Thursday, June 16, 2011

Drug Companies and Psychiatrists: The Economics of Mental Illness

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

Here we provide yet more provocative considerations arising from Robert Whitaker’s fascinating, but frightening book: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Whitaker tells the tale of ineffective and dangerous drugs foisted on the public in the guise of “treating” mental illness. He attributes the epidemic in mental illness to the increased use of psychoactive drugs that do more harm than good. He points out that mental illness used to be rare, episodic, and usually self-correcting. He makes a compelling case for the belief that psychiatrists, aided and abetted by drug companies, redefined mental illness into something common and widespread, thus gaining themselves access a large pool of “patients” on whom they can experiment with their drugs. Under their guidance, mental illness is now common, chronic, and almost completely debilitating.

In 1980s the American Psychiatric Association produced a document called the Diagnostic and Statistical Manual (version III) that would provide the basis for proceeding along a drug-driven path. This volume identified (created?) 256 mental disorders. It listed symptoms and provided guidance on making diagnoses. This gave psychiatrists and drug companies multiple new opportunities for drugs and drug prescribing. One of the “conditions” identified for the first time was “panic disorder.” Naturally there was a rush to provide a drug for this malady. In 1981 Xanax (alprazolam) was approved by the FDA for use against anxiety. Upjohn then set out to get it approved for “panic disorder.”

Whitaker uses the clinical testing of Xanax as an example of what passes for science in the psychiatric drug business. Whitaker begins by telling us how drug companies bias the selection of the participants in the study in order to emphasize the beneficial effect of the drug. For our purposes here we can ignore that for now because the results will be sufficiently outrageous without considering that bit of chicanery. Here are results that the author extracted from the scientific literature.

Some measure of panic symptoms was plotted against time for subjects who were taking the drug and subjects who received a placebo. Between weeks eight and twelve those on the drug had the dosage gradually reduced to zero. The results are startling.

“In sum, at the end of fourteen weeks, the drug-exposed patients were worse off than the placebo group: They were more phobic, more anxious, more panic stricken, and doing worse on a ‘global scale’ that assessed overall well-being. Forty-four percent had been unable to get off the drug, on their way to a lifetime of addiction....The first few weeks of relief came at a very high long-term cost, with those stuck on the drug....likely to end up physically, emotionally, and cognitively impaired.”

Incredibly, the FDA approved this drug as a treatment for panic disorder in 1990. How Upjohn paid researchers to taint the scientific literature with misleading conclusions, and why the FDA would consider unleashing it on an unsuspecting (and trusting) population are subjects for another day. What we are concerned with here is consideration of what might be the motive of Upjohn in trying so hard to get a harmful drug into the marketplace.

First, let us allow Whitaker to introduce us to a psychiatric victim named Jeena. Jeena had been a normal active child. She suffered an episode of seizures when in the second grade. She reacted very badly to an anticonvulsant that was prescribed, but the seizures went away and the side effects left also when she was taken off the drug. For ninth grade she was sent away to an elite boarding school where she began to have “behavioral and emotional” problems. Kicked out of the first school, she was sent to one for troubled teens. The social troubles there continued and she ended up getting arrested for a minor shoplifting incident. That got her shipped to another school where she was prescribed Paxil (paroxetine), an antidepressant. According to Wikipedia:

“....paroxetine is associated with clinically significant weight gain and statistically significant increase in the risk of suicidal thoughts in adults. Pediatric trials of paroxetine for depression did not demonstrate statistical efficacy better than placebo and showed an increase in the risk of harmful outcomes, including episodes of self-harm and suicidal thoughts.”

You can guess that this is not going to end well.

“’The minute she takes the drug she starts shaking,’ her mother said. ‘I tell the doctor, “Oh my gosh, it is from the medicine.” The doctor says “Oh no, it’s not the medicine.” I said “Yes it is.” We went from one doctor to another, doing test after test, but they couldn’t find anything and so they kept her on medications, which made everything worse. They just wouldn’t listen to me’.”

What Jeena was experiencing resulted from the fact that modern psychiatrists seem to be unable to do anything but subscribe medications.

“In addition to the tremors, Jenna became suicidal while taking Paxil, and soon her life transformed into a psychiatric nightmare. She began cutting herself regularly, and at one point, she used an electric saw to take off the middle finger on her left hand. The Paxil gave way to cocktails of Klonopin, Depakote, Zyprexa, and other medications, and during a nearly four year stay in a psych hospital, she ended up on a cocktail of fifteen or so drugs, so doped up that he didn’t even know where she was.”

