{"id":39358,"date":"2013-08-22T12:24:17","date_gmt":"2013-08-22T16:24:17","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=39358"},"modified":"2013-08-24T14:58:23","modified_gmt":"2013-08-24T18:58:23","slug":"if-and-only-if","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/08\/22\/if-and-only-if\/","title":{"rendered":"if [and only if]&#8230;"},"content":{"rendered":"\n<ul>\n<div align=\"justify\"><em>There&#8217;s more than one answer to these questions,<\/em><\/div>\n<div align=\"justify\"><em>Pointing me in a crooked line&#8230;<\/em><\/div>\n<div><sup>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<a href=\"http:\/\/www.youtube.com\/watch?v=DQJAbyLjXtE\" target=\"_blank\">Closer to Fine<\/a>, Indigo Girls 1989<\/sup><\/div>\n<\/ul>\n<p>                                  <\/p>\n<blockquote>\n<div align=\"center\" class=\"big\"><a target=\"_blank\" href=\"http:\/\/www.nytimes.com\/2013\/08\/20\/health\/a-dry-pipeline-for-psychiatric-drugs.html?_r=0\">A Dry Pipeline for Psychiatric Drugs<\/a><\/div>\n<div align=\"center\" class=\"big\"><strong><font color=\"#200020\">New York Times<\/font><\/strong><\/div>\n<div align=\"center\" class=\"middle\"><strong><font color=\"#200020\">Perspective <\/font><\/strong>                    <\/div>\n<div align=\"center\" class=\"small\">By  RICHARD A. FRIEDMAN, M.D.<\/div>\n<div align=\"center\" class=\"small\">August 19, 2013<\/div>\n<p align=\"justify\"> Fully 1 in 5 Americans take at least one psychiatric medication. Yet when it comes to <span class=\"meta-classifier\">mental health<\/span>, we are facing a crisis in drug innovation. Sure, we have many <span class=\"meta-classifier\">antidepressants<\/span>, antipsychotics, hypnotic medications and the like. But their popularity masks two serious problems. First, each of these drug classes is filled with &ldquo;me too&rdquo; drugs, which  are essentially just copies of one another; we have six S.S.R.I.  antidepressants that essentially do the same thing, and likewise for the  10 new atypical antipsychotic drugs. Second, the available drugs leave a lot to be desired: patients with illnesses like <span class=\"meta-classifier\">schizophrenia<\/span>, <span class=\"meta-classifier\">major depression<\/span> and <span class=\"meta-classifier\">bipolar disorder<\/span> often fail to respond adequately to these medications or cannot tolerate their side effects. Yet even though 25 percent of Americans suffer from a diagnosable mental illness in any year, there are few signs of innovation from the major drug makers.        <\/p>\n<p align=\"justify\"> After a series of failed clinical trials in which novel antidepressants  and antipsychotics did little or no better than placebos, the companies  seem to have concluded that developing new psychiatric drugs is too  risky and too expensive. This trend was obvious at the 2011 meeting of  the American Society for Clinical Pharmacology and Therapeutics, where  only 13 of 300 abstracts related to psychopharmacology and none related  to novel drugs. Instead, they are spending most of their research  dollars on illnesses like cancer, heart disease and diabetes, which have well-defined biological markers and are easier to study than mental disorders. To understand this predicament, it helps to know how we got here.        <\/p>\n<div align=\"justify\">All of our current antidepressants, antipsychotics and anti-anxiety  drugs share the same molecular targets in the brain as their prototypes  from the 1950s. For example, the new antipsychotic drugs block dopamine  receptors in critical brain regions, just like the first antipsychotic,  Thorazine, synthesized in 1950. And all of our current antidepressants  increase the levels of one or more of the neurotransmitters serotonin,  dopamine or norepinephrine, just like the early tricyclic  antidepressants. With rare exceptions, it is hard to think of a single truly novel  psychotropic drug that has emerged in the last 30 years. True, the new  psychotropic drugs are generally safer and more tolerable than older  prototypes, but they are no more effective. <strong><font color=\"#800000\">So why has the  pharmaceutical industry churned out so many copycat drugs?<\/font><\/strong> The simple answer is that we don&rsquo;t yet understand the fundamental cause  of most psychiatric disorders, in part because the brain is uniquely  difficult to study; you can&rsquo;t just biopsy the brain and analyze it. That is why scientists have had great trouble identifying new targets for psychiatric drugs.