Should pharmaceutical advertising be banned?

In many countries, direct to consumer advertising (DTCA) of prescription drugs is either prohibited or tightly restricted.  The United States is a notable exception, along with New Zealand.  For tv ads, the standard pattern is to talk about the illness, talk about the amazing benefits of the drug, and then provide the required long list of side effects in an upbeat tone of voice while cheerful music plays and people are shown happily living their wonderful lives.  The ad closes with something along the lines of “ask you doctor if _____ is right for you”.  If you haven’t seen one of these ads before, there are a couple of examples at the end of this post.

Drug company marketing to health care providers is a related but distinct issue that’s deserving of its own post, so I’ll set it aside for the sake of this post and focus solely on issues around DTCA.

Wikipedia cites a study that reported expenditures in the U.S. grew from $1.1 billion in 1997 to $4.2 billion in 2005.  In the last ten years, four major pharmaceutical companies have reached settlements of greater than $1 billion with the U.S. Food and Drug Administration (FDA) over allegations of illegal marketing.  Psychiatric medications were among the drugs involved in all of these settlements.  Prescription drug ads do not need to be pre-screened by the FDA before they can be printed or broadcast, so even if an ad is later found to be in violation of the laws, it will have already been seen by large numbers of consumers.

In Canada there’s a loophole of sorts that allows marketing of drugs as long as there’s no mention of what medical condition the drug is used for.  In 2006 the independent Health Council of Canada published a report looking at at the public health implications associated with direct to consumer advertising of prescription drugs.  They recommended closing this loophole and prohibiting all DTCA of prescription drugs.

What are the potential benefits?

Clearly the winner here is the drug companies themselves.  But what are the supposed benefits to consumers from this kind of advertising?  According to the Health Council of Canada report, some of the benefits that are claimed are consumer education, increased autonomy in health care decision making, earlier diagnosis of illnesses, and increased medication compliance.

Public service announcements may be educational, but commercial advertisements are not.  Whether its drugs or laundry detergent, the purpose is to sell a product.  Any information that is gained through commercial advertising is only to support the primary sales purpose and will likely heavily biased.

In terms of autonomy, I’m not sure that going to the doctor and requesting drug X truly represents autonomous decision making.  In fact, if patients are forming spurious judgments about the state of their health and the treatment they need, they lose the true autonomy that comes from getting a well-reason diagnosis and being presented with appropriate treatment options in a way that allows them to make informed decisions.

As for earlier diagnosis, this brings to mind issues with misleading Paxil advertising that essentially claimed that everyone (and probably their dog too) had social anxiety disorder and needed to be medicated.  Social anxiety is a very real and potentially debilitating condition, but the makers of Paxil were casting a much wider net than that.  People who are unwell will make their own decisions about whether or not to seek medical help, but there’s no need for the masses to go rushing to their doctor asking for drugs because pharmaceutical marketing campaigns told them they were most likely sick.

I fail to see how compliance could be improved, unless the line of thinking goes that if a patient asks their doctor for drug X (whether they need it or not), they’re more likely to take drug X?  Or does seeing a Pristiq ad on tv remind someone that they forgot to take their medication that morning?  It all seems like a rather flimsy argument.

What are the potential harms?

According to studies cited in the Health Council of Canada report, direct-to-consumer advertising influences both patient demand and physician prescribing.  A study of general practitioners in New Zealand found that almost 70% felt pressured by their patients to prescribe medications.  A study conducted in the U.S. and Canada found that when patients went into an appointment requesting a drug, they were 17 times more likely to be prescribed a drug by the end of that appointment.

Pharmaceutical ads that claim Drug X is wonderful for condition Y are targeting consumers who likely don’t have the medical knowledge base to determine whether Drug X is in any way appropriate for them, and may have no idea if they actually have condition Y or not.  If they go to their doctor requesting Drug X, a prescriber may order Drug X rather than the more appropriate Drug Z in order to appease the patient, or they may try to appease the patient by giving them Drug X even though they don’t actually meet the full diagnostic criteria for condition Y.  While this may seem like poor practice on the part of physicians, it’s certainly not unheard of.  As an example, overprescribing of antibiotics is driven in part by patients who are going in to see their doctor and demanding antibiotics even though they most likely have a viral illness that antibiotics will do nothing for.  Doctors are busy enough without having to spend time trying to re-educate patients who have been misinformed by drug company ads.

 

Decisions about an individual’s medication treatment should be made by that person and their healthcare providers based on their specific health concerns.  Pharmaceutical companies should not have the opportunity to interfere in that process.  The whole reason drugs are prescription only is that medical professionals need to determine whether or not they are appropriate for a given patient.  If patients are going into their medical appointments having actually researched treatment options, that’s great, but watching a pharmaceutical ad is not research.  It’s a sales pitch.

A 2013 opinion piece in the New York Times says that “biased pill-pushing messages are a public health menace.”  I agree, and it would be nice to see regulators in the U.S. and New Zealand stand up to the powerful pharmaceutical lobby and put an end to direct to consumer advertising.  Sales tactics have no place in mental health care.

 

What are your thoughts?

 

Sample ads posted on Youtube:

 

psych meds made simple

 

My first book, Psych Meds Made Simple: How & Why They Do What They Do, is now available on Amazon as an ebook or paperback.  It’s everything you didn’t realize you wanted to know about medications!

