Showing posts with label antidepressants. Show all posts
Showing posts with label antidepressants. Show all posts

Will This Trauma Never End?

I found this video while trying to survive the cluster f*ck of misdiagnosis, antidepressants, mixed episodes, and a psychiatrist and therapist who didn't know what they didn't know, so it must be me and maybe I had borderline personality disorder - the go to diagnosis for patients that the professionals are tired of.

OK Go - This Too Shall Pass. And in fact, it did. I survived to... today? I offer it to everybody who is trying to survive the current COVID cluster f*ck in the US.

What People with Depression Need to Hear

Depression is one tough condition. Contrary to those cheery ads on tv and friends who want you to get over it, it is not easy to recover. Doctors also, in their eagerness to get you to do something that will help, sometimes oversell their solutions.

Chris Aiken's recent article in Psychiatric Times presents a more helpful picture.

Five Things to Say to People with Depression

You can expect, and do deserve, a full recovery. Aiken's point is that people with depression have a hard time believing we will ever feel any differently. (This is true. Boy, is this true.) Nevertheless, chances are, we will feel better. There is a rub here however. Most people get to full recovery, not all. As a patient, I'd like to hear up front that even if it comes back, chances are that things will get better again. So many of us feel like failures when depression recurs, when actually both remission and recurrence are part of the natural course of the illness.

Misconceptions about Antidepressants

What do you think are the most common misconceptions about antidepressants?


Prozac Monologues: A Voice from the Edge is at the press kit stage with Q&A in development. My publicist wants me to answer questions that interviewers might ask. My responses should be in the three to seven sentence range, she says.

Three to seven sentences are not my forte. I am doing my best and taking comfort that in an interview format, there might be a follow-up when I can say more.

They are good questions and worth a blog series, I think, where I can expand to three to seven paragraphs. Mostly seven. Maybe more. Plus, you know, pictures. So that's what you get for a few weeks.

No, antidepressants are not happy pills

Six Ways to Heal the Holes in Your Head


Do you ever feel like you have holes in your head? Actually, you do. Ventricles are the spaces between the grey matter (brain cells) and white matter (wiring that connects the brain cells) in your brain. Depressive episodes, manic episodes, and psychosis all burn up brain tissue, leading to bigger ventricles. (Image: Effects of Western diet on the brain. See companion image, Effects of Mediterranean diet below.)

This loss of brain cells hits the hippocampus (in charge of memory and emotion regulation) particularly hard. In the early years after my last mental health crisis, I talked about my “Swiss cheese brain.” At my worst, I lost bills, I lost words, I lost everything my wife said to me on the way out the door in the morning. She took to writing down what I said I would do before she got home, never more than two items.

I lost the list.

Making Music to Build Your Brain

Manic episodes burn up brain cells. So do depressive episodes. So do panic attacks. Cortisol run amuck leaves you with potholes in your head. Not to worry -- the brain has a built-in repair system, Brain Derived Neurotrophic Factor, BDNF.

They've been trying forever to reverse engineer antidepressants. If they can figure out how they work, they figure they will know what causes depression in the first place. At first they thought it was low serotonin levels, the proverbial "chemical imbalance." A more recent thought is that a low serotonin level is not the cause, after all; it's the effect. Fix the problem farther upstream by stimulating BDNF to repair the brain damage, and the serotonin level sorts itself out.

But the natural thing that gets this hormone humming to patch your potholes is learning! There's this big deal about seniors doing Sudoku to ward off dementia. But it only works until you get good at it. You have to keep doing new stuff that you don't already know how to do.

And what better than learning to play a musical instrument? You have no talent? You tried it as a kid and you were lousy? Hear me out. If you were good at it, it wouldn't build your brain. Seriously, it's like exercise. If you don't feel the struggle, you're not building the muscle. Making music turns out to be a full body/brain workout.


So go get yourself a ukelele! Your brain will be glad you did.
photo of pothole in public doman
photo of road repair taken by US Air Force and in public domain

Antidepressants and Suicide: Defending Prozac

It amazes me how many research scientists seem to have flunked statistics.  Or ought to have.  Me, I majored in the liberal arts.  But at Reed, even those who took Science for Poets would be required to rewrite some of the scientific papers I have read on the subject of antidepressants.

So the vocabulary terms for the week are observer bias and confounding variables.  No worries -- lots of pictures.

Clinical Experience in Defense of Prozac

Let's say you are a doctor treating 100 patients with severe depression.  You give them all antidepressants.  It seems irresponsible not to, doesn't it.  Thirty of them get better.  Fifteen do not make a follow-up appointment.  You switch the fifty-five who are still trying to another antidepressant.  Another fifteen get better.  And another fifteen do not make a follow-up appointment.

Over the course of a year, you get up to fifty whose depression is remission and ten who are still struggling.  You don't know what happened with the forty who are no longer seeing you. They couldn't afford treatment; they didn't like your face; they couldn't find parking; they got worse on your medication. You have no idea.  But you have fifty patients who think you saved their lives.  You feel pretty good about yourself, don't you.

Antidepressants and Suicide: A History

Do antidepressants prevent suicide, or do they cause it?

Yes.

Well, maybe.

It's a no-brainer, right?  People who commit suicide are depressed.  Take away the depression, and how better than with an anti-depressant, and you decrease the risk of suicide.

So what's with the question?  Here is the story:

History of Antidepressants

Looking Under the Hood - A Better Depression Diagnosis?

