<div align=\"justify\">That comes out to a <strong><font color=\"#200020\">43% Unemployment Rate among STAR*D subjects<\/font><\/strong> [study done before the 2008 recession]. Pretty impressive! Here are their results from Questions 2 and 5 for their working subjects after the Level 1 treatment with Citalopram:<\/div>\n<div align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"400\" vspace=\"5\" height=\"213\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/trivedi-work-1.gif\" \/><\/div>\n<div align=\"justify\">I had some trouble with this table. All three groups [non-responders, responders, and remitters] improved. And the Baseline for the tree groups was different. I didn&#8217;t have the data to do analysis of variance but simple t-test showed a significant response in all three groups on the left below with mean <u>+<\/u> SD. The mean drop in hours missed per week for the three groups is on the right with the 95% Confidence Limits of the mean. I guess it&#8217;ll do in an <em>iffy<\/em> sort of way, but definitive stats weren&#8217;t shown:<\/div>\n<div align=\"center\"><img decoding=\"async\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/trivedi-work-3.gif\" \/><\/div>\n<p align=\"justify\">What bothered me more was what always bothers me when STAR*D is in the picture &#8211; the drop-out rate and missing data rate is extremely high. <strong><font color=\"#990000\">And in Table 3, <\/font><font color=\"#990000\">they didn&#8217;t use the start values that they had exit values for. They used <u>all<\/u> of the start values [1924] compared with the exit values [1097].<\/font><\/strong> So the results suggest a continuity that&#8217;s not really there [1-(1097\/1924)=43% missing exit values from drop-outs or failure to phone home]. <strong><font color=\"#990000\">It becomes even more tangled because with the Level 2 data, they <u>only<\/u> reported subjects if they had both start and exit data.<\/font><\/strong><\/p>\n<p align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"500\" height=\"287\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/trivedi-work-2.gif\" \/><\/p>\n<p align=\"justify\">They say this Level 2 table shows non significance. I guess I&#8217;ll take their word for it [I couldn&#8217;t figure out a way to vet it]. And with STAR*D papers, we must always include this part:<\/p>\n<table cellspacing=\"0\" cellpadding=\"2\" border=\"0\" align=\"center\">\n<tr>\n<td align=\"justify\"><sup><strong>  <u><font color=\"#200020\">Dr. Trivedi<\/font><\/u> has received research support from or served as an adviser, consultant, or speaker for Abbott Laboratories, Abdi Ibrahim, Agency for Healthcare Research and Quality, Akzo (Organon Pharmaceuticals), Alkermes, AstraZeneca, Axon Advisors, Bristol-Myers Squibb, Cephalon, Corcept Therapeutics, Cyberonics, Eli Lilly, Evotec, Fabre Kramer Pharmaceuticals, Forest Pharmaceuticals, Glaxo-SmithKline, Janssen Pharmaceutica Products, Johnson &amp; Johnson PRD, Libby, Lundbeck, Mead Johnson, MedAvante, Medtronic, Merck, National Institute on Drug Abuse, NARSAD, Naurex, Neuronetics, NIMH, Novartis, Otsuka Pharmaceuticals, Pamlab, Parke-Davis Phar- maceuticals, Pfizer, PgxHealth, Pharmacia &amp; Upjohn, Predix Pharmaceuticals (Epix), Rexahn Pharmaceuticals, Roche Products, Sepracor, Shire Development, Sierra, SK Life and Science, Solvay Pharmaceuticals, Takeda, Transcept, VantagePoint, and Wyeth- Ayerst Laboratories.<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>  <u><font color=\"#200020\">Dr. Wisniewski<\/font><\/u> has served as a consultant for Dey Pharmaceuticals and Venebio and has received grant support from Eli Lilly. Dr. Lesser has received grant support from NIMH..<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>   <u><font color=\"#200020\">Dr. Nierenberg<\/font><\/u> has received research support from or served as an adviser, consultant, or speaker for AstraZeneca, Basilea Pharmaceutica, Brain Cells, Bristol-Myers Squibb, Cederroth, Cyberonics, Dainippon Sumitomo, Eli Lilly, EpiQ, Forest Pharmaceuticals, Genaissance, GlaxoSmithKline, Janssen Pharmaceutica, Jazz Pharmaceuticals, Innapharma, Lichtwer Pharma, Eli Lilly, Merck, Neuronetics, Novartis, Organon, Pamlab, Pfizer, PGx Health, NIMH, NARSAD, Sepracor, Shire, Stanley Foundation, Targacept, Takeda, Wyeth-Ayerst Labora- tories, and Massachusetts General Psychiatry Academy (MGHPA talks are supported through Independent Medical Education grants from AstraZeneca, Eli Lilly, and Janssen Pharmaceuticals); he has equity holdings (excluding mutual funds\/blind trusts) in Appliance Comput- ing. .