Dead if you do, dead if you don’t? Weighing the risks & benefits of medications

I recently watched the documentary Letters From Generation Rx on Amazon Prime, which looked at instances of people experiencing significant side effects while on psychiatric medication, including people who took the lives of either themselves or others while on psychiatric meds.

One man featured in the film was a Canadian Member of Parliament whose teenage daughter had died while taking medication.  He expressed his belief that Big Pharma has made its way into “every institution in our society we rely of for critical thought”, echoing the sentiments of another interviewee who believed that coroners investigating drug-related deaths were  “the first line of defense for the industry.”

One statistic mentioned by the Member of Parliament was that adverse reactions to pharmaceuticals are the fourth leading cause of death.  I was skeptical of that, and turns out this was for good reason.  The paper where that statistic originated did some fishy extrapolation to arrive at those numbers; additionally, it looked solely at people who died while in hospital and did not consider deaths occurring in the community.

Two men were interviewed who had killed their children while taking SSRIs.  One of them had found out afterwards that because of a genetical polymorphism his body was unable to properly metabolize the Paxil that he had been taking.  He was found not criminally responsible for the deaths because of his mental state at the time (this is the Canadian equivalent of the insanity defense).  Both of the men interviewed, as well as their families, attributed the violent behaviour to the medication.  The film also suggested that mass shootings are often related to psychiatric medication.

A mother and father spoke about their teenager son coming home with a sample pack of the antidepressant Cipralex after going to see his doctor because of a cold.  Within a relatively short period of time, he ended up leaving the house while extremely restless, went to buy a rope, and then hanged himself.  While of course this is deeply tragic, something is clearly missing here; even the most incompetent physician is not going to give someone an antidepressant to treat a runny nose.

Two parents talked about their daughter, who had been diagnosed with Tourette’s, being given the antipsychotic Haldol (haloperidol), and for them that just crossed the line.  They expressed their vehement belief that no 9-year-old should ever be given Haldol.  I think it’s problematic to let statements like this slide into a documentary when these parents are entirely unqualified to be making that broad judgment, regardless of whatever side effects their daughter may have had.  Haldol is in fact approved for pediatric use for Tourette’s, and while regulators may have their shortcomings they are still in a better position to make these judgments than people with no medical training whatsoever.

Fear-mongering messages like those in this documentary may seem to be helpful in raising awareness about serious side effects, but my sense is they cause more problems than they solve.  There is tremendous stigma around psychiatric medications, which makes it more challenging for people struggling with mental illness to make decisions around treatment.  It’s more useful to present the risks in a broader context to empower people to make the best decisions for them.

With any sort of treatment, medication or otherwise, there should always be an individual weighing of risks vs benefits. What’s important to consider, especially for psychiatric conditions, is that the risk associated with not getting treatment can be very high, and suicide can become a very real possibility.

All medications carry some level of risk, and the level of risk that’s considered medically acceptable depends on the nature of the illness. With potentially deadly illnesses, the tolerable potential risk is going to be far higher than what would be considered acceptable for a minor ailment.  With higher risk medications it is incumbent upon prescribers to make sure they are properly monitoring their patients, and for patients to be proactive in reaching out to the prescriber if things are going wrong.

In 2004, the U.S. Food and Drug Administration (FDA) required a “black box” label on all SSRIs warning that they could increase the risk of suicidal thoughts and behaviour in children and adolescents.  This has not been demonstrated in studies of adults using SSRIs.  It’s also important not to confuse this with the spike in suicide risk that occurs when someone has started to respond to treatment but their mood hasn’t caught up yet, which means they may have the energy to act on suicidal thoughts that were already present.  Again, knowledge is key, and everyone involved needs to understand what to watch out for.

It’s also important to address the cozy relationship between national regulators and Big Pharma, which is described in Letters From Generation Rx.  If regulators and Pharma are engaging in any sort of coverup around the frequency of side effects, that means that inaccurate information is getting to prescribers, which impacts that ability to accurately weigh risks and benefits with their patients.

What we need most is not fear.  We need factual, unbiased information so that we can make the right decisions for ourselves, and the more openly we can all talk about it, the better.  Personally, the risks associated with taking my medications for depression are far outweighed by the very really risk of suicide if I don’t take them.  We’re all different, but that’s me.

 

psych meds made simple

 

My first book, Psych Meds Made Simple: How & Why They Do What They Do, will be available Feb 4/19 on Amazon as an ebook or paperback.  It’s everything you didn’t realize you wanted to know about medications!  Find out more on my Psych Meds Made Simple book page.

Where did our meds go?

pills spilling out of a bottle

nosheep on Pixabay

I recently saw an article on the Canadian news site cbc.ca.  It warned that there was a manufacturer’s shortage of the antidepressant bupropion, both brand name and generic.   No reason was given for the shortage, and Health Canada doesn’t require this information.  The brand name manufacturer told CBC that the shortage had been resolved and the medication would be appearing in pharmacies “imminently”.  Earlier this year, there was a Canadian shortage of Epi-Pens, the life-saving medication to treat anaphylaxis.

Canada is certainly not the only country to have drug shortages.  The blog Vision of the Night has mentioned shortages of the antidepressant clomipramine in the UK.  A 2017 article in The Lancet said that the antipsychotic haloperidol was one of the most commonly shorted medications in South Africa.  A 2017 study in the Saudi Pharmaceutical Journal found that over half of the community pharmacies surveyed had shortages of  psychiatric medications including amitriptyline, aripiprazole, bupropion, buspirone, duloxetine, haloperidol, and lithium.

