Tag Archives: ECT

Stimulants in Childhood, the actual cost of pharmaceutical ingredients, and other heresy

What’s New

jock_suitFirstly, my apologies for taking so long to get this back on track, we moved to our new house at the end of November so I spend my weekends barrowing dirt around the place. I’ve also rather foolishly agreed to work part-time for the local mental health service as they were short of staff. Now I know why they’re short of staff. Actually, it’s good experience, I’ve been out of the government for nearly twenty years. If anything, government mental health services are worse than they were back then.

Stimulants in Childhood

The medicalisation of childhood proceeds apace. A report from the US Center for Disease Control, published in the Journal of the American Academy of Child and Adolescent Psychiatry (November 2013) showed that the numbers of American children taking stimulants continues to rocket: “11% of 4-17yr olds were reported by their parents to have received an ADHD diagnosis from a healthcare provider, a 42% increase from 2003-04 to 2011-12.” This translates as 6.5million children, with over half of them (3.5mln) taking highly addictive drugs during their formative years. Needless to say, the rates of this “genetic disease” vary quite dramatically, from as low as 4% in Nebraska to 15% in Arkansas and Kentucky. In 1977, there were 400,000 children in the US taking these drugs; I remember that figure because in that year, there were 400 children in the Netherlands taking them. By 1990, it was 600,000 and the numbers just keep going up. Fortunately, it is starting to dawn on some of the experts that this isn’t necessarily a good thing. One of them, Prof. Keith Connors, a psychologist at Duke University and developer of the widely used rating scale bearing his name, said: “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”

In fact, genetic diseases don’t increase by 900% in one generation, so something else is happening. For an example of that “something else,” look no further than this gem: a New Disease. Not satisfied with snagging 15% of the juvenile population and putting them on drugs, at a national cost of about $9billion a year, the bounds of pathology are to be stretched again, further eroding the concept of normality. Psychiatrists and psychologists have decided that the quiet little day-dreamers in school are mentally ill: “Called sluggish cognitive tempo, the condition is said to be characterized by lethargy, daydreaming and slow mental processing. By some researchers’ estimates, it is present in perhaps two million children.”

It is early days yet, though, and people involved in the push to have this condition recognised as a mental disorder are still working out the diagnostic criteria. One author, who has put the condition in Wikipedia, defined the symptoms as: “prone to daydreaming, difficult staying awake or alert in boring situations, easily confused, easily bored, spacey or in a fog, lethargic or more tired than others, underactive or less energy than others, slow moving, don’t process information as quickly or accurately as others.” The same author “has also published a symptom checklist for mental health professionals to identify adults with the conditions; the forms are available for $131.75 apiece.”

Needless to say, Big Pharma is watching closely, ready to offer their usual drugs to help the sufferers. At $10.00 a day per child, it would be a windfall of $7billion a year for the drug companies, especially as it would cost nothing to ramp up production. But who would get the drugs? Bored children? I was bored senseless for twelve years of school, and couldn’t stay awake in university lectures. I was certainly a day-dreamer and underactive at school because I worked six days a week and studied late each night. But it would also snare all unhappy children, children who were kept awake half the night by brawling or drunken parents or who didn’t get a proper breakfast, children who were cold, sick, partly deaf, nervous of the teachers or the other children and so on.

It’s just another example of psychiatrists needing to invent a new disease if they want to get fame and lots of research grants from the drug companies.

The Actual Cost of Pharmaceutical Ingredients
Talking of drug companies, a lady called Sharon L Davis, a Budget Analyst at the US Dept of Commerce, put an article on line regarding the actual cost of ingredients used to produce standard medication. Here are some of her figures:

 

Drug name

Dose

Consumer price (100 tablets)