<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>   <u><font color=\"#200020\">Dr. Daly<\/font><\/u> is currently a full-time employee and stockholder of Johnson &amp; Johnson PRD; at the time of this study, she was an assistant professor at the University of Texas Medical Center, Dallas, where she continues to hold a position as adjunct faculty. .<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>   <u><font color=\"#200020\">Dr. Kurian<\/font><\/u> has received research grant support from Evotec, Forest Pharmaceuticals, Johnson &amp; Johnson, Naurex, NIMH, Pfizer, Rexahn, and Targacept. .<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>   <u><font color=\"#200020\">Dr. Gaynes<\/font><\/u> has received research support from or served as an adviser, consultant, or speaker for the Agency for Healthcare Research and Quality, Bristol-Myers Squibb, GlaxoSmithKline, M-3 Corporation, NIMH, Novartis, Ovation Pharmaceuticals, Pfizer, Robert Wood Johnson Foundation, Shire Pharmaceuticals, and Wyeth-Ayerst..<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>   <u><font color=\"#200020\">Dr. Rush<\/font><\/u> has received research support from Duke-National University of Singapore Graduate Medical School and NIMH; consulting fees from Brain Resource, Otsuka, and University of Michigan; speaking fees from Singapore College of Family Physicians; royalties from Guilford Publications and the University of Texas Southwestern Medical Center; and travel support from Collegium Internationale Neuro-Psychopharmacologicum. .<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>   The other authors report no financial relationships with commercial interests..<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>   Supported by NIMH contract N01MH90003 to University of Texas Southwestern Medical Center at Dallas [principal investigator, Dr. Rush]. Medications for this trial were provided at no cost by Bristol- Myers Squibb, Forest Laboratories, GlaxoSmithKline, King Pharma- ceuticals, Organon, Pfizer, and Wyeth..<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>   Clinicaltrials.gov identifier: NCT00021528..<\/strong><\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"justify\"><sup><strong>  The authors acknowledge the editorial support of <u><font color=\"#200020\">Jon Kilner, M.S., M.A<\/font><\/u>..<\/strong><\/sup><\/td>\n<\/tr>\n<\/table>\n<p align=\"justify\">In case you don&#8217;t recall, Jon Kilner is a medical writer whom I presume to be the ghost-writer\/editor for the whole STAR*D enterprise when he&#8217;s not writing science fiction. Look <a title=\"a study in pollen...\" target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2011\/04\/13\/a-study-in-pollen\/\">here<\/a> for what I could find a couple of years back:<\/p>\n<p align=\"justify\">I&#8217;ve already concluded the the STAR*D Trial was a <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2011\/04\/03\/a-thirty-five-million-dollar-misunderstanding\">$35 M misunderstanding<\/a> for countless reasons and wouldn&#8217;t have bothered with this iteration had it not been displayed so prominently. But going through it, it has the same kind of internal flaws and non-transparency as so many of its predecessors. Even if taken at face value, the changes in missed hours and subjective self-reported impairment are small. I suspect that the always-missing primary outcome variable [HDRS] and the huge drop-out and missing data rates in STAR*D resulted from the impersonal and mechanized way the study was conducted [check lists done over the phone]. Had I been a subject, I would have felt like a depersonified part of an algorithmic treatment machine. And the list of the authors&#8217; industry connections [in spite of being a NIMH Study] just adds to its industrial feel.