Corrected July 7, 2013

Maybe my writer's block is an Ecclesiastes issue.  There is nothing new under the sun.

But finally, there is.  No, not the DSM.  Keep reading.

The DSM. Sigh.

But regarding the DSM, and it makes no difference at all which edition, you have to wonder when somebody who is suicidal, losing weight, irritated at the drop of a hat and can't sleep gets the same diagnosis as somebody else who is immobile, gaining weight, couldn't be bothered about anything anymore and sleeps the night and day away.  It's all depression -- the DSM's junk drawer.

Finally, somebody thought to sort the junk drawer, by looking inside the brains of these two sorrowful souls, both taking the same meds for God's sake.

PET Scans - Looking Under the Hood

Helen Mayberg and her team at Emory University School of Medicine used PET scans to look under the hood (to use John McManamy's favorite metaphor).  PET scans use a radioactive tracer to determine where glucose is being used in the brain, i.e., what part of the brain is busy.

Anniversary - Prozac Monologues

Do you take antidepressants for depression and you are not getting better?  Do they make you agitated, anxious, insomniac?  Have you heard it often takes a while to find the right med, so you keep trying, you brave little soldier, you?

My friend, today you tapped your ruby slippers together, and Google brought you here.  Maybe not to your home, but to mine.  What follows is the back story to Prozac Monologues.  But first things first:

Stop.  Stop trying.  Go no further until you have taken the MDQ, Mood Disorder Questionnaire, right here at this link, and have asked a friend or housemate who knows you really well and loves you enough to tell the truth to fill it out for you, as well.

Grief/Depression IV - Not the Same/Maybe Both

So a woman goes into the doctor's office, three weeks after her husband died. I got through the funeral just fine. But now I feel awful. There is this ten ton weight on my chest. I'm exhausted; I don't have the energy to wash the dishes. I'm trying to pack up my husband's things, and I am too weak to pick up his shoes. I can't eat. Sometimes I get hit so hard with this wave of anxiety, I think I'm going to throw up.

What are the chances the doctor will say, Of course you feel awful. These are all very natural symptoms of grief. You just need time. But if you still feel like this a month from now, call my nurse and set up an appointment. What are the chances the doctor will not pull out the stethoscope and listen to her chest?

Answer: It depends on whether the doctor is stupid.

Or a psychiatrist.

These are classic symptoms of heart disease. There is significant overlap between the symptoms of heart disease and the experience of grief. But there is no Bereavement Exclusion for a diagnosis of heart disease. Instead, family physicians and cardiologists take the time to examine whether the person presenting these symptoms may have both.

Grief/Depression II - Rise in Rates of Mental Illness

Are we really getting sicker?

A New York Times article, When does a broken heart become a diagnosis? sells papers with its usual technique - latch onto a fringe element and substitute good writing skills for substantive analysis.

I am all for good writing skills, and perhaps stumble in the same direction at times. But depression is my beat. So God willing and the brain permitting, I am going to beat this bit to the ground. Two weeks ago I discussed three contexts for the discussion, the cost of health care, the scientific value of the DSM and the hobby horse of the author featured in the Times article. I promised more contexts to come.

Are We Getting Sicker? - Context IV

James Wakefield's thesis is that we are turning natural human emotions, (the ones we want to get rid of, because they are unpleasant), into a diagnoses. His beat is depression, as well, but the Times is on this bandwagon with autism and no doubt other diagnoses to come.

Well, I grant some validity to the concern in general. Is it shyness or Social Anxiety Disorder? Is it artistic nonconformity or Attention Deficit Hyperactivity Disorder? Is it the sleep disruptions of normal aging or Overactive Bladder Disorder? Was it all those wings, doritos and beer you guzzled Superbowl Sunday (and most Sundays), or Gastroesophageal Reflux Disease?

Prozac Monologues - How It Began

First conceived as a stand up comedy routine, birthed as a book, morphed into a blog, on August 29, 2011 Prozac Monologues came full circle at Happy Hour at the Pato Loco, Playas del Coco, Costa Rica.  This was the very spot where in January 2005, the book was originally written over the course of eight heavenly (my wife wouldn't use that word), hypomanic days.  Micah pulled out his laptop.  Patricia set it up on top of a bar stool.  And I held forth.


You can hear a bit of our little beach town's rush hour in the background.  So here is the text:

Prozac Monologues - How It Began

2004 was not a good year for me.  My doctor tried to make it better by prescribing Prozac for major depression.  Only Prozac didn't make it better.  So she prescribed more Prozac.  And that made it so much more not better that I concluded the only way I could describe how much more not better would be a stand-up comedy routine.  And thus was planted the seed for what has become Prozac Monologues.

So I went off Prozac, and on January 25, 2005, I boarded an airplane for Costa Rica, armed with a yellow legal pad and a ball point pen. 

Hypomania In Action

For eight days in beautiful, tropical Costa Rica, my wife went to the beach, explored neighborhoods, visited with family, tried new foods, while I wrote.  And wrote.  And wrote.  When I filled up one side of the yellow legal pad, I wrote on the back.  When I filled up the back, I wrote in the margins.  When I filled up the margins, I wrote between the lines.

I came home with seven chapters.  Two weeks later, the book was done.

I told my doctor about my book and maniacally writing it.  That word maniacally raised a red flag.  So she screened for bipolar.  She said, Are you manic?

I said what anybody who thought she was Jesus Christ come back as Jessica Christ might have said, I'm not manic.  I'm excited!

