Thursday, August 27, 2009

The Chemistry Experiment -- Placebo

Wouldn't you know.  I take a few days off before my placebo post, and wired.com scoops me with Placebos are Getting More Effective.  Drug Makers are Desperate to Know Why, by Steve Silberman 08.24.09.  Well, Steve put a lot more into his article than I intended for mine.  It makes for a fascinating read, about the history and current study of the placebo effect, beginning with its discovery during World War II, when an Army nurse lied to a soldier in pain.  They were out of morphine.  So she told him the injection of saline solution was a potent new pain killer.  And the patient's pain was relieved.  

That story is the essence of the placebo effect.  "When referring to medicines, placebo is a preparation which is pharmacologically inert but which may have a therapeutical effect based solely on the power of suggestion." -- thefreedictionary.com.  

In 1962, the Food, Drug and Cosmetic Act began to require that medications prove their safety and effectiveness against placebos.  One group takes the medication.  Another group takes a placebo, or "sugar pill."  Their rates of improvement and side effects are then compared, to find out whether the medication itself causes the healing, or something else does, like the belief  in the medication, which marshals the body's own healing powers.  

Fast forward to the last decade, when more and more antidepressants have "failed trials," meaning that they perform no better, or not much better than the little sugar pills.  It seems that the new neurological medications are performing just as well as the old ones.  (I think this usually means that within 8-12 weeks, about 30% of people who take them improve their scores on various questionnaires that measure levels of depression.)  But oddly, over time, the placebos are performing better.  Which means the bar that the new meds have to cross to get approved is getting higher.

This is a problem for pharmaceutical companies, who have made a lot of money over a lot of years on neurological medications whose patents keep expiring, at which point the pharmaceutical companies make a lot less money.  They try to get around the patent law, to keep their economic engines turning.  But there are just so many ways you can repackage Celexa/Lexapro and Effexor/EffexorXR/Pristiq, and then you have to come up with a new idea.  And since Prozac seemed to work so well and made so much money, the pharmaceutical companies have been tinkering with the same old idea, not coming up with any new ones, ever since. This is such a problem that the pharmaceutical companies, who are usually very big on their trade secrets, are getting together to figure out what to do.

Why?  Why are placebos getting better?  wired.com's article explores some possible explanations.  But myself, I am taking a different tack.  See, I don't think this is a problem.  I think it is very good news, indeed.  Like I have said before, given the side effect issue, and as one who wasn't near so suicidal before I took SSRI's and SNRI's, sign me up for the placebo! 

Given the paucity of new things to try, doctors have been making do with "augmentation."  If you run out of antidepressants to try, how about adding on something else?  Now the possibilities are endless.  And as long as mood stabilizers, anticonvulsants and antipsychotics are on the table, why not add placebos to the mix?  And thus was born last week's post, in which I explored the potentially beneficial synergy between nortriptyline and Peeps.  

I intended to continue the saga this week, with other ideas about antidepressant/placebo combinations that hold promise.  But wired.com has led me in another direction.  Forget the antidepressant entirely!  Let's really expand the chemistry experiment, as in The Cure, and  try monotherapy with placebos.  Carefully chosen placebos, depending on your symptom profile, of course.

Remember, I am not a doctor, have no business suggesting that you ever question the wisdom of the FDA and your personal psychiatrist, and am simply tap dancing as fast as I can over a frozen lake in late spring.

That said, let's go at it, starting with the biggest, baddest antidepressant for the deepest, darkest depression, Effexor.  If what you need is for your psychiatrist to swing a baseball bat at the base of your skull, this is the drug for you.  Taper off slowly, because if you have been taking it, you are addicted to it.  Replace it with the biggest baddest basesball bat of another age, Baby Ruth!

Got the idea?  Okay, moving on to Effexor's clone in a velvet glove, Pristiq.  I am vastly amused at the cojones of a pharm company (Wyeth) that would tinker with a medication so little and change its marketing profile so drastically that it seems like a sex change operation.  Replace Pristiq with Godiva.

Now let's give some space to the bipolar spectrum.  Lithium, anyone?  On the left is the formula for lithium citrate.  I think it looks kinda cute.  Monotherapy just isn't going to cut it in the bipolar spectrum, but you can still stay with the same company, pairing Almond Joy with Mounds. Isn't it obvious?  The embedding code is disabled, so I have to simply give you the link to youtube.  Thanks to Helen for finding this for us.

A few years ago, Helen brought home a cd from the hospital.  It said "Zoloft (sertraline HCl)."  I thought, "Cool.  Here is some information about my options."  Nope.  It was music, Vivaldi's Four Seasons -- Summer, Winter, Spring and Fall. On the back it listed Zoloft's four indications: 

  • Major Depressive Disorder 
  • Post Traumatic Stress Disorder 
  • Panic Disorder 
  • Obsessive Compulisve Disorder    

 
I swear to God, instead of the bullet points, there were musical notes. Evidently, Pfizer finds merit in the seasonal theme.  I figure, with M&M's, you have your options.  You can either choose the season that corresponds with your primary diagnosis.  Or you can keep changing the med to suit the season.  Red and green for winter, pastels for spring, red, white and blue for summer.  In the fall, you can even match your medication to your school's colors! -- black and gold for the Hawkeyes.

Now what about those of you who would be taking Abilify, if you choose not to follow the Placebo Program?  The med that passed its exam because it had a friend who did the ghostwriting, spinning the data so hard that some of it disappeared entirely, and barely passed at that.  Salted Nut Roll.  Enough said.

So what are your ideas for your own meds?  Do you think we could really start a revolution in treating neurological disorders? 

Remember, the Placebo Program is not for everybody.  Talk to your physician about what might work best for you.  Weigh your risks and benefits.  The Placebo Program is contraindicated for those with certain food allergies and/or pancreatic issues.  The good news is that I do not have to be a speed talker to get through the list of side effects in the length of an Abilify commercial.  The primary side effect is weight gain, particularly at higher dosage levels.  But as the man from Lilly says about Zyprexa, "Would you rather have a patient who is happy and fat, or skinny and miserable?" 

Sugar cube photo by Uwe Hermann, licensed under the Creative Commons Sharealike 3.0 License.  Pristiq photo by Tom Varco.  M&M's by Broken Sphere/Wikimedia Commons.  All others in public domain.  Anyone want to send me a picture of a Mounds bar?

2 comments:

  1. This post is too funny! I too think the "placebo effect" is worth cultivating! Since I also enjoy ruminating my mind seems to come up with thoughts very similar to those you articulate in this blog.

    Oh for the day when we see ads from Godiva Chocolates "Is your anti depressant not treating all of your depressive symptoms? Then try our new Godiva anti depressant adjunct! This new chocolate delight comes in three flavors to best assuage your feelings of worthlessness and guilt. Try some today!"

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  2. That is rich! Get it? Nudge, nudge, rich?

    ReplyDelete