I just had this weirdo idea. I saw a commercial the other day for Nasacort, which is now over-the-counter. This is awesome. I have seasonal allergies, antihistamines make me groggy, sudafed makes me jumpy, so every year I have to procure some prescription flonase. And now I don't.
Here's my idea. What if SSRIs were sold OTC? What would that be like?
I poked around online to try to find out if SSRI's are sold OTC anywhere, currently. Maybe India, China, Mexico. I could not find any current information-most recent was 2009.
So I'll have to stick to the fantasy. What would that be like?
In medical school, they taught us that the best down-and-dirty way to find out if a patient in a primary care setting was depressed was to ask, "Are you depressed?" Embedded in that is the notion that people know when they're depressed.
So maybe you'd realize you were depressed, and then you'd mosey on down to your local drug store and pick up a pack of zoloft, along with a birthday card for your niece and a couple of pieces of bazooka gum.
Maybe people would take SSRIs PRN, like tylenol. Maybe this would help with PMDD (I still find it hard to believe that women who take SSRI's for PMDD don't end up with withdrawal symptoms each month, even if the PMDD effects do work via a GABA-ergic mechanism).
Maybe people who weren't depressed would take them. Maybe they'd feel sad that they're hamster died, and think, Oh, I'm bereaved and depressed, I should take prozac.
Maybe there would be more suicides. Maybe there would be fewer. Maybe there would be more work days lost due to side effects and withdrawal. Maybe there would be fewer work days lost due to depression. Maybe there would be more substance abuse. Maybe there would be less.
Maybe people would be emotionally disengaged and spend hours on Facebook and Twitter and playing League of Legends online without ever leaving the house to see their friends. Oh, right, that already happens. Maybe because SSRI's are so freely prescribed by primary care providers.
Maybe there would be fewer starving people in the world, because those taking SSRI's would stop having sex and reproducing, and the population of the planet would be contained.
Maybe people would begin to realize that pills won't fix their character pathology or their interpersonal problems. Maybe more people would make use of therapy. Maybe insurance companies would be forced not to find sneaky ways to withhold reimbursement for therapy.
Maybe the reason I have so much conjecture about what would happen if SSRI's were freely available to whoever wants them is because not much is actually known about what they do. Or more accurately, they do so many things, or are SUPPOSED to do so many things, that it's hard to tell what they are and aren't doing.
Showing posts with label SSRIs. Show all posts
Showing posts with label SSRIs. Show all posts
Sunday, March 9, 2014
Wednesday, October 23, 2013
Book Review, Sort Of
I just finished reading David Healy's Let Them Eat Prozac.
In it, he takes a passionate position on the adverse effects of SSRI's, particularly with respect to suicidality. While initially convinced that prozac did not induce suicidality, Dr. Healy was subsequently an expert witness on several suicide/homicide lawsuits related to SSRI use. While researching those cases, he had more data made available to him, and was then convinced that SSRIs significantly increase suicidality. The supporting data include:
*Re-evaluations of results from SSRI studies
*Cases in which patients were started on an SSRI, became akathetic and agitated, stopped the SSRI, improved, then were subsequently restarted on the SSRI (or other serotonergic drug) and deteriorated once more (challenge/dechallenge/rechallenge, which is how causality can be established)
*Internal Memos from Lilly, which stated things like, "We know prozac causes a 5.6 times greater risk of suicidality than placebo, so we need to figure out how to deal with it, and specifically, how to figure out which patients will benefit from Prozac."
*His own trial of and SSRI in healthy volunteers, in which suicidality emerged
*Early studies in which subjects who developed akathisia and agitation on Prozac were either removed from the study, or given benzos for those side effects, essentially demonstrating that benefits in the study may have been from benzos, rather than Prozac.
*The fact that the BGA (the German equivalent of the FDA) did not approve fluoxetine, claiming that it was not sufficiently effective, and that it induced akathisia and agitation in patients, and ran the risk of inducing suicidality. Fluoxetine was approved in Germany a number of years later, under what appears to be powerful political pressure.
What I liked about the book is the fact that, despite how strongly Dr. Healy feels about this subject, and despite the fact that he lost a job because of his opinions, he still doesn't assume a conspiracy took place. Rather, he makes a case for a series of bad decisions, bad luck, predictable greed, overall good intentions, and selective blindness.