Oh.  Okay.  So she prescribed the second antidepressant, and began what will have to become a new book, but I haven't recovered enough to write it yet.

Was I manic?  No, I was hypomanic.  But I didn't know that word.  And maybe you don't know it either.  So I submit for definition and for evidence the first four pages of

Prozac Monologues

by
Willa Goodfellow

Chapter One
Bizarre: In which I decide to write a book

Okay, let's start with the basic Prozac dilemma.  Just who is the crazy one around here?  If, after you read the morning paper, you are happy, content, secure, at peace, able to get up, go out and carry on your activities of daily living, full of confidence and a sense of purpose, then tell me -- are you pathologically delusional?

Or are you on Prozac?

Citizens of the United States of America (called Americans and thereby hijacking the identities of thirty-eight other nations in the Western Hemisphere -- Remember Canada?  Every heard of Paraguay?) make up 5% of the population of the planet and consume 24% of its energy resources.  We spend more on trash bags than the gross national product of 90 of the world's 130 nations.

What was that?


We spend more on trash bags than the whole gross national product of 90 nations.

So who is the crazy one around here? 


The Crazy Delusion 

We get such a sliver of time to enjoy this wildly extravagant planet, and we spend precious moments of it, watching couples on TV compete for cash prizes on the basis of how many maggots they can eat. 

Until the maggot-eating is interrupted by somebody who wants to sell you an air freshener that uses an electronically operated fan to circulate chemical compounds around your living room to make you think you are out of doors. 

The fan is the latest advance in civilization which will enable you to stop feeding your Shiatsu little treats, which you previously had to do to get it to wag its tail to disperse the chemical compounds around your living room. 

So now you have to take Prozac, so you can get yourself up off the sofa where you have been sitting in a semi-catatonic state, watching the maggot-eating and dog-treating, out of your pajamas and into your four-wheel drive SUV, which you were compelled to purchase after viewing those commercials of SUV’s climbing over mountainous terrain beside raging rivers,

But which you happen to use to commute an hour and forty-five minutes on some freeway to work in a cubicle with a picture of mountainous terrain and raging rivers and some motivational caption underneath, so you can buy the air freshener with its self-contained and electrically-operated fan that disperses the chemicals that make you think you are out of doors, because you wouldn’t want actually to go out of doors – the air is so nasty from the fumes of your SUV.  Who is the crazy one around here? 

And don’t even get me started on the taxes you will pay from your job in your cubicle to fund somebody’s research into that missile that can shoot another missile out of the sky, to protect us from the bad guys who can bring down two 100-story buildings armed with the equivalent of a Swiss Army knife.  If it’s your job to figure out how to shoot that missile out of the sky, stop taking Prozac and go do something else to do with your life.  Or just go back to your sofa.  Please. 

Okay, now I sound like Michael Moore.  Let’s just call this the Crazy Delusion, a concept not original to me, and of which you can think of your own examples, so I don’t need to continue this rant which is not really the point of this book, but only the context of our consideration of the title of its first chapter.

In short –

It’s hard to know whether depression is a problem of distorted thinking or the result of clarity. 

In either case, sitting on the sofa in your pajamas does not turn the economic engine of this great nation, no matter what you’re watching.

Except for the pharmaceutical industry’s economic engine.  They keep making money, as long as they are able to sell you images of people who are happy and confident, popping their Prozac, (nowadays it’s Abilify), which you really start to believe when you’re still sitting on that sofa, watching those images over and over and over again. 

Ads For Antidepressants

Have you noticed how all the ads for antidepressants run during the afternoon soaps?  (If you are not depressed, you haven’t noticed, because you’re off at work, turning that economic engine.)  No, those pharmaceutical guys know where to find their audience, and when, on the sofa, in our pajamas, in the middle of the afternoon. 

Now I’m talking to you, the one in the pajamas.  You thought you might get up and go for a walk, like you promised your sweetie (who has gone to work) that you would.  But here it is, two o’clock in the afternoon.  The recap of yesterday’s episode comes on, and before you can find the remote to turn it off after the last soap, that theme song begins.  It sounds inspirational, but for some reason, you start to cry. 

After the theme song, and before the start of today’s episode, it’s time for that gentle, compassionate voice, who lists all your symptoms, including another one you have, now that the voice mentions it, but up until now you didn’t realize that it also is on the list, so you must be even sicker than you thought.  Who is that voice that understands you so well, better than your doctor, it seems, and so must know exactly what you need to ask your doctor to prescribe.

Symptoms Of Depression

Here is that list, by the way: sadness (no duh!), sleep disturbance (too much, too little ) weight gain (or loss), lack of energy, loss of interest in the things you used to like to do, loss of motivation (hence, all that time on the sofa), slowed pace, poor memory, poor concentration (they don’t want you at work anyway – you might break something), loss of self-confidence (like, they really don’t want you at work – you might break something), guilt, feelings of worthlessness, suicidal thoughts or attempts.

If you have been sad or lost interest in things for at least two weeks, plus four of the others, I’m talking about you.  You and 12% of the population who will experience an episode of depression sometime in their life (that’s major depression), plus another 6% who just feel lousy all the time (that’s dysthemia), and another 6.4 who sometimes are way up and sometimes way down (that’s bipolar), or …

One in twenty people in any given month.

When you have so much company, how is it you feel so alone?

You are not alone. 