<\/p>\n<div align=\"center\"><img decoding=\"async\" width=\"200\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/trivedi-work-4.gif\" \/><\/div>\n<p align=\"justify\">The accompanying editorial feels the same way &#8211; a pitch to Managed Care and industry in general to support the pharmaceutical industry [and its academic allies] in developing drugs to <em><strong><font color=\"#200020\">increase productivity<\/font><\/strong><\/em> in the workplace, following the <em><strong><font color=\"#200020\">future-think<\/font><\/strong><\/em> motif so prevalent in the psychiatry of the last three decades [<strong><a target=\"_blank\" href=\"http:\/\/ajp.psychiatryonline.org\/article.aspx?articleID=1694213\">Workplace Depression: Personalize, Partner, or Pay the Price<\/a><\/strong>].<\/p>\n<p align=\"center\"><a href=\"http:\/\/www.marxists.org\/subject\/art\/visual_arts\/painting\/exhibits\/muralists\/detroit_industry_north.jpg\" target=\"_blank\"><img loading=\"lazy\" decoding=\"async\" width=\"520\" height=\"364\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/trivedi-work-5.gif\" \/><\/a><\/p>\n<div align=\"justify\">So I&#8217;m going with cover art of Diego Rivera. He may have said <em>&quot;that &#8216;Henry Ford [is] a true poet and artist, one of the  greatest in  the world&#8217; and proclaimed that Detroit embodied the best  expression of  American art&mdash;the factory&quot;<\/em> but I expect his tongue was firmly planted in his cheek. The audience saw <em>op<\/em>pression and the anticommunist backlash prompted <a target=\"_blank\" href=\"http:\/\/upload.wikimedia.org\/wikipedia\/commons\/f\/fa\/Diego_Rivera_Mural_Sign.jpg\">this sign<\/a> to be prominently displayed at the entrance to the Museum that housed the Mural:<\/div>\n<ul>\n<div align=\"justify\"><sup><strong>&quot;Rivera&#8217;s politics and his publicity seeking are detestable. But  let&#8217;s get the record straight on what he did here. He came from Mexico  to Detroit, thought our mass production industries and our technology  wonderful and very exciting, painted them as one of the great  achievements of the twentieth century. This came after the debunking  twenties when our artists and writers found nothing worthwhile in  America and worst of all in America was the Middle West. Rivera saw and painted the significance of Detroit as a world city.  If we are proud of this city&#8217;s achievements, we should be proud of these  paintings and not lose our heads over what Rivera is doing in Mexico  today.&quot;<\/strong><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">What I see in the full Rivera Mural is buried black men handing up mineral ore [top frame] to be burned with coal to make steel [middle frame] to use in the Detroit assembly lines of the era where the workers are indistinguishable from other pieces of the machine [bottom frame]. I think that&#8217;s how I see STAR*D and the other algorithmic approaches to the treatment of mental illness [in this article and editorial in particular] &#8211; impersonal, dehumanizing, and misdirected. I&#8217;m actually surprised that the <strong><font color=\"#004400\">American Journal of Psychiatry<\/font><\/strong> published it. It&#8217;s supposed to be a journal for psychiatrists. Both the editorial and the article seem directed to another audience &#8211; the various industries involved. But that&#8217;s just my editorial opinion. Objectively, the front page for STAR*D is that the science sucks.<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Depression and bipolar illness in the workplace impair productivity and are dearly expensive, as multiple studies have documented for decades. One would assume that such reports would have fueled widespread concern and action, but they have not, despite huge potential payoffs. Workplace Depression: Personalize, Partner, or Pay the Price by John F. Greden, M.D. I [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-37119","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/37119","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=37119"}],"version-history":[{"count":66,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/37119\/revisions"}],"predecessor-version":[{"id":37185,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/37119\/revisions\/37185"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=37119"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=37119"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=37119"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}