The thought that the medications had made her worse rather than better was never seriously entertained by her doctors, although in her words she pleaded to be taken off them “billions of times.”

The point Whitaker makes by introducing the reader to Jeena is that hers is not an unusual case. People who fall into the modern psychiatric trap often spend the remainder of their lives disabled and doomed to a drug regimen.

“....provided me with the details of Jeena’s daily cocktail: two antidepressants, an antipsychotic, a benzodiazopine, a Parkinson’s medication, and three others likely related to the psychiatric drugs. Later, I calculated that even if generics were prescribed whenever possible, she was consuming $800 of medication monthly, or $10,000 annually. She had been on psychiatric medications for twelve years, which meant that her Rx bill for psychiatric medications might already have surpassed $100,000, and given that she will likely remain on the drugs for the rest of her life, this bill could eventually end up well north of $200,000.”

After that lengthy aside, let’s return to the topic of Xanax and why a drug company might deliberately market something that would be harmful to its consumers. GM wouldn’t sell a car that didn’t perform well and that would injure a great many of its customers. Boeing wouldn’t design a plane that was likely to crash in the first year of service. Drug companies have apparently found themselves a niche where product quality and customer satisfaction are not an issue.

In terms of business models, the narcotics trade provides the closest analogy. Narcotics provide no lasting benefit, they are addictive, and the cash flow is enormous and never ending. As my anger and outrage at the practices Whitaker describes in his book ebb and surge, I occasionally derive some juvenile satisfaction from viewing CEOs of drug companies as the equivalent of Columbian drug lords, and psychiatrists as street hustlers peddling their wares in dark places.

In calmer moments, I realize that psychiatrists do not go to medical school in order to learn how to torment sick people. They must actually feel that they are performing a useful service. They are in a profession where they are surrounded by colleagues who have been taught the same things, and who provide reinforcement for their belief that they are taking the appropriate actions for their patients. However, as in all professions, there will be some who will be seduced by easy money and become shills for the drug companies.

It is hard to be lenient with the drug lords. These companies have a history of misleading the public, the FDA, and medical providers about the efficacy of their product. They have no problem breaking the law, issuing bribes, and misrepresenting research. Let us consider how much money is on the table.

This chart indicates how many people have entered into long term disability due to mental illness.

As of 2007 the number was around four million. And if the slope doesn’t convince you that something has gone terribly wrong, then you really do need to read Whitaker’s book. Now let us remember Jenna’s history. Her treatment will easily exceed $200,000 over the course of her lifetime. The chart tells us that there could be as many as four million Jennas out there, with more coming every day. A million Jennas would cost the nation $100 billion just in drug costs. That is a lot of money—enough to assist in the rationalization of almost any kind of behavior.

Getting back to Xantac, how might Upjohn rationalize putting it on the market? Since none of the drugs in this arena seem to be of much value, they would only be replacing one bad drug with another. What’s the harm in that? If it is addictive, isn’t that just another nasty side effect? All the drugs have withdrawal issues—so what’s new? And then there is the ever popular: “If there is a problem, then we will treat it with another drug, just like we always do.” If there is enormous wealth available, and you surround yourself with a supportive community, there is nothing that one cannot find a way to justify. And remember, these are not the people who have to wipe up vomit, or call parents and tell them that their child has just committed suicide.

It is really not that surprising that the drug companies would conduct themselves in the manner that they do. History provides too many examples for us to allow ourselves to be surprised.

Perhaps the fault lies with the general public. For some reason, people just assume that doctors are honorable, intelligent, well-educated, and always working in the best interests of the patient. Most of them are. The mistake is in assuming that psychiatrists are the same as “real” doctors. A medical doctor will have a good idea about what needs to be done when confronted with a bacteria or a virus or a cancer. These things are understood and have known treatments. Psychiatrists have reduced themselves to pill-pushers and rejected any kind of social approach to mental problems. Unfortunately, they are claiming to be treating something about which they have no knowledge. There is no physical understanding of mental illness. The best they can do with their drugs is trade one set of symptoms for another set of symptoms. Since they cannot cure anything, they need a continual flow of new drugs to make people forget that their old promises were false. They could not exist as a discipline without the drug companies.

This unholy alliance will continue. The drug companies will continue to crank out drugs and the psychiatrists will continue to provide them with scientific cover. They have no other choice. Both groups will continue to rake in the money, and we will wander around aimlessly trying to figure out why health care is so expensive.

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