Unlike Health Canada, the Food and Drug Administration (FDA) in the United States requires that manufacturers report the reasons for drug shortages.  2017 statistics from the FDA show that the reasons given were manufacturing (30%), supply/demand (8%), natural disaster (3%), raw material (2%), discontinuation (2%), and the most common reason unknown (53%).  It seems rather unlikely that more than half the time someone suddenly woke up at the factory and realized they’d stopped producing pills, and called the Ghostbusters to come investigate.

Sarcasm aside, it doesn’t seem as though the pharmaceutical industry is very motivated to address this issue.  Presumably there is a business case for this, although at first glance it would seem that the best way to make money is to actually sell the product.  While I’m not strongly anti-Pharma overall, the frequency at which drug shortages are occurring has a rather unpleasant smell to it.

Drug shortages impact health conditions across the spectrum, but I think the potential impact of psychiatric medication shortages is quite high.  Medications are often grouped into classes based on their mechanism of action, such as selective serotonin reuptake inhibitors (SSRIs).  For some classes of medication, a person can switch between drugs in the same class without much difficulty.  It’s not that simple with psychiatric meds.  Someone might respond well to one SSRI, but have poor effect and considerable side effects with another.  For some psychiatric medications, like bupropion, mirtazapine, and lithium, there are no other medications that have exactly the same mechanism of action.

Aside from hoping that our meds won’t be shorted, there’s not a lot we can do.  If you hear about a shortage, coverage issues can make it hard to follow the example of Elaine on Seinfeld in her quest to buy up every remaining Today sponge from every pharmacy in the area.  I don’t know what the answer, but I think our national health regulators need to lean on Big Pharma a little harder than they’re doing right now.

Have you ever experienced a shortage of your medication?  How did you manage?

 

My experiences of going off meds

I have never had  a problem with medications in general, and in my work as a nurse I’ve seen how much good they can do.  Despite that, I’ve gone off the meds I take for depression a few times, and that’s what this post is about.

My first episode of depression was in 2007.  I ended up hospitalized following a suicide attempt, and spent 2 months in hospital.  I continued taking my meds for a few months and I then I had another suicide attempt, this time by overdosing on my psych meds.  I didn’t do any significant damage, so I chose not to tell anybody at the time.  I decided that to hell with it, if I was on meds and still feeling shitty, what was the point of continuing meds?  Continuing on my deceptive theme, I didn’t want my treatment team to know I wasn’t taking meds, so I continued to pick them up regularly from the pharmacy.  I ended up getting into full remission without meds, and I remained well for almost 4 years.

My plan all along was that if I started to have signs of getting worse, I would restart meds.  When the depression started to hit me in 2011, I quickly recognized the red flags of poor sleep and low mood, and made an appointment to see my GP.  I had to practically beg for meds, and he begrudgingly gave me 10mg of citalopram, although his preference was that I attend group therapy.  2 weeks later I ended up in hospital.

It took a year and a half to get fully well again, and I ended up on multiple weight gain-inducing meds (lithium, quetiapine, and mirtazapine).  The weight gain was hard to adjust to, although I recognized it was probably a fair price to pay for being well.  After 2 years in full remission, I decided I wanted to try going off the quetiapine, and my psychiatrist was agreeable.  We tapered down the dose gradually, and at first it seemed like I was going ok, until suddenly it wasn’t.  I got really slowed down, and ended up having to go back on the quetiapine as well as up my dose of lithium.  Clearly I needed my full med cocktail.

It wasn’t too long afterwards that my workplace bullying debacle began.  This culminated in me deciding to quit my job, and I became quite depressed again.  My psychiatrist ‘s reaction was tremendously invalidating, so I stopped seeing him.  I had recently begun seeing a new GP, and when I told her why I wasn’t seeing the psychiatrist any more, she came out with the same invalidating comments he did.  I refused to see her again, so she booked me in to see another GP at the same clinic, who ended up being even worse.  I couldn’t bear the  thought of going to see another doctor, so I decided that with the meds I still had at home I would do a gradual taper and then stope them.   It wasn’t that I wanted to stop taking meds, I just wasn’t willing to see another doctor.  Not surprisingly, that strategy didn’t work out very well for me.  I was barely sleeping despite taking everything over-the-counter I could think of.

It was when I decided that I needed to go back on meds that I found my current GP, who’s very reasonable and pragmatic.  Even so, there have been a couple of times that I’ve thought screw it, there’s no point going in to get my meds reordered because I just feel like crap anyway.

My logical mind is very adamant that I need meds.  Unfortunately, sometimes depression sneaks in and twists things around, and for me I don’t think that’s something that will ever go away no matter how pro-meds I am most of the time.

Have you gone off meds before?  What was the experience like?

Evidence-based treatment of anxiety

In this post I’ll take a look at some of the available treatment guidelines for anxiety disorders.  While psychotherapies are extremely important in the management of anxiety disorders, this post will focus only on anti-anxiety medications.  The treatment guidelines I refer to come from the British Association for Psychopharmacology and the World Federation of Societies of Biological Psychiatry.

Benzodiazepines, while effective, are generally only recommended for short term use or where other treatments have failed, and there should be a careful consideration of the risks vs benefits for the specific individual.

Generalized Anxiety Disorder

It may take up to 12 weeks to achieve full response to antidepressant medication, but if there is no response at all after 4 weeks it is unlikely that particular medication will start to work with a longer duration of treatment.

