Friday, February 11, 2011

Health Policy of Sleep

Pharma/Research/Medicine Industrial Complex

A psychiatrist friend directed me to PharmedOut.org, a  source for all things seedy in medical research, medical education, and the sale of pharmaceuticals.  I don't need to repeat what you already know about ghost writing research articles, how pharma gets around restrictions on bribes by paying doctors to "teach," the sample scam, etc.  I am not spending time this week on what I didn't know until now about the editorial/advertising relationship in medical journals, or that the drug companies are the major subscribers to these journals and give them to doctors, and are the major purchaser of reprints (at inflated prices) to be distributed by drug reps to doctors.  But it is more of the same.  Just thought I'd mention it.

We go round and round about this.  Still, every research article ends with a cry for more funding, which will come from just one source.  Every doctor gets everything he/she knows about medications ultimately from just one source.  Every friend and family member who wants to help repeats the message taught by one source -- Keep trying.  Translation: keep buying drugs.

Addicted To Big Pharma

Bottom line, every part of the mental health industry is an addict.  Everybody in the system is a pusher.  Most patients are not even lab rats, because that would suggest somebody is learning from results.  No, we are simply little mice caught in a big machine.  This trifecta of pharma/research/clinical practice is crushing us with barely effective or ineffective and often toxic treatments.

Okay, how much time and ink are we going to spend wailing and railing?

One way to get out of vicious vortex thinking is to bring in another perspective.

Enter The Gorilla

So I open my mailbox.  There is the winter issue of Blue, Wellmark Blue Cross Blue Shield's customer journal.  First article inside, page 4, Are Antidepressants The Answer?

Blue usually supplies information for healthier lifestyles, extolling exercise, weight loss, sleep, stress reduction strategies, all that stuff you know very well.  But here was something new.

Because medications help us address so many health conditions, it is easy to assume that popping a pill will fight depression.  In some cases, it does.  However, the side effects of antidepressants, such as weight gain, loss of sexual desire, insomnia and increased suicide risk, can add to an individual's struggles.

This article will not be published in JAMA's next edition.

If any research scientist said such a thing, he/she would be compared to a blogger.

The content has, in fact, found its way into many a blog.  The news is that an 800 pound gorilla has entered the room.

At this point, we may practice the reflex we learned in our doctor's office -- that 800 pound gorilla has one aim, to deny coverage.

Follow The Money

Or we could do something new.  No illusions here.  The insurance companies' interests and patients' interests do not coincide.  But neither do those of the pharmaceutical companies and us.  So let's just follow the money.

Wellmark of Iowa reports that The number of Americans taking antidepressants has doubled in a decade, from 13.3 million in 1996 to 27 million in 2005... the number of Wellmark members using antidepressants increases by an average of six to eight percent each month.

Lilly and Pfizer might cite the same statistic in a shareholder's report.  It's great news for them.

Wellmark is not so sure it's great news for you and me.  Insurance companies have been paying the bulk of the astronomical cost of these medications.  In turn, these costs are passed on to you, the consumer, in the form of higher premiums.

Premiums.  Follow the money.  Premiums.

Blue Cross Blue Shield Already Got Theirs

The insurance companies get paid upfront.  Their interest is to control costs.  They have no interest in increasing numbers of people with mental illness, no interest in creating new diseases to be treated with the latest medication (nor the old one that needs a new market), no interest in getting you to keep trying.  Regarding those of us who have a mental illness, they want to control costs.  They would just as soon we got better.

The pharmaceutical companies don't get paid unless we are sick.

Again, no illusions.  The insurance companies' interest is not our health.  They just don't want us to use services that cost them money.  So they keep sending out magazines that tell us how to eat right, exercise, reduce stress and get a good night's sleep.  If we did that stuff, we wouldn't be so sick.  We wouldn't go to the doctor.  They wouldn't pay out so much to the pharmaceutical companies.

Not the same as our interest, but we can find some common ground.

Healthy Habits -- Good Luck With That Message

The problem for Wellmark, et al is that they have sent us the same material for years.  Yet we are more overweight, less active, more stressed and sleep less than ever.  Their message is not getting through.

So now they have a new approach -- tell us that if we take antidepressants, we will lose our sex lives and might become suicidal.

Frankly, that won't work either.  We are still the mice caught in the rock crushing trifecta of pharma/research/clinical practice.  We could be grown-ups, of course.  But people who do not have a mental illness are not grown-up about health practices.  So get real.

It's The Economy, Stupid

The mice cannot do the heavy lifting here.  King Kong, on the other hand, can be a game changer.  It sure got its way in health care reform.  It needs to step into the fray against the coercive sales pitch we face whenever we try to get help.

The structure of the economy has changed our sleep patterns.  Here is their opportunity.  The insurance industry can address its bottom line by influencing customers' sleep patterns through the economy -- much more effective than these quarterly magazines that customers get in the mail.

This is what I mean:

Poor Sleep Hygiene Surcharge

As Prozac Monologues reported last week, sleep (the lack thereof) and suicidality are intimately connected.  Suicidality is often the the symptom that trips the trigger and gets people to the doc to deal with their depression (which is a good thing, getting yourself to the doc if you start thinking about knives.)  What if health insurance companies charged a poor sleep hygiene surcharge to companies that regularly require workers to put in more than fifty hours a week, or stay connected in "off hours," or change shifts, disrupting workers' circadian rhythms?

Hospitals could be at the top of the hit list, especially those with residency programs.  Did you know that surgery residents in the US often put in 100 hour work weeks?  That lack of sleep and suicidality are clearly linked in a variety of studies?  That doctors, especially young ones have one of the highest suicide rates among professions?  Can you connect the dots?