Prozac Monologues 

photo of Playas del Coco by Helen Keefe, used by permission
photo of trash bags by Yuyudevil, in public domain
photo of Cubicle Land by Larsinio, in public domain
photo of prozac by Tom Varco, used by permission
photo "Loneliness" by graur razvan ionut

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

Sleep -- The Real Antidepressant

Your sink has backed up three times in as many weeks.  This time the plunger won't work, and it's beginning to stink.

The hardware salesman says you need a new garbage disposal -- $169.00.

Your plumber takes the pipes apart and clears the plug.  Depending on the plumber, she might show you how to do it yourself next time.  (My plumber is a woman.) -- $60.00 in my neighborhood.

Your brother says, stop putting banana peels in the garbage disposal.  (My brother owns rental property, and tells me what the plumbers almost always find in the plug.) -- $0.00.

The hardware salesman says a better garbage disposal could handle banana peels, and whatever else might also be causing that plug -- $249.00.

All of them are trying to help.  Each of them is working with the tools at his/her disposal.

Okay, now let's look at your depression.

Remember last week's list?

DSM On Depression -- The Chinese Menu

Why Antidepressants Don't Work

Diagnosing Depression

You go to the doctor complaining that you don't feel like yourself.  You aren't having fun, you are tired, you don't sleep well, you have no appetite and feel pretty worthless about your inability to exercise control over anything in your life.  Sometimes you feel like just ending it all.

Your doc asks whether you have a plan (sometimes you think about how you might do it), if anyone in your family has bipolar (not that you know of) and checks your thyroid and glucose levels.

DSM On Depression -- The Chinese Menu

But before the blood tests come back, your doc has already checked the magic list from the Diagnostic and Statistical Manual of Mental Disorders:

Column A:
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
Column B:
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Ding, ding, ding.  One from Column A, four from Column B. (Your weight loss has been too gradual to count.)  That is all the doc needs to write out a prescription for an antidepressant.  Zoloft is the latest favorite, being the newest.  But if your drug coverage is lousy, you get fluoxetine -- Prozac in its non-generic incarnation.

Depression As A Chemical Imbalance?


You are not sure you want to take an antidepressant.  But your well-educated neighbor assures you that there is no shame in it.  It's not your fault.  Depression is a chemical imbalance in the brain, and antidepressants fix the imbalance.
 


I call this the chemical stew theory.  Your brain is too bland.  Add some salt and you will be good to go.

What a great marketing technique.  It's simple.  It's morally neutral.  It's even kinda manly, if that's an issue for you -- chemistry, you know.  And your next door neighbor, whose education comes from TV ads, is part of a sales force which has been so effective that one out of every ten people in the United States of America is taking an antidepressant right now.

Too bad it hasn't worked out.

No -- Antidepressants Do Not Fix A Chemical Imbalance

There are a couple reasons (at least) why adding a chemical to the stew does not solve the chemical imbalance.

The first reason is that your brain is not a stew.  If you like the food metaphors (and as you can see, I like the food photos), adding a chemical to your brain is more like adding it to a souffle.  The chemical balance in your brain is finely tuned to a variety of interacting factors.  Changing one of the factors has multiple effects, not all of them intended, and not all of them so good for you.

For example, a souffle has fat in it.  Maybe the problem with your souffle is not enough fat.  But when you mix fat into the egg whites, the whole thing falls flat.

The second reason antidepressants fail to do their intended job is that they do not address the problem at the right location. The theory suggests you can fix the imbalance by increasing the serotonin in your synapses.  But scientists have figured out the problem occurs farther upstream.

Or at least that is what the scientists say who fund their labs with money from the pharmaceutical companies who still want to add a chemical to your brain, just maybe a different chemical than the ones whose patent protections have expired.

The Brain As Machine

The new meds are not going to work either, because they are working with, not a food, but a mechanical metaphor.  So second millennium!

Like this:



If only they can find the right place to change the course of the inevitable falling blade?  I don't think so.  Your brain is not a machine.

The Brain As A Living System

Here we go:


Your brain is a whole world.  Those who would tinker with it need to understand its ecology.

Put the internal combustion machine onto this planet, and the whole rest of it experiences the consequences.

Block serotonin from reentering your neurons, and your tear ducts and intestines dry up.  And your sex life.  Put enough of us on antidepressants and we could become an endangered species.

So if you want to do something about depression, if you have it or love anybody who has it, then you have to pay attention to the ecology.  Your interventions will have complex consequences.

And -- this would be a third reason and most intractable reason why antidepressants don't work -- the planet/body/brain/ecosystem is always working to restore balance to the system.  Up the serotonin in your synapses and eventually another part of the brain adjusts to overcome your interference.  In ecology this phenomenon is called homeostasis.  Psychiatry calls it Prozac Poop-out.

I kept complaining about insomnia, one of my Chinese menu choices that did not go away.  A psychiatrist told me my symptoms were caused by my depression.  Address the underlying depression and eventually the symptoms would be relieved.  Never mind about the symptoms that replace them.  Those symptoms are not on the depression menu, and have nothing to do with the psychiatrist.

A Twenty-First Century Approach To Depression?

But systems theorists tell us that any intervention will move the whole rest of the system.  This works in the environment, the economy, the workplace, the family dinner table.  And in the brain.

So what if we go back to that menu and devise some interventions that are not the equivalent of a chemical sledge hammer?

That brings me back round to last week's post about insomnia, when I promised that the next installment of my sleep series would be:

The Good News About Sleep Deprivation and Suicidality 

The good new is coming next -- implications for treatment of mood disorders and other causes of suicidal thoughts and behavior.