1st line: SSRI (selective serotonin reuptake inhibitor): citalopram, escitalopram, paroxetine, sertraline

Alternatives to SSRI: SNRI (serotonin and norepinephrine reuptake inhibitor: venlafaxine, duloxetine), pregabalin (high dose may be more effective); quetiapine may be effective as monotherapy at doses of 50-300mg/day

2nd line: agomelatine, quetiapine, some benzodiazepines (alprazolam, diazepam, lorazepam), imipramine (a tricyclic antidepressant or TCA), buspirone, hydroxyzine (a sedating antihistamine), trazodone

Panic disorder

It may take up to 12 weeks for medication to fully take effect.  When discontinuing medication after long-term treatment a lengthy gradual taper is recommended (over at least a 3 month period).

1st line: SSRI

Alternatives: some TCAs (clomipramine, desipramine, imipramine, lofepramine) venlafaxine, reboxetine, some benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam), some anticonvulsants (gabapentin, sodium valproate)

Avoid: propranolol, buspirone and bupropion

Social Anxiety Disorder

It may take up to 12 weeks for medication to fully take effect.

1st line: SSRIs

Alternatives: venlafaxine, phenelzine, moclobemide, some benzodiazepines (bromazepam, clonazepam) and anticonvulsants (gabapentin, pregabalin), and olanzapine

Avoid: atenolol or buspirone in generalized social anxiety disorder; beta blockers can be effective for performance anxiety but not social anxiety disorder in general

Obsessive Compulsive Disorder

1st line: SSRI (may need a high dose)

Alternative: clomipramine

Add-on treatment: atypical antipsychotic, haloperidol, mirtazapine (may speed up response to citalopram)

 

What has your experience been like with anti-anxiety medication?

 

You can learn more about these medications in my book Psych Meds Made Simple: How & Why They Do What They Do, available on Amazon.

What the STAR*D study means for depression treatment

brain shining like a star

geralt on Pixabay

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial studied 2876 people with major depressive disorder to evaluate their response to depression treatment in a real-world setting.  Unlike the randomized controlled trials that are often used to evaluate a drug’s efficacy, there were few exclusion criteria, the patient and their physician knew which drug they were taking, and patient choice was incorporated.  Four sequential levels of treatment were established, and if a patient failed to achieve remission after 12-14 weeks, they would be moved to the next level.  The target was full remission, unlike many other studies which measure response (i.e. a ≥50% reduction in symptom rating scale scores).  Remission rates can be substantially lower than response rates, but are useful because there are better long-term outcomes for people who do achieve full remission.

Level 1 treatment consisted of citalopram, and 28% of patients achieved remission based on the Hamilton Rating Scale for Depression (HAM-D).  Certain factors were identified, such as other comorbid mental illnesses, that were associated with lower or higher remission rates.

In level 2, patients were offered cognitive psychotherapy, a switch to another antidepressant (randomly selected), or the addition of another medication to augment the treatment.  Among level 2 patients who switched to another medication, remission rates were 21.3% for bupropion, 17.6% for sertraline, 24.8% for venlafaxine.  Rates were similar among those patients who switched to cognitive psychotherapy.  Among the patients who received augmentation treatment, the remission rates were approximately 30% for both bupropion and buspirone.  Augmentation with medication produced more rapid remission than augmentation with cognitive psychotherapy.

In level 3, patients who switched medication were randomly assigned to mirtazapine or nortriptyline, and patients who received an medication for augmentation were randomly assigned to lithium or the T3 form of thyroid hormone (liothyronine).  Remission rates were 12.3% for mirtazapine, 19.8% for nortriptyline, 15.9% for lithium, and 24.7% for thyroid hormone.

In level 4, patients were randomly assigned to switch to either tranylcypromine (an MAOI antidepressant) or venlafaxine plus mirtazapine.  Remission rates were 6.9% for tranylcypromine and 13.7% for venlafaxine plus mirtazapine.

Altogether, 67% of patients were able to achieve remission.  The study found that people may still remit by 12 weeks even if there’s only a modest symptom reduction at 6 weeks.  However, the more treatment steps that are required, the lower the chance of a patient achieving remission and the higher the chance of intolerable side effects and relapse.

Personally I found the take-home message from this study rather discouraging.  During my last hospitalization I argued that my suicide attempt was supported by the STAR*D’s not so subtle hint that I was shit outta luck.  I think it’s crucial that we find new kinds of treatment that will help that 33% of people who are treatment-resistant and just aren’t achieving remission with many currently available antidepressant medications.  This study doesn’t consider all potential treatments; for example, atypical antipsychotics, ketamine, and ECT aren’ included, and psychotherapy plays a limited part.  Still, we deserve better.  A lot better.

 

For more info on the research terminology I’ve used in this post, see my post on research literacy.

You can find out more about these medications in my book Psych Meds Made Simple: How & Why They Do What They Do, available on Amazon.

Our complicated relationships with medications

capsules filled with sparkles

I can’t think of any other type of health condition that has as polarized a relationship with medication as mental illness.  In some ways, to medicate or not to medicate has become a moral issue, with various involved parties taking a stance based on principle.  Often this stance is very broad, making sweeping generalizations.  I recently read and reviewed the book Lost Connections, which argues that all depression is situational and medications should not be used.  Some people connect psychiatric medication use to violence, such as the incoming director of the National Rifle Association (NRA) who has suggested a link between school shootings and Ritalin (methylphenidate).  I’ve seen Twitter comments blasting people who wrote about the positive effects they experienced from medication.  We would never hear any of this kind of thing if we were talking about blood pressure medication, so why are there so many eager to shout from the rooftops when it comes to psychiatric meds?

