Thursday, February 25, 2010

DSM V and Mood Disorders, Part II -- How Did We Get Here?

 
Lost Creek Wilderness

Starting point -- Okay, the only way we get anywhere is if we understand very clearly who owns this map.  The pharmaceutical companies do.  It's their map.  Get over it.  This knowledge will help us steer a course, or maybe give them a nudge, or at least anticipate where they are taking us.

For the longest time, depression got no respect.  When they started using medication for schizophrenia, depression was still lost in the la-la-land of Freud's neurosis.  You could either talk it out over years on the couch, or you could snap out of it.   Medical advances in the treatment of depression came about by accident.

So back in the 1950's, Smith Kline and French (today GlaxoSmithKline) were making a killing on thorazine, the first med to treat schizophrenia.  It worked, but thorazine has so many side effects they list them alphabetically.  Other drug companies wanted a piece of the action.  Seeking to improve the side effect profile, they came up with the first tricyclics.  Tricyclics (Elavil, et al.) were a bust, as far as psychosis goes.  But they had an interesting new side effect -- mania.  Happy psychotics.  

Same time frame, different illness, MAOIs were developed to treat tuberculosis.  Again, not so effective against tuberculosis.  But suddenly sullen patients were skipping down the hallways and creating "discipline problems." Happy coughers.

Mile Marker #1 -- We have a whole new market for psychotropic medications -- depression.

These accidental discoveries drove research into the neurological mechanisms of depression, posing not the question, "What causes depression," but rather, "How come antidepressants work?"  Well, one of the consequences of taking these medications is an increase in the presence of neurotransmitters, serotonin et. al.

Mile marker #2 -- We have a simple, catchy sales pitch.  Depression isn't a rich lady's neurosis, after all.  It's a "chemical imbalance in the brain" -- just as diabetes is an imbalance of insulin.  Well, that's not an issue of character, as depression was thought to be.  (And still is, you will find out if you don't get better.)  It can happen to anybody.  And it can be fixed, too.  Take a pill, just as diabetics take insulin, and you fix the imbalance.

At this point, the neurotransmitter hypothesis takes us deep into our map.  Prozac and other SSRIs (Celexa, Zoloft...) were developed by tinkering with the basic concept behind tricyclics, again as attempts to improve market share by improving the side effect profile.  But SSRIs didn't really work as well as the sales pitch did.  The market share threatened to drop as "treatment refractory" patients ran out of new meds to try.  Meanwhile, pharmaceutical companies were running out of patent protections.  Along came SNRIs (Cymbalta, Effexor...), more tinkering.

By now marketing drove/drives the research.  The pharmaceutical companies were not interested in figuring out what is happening inside the depressed brain -- they thought they already knew.  Instead, they funded research into a jillion examinations of the same "chemical imbalance" and what their own medications do for it.

Mile Marker #3 -- The pharmaceutical companies, with their already developed products to market, take over research departments of universities and medical schools.  Research departments fund their way having their top scientists sign on to reports that they have not written.  A scientist will sign more reports than he or she has time to read, much less write.  The practice is called "guest authorship."  (In other academic departments, this is called "plagarism.")  Often the pharmaceutical companies contract out the writing or do it themselves, called "ghost authorship."  They write slightly altered reports of the same clinical studies, and flood the medical journals, who publish the seemingly different reports, neglecting their own publishing standards that call for disclosure of these practices and conflicts of interest.  

No, really. The ethics of medical journal publishing has become so problematic that the AMA (American Medical Association) convened a special forum five months ago to examine the issue.  The results of study after study on various practices in authorship and publishing demonstrate that this problem has not improved since it was raised in the mid-1990's and standards were developed.

What are the prospects for improvement in publishing?  I find particularly amusing/astounding/discouraging the report on Background, Training, and Familiarity With Ethical Standards of Editors of Major Medical Journals. "Although 86% of respondents were “confident” or “very confident” in their knowledge of scientific publication ethics when they began the survey, this number dropped to 71% by the end."  Indeed.  Because: "Performance on the editorial scenarios was poor; correct answers were given by 18% to the question on plagiarism, 30% to authorship, 15% to conflicts of interest, and 16% to peer review."

These are failing grades received by the editors of medical journals.  These are the people who decide which studies get published, what information is available to my doctor and yours.  Why does this matter?  Because reading journals is how my doctor and yours keep up to date, their continuing education after medical school.

So the science has gotten pretty bad.

And in the field of mental health, the pharmaceutical companies own it.  There is one sales representative for every five doctors.  This is the United States of America.

(You get better science, and different results, if you read the journals from Europe.)

Okay, getting us into this map has made for a long enough blog post.  Next week -- Mile Marker #4, and onward.

map of Lost Creek Wilderness made by David Benbennick
in public domain

2 comments:

  1. Hey, Willa. Can't wait till next week. I want my Mile Marker #4 NOW! :)

    PS: How come all the jerks are daily bloggers?

    ReplyDelete
  2. I don't know about jerks -- I just assume your meds work better than mine!

    ReplyDelete