It just took me an extra week to get there.  So what else is new.  It's a Prozac Monologues series.

photo "Loneliness" by  Graur Razvan Ionut, from FreeDigitalPhotos.net 
photo of Chinese menu by Hoicelatina, permission to copy under the terms of the GNU Free Documentation License 
photo of bell by Salvatore Vuono from FreeDigitalPhotos.net 
representation of serotonin in public domain 
 photo of pote asturiano by jlastras and used under the Creative CommonsAttribution 2.0 Generic license 
photo of chocolate souffle by Akovacs.hu at the wikipedia project, who has released it to the public domain
representation of lactic acid in public domain
NASA photo of the Earth in public domain
photo of Anthia goldfish in public domain

Weighing Costs and Benefits Part V -- Down and Dirty Algorithm

SE + NE + $$$ + STG + TR = STC.

E#PT X NSR = STB.

STB TO STC = ODDS OF SUCCESS


There it is, the Prozac Monologues Down And Dirty Algorithm, to weigh your costs and benefits for medication or any other treatment for any mental illness, or any other medical condition, for that matter.  Click on the first and second lines.  They will take you to the posts that develop the formula.

Can you believe we finally made it?

We started with the:

Manifesto of a Lab Rat. 


I am a Lab Rat.  Yes, I am.

The Manifesto begins there.


It continues: 
 
If I am a lab rat, I will be a free-range lab rat.

What I mean by free-range lab rat is this: 

I insist that I contribute more to this enterprise than my body.

Your doctor tells you to weigh your costs and benefits, but gives you no way to do so, other than insufficient information + gut + desperation = noncompliance, if you don't come up with the same answer as your doctor.

What we need is an algorithm: logical rules that we can apply to objective data to solve a problem.

This algorithm does not exist.

So as an interested party, a very interested party, given that my body is the test tube, I decided that my contribution to this chemistry experiment would be the algorithm.

The problem we want to solve is this:

Do I Want To Put These Chemicals Inside My Body?

This task has continued over several posts this fall, interspersed with a few sick leaves and vacation days.  Click on costs and benefits to follow the whole development.  (The first post is at the bottom, dated August 19, 2010).

What To Do With The Algorithm

The resulting algorithm can be applied not only to the chemicals you put in your body, but any other form of treatment as well, talk therapy, aerobic exercise, yoga, Chinese medicine, acupuncture, even aroma therapy, should you choose.

You can compare the results of the cost/benefit analysis of different treatments, and do the same with various combinations, when you can find the numbers.  Which admittedly, you cannot for any of these that do not get Blue Cross Blue Shield reimbursement.

There are numbers out there for talk therapy and aerobic exercise.  But doctors do not usually use the word therapy for anything other than chemicals or electro-convulsive therapy (ECT) or any of those new-fangled electrical interventions.  That is the context in which you are told to weigh your costs and benefits.

For the most part, I have used antidepressants as examples.  One out of every ten people in the United States is taking them right now.  So this would be the most common application, among psychotropic medications.

It was helpful to look at chemicals as I developed this algorithm, because they are the form of treatment with the greatest costs and greatest variety of costs:





dizziness and confusion,





insomnia and fatigue,



weight gain, irritability, sexual dysfunction,  irritability.




So this is what you do when you use the algorithm to weigh your costs and benefits -- you compare two numbers, STC (Short Term Costs) and STB (Short Term Benefits).

And how do we get those numbers?

Remember,

SE + NE + $$$ + STG + TR = STC.
E#PT X NSR = STB.

The abbreviations increase the confusion quotient, and thus make it look scientific.  Here is a translation:

Side Effects (SE) plus Not Effective (NE) plus Money ($$$) plus Stigma (STG) plus [lack of] Trust (TR) are your costs (STC).  These costs are based on the reasons people give for discontinuing their medication.

Efficacy Given The Number of Present Trial (E#PT) times How Many Would Not Experience Spontaneous Remission Unless They Took the Medication (NSR) are your benefits (STB).

Did you like my illustrated tour of the previous posts?

And Where Are We Supposed To Get Our Data?

They ought to be provided to you by your doctor, who has told you to weigh your costs and benefits.  Except for money, stigma and trust -- you have to come up with your own odds that you will quit taking your medication because you can't afford it, you are afraid for your reputation, or you do not trust your doctor.

They ought to be provided to your doctor by the drug reps.

But they are not.

So you have to do your own research.

I think the algorithm would make a fabulous app.  The numbers could be regularly updated, from the latest research by scientists not funded by the companies that sell these chemicals.

I claim copyright, by the way. 

Long Term Costs And Benefits Are Missing

Notice that I refer to short term costs and benefits.  Some will object that I left out good reasons to take meds: the difference that meds make to how quickly another episode occurs (relapse rate), how long various approaches take to work (time to remission), how medications affect things like brain mass, suicide risk.

Others will object that I left out good reasons not to take them: the possibility that medication might accelerate the natural progression of the disease, the possibility that the diagnosis is off and you will flip into mania or hypomania, liver damage, the consequences of weight gain, such as heart disease and diabetes, suicide risk.

Someday I will do a post or two on that suicide risk issue.  There is a lot to say about that.

Well, this algorithm is complicated enough and took five posts already.  This one has that i-Pod potential.  The one that includes all those other issues will take more gigabytes.