<\/div>\n<\/blockquote>\n<div align=\"justify\">Reading the highlighted question, I thought of the line from that song up there. Some other answers to <em>these questions<\/em>? because they work for some; because doctors prescribed them; because patients kept taking them; because they were incredibly profitable; because hope springs eternal. And it&#8217;s almost impossible to think about the answer to these questions without blaming somebody [else]. We&#8217;ve all done our share of that, myself included. And to be accurate, <a href=\"http:\/\/www.allspirit.co.uk\/fine.html\" target=\"_blank\">the song<\/a> is actually about the singer&#8217;s journey and her therapy:<\/div>\n<div align=\"justify\">\n<ul>\n<div align=\"justify\" class=\"small\">I&#8217;m trying to tell you something about my life<br \/>       maybe give me insight between black and white<br \/>       and the best thing you&#8217;ve ever done for me<br \/>       is to help me take my life less seriously<br \/>        it&#8217;s only life after all<\/div>\n<div align=\"justify\" class=\"small\">well darkness has a hunger that&#8217;s insatiable<br \/>       and lightness has a call that&#8217;s hard to hear<br \/>       I wrap my fear around me like a blanket<br \/>       I sailed my ship of safety till I sank it<br \/>       I&#8217;m crawling on your shores<\/div>\n<ol>\n<div align=\"justify\" class=\"small\">I went to the doctor,<br \/>       I went to the mountains<br \/>       I looked to the children,<br \/>       I drank from the fountains<\/div>\n<\/ol>\n<div align=\"justify\" class=\"small\">there&#8217;s more than one answer to these questions<br \/>        pointing me in a crooked line<br \/>        and the less I seek my source for some definitive<br \/>        the closer I am to fine&#8230;<\/div>\n<\/ul>\n<div align=\"justify\">Sometimes our poets in frayed jeans hit the bulls-eye. But that&#8217;s not why I picked the song or flagged this article:<\/div>\n<blockquote>\n<div align=\"justify\"> Also, knowing how a drug works in the brain doesn&rsquo;t necessarily reveal  the cause of the illness. For example, just because an S.S.R.I.  antidepressant increases serotonin in the brain and improves mood, that  does not mean that serotonin deficiency is the cause of the disease;  many depressed patients get better with medications that have no effect  on serotonin. Until very recently, scientists have relied on the same animal models to  screen for potential psychotropic drugs that had been used for decades,  which predictably yielded a raft of &ldquo;me too&rdquo; medications that shared  the same mode of action as the old drugs. Sure, this old method of drug development has produced commercially  successful blockbuster drugs, like the antipsychotics Seroquel and  Abilify. <strong><font color=\"#800000\">But soon the patents on these medicines will expire, and there  is little new in the pipeline<\/font><\/strong>&#8230;<\/div>\n<\/blockquote>\n<div>I flagged the article because of that sentence in <strong><font color=\"#800000\">red<\/font><\/strong>. What in the hell does the patent life of the drugs have to do with anything that really matters? We all know it has had a huge impact on psycho<strong>&middot;<\/strong>economics and pharmaco<strong>&middot;<\/strong>economics, but what in the hell does it have to do with patient care? [&quot;nothing&quot; is the answer I&#8217;m looking for here]. It doesn&#8217;t even have anything to do with Dr. Friedman&#8217;s sentence. The sentence &quot;<strong><font color=\"#800000\">there  is little new in the pipeline<\/font><\/strong>&quot; would&#8217;ve sufficed on its own. I think its inclusion says something about Dr. Friedman&#8217;s perspective that he even sees the expiring of patents as relevant to his point. He&#8217;s in a PHARMA frame of mind.<\/div>\n<p>And as long as I&#8217;m on the topic of that sentence, the metaphor of <strong><font color=\"#800000\">the pipeline<\/font><\/strong> has outlived its symbology [and its usefulness, in my humble opinion]. It&#8217;s a pharmaceutical industry buzz-word used to catalog the drugs they have in development to replace the ones they lose exclusive rights on due to expiring patents. Maybe it&#8217;s useful to them as a way to conceptualize their business plans, but it has taken on a different meaning as the pundits talk about psychiatric drugs. I never even heard the term, <strong><font color=\"#800000\">the pipeline<\/font><\/strong>, until a few years ago when people started talking about it going <strong><font color=\"#800000\">empty<\/font><\/strong>. I said <em>talking<\/em>, but maybe I should