My own view is certainly shaped by my professional training; I used to be a pharmacist, and now I’ve been practicing as a nurse for 13 years in mental health settings.  I understand how medications produce the effects (both positive and negative) that they do, and have the research literacy to separate the BS from legitimate information.  I look at medication as a tool, and any given medication may or may not work for any given individual, and may or may not be tolerated by that individual.  I have seen medication be life-saving for people, and it certainly has made a huge difference in my own illness.

In general it seems like people tend to speak up, both online and in person, more often about things that go badly for them than things that go well.  The same appears to be true with medication.  I’m a bit fuzzy remembering the details, but not too long ago someone had written a post about antidepressant withdrawal, and someone else commented about how venlafaxine is a garbage drug that no one should take because of the withdrawal effects.  I’m sure that individual’s experience was very negative, but it’s easy to see remarks like this about side effects and overgeneralize, making the assumption that they occur for all/most people taking the drug.  Unfortunately we don’t yet have a way of predicting who will respond to or tolerate particular drugs (although I’m sure the science will get there as the role of pharmacogenomics expands), but to allow treatment decisions to be based on people’s negative comments online doesn’t seem particularly helpful.

I suspect that some of the time meds are demonized because of poor clinical practice by prescribers.  If physicians aren’t responsive to the side effects people are having, ordering any necessary bloodwork, or prescribing drugs that are actually appropriate and effective for the condition being treated, those things don’t mean the drug itself is inherently bad.  Instead, it means that the prescriber is being irresponsible.  I can’t help but think of a blogger with bipolar disorder who was treated for many years with high-dose clonazepam, and then had it discontinued abruptly.  In my mind that is shocking malpractice and a gross misuse of a medication that is not even indicated for treatment of bipolar disorder (but can be very useful when used carefully and appropriately).

It’s also problematic when doctors prescribe a medication and make it out to be a sort of panacea that will fix everything.  We all know there’s a lot of different things involved in getting well, whether we’re on medication or not.  Psychosocial stressors and underlying trauma aren’t going to disappear with a wave of the SSRI wand, and that’s fine, but doctors should be open with their patients about what medications will and will not do.  If patients are coming in misinformed and expecting to pop a happy pill, the health professional has a responsibility to educate them about the nature of mental illness and its treatment.

As Shakespeare’s Hamlet might say:

To medicate, or not to medicate: that is the question:
Whether ‘tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles,
And by opposing end them?

Where do you stand when it comes to medications?

 

Image credit: rawpixel on Pixabay

Evidence-based treatment of bipolar disorder: The CANMAT/ISBD guidelines

In 2013 the International Society for Bipolar Disorders and the Canadian Network for Mood and Anxiety Treatments combed through the scientific literature and put together these guidelines for the pharmacological treatment of bipolar disorder.  Treatments are classified as 1st, 2nd, or 3rd line based on the strength of existing evidence to support their effectiveness.  Also included are treatments that are sometimes used in bipolar disorder but for whatever reason don’t necessarily have a research base to back them up.

No treatment guideline in the world is going to be able to say what treatment is going to work in a specific individual.  However, they can provide a good idea of what has the best chance of working, and I think it’s always valuable to know what your options are.

Here are the recommendations for acute mania, acute depression, and maintenance treatment.

Acute mania

1st line:

2nd line:

  • carbamazepine (mood stabilizer)
  • haloperidol (typical antipsychotic)

Not supported by evidence:

  • gabapentin
  • lamotrigine
  • topiramate

 

Acute bipolar depression

1st line:

  • lithium
  • lamotrigine
  • quetiapine
  • lithium/divalproex + selective serotonin reuptake inhibitor (SSRI) or bupropion
  • olanzapine + SSRI
  • lithium + divalproex

2nd line:

  • divalproex
  • lurasidone (an atypical antipsychotic)
  • quetiapine + SSRI
  • modafinil (stimulant)
  • lithium/divalproex + lamotrigine or lurasidone

3rd line:

  • carbamazepine
  • olanzapine as monotherapy (i.e. the only treatment)
  • electroconvulsive therapy (ECT)
  • lithium combined with carbamazepine, pramipexole, or an MAOI antidepressant
  • lithium/divalproex + venlafaxine or tricyclic antidepressant
  • lithium/divalproex/carbamazepine + SSRI + lamotrigine
  • quetiapine + lamotrigine

Not supported by evidence:

  • gabapentin
  • aripiprazole
  • ziprasidone

Acute bipolar II depression

1st line: quetiapine

2nd line:

  • lithium
  • lamotrigine
  • divalproex
  • lithium/divalproex + antidepressant
  • lithium + divalproex
  • atypical antipsychotic + antidepressant

3rd line:

  • antidepressant monotherapy
  • quetiapine + lamotrigine
  • ECT
  • N -acetyl cysteine
  • T3 form of thyroid hormone

Maintenance therapy

1st line:

  • lithium
  • lamotrigine
  • divalproex
  • atypical antipsychotics: olanzapine, quetiapine, risperidone, aripiprazole
  • lithium/divalproex + quetiapine/risperidone/aripiprazole/ziprasidone