Cost of active ingredients

Percentage markup

Celebrex

100mg

$130.27

$0.60

21,712%

Claritin

10mg

215.17

0.71

30,306%

Keflex

250mg

157.39

1.88

8,372%

Lipitor

20mg

272.37

5.80

4,696%

Norvasc

10mg

188.29

0.14

135,493%

Paxil/Aropax

20mg

220/27

7.60

2,898%

Prevacid

30mg

44.77

1.01

4136%

Prilosec

20mg

360.97

0.52

69,417%

Prozac

20mg

247.47

0.11

224,973%

Tenormin

50mg

104.47

0.13

80,362%

Vasotec

10mg

102.37

0.20

51.185%

Xanax

1mg

136.79

0.024

569,958%

Zestril

20mg

89.89

3.20

2809%

Zithromax

600mg

1482.19

18.78

7,892%

Zocor

40mg

350.27

8.63

4,059%

Zoloft

50mg

206.87

1.75

11,821%

Two things to remember: First, I can’t vouch for her figures but they are probably reasonably accurate. The actual cost of the active ingredients in medication is trivial. If you buy Winthrop Panadol in the supermarket, you will pay about 25c per tablet. If you buy the same ingredient (paracetamol/acetaminophen) in the cheap version, you can get them for under 2c per tablet. That’s 1050% more for exactly the same drug, possibly made in the same factory. In Asia, those drugs sell for about 0.5c per tablet and still make a profit. In the US, Walgreens sell Tylenol for about $0.36 a tablet while their own brand acetaminophen sells for 11c a tablet, only about 330% markup. 

Second point: in the US, drug prices are protected by the Medicaid amendments pushed through by the Bush Administration. This blocked government agencies from using their purchasing power to get lower prices of drugs, as happens everywhere else in the world. Those prices are much higher than anybody pays in Australia, Canada, the UK etc, but the profits are still outrageous. Also, all consumer prices of drugs in Australia are capped at $37.50 per prescription, so it doesn’t matter how much it costs the government, the patient pays only that amount. Pensioners pay a maximum price of $6.20 per script regardless. I’ve put more of these details in an article in Truthout (and don’t tell me about the error in the title, I know).

The Question of ECT

We have just gone through the drama of two states amending their mental health acts. I’ve mentioned West Australia before, they had the brilliant idea of permitting psychosurgery for children twelve and over if the child consented. Not the parents, they didn’t get a look in. If the child’s psychiatrist certified that his patient was sufficiently mature to understand the nature of the operation, then it could go ahead, even against parental wishes. Fortunately, that bit of lunacy was dropped but the battle then moved to ECT. I sent this letter to every politician in the Victorian and West Australian parliaments arguing that they should oppose any move to loosen restrictions on ECT. It helped but wasn’t entirely effective:

People who advocate wider use of electro-convulsive therapy (ECT) often point to the position statement issued by the Royal Australian and New Zealand College of Psychiatrists to justify their views. Despite the widespread misunderstanding, this is not a scientific statement; it is a consensus opinion derived by an overtly political process. It draws on some scientific facts but not all.

“The statement asks a series of questions such as whether it is safe (generally) and effective (in the short term) or who should do it but the one question it does not pose is this: Is ECT necessary? It must be understood that many psychiatrists do not use it at all, that its use varies dramatically from one hospital to another, or one part of the country to another. Some practitioners use it so commonly that it is almost routine; others, practicing in the same setting seeing a similar if not identical population of patients, never use it.”

I have practiced psychiatry in some of the most difficult parts of this country for 37yrs without using ECT. In two hospitals to which I was appointed chief psychiatrist, one for five years and one for three, ECT was used prior to my taking up my appointment. It was not used for the time I was in charge, then it was started again some time after I left. This says that while ECT is a treatment option, it proves emphatically that ECT is not “(an) essential treatment option that should be available to all patients in whom its use is clinically indicated.”

“For some practitioners, ECT is close to the first treatment option considered. For many others, treating the same types of cases, its use is never “clinically indicated.” It is of interest that in both hospitals, during my total of 8 years as chief, the admission rates, bed occupancy rates and duration of stay all dropped, only to rise again after I left. This is despite the lack of use of ECT. The notion that ECT achieves some therapeutic goal not available by other means is simply not true in my experience.

The RANZCP statement on ECT says that patients should give informed consent. Strictly, this should include patients being told that some psychiatrists use ECT a great deal, while others rarely or never use it, and it is a matter of chance to which psychiatrist the patient has been referred.