STC versus STB give you the odds.

Once more I repeat, they do not give you your decision.  There are additional personal factors that influence or even override logical rules, objective data, and problem solving.

Personal Factors:

You have used up your sick leave, your vacation time and your family leave for this year and next, and your boss will fire you if you don't start taking meds.

Your wife has issued a similar ultimatum.

You can't get out of the loony bin any other way.

You are desperate.

You have the knife to the wrist.

Like I said, it is your decision.  I am merely your humble servant.  Who does occasionally buy a Powerball ticket.

How Does The Algorithm Work?

Let me give you a personal example.

When I first took Prozac, Eli Lilly's website said that it had helped 70% of the 55,000,000 who had already taken it.  I didn't know anything about spontaneous remission or the effect of which trial this was.  So STB = 70.

Meanwhile, none of the side effects (SE) reported went above the 15% range; the odds that it would not be effective (NE) were 30 out of 100; it was already generic, and I could afford it ($$$); stigma (STG) was not an issue for me; and I had total trust (TR) in my doctor.  So STC was 15 + 30 + 0 + 0 + 0 = 45.

That meant (with the information I had) that the odds for Prozac were 70 to 45 in favor.  And I could put off therapy.  No brainer.

Next up -- actually, five keep trying's later, we had moved on to a psychiatrist who prescribed Effexor.  Crazy Meds says: for deep, despairing clinical depression that needs to respond to the standard tweaking of the three most popular neurotransmitters, Effexor XR (venlafaxine hydrochloride) often pulls people out of the abyss.  By then, the deep, despairing abyss -- that would be me.

My doc said I get good results from Effexor.  She didn't say how good results translated to a number,.  (That's case studies, by the way -- not research.)  But she did tell me to weigh my costs and benefits.  By then I knew that most antidepressants have about the same effectiveness level, which I took to be around 40%.  I didn't know it mattered that I was on my sixth go round.  Odds for benefit, STB = 40%

She also gave me the usual side effects, because I asked.  Since insomnia was a major issue for me, and we had run through a number of sleep aids, she said that the insomnia risk (SE) was 15%.  Not effective odds (NE) would come in at 60 out of 100.  Since she didn't ever answer phone calls, and I knew I couldn't stop this med without help tapering off, and I was wary of her by now, I grilled her on how to discontinue without her help.  Trust, lack thereof, (TR) was in the 40% range.  STC was 15 + 60 + 40 = 115.

With Effexor, my odds were 115 to 40 against.  Not so good this time.  However, desperation overcame gut instinct.  So I kept trying.

The rules of the algorithm work, but the results are only as good as the objective data.  What if I knew then what I know now?  Without going into the whole story, and by tweaking numbers actually available: 

Prozac -- 

STB = 40 (E#PT) X .8 (NSR) = 32.
STC = 30 (SE) + 60 (NE) + 0 ($$$) + 0 (STG) + 20 (TR) = 110. 

110 to 32 against.  I still had issues with therapy (nothing to do with any therapist I have ever known, by the way).  And being over-educated, I am on the compliant side.  So I would have given it a shot. 

Effexor --

STB = 10 (E#PT) X .8 = 8.
STC = 34 (SE) + 92 (NE) + 0 ($$$) + 0 (STG) + 95 (TR) = 221.

221 to 8 against.

The numbers for Effexor come from the STAR*D study, and were available at the time I started taking it.  But I didn't know that.  STAR*D's original conclusion was that after two antidepressants have been tried, subsequent results are dismal, and more research for better medications should be a priority.

Since then, a jillion articles have been written about how STAR*D was a lousy research design that cooked the books in way favor of the chemicals at every step, starting with the selection of subjects.  Click here for my posts that reference STAR*D.  But Google it for for what the scientists say.

Anyway, 221 to 8 against -- I would have given it a pass.  Even I could tell the books were cooked.  And I got so much better after I went off it.

And So The Manifesto Of A Lab Rat Concludes

Of course, your results may vary.  Just remember, it's your test tube.




flair from Facebook
Photo "Tired Man" by graur codrin
Photo "Angry Father" by Akapl616.  Permission is granted to copy
under the terms of the GNU Free Documentation License
i-Pod family photo by Matthieu Riegler, licensed under
the Creative Commons Attribution 3.0 Unported license.png
photo of Warren G. Harding in public domain
photo of woman pointing taken by David Shankbone,
used by permission under the Creative Commons 
Attribution-Share Alike 3.0 Unported licence and modified
photo of prozac by Tom Vasco and is licensed under
photo of effexor by Parhamr who has placed it in the public domain
photo of John LeCompte of Evanescence by Samuel Lang,
permission to copy and modify granted under GNU Free Documentation License

Weighing Costs and Benefits Part IV: Costs

Some people quit taking meds that their doctors believe will relieve their symptoms of mental illness.  Why?

Because the meds don't work, because they can't afford them, because the meds make them sick.

Manifesto:

For any of these reasons, people who quit are making intelligent decisions in their own best interests.

On The Other Hand 

Sometimes the meds do work.  Sometimes people have decent health insurance with good drug coverage.  Sometimes the side effects are not as bad as the disease.  In that case, those who quit their meds are stupid.

Let's just get that right out front.

Moving On To The Costs

Today my series on weighing costs and benefits turns to the costs.  The costs do not tell you whether you should try a medication.  They simply give you the odds.  It is up to you to decide how you want to play the odds.  I calculate the odds based on the numbers of those who quit.  Those who consume have the best information about costs, what actually happens when they put these chemicals in their own particular test tubes.