2nd line:

  • carbamazepine
  • paliperidone
  • lithium + divalproex/carbamazepine
  • lithium/divalproex + olanzapine
  • lithium + risperidone or lamotrigine
  • olanzapine + fluoxetine

3rd line:

  • asenapine
  • phenytoin
  • clozapine
  • ECT
  • topiramate
  • omega-3 fatty acids
  • oxcarbazepine, gabapentin

Not supported by evidence:

  • gabapentin, topiramate, or antidepressants when used alone as monotherapy
  • flupenthixol as an adjunctive treatment

 

The role of antidepressants:

Antidepressants don’t always work well in bipolar disorder, and they can potentially do more harm than good.  In case you’re interested, the International Society for Bipolar Disorder has a task force report on the use of antidepressants in bipolar disorder.

 

And there you have it, folks.  Was there anything in the guidelines that surprised you?  And for those with bipolar disorder, how does your treatment regimen compare to what’s in the guidelines?

 

For more information about these medications, you can check out my book Psych Meds Made Simple: How & Why They Do What They Do, available on Amazon.

 

Full reference:

Yatham, L.N., Kennedy, S.H., Parikh, S.V., Schaffer, A., Beaulieu, S., Alda, M., O’Donovan, C., MacQueen, G., McIntyre, R.S., Sharma, V., Ravindran, A., Young, L.T., Milev, R., Bond, D.J., Frey, B.N., Goldstein, B.I., Lafer, B., Birmaher, B., Ha, K., Nolen, W.A., & Berk, M. (2013). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAD guidelines for the management of patients with bipolar disorder: Update 2013. Bipolar Disorders, 15, 1-44.  The abstract is available on PubMed.

 

Book review/rant: Lost Connections

Book cover: Lost Connections by Johann Hari

In Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions, Johann Hari takes a stand against the idea of biological causation of depression and anxiety.  I expected going in that this book would annoy me, but at times it was just plain ridiculousness.

To start off, let me tell you the perspective I’m coming from.  I support a biopsychosocial model that recognizes mental illness as complex and often multifactorial.  Every individual’s illness stems from a unique combination of factors, and for a treatment plan to work best it needs to effectively target whatever contributing factors can be identified.  Sometimes that’s meds, sometimes that’s psychotherapy, and more often than not it’s a combination of multiple different strategies.  Meds aren’t a miracle cure but can get you well enough to do whatever it is you need to do to find true wellness.  Ok, now that we’ve got that out of the way, let’s jump headfirst into the book.

Red flags were set off for me early on in the book when the author wrote that at age 18 he had an epiphany that he had the medical condition called depression, and from information in the media he knew that antidepressants were just what he needed to quickly make him all better.  Initially he was convinced paroxetine made him feel even better than simply not depressed, and he spread the word to others that depression was solely about serotonin and antidepressants were the best thing since sliced bread.  Years later, his therapist pointed out to him that it seemed like he was still depressed; the author responded that no, he couldn’t possibly be depressed because paroxetine was keeping his serotonin levels up; but then changed his mind and decided to stop meds.  “It was only when I stopped taking the [SSRI] and I started having more pleasurable sex again that I remembered regular sex is one of the best natural antidepressants in the world.”  I guess I’m just a little (or a lot) judgmental, but this dude seemed like he was energetically leaping onto the train to out-there-ville.

toy train

Next stop on that train is with researcher Irving Kirsch.  Kirsch criticized the typical design of drug trials, i.e. randomized placebo-controlled trials (you can find more about that in my post on research literacy).  He argued that to truly understand the effect of a drug there should be 3 arms to these kinds of studies: drug, placebo, and no-intervention, with the third arm capturing the number of people who get better with no treatment or placebo at all.  This sounds all well and good except that it gives you zero new information about what the drug does.  The people who would respond to no intervention are already captured in the placebo responders, so adding a do-nothing arm only gives you information about how much of the placebo effect is due to that sugar pill the researchers are giving the patients.  Now that information may be useful in examining the placebo effect, but it doesn’t in any way change what a study shows about the effect of drug response over placebo.

Next stop on the train is holding up the old serotonin deficiency hypothesis for depression as evidence that the illness doesn’t have a biological basis.  That hypothesis was originally developed to try to explain why drugs that blocked serotonin reuptake had an antidepressant effect, and at the time they didn’t have the scientific techniques available to test whether this was really accurate.  It has since become clear that depression is not related to a deficit in the absolute amount of serotonin, but that doesn’t mean we should throw the baby out with the bathwater.  Just because the overly simplistic early explanation was wrong doesn’t mean that neurotransmitters have nothing to do with depression period, and it doesn’t mean that antidepressants that affect neurotransmission won’t work.  It’s like saying that because the flat earth hypothesis was wrong there must be no earth at all.

The author talked about bereavement being mislabelled as depression.  A woman he interviewed said “So now if your baby dies and you go to the doctor the next day and you’re in extreme distress, you can be diagnosed immediately.”  People have the right to be ignorant, but that doesn’t mean their ignorant comments should be thrown into a book as evidence.  This idea that the DSM diagnostic criteria are a checklist and if you tick enough boxes you must be labelled with the disorder, well, it’s just not correct, which is why only highly trained clinicians are qualified to diagnose.  Admittedly, some clinicians are too quick to jump to a diagnosis, but that’s very much a separate problem.