“Parliaments should impose more restrictions on ECT, not loosen them.”

You might expect that the college would start whining about disrespect or some such rubbish but they usually know when to shut up and say nothing. Pity.

Highlighted Books and Articles

Flaws in the Serotonin Hypothesis of Depression

In this newsletter I want to address the serotonin hypothesis of depression as for years we’ve been hearing that depression is associated with low levels of serotonin (which has been used to support the biological basis of psychiatric disorders). In fact, the evidence for this claim is skimpy. An outstanding review by Jeffrey Lacasse, published in PLOS, is essential reading for anyone who prescribes these drugs. He reviews the evidence and shows that numerous researchers, including Stephen Stahl, the author of the most widely circulated psychopharmacology textbook in the US (Essential Psychopharmacolgy), do not make this claim. Stahl’s textbook states “So far, there is no clear and convincing evidence that monoamine deficiency accounts for depression; that is, there is no “real” monoamine deficit.”

Additionally, Robert Whitaker shows in his book, Anatomy of an Epidemic, that the findings of low serotonin were published in patients who were already on treatment with agents with serotonin re-uptake properties. He argues that this does not prove a primary imbalance but gives evidence to show this is a homeostatic effect (ie blocking degradation of serotonin via SSRIs/TCAs maintains higher levels of serotonin which signals the body to makes less serotonin to circumvent this chemically induced imbalance). Per his review of the literature he cannot find a study which prospectively shows that SSRI/TCA naive individuals who develop depression have this imbalance.

People often call the SSRIs “Teflon drugs.” The reason is that they blunt one’s feelings and all their concerns just bounce off. To quote Teal et al’s phenomenological 2010 paper on SSRIs –> “Now participants found themselves to be “fine.” They felt safe, secure, and “untouchable,” even in the midst of a manifestly hostile world.”  “Their stance becomes an essentially passive approach toward a world that can no longer “touch” them and to which takers are no longer responsible, and numbing “side-effects” are inseparable from the “treatment effect.””

If you doubt the “Teflon” claim, a paper by McCabe et al, published in Biological Psychiatry (2010) shows that SSRIs diminish neural processing of both aversive AND positive stimuli. In fact, it has emerged they have major side effects but drug companies carefully suppressed this information. The list of side effects includes confusion; headaches; anorgasmia leading to loss of libido; severe agitation with or without suicidal ideas; dependency, and severe withdrawal states.

SSRIs may also help people with severe depressive states but it is clear that the lower the level of depression, the more the risk-benefit ratio skews towards the risks. The sexual side effects, including complete anorgasmia, are seriously under-appreciated (see figure 1). They affect the majority of patients on some level, with 30-50% rate of anorgasmia. This is very troublesome, especially in young men who can panic over it in case they have been permanently damaged or, in a few extreme cases, that they may be changing their sexual orientation. Anxiety over diminished sexual performance can add very substantially to trouble between couples and is just another way drugs can make people worse off.

I always list the side effects of psychiatric drugs before prescribing them: Rapid weight gain (many antipsychotics, mirtazapine), marked cognitive deficits and confusion (benzodiazepines, see figure 1), drowsiness, lethargy and inertia (worst with dopamine antagonists), difficulty in achieving or absence of ability to orgasm (SSRIs), habituation which results in severe withdrawal effects (all classes). Strangely enough, few want them when they hear that list. However, an astounding proportion of patients who have had them in the past were told by the physician: “These drugs have no side effects.” This comes straight from the drug company handouts but the remarkable thing is how physicians are able to convince themselves it’s true. I see people every day who have gained massive amounts of weight from these drugs (especially olanzapine), such as 38kg in 20 months, 42kg in 30 months and so on.

While I still use SSRIs I do so at a substantially lower rate than my peers (I’m in 8th percentile for prescription rate in Australia). I recommend the next time you’re about to prescribe an SSRI/SNRI you ask yourself if the patient’s depression is bad enough to take a 50/50 chance at ruining their sex life.

Q&A 
 

Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month.

Thanks again to all who have submitted questions.
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