have said <em>wailing<\/em> &#8211; maybe thrown in something like <em>with great gnashing of teeth<\/em>. They talked [and still talk] like <strong><font color=\"#800000\">the pipeline<\/font><\/strong> is [or should be] something real, like there are un-found drugs that will be better [stronger, more efficacious, less toxic, more specific, etc.] than the ones we have now [and we need to get cracking to find them]. Well,  <strong><font color=\"#800000\">the pipeline <\/font><\/strong>isn&#8217;t a real thing. We don&#8217;t know if there are these hypothesized drugs up ahead. The majority of the people now taking them don&#8217;t have the <em>probably biological<\/em> mental illnesses the drugs were developed for [Schizophrenia, Manic Depressive Illness, Melancholia, etc.]. They have other kinds of problems with emotional symptoms. Actually, Dr. Friedmans&#8217; article raises the question, &quot;<strong><font color=\"#200020\">Was there ever a pipeline in the first place?<\/font><\/strong>&quot; [<em>&quot;With rare exceptions, it is hard to think of a single truly novel  psychotropic drug that has emerged in the last 30 years.&quot;<\/em>]. Probably not.<\/p>\n<p>And the reason I picked that song\/poem is obvious. There really are <em><strong><font color=\"#200020\">more than one answers to these questions<\/font><\/strong><\/em> on the way to&nbsp; <em><strong><font color=\"#200020\">closer I am to fine<\/font><\/strong><\/em>. Dr. Friedman&#8217;s article goes on to talk about ketamine, and brings up that academic researchers are less bound by commercial interests, can be more creative, think out of the box, maybe make some <em>novel<\/em> discoveries. He ends with: <\/p>\n<blockquote>\n<div align=\"justify\">&#8230;These discoveries, in turn, may  entice the drug makers to reinvest in psychiatric drug development. As consumers desire new treatments, they have to recognize that  innovation carries risks. Drugs are approved by the Food and Drug  Administration on the basis of short-term studies, so there is always  limited knowledge about the long-term safety of new medications. This is  particularly true for drugs that act on new targets in the brain about  which relatively less is known. But if we are to find better medical solutions for the mental illnesses  that disrupt and destroy so many lives, we need to acknowledge a simple  truth: there can be no innovation without financial &mdash; and medical &mdash;  risk.        <\/div>\n<\/blockquote>\n<div align=\"justify\">As I read this, he&#8217;s admonishing doctors and patients [AKA consumers] that they may have to tolerate more risk to get what they want. The glaring point he doesn&#8217;t address is that we may or may not know that already, but what we&#8217;re complaining about is that <strong><font color=\"#200020\">we already had to deal with more risk than we <u>knew<\/u> about!<\/font><\/strong> Maybe some are complaining about the efficacy and the toxicity of the drugs. I&#8217;m not. The drugs are what they are. It&#8217;s just chemistry. <strong><font color=\"#200020\">My complaint is that their efficacy was misreported &#8211; falsely inflated &#8211; and that the toxicity was misreported &#8211; hidden &#8211; and they knew it at the time.<\/font><\/strong> Doctors and patients are perfectly capable of making the kinds of decisions Dr. Friedman is talking about, if [and only if] they know the truth about the drugs presented to them&#8230;   <\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>There&#8217;s more than one answer to these questions, Pointing me in a crooked line&#8230; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Closer to Fine, Indigo Girls 1989 A Dry Pipeline for Psychiatric Drugs New York Times Perspective By RICHARD A. FRIEDMAN, M.D. August 19, 2013 Fully 1 in 5 Americans take at least one psychiatric medication. Yet when it comes to mental [&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_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-39358","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39358","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=39358"}],"version-history":[{"count":31,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39358\/revisions"}],"predecessor-version":[{"id":39448,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39358\/revisions\/39448"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=39358"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=39358"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=39358"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}