How Many Of Us Are Noncompliant?

Out of 100 prescriptions that providers write, 10 consumers never consume.  They don't show up at the pharmacy at all.

28 consumers quit within the first month.  That includes those first 10.

50 quit within 60 days.

72 are outta there at six months, 78 within the year.

That leaves 22 compliant consumers.

How Do Noncompliant Consumers Explain Their Decision?

10 out of the 78 don't.  Providers failed to close the sale.  Providers would be interested to know why these 10 are pharmacy no shows, because it might help them improve their pitch.  Their assumptions are that it was because the consumers didn't understand, or the providers didn't establish trust, or that good old back up -- stigma.  But often, consumers don't report their decision.

We could invent reasons, which might be fun, top ten list, that sort of thing.  The drinking buddy said, Buck it up.  Real men don't get depressed.  The transmission fell out of the car on the way to the drug store.  My favorite -- the primary care physician said, Are you kidding?  With your blood glucose and lipid levels?  Does this so-called doctor even own a blood pressure cuff?  However, all this speculation is just that.  These 10 do not give us information about the costs of taking the medication, because they never take it.

So now we have 68 consumers who quit after they tried the meds.  AK Ashton et. al. actually asked them why.

30 (out of the 90 who actually filled the prescription) say they quit because they could not tolerate the side effects.

30 say the medication was not effective.

That already adds up to 70 nonconsumers, counting the nonstarters and leaving eight who quit for other reasons.  I will suggest some of these other reasons, and you will have to come up with the odds yourself that any of them might put you among these 8.  (They may have reasons similar to the 10 who never started.)

And by the way, these numbers vary by how many different medications the consumer has already consumed, which primarily affects the efficacy number.  They also vary by which medication is currently being considered, primarily effecting the side effect number.

We don't have all the numbers we need.  Somebody needs to be collecting this data.  A consumer group, looking at real world data over the course of a year, not the guys with 6-8 weeks of information, seeking FDA permission and doctors' cooperation to sell pills.  But the algorithm itself will work for whatever the numbers turn out to be. 

Let's Start With Side Effects

30 of the 68 who consumed and quit say they quit because of side effects.  The clinical trials, lasting eight weeks or so, report much lower numbers.  The numbers the providers give you are from the clinical trials.

The common belief among providers is that they could improve compliance by giving consumers more information up front about side effects.  Small isolated studies sometimes confirm this over the short haul.  But this belief does not stand up to more research and more time.

Up front discussion of side effects can give the consumer strategies for dealing with insomnia, reducing nausea, preventing falls when they get out of bed.  These are the side effects we notice immediately.  Maybe they are tolerable if you have social supports to get you through the roughest first weeks.  Sometimes your body does  acclimate, and the immediate side effects become less bothersome.

But sometimes these strategies don't work.  Social supports wear out.  Mom has to go home and stop helping you with the kids.  You run out of sick leave.  The body does not adjust.  And sometimes these side effects are indications that you are taking the wrong medication!

But the major side effects appear later.  Which are the most bothersome?  The results: weight gain (31%), erectile dysfunction (25%), failure to reach orgasm (24%) and fatigue (21%).

Weight gain -- a few pounds in the first few months are not a problem.  You hardly notice.  But over the months, when you are moving from overweight to obese, you get a reality check on what this medication really costs.  Morbid obesity takes 8-10 years off your life.

Tell that to your psychiatrist when you complain and he/she says you have to weigh your costs and benefits.  Your doctor may not even know about how serious the health risks of obesity are.  Obesity even increases the risk of dementia.  But psychiatrists treat psychological problems with pharmacology.  They do not treat your heart, pancreas or liver.

Then there are the sexual side effects.  When you started the medication, you weren't getting much anyway.  That was one of the symptoms -- loss of interest in formerly pleasurable activities.  But six months later when you're not getting any, you (and your partner) recalculate your costs and benefits.

Hence, these noncompliance numbers go up over time.

Side Effects In The Algorithm

The major competition between makers of psychotropic medications has always been on this side effect issue.  It turns out, we just won't keep taking stuff that makes us feel worse.  So sometimes you can find studies that pit one against the other and get real numbers about side effects.

STAR*D found that in just 8 weeks, a combo of lithium/sertraline (Zoloft) got an intolerable rate of 45%, 2-5 times any other treatment.  Effectiveness rate -- 9%.  I wonder how many of the 91% who didn't get better would have been better off if they had taken nothing at all.

Or to put a finer point on it, did lithium/sertraline make matters worse?  They didn't test against placebo, so we don't know.

If the odds of harm are five times the odds of help, I will give it a pass.  That is like rolling the dice, looking for one particular number.  Only it's not dice; it is my body.  That is my personal decision, made after my eighth trial.  It is up to you how you play the odds.

For the sake of the algorithm, SE means the odds that you will quit taking this medication within a year because of side effects.

Efficacy -- What If It Just Doesn't Work?

We already discussed effectiveness in detail on September 2, Weighing Costs and Benefits Part II: Benefits.  Go back there for the details.  It makes more sense if you know the back story.  In summary:

Efficacy for Number of Present Trial (E#PT) means how many people got better with this med after they tried a number of others that didn't work.  Non-Spontaneous Recovery Rate (NSR) means how many people would not have gotten better if they had simply waited for the depression to go away on its own.  Efficacy for Number of Present Trial times Non-Spontaneous Recovery Rate equals Short Term Benefit (STB).  Those are the odds that it will work.