I also liked the fact that he is not advocating a complete moratorium on SSRI use. He believes, and this confirms my clinical impression, that there are subgroups of patients, some of whom do well on SSRIs, and others who don't. He advocates for research to figure out how to predict which group a given patient will fall into. He also advocates for research to specifically examine suicidality in SSRI use, and points out that, remarkably, no such study has been undertaken.
What I didn't like about the book was that his arguments are sometimes difficult to follow, causing me to question his conclusions, My impression, in general, though, is that the dude knows his stuff.
This is only "sort of" a book review because I'm including a link to his paper, Antidepressants and Suicide: Risk-Benefit Conundrums, as part of the online journal club The link is from his site, and another thing I like about his work is that he encourages open sources, and provides links to publications.
He's written more recent papers on this topic, but this one, in particular, summarizes what he covered in Let Them Eat Prozac, although the paper is for a professional audience, while the book is more for a lay population.
This is a table from the paper:
Note that on Placebo, there were 2 completed suicides, and 21 suicide attempts, on Active Comparators (e.g. TCAs), there were 5 completed suicides, and 24 attempts, and on All SSRIs, there were 23 completed suicides, and 186 attempts.
I'm very curious to hear people's evaluations of his statistical methods, so please comment.
In it, he takes a passionate position on the adverse effects of SSRI's, particularly with respect to suicidality. While initially convinced that prozac did not induce suicidality, Dr. Healy was subsequently an expert witness on several suicide/homicide lawsuits related to SSRI use. While researching those cases, he had more data made available to him, and was then convinced that SSRIs significantly increase suicidality. The supporting data include:
*Re-evaluations of results from SSRI studies
*Cases in which patients were started on an SSRI, became akathetic and agitated, stopped the SSRI, improved, then were subsequently restarted on the SSRI (or other serotonergic drug) and deteriorated once more (challenge/dechallenge/rechallenge, which is how causality can be established)
*Internal Memos from Lilly, which stated things like, "We know prozac causes a 5.6 times greater risk of suicidality than placebo, so we need to figure out how to deal with it, and specifically, how to figure out which patients will benefit from Prozac."
*His own trial of and SSRI in healthy volunteers, in which suicidality emerged
*Early studies in which subjects who developed akathisia and agitation on Prozac were either removed from the study, or given benzos for those side effects, essentially demonstrating that benefits in the study may have been from benzos, rather than Prozac.
*The fact that the BGA (the German equivalent of the FDA) did not approve fluoxetine, claiming that it was not sufficiently effective, and that it induced akathisia and agitation in patients, and ran the risk of inducing suicidality. Fluoxetine was approved in Germany a number of years later, under what appears to be powerful political pressure.
What I liked about the book is the fact that, despite how strongly Dr. Healy feels about this subject, and despite the fact that he lost a job because of his opinions, he still doesn't assume a conspiracy took place. Rather, he makes a case for a series of bad decisions, bad luck, predictable greed, overall good intentions, and selective blindness.
I also liked the fact that he is not advocating a complete moratorium on SSRI use. He believes, and this confirms my clinical impression, that there are subgroups of patients, some of whom do well on SSRIs, and others who don't. He advocates for research to figure out how to predict which group a given patient will fall into. He also advocates for research to specifically examine suicidality in SSRI use, and points out that, remarkably, no such study has been undertaken.
What I didn't like about the book was that his arguments are sometimes difficult to follow, causing me to question his conclusions, My impression, in general, though, is that the dude knows his stuff.
This is only "sort of" a book review because I'm including a link to his paper, Antidepressants and Suicide: Risk-Benefit Conundrums, as part of the online journal club The link is from his site, and another thing I like about his work is that he encourages open sources, and provides links to publications.
He's written more recent papers on this topic, but this one, in particular, summarizes what he covered in Let Them Eat Prozac, although the paper is for a professional audience, while the book is more for a lay population.
This is a table from the paper:
Note that on Placebo, there were 2 completed suicides, and 21 suicide attempts, on Active Comparators (e.g. TCAs), there were 5 completed suicides, and 24 attempts, and on All SSRIs, there were 23 completed suicides, and 186 attempts.
I'm very curious to hear people's evaluations of his statistical methods, so please comment.
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