The poor sleep hygiene practices built into residency programs have ripple down effects.  Just as doctors who smoke don't do good patient education on the health risks of smoking, doctors who don't sleep are not going to do good sleep hygiene education.

These studies have not changed medical education practices or hospital administration.  But I'll bet a poor sleep hygiene surcharge would get action. 

School Is Bad For Teenagers' Health

There are 3,756,000 elementary through high school teachers in the US, a huge cohort of health insurance purchasers.  Education as an industry works close to the bone financially.  And health insurance premiums are a major portion of education budgets.  The insurance industry, which really names its own price, is uniquely placed to pressure schools and school systems to apply research findings about sleep to their schedules.

If high schools shifted their hours, starting one hour later, they could improve their students' sleep, decrease student suicidality, and roll back this exponential growth in numbers diagnosed with depression and treated with antidepressants.  This move would be akin to anti-smoking efforts directed at teenagers, preventing them from developing illnesses that will be with them, and costing health insurance companies for their lifetime.

This skirmish, by the way, could be a warm-up for the battle with Coke, Pepsi and Frito Lay over vending machines in schools.  Michelle Obama will not win this battle on her own.  Improved eating habits would push back against the epidemic of obesity, again yielding life-long savings for health insurance companies, and decreasing depression at the same time.  See Sleep -- The Real Antidepressant on the way that obesity works its way through the DSM criteria for depression.

Incentives For Better Sleep Hygiene

The big money is with the stick approach.  But here is a carrot.

Offer college students a rebate on their student health fees if they live in a dormitory, fraternity or sorority house with a noise curfew.  Oo oo, here is one better:  Offer ITunes credits and a **$$CHANCE TO WIN$$** an IPod and, for one lucky student in the Big Ten or whatever, **$$SPRING BREAK SOMEWHERE WARM$$**

I am not going to do their work for them.  The insurance companies can pay for more ideas.  The essential point: Health insurance companies can become game-changers in the overuse of noneffective antidepressants by throwing their weight around where it could really make a difference -- society's structures that discourage healthy habits.

One More Time -- The High Cost Of Insomnia

Here is one more research study providing economic incentive for health insurance companies to do something effective about sleep issues.  A study at the Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA found:

Current insomnia was associated with significantly greater functional impairment.., more days of disability due to health problems, and greater general medical service utilization.  While insomnia was associated with depressive disorder and chronic medical illness, adjustment for these factors only partially accounted for the association of insomnia with disability and with health care utilization.  Of the patients with current insomnia, 28% received any psychotropic drug, 14% received benzodiazepines and 19% received antidepressants.

Utilization is King Kong's word.  Income - costs = profits.  For insurance companies that translates to  premiums - utilization = profits.  Decrease utilization by decreasing insomnia, they increase profits.  And note -- better sleep results in lower utilization, even for those who do not have a mental illness.  Follow the money. 

Sleep Hygiene -- Do It Yourself Version

Meanwhile, I'm not holding my breath.  I want to sleep tonight.  Now that I kept trying antidepressants all the way to disabled, my job no longer requires long and irregular hours with fast food to keep me awake while I drive the interstate after antidepressant-induced insomnia.  My job is to manage my symptoms.

Maybe you are already with me.  Maybe you would just as soon not join me.  You think getting mental health care reimbursement is difficult?  Try SSDI.  It takes a team of lawyers and a very long time to get those benefits you have been paying for all your working life.  And once you get them, disability still sucks.

There's a lot working against you.  But it is worth your while to find a way out of that mouse crushing machine.

The University of Maryland Medical Center has a long list of things you can do to address your sleep difficulties.  They start with circadian rhythms (keeping a regular schedule), work through diet, take a short cut through medications, and keep going -- Chinese medicine, homeopathy, foot massage with lavender oil...  There's something there for everybody.

That circadian rhythms thing will find its way into another post soon.

For now, good luck and sweet dreams.



Godzilla poster from Toho Company Ltd 1954 is in the public domain
King Kong poster in public domain
photo of rock crusher gears by Les Chatfield and used under the Creative Commons Attribution 2.0 Generic license
photo of Big Mac by kici and in the public domain
Caduceus drawing by Rama and in public domain
flair from facebook
photo of vending machine by Nenyedi and released to the public domain
The Dream by A Cortina (1841-1890) 

3 comments:

  1. The pharma/research/clinical practice connection is disturbing, and has corrupted medical practice in America. I left the "mouse crashing machine" in 2006, and have never looked back. I use a variety of techniques to manage Bipolar II symptoms. It has not made me non-bipolar BUT I am as stable as my counterparts who take psychotropic drugs, with the caveat that I don't have those nasty drug side effects. Thanks for writing such an insightful, humorous and well researched blog. I look forward to each installment.

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  2. Willa, I just wanted to thank you for the very solid advice you offered to my comment on John's blog yesterday.

    I went without my husband, as he could not get away from the office. But next time I shall bring him along.

    My doctor did a complete medication switch for me, and I am a bit uncertain as to whether the protocol is too quick.... but I am going to give it a chance. Meditation is proving to be a helpful adjunct in my recovery this time. It's possible will help me in assessing the appropriateness of my medication changes...

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  3. Smitty, I am go glad for this news. Thanks for letting me know. A real partnership with your pdoc is so important. And I am glad to read that he/she was responsive to your concerns. It seems that each of you did your part in this problem-solving.

    And yes, meditation probably will help. Repeating one of John's themes -- All that other self-help stuff is essential. Our medication would work better if we didn't ask it to carry the whole load. Sort of like spouses...

    Best of luck.

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