Or, E#PT X NSR = STB.

The abbreviations are there to make me look smart.  Which, as a matter of fact, I am.  Some days, I can make the smart parts of my brain connect  again and actually work smart.

Another way of looking at it: STB is a number between 1 and 100.  That many times out of a 100 are the odds that you have come up a winner.

So then the odds that the medication will not work are 100 minus Short Term Benefit.  We will call that Not Effective (NE)100 - STB = NE.  You have wasted your time, and are more discouraged than ever.  Bummer.

Now you may have noticed, the algorithm calculates the Short Term Benefit for eight to twelve weeks.  And the Short Term Cost refers to one year.  Why the difference?  Because you will likely be one of the early quitters (50%) if you don't get relief by twelve weeks.  And if you do get relief by then, you are likely to keep taking the medication for a year.  It may quit working for you eventually.  But you are probably good to go for a year.  Hence, twelve weeks for STB and twelve months for STC are probably equivalent measures.

Efficacy -- What About Those Who Quit Before They Gave The Medication An Adequate Trial?

I did not consider how many reported that they discontinued because the medication was ineffective, the 30 out of 90 that Ashton, et al, discovered in their survey.  This number is not helpful, because some of these 30 quit before the full 60 days needed to determine efficacy.

Instead, I used the efficacy numbers reported from the clinical trials.  As a result, those 8% discussed below is a larger group.  It would include the early quitters, because some of them might have gotten better if they had been more patient.

But these numbers are for illustration purposes only.  The algorithm is designed to be general, so that you can insert whatever the numbers turn out to be.

If you quit simply because the medication does not work faster than it works, and for no other reason, then you go into the stupid category.  Just to get that right out front.

Other Costs

8% (plus) quit taking the medication primarily for other reasons.  I expect that money, stigma and trust are the the big ones, with stupid in there, too, as stated above.

Money

Let's face it.  These medications cost money.  There are two costs to consider.  The first is the pills themselves.  The provider may provide you with samples, if yours is the newest wonder drug being promoted this week.  The samples likely last for two or three weeks.  This is good, if it helps you determine early on that there is no way you can tolerate the medication, even long enough for some of the side effects to become less troublesome.

On the other hand, it does not help you determine whether the medication will be effective.  That takes more time and your own money, a lot of it, if yours is the newest wonder drug being promoted this week, which you can count on, if you have failed to prove your provider a genius by getting better with his/her first or second choice.

If you have a good drug benefit, cost of medication may not be a major issue.  I now get my generics for free.  I represent a very, very small portion of the U.S. population.

I used to have insurance with a high deductible and mediocre drug benefits.  After the samples ran out, I paid $120 for a two month supply from a company that required I buy from them by mail order.  By the time the pills arrived, I had already discovered I couldn't tolerate the med.  I never even opened their bottle.  Meanwhile, I had to pay through the nose at my local pharmacy for the two weeks it took me to taper off.

In addition to the medications, you will pay for medical management, trips to the provider who will monitor your condition and tweak the chemistry experiment.

Again, these costs will vary by insurance plans and whether you have insurance at all.  With my current insurance, I pay $5/visit.  In my previous plan, I paid $40.  If I had no insurance at all, the cost would be $135.  And I see my doc every six weeks on average.

I cannot assign a number to the odds that you will quit a medication because of how much money it will cost you.  That is your call. Out of 100, what are the odds that you will quit because you cannot afford it?  We will call that $$$ in the algorithm.

Stigma

Okay, if you have made it this far through the Costs and Benefits series, you ought to be motivated enough to resist those who shame you (including yourself) for relying on a pill, for being weak, for being sick... whatever garbage they throw at you and you throw at yourself.  Please let's get over it.  I hope your stigma number is low.  But again, that is your call.  Out of 100, what are the odds you will quit for reasons of stigma? -- STG.

Trust

Next, out of 100, what are the odds that you will quit because you cannot find a provider you trust with your body, or because you think the pharmaceutical industry is corrupt? -- TR.

Stupid

Stupid is a side note.  Providers prescribe the medication because they already believe that the benefits outweigh the costs.  So they expect the stupid category is a large proportion of the noncompliers.   Only they call it confused.

Stupid is irrelevant to the algorithm, which is designed to weigh costs and benefits.  So stupid (or confused) is not in there.  Like stigma, stupid can be fixed.  But it is not a cost.  It is a prior condition.

Down And Dirty Costs

So now we simply add the odds of each of these costs together:

Side Effects plus Not Effective plus Money plus Stigma plus Trust (lack thereof) equals Short Term Costs.

SE + NE + $$$ + STG + TR = STC.

So How Do You Decide?

STC versus STB give you the odds.  Once more I repeat, they do not give you your decision.

We will look at a couple other issues and pull this all together in our next installment.  Whew.  My brain is about to explode.

Flair from Facebook
Clipart from Microsoft
Photo of die by Roland Scheichder, in the  public domain
Photo "Solution" by Salvatore Vuono
Photo "Angry Father" by Akapl616.  Permission is granted to copy
under the terms of the GNU Free Documentation License
Photo of "Tired Man" by graur codrin
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Photo "Loneliness" by graur razvan ionut 
Photo of Pristiq by Tom Varco.  Permission is granted to copy
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Mademoiselle Zizi Feints at Fainting, by John Sloan

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