In the DSM-IV, bereavement was listed as an exclusion criteria for diagnosing a major depressive episode; this was done in an attempt to avoid bereavement from being mistaken as depressiom.  The author raised concerns that maybe depression wasn’t so sound an entity if a normal experience mimicked the symptoms.  But then he does a 180 and questions the removal of that bereavement exclusion in the DSM-5 and the addition of only a “vague footnote”.  That “vague footnote” is actually part of diagnostic criterion C for a depressive episode, and says: “Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.”  So yeah, no day-after-death diagnosis.

toy train

The author announced that based on his information gathering (and no training whatsoever in psychiatry/psychology) he has identified 9 causes of depression.  He adds that depression is a form of grief over these various forms of disconnection.  The identified causes are:

  1. Disconnection from meaningful work
  2. Disconnection from other people
  3. Disconnection from meaningful values:  The author talked about “junk values”, and particularly materialism, as being problematic and something he had struggled with.  It was around this point that it really started to sound like the author was referring to depression and anxiety as negative emotional states and existential malaise and not necessarily appreciating the difference between these emotion states and mood/anxiety disorders.
  4. Disconnection from childhood trauma
  5. Disconnection from status and respect
  6. Disconnection from the natural world
  7. Disconnection from a hopeful or secure future
  8. The real role of genes and brain changes: The author saw 2 potential roles for biology: circumstances can cause brain changes that accelerate the problem, OR
  9. genetic variations may contribute to depression but only in specific environmental circumstances; they can’t cause depression without an environmental trigger

Part II of the book, “Reconnection: A new kind of antidepressant”, looks at ways in which people can reestablish those needed connections.  This starts off with what to me seemed to be a rather rambling story about an apartment block in Berlin slated for demolition.  An older woman had posted a note saying she was going to kill herself because she’d be losing her housing and she had no other options (there’s no indication that this was a woman with any history of mental illness).  This sparked community activism that positively impacted all of those involved.  And lo and behold, the woman’s suicidal thinking disappeared – so that’s what I must have been missing those times I tried to kill myself!  It made me think of a line from a medical historian interviewed in the documentary The Age of Anxiety: “If your problem can be corrected by a new boyfriend or a cheque for $5000, you probably don’t have a psychiatric disorder.”

The author came to the conclusion from this and other examples that “if you want to stop being depressed, don’t be you. Don’t be yourself.  Don’t fixate on how you’re worth it. It’s thinking about you, you, you that’s helped to make you feel so lousy. Don’t be you. Be us. Be we. Be part of the group. Make the group worth it…  So part of overcoming our depression and anxiety—the first step, and one of the most crucial—is coming together.”

The author says that “work is essential”, which made me wonder why he has his head up his privileged ass.  He talked to a woman who was anxious because of her negative work situation, then she joined with her husband and others in creating a cooperative bike repair business and things were hunky dory.  The author describes this “recipe for mental health” as “Elect Your Boss”.  So that’s what we’re all doing wrong…

toy train

Hari wrote that if he could speak to his younger self, he would say: “You are not suffering from a chemical imbalance in your brain. You are suffering from a social and spiritual imbalance in how we live. Much more than you’ve been told up to now, it’s not serotonin; it’s society. It’s not your brain; it’s your pain… Because you are being told depression and anxiety are misfirings of brain chemicals, you will stop looking for answers in your life and your psyche and your environment and how you might change them. You will become sealed off in a serotonin story.”  I suspect there may be some funky paint fumes going on up in that serotonin story.

If this had been a book about general dissatisfaction and unhappiness in society at large, I would be writing a very different review right now.  I suspect that Hillary Clinton and some of the other well known people who have commented positively on the book may have been looking at it from that perspective.  If the book had talked about some people having mental illness that is heavily influenced by social/environmental factors, or the need to take social/environmental factors into account in approaching the treatment for mental illness, then I would have far more positive things to say.  But that’s not the case.  He is saying that mental illness is not biologically caused and medication is not a valid treatment for depression.  Full stop.  I think that’s just as bad as the purely biomedical stance that he criticizes.  Such a reductionistic approach really isn’t useful to anybody, and is insulting to those of us living with the complexity of mental illness.

So what can I conclude personally from this book?  Apparently to get better I’m supposed to engage in local activism, participate in a community garden, start a co-op, hang out in nature, and get laid.  Forget meds, give me a little penis therapy instead.  Why would anyone be suicidal when they could bond over community activism?  Of the various disconnects that he believes cause depression, I had a whopping none of them for my first two depressive episodes.  Screw pain, I was generally happy and optimistic, and had no childhood trauma, a supportive social circle, a job I liked, a strong preference for the value of travelling the world rather than accumulating possessions, a home in an urban oasis right with a forest just steps away… and yet there I was, depressed, psychotic, suicidal.  Meds are certainly not the only tool in my toolbox, but without them, I probably wouldn’t be alive today.  So rather than go postal on the author’s ass for presuming to tell me what’s going on with my illness, I’ll just wave as he goes by on the train to out-there-ville.  Enjoy the ride!

 

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Why is Netflix jumping aboard the stigma train?

Netflix Take Your Pills

Sigh.  This again?  I’ve written before about documentaries that portray psychiatric medications in a problematic way that tends to promote stigma (A Prescription For Murder and Stigma and the Pathologization of Normal).  Now Netflix has come out with Take Your Pills, which looks at the use of stimulant drugs like Adderall and Ritalin for mental performance enhancement.

I started watching this documentary and gave up in disgust.  But after I read a critique by Mental Health: Let’s Stamp Out the Stigma, I decided it was important to speak up about it, and to do that I thought it was important to give it another go and watch the whole thing.  While a somewhat more balance perspective was conveyed when I watched the film in its entirety, I was still left with a lot of concerns.

The documentary describes psychostimulants as a tool for cognitive enhancement, enabling people to get an academic or career edge, get higher grades, perform in a way they perceive as ideal (particularly in the tech and finance sectors), do more detail-oriented work, and control weight.  Medications like Adderall are described as enabling people to “get to perfect” or be “jolted back to life”.  One psychologist says that these medications prime people to to expect that a pill will give them what they want.  A researcher who was interviewed jumped on the bandwagon, saying he’d tried Ritalin once and it felt like “such an enhancement of my day; it was a good experience”, something it strikes me as irresponsible to say when being interviewed as an expert on the topic.

A university student said that her parents told her she should get a lockbox for her stimulant medication.  “It’s RX gold” she said, adding “I don’t think I know anyone who’s prescribed it who doesn’t sell a little on the side”, and “everybody takes Adderall.”  One male interviewed said that as a millennial who went to a great college and worked in finance, “it’s impossible to avoid stimulants”, and loopholes would be found and taken advantage of in order to obtain them.

Taking stimulants to be more productive was documented as early as the “pep pills” of the 1930’s.  ADHD was described as something that developed out of the marketing of stimulant medications as a way to improve children’s behaviour and grades.  The documentary explains that more children are diagnosed with ADHD in the United States than in any other country in the world, and the majority of them are medicated.  The implication was that ADHD was a mostly artificial condition created by drug companies’ marketing campaigns.  This is certainly not the first time I’ve seen this logical fallacy; misleading advertising does not invalidate the medical condition just because they falsely suggest that everyone suffers from it.

Serious side effects such as addiction are mentioned but the film doesn’t do a good job of contextualizing this as an individual risk vs benefit decision.  A political theorist interviewed suggested that stimulants blunt the human experience and creativity (I’ll just say that a PhD in one field does not qualify someone to speak as a subject expert on an unrelated field).  One student believed her stimulant medication made her more boring and angrier.  These examples provide a very limited context by which to judge the appropriateness of these medications.

A psychotherapist featured in the film said that “just like opiate painkillers are heroin in a pill, ADHD medicine is a very small dose of meth in a pill.”  A psychologist suggested that as a society we make a false distinction between licit amphetamines and illicit methamphetamine, and pointed out the chemical similarity of prescription amphetamines and illicit methamphetamine (which has an added methyl group consisting of 1 carbon and 3 hydrogen atoms).  To me this was an astonishing display of ignorance from someone whose doctorate in psychology doesn’t necessarily necessarily confer expertise in medicinal chemistry.  You know what also differs by a single methyl group?  The ethanol that you find at a liquor store and the poisonous methanol that’s in the antifreeze and can kill desperate alcoholics looking for a fix, including a former patient of mine.  Never mind a full 4-atom methyl group, think of what happens when you throw a few subatomic neutrons on an atom and create a radioactive isotope.  One need only look so far as Wikipedia, which points out that, “unlike amphetamine,  methamphetamine is directly neurotoxic to dopamine neurons in both lab animals and humans”; this statement is backed by 3 references from scientific journals.

I cheered a little inside my head when one student who was interviewed expressed concerns about people saying things like “everyone has a little ADHD”, as this delegitimizes the actual illness.  Another student with ADHD had chosen to go off of Adderall, even though his mother believed he likely wouldn’t have made it through high school without it.  It appeared from the documentary that those with a genuine medical need were actually the most reluctant to take medications.

In a study of college students without ADHD, using Adderall didn’t lead to objective improvements in cognitive performance, but participants did report a subjective sense of performance improvement.  A journalist interviewed in the film said that “what you have here is a dynamic of not only people using what is, you know, a dangerous drug… but you also find a bit of an arms race building up where if enough people see that their competition is doing it, they feel like they kind of have to do it too.”  The societal pressure  to always be competitive and outperform others is well worth exploring, but to me that got lost in the focus on stimulant medications.

I freely admit my own bias viewing this documentary, as I take Dexedrine (dextroamphetamine).  I first started taking it for significant psychomotor retardation (slowing of movement and thoughts) that I experienced as a symptom of depression.  When that resolved, I cut down on my Dexedrine dose, and my mood worsened.  I’ve tried a few more times since then to cut back the dose, and it’s become clear that it’s definitely having a beneficial effect on my mood.  My doctor is very comfortable keeping me at a dose of 10mg in the morning and 5mg at noon because it is obviously having a therapeutic benefit.  I don’t feel “high” from it and never have.  Dexedrine isn’t enough to fully compensate for the cognitive slowing and low energy I experience with depression, and my overall cognitive performance and energy level remain lower even while on Dexedrine than they are when my depression was previoulsy in remission.

So when Netflix portrays my medication as either a performance enhancer or a legal version of crystal meth, it does not sit well with me.  There is already so much stigma against mental illness and psychiatric medication, and this sort of messaging is not helpful.  There was a really valid point buried underneath the performance-enhancing pill-popping message, and it would be great to see a documentary that truly addresses the issue of societal hyper-competitiveness.  Unfortunately Netflix missed the mark.