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Wednesday, March 19, 2008
Full Disclosure = MORE Bias?
Lacking any urgent CME news, I caught up on some reading and came across this interesting article on the perverse negative effects of full disclosure. Usually, we think that disclosure minimizes the biasing effects of conflict of interest (COI). Accordingly, the ACCME's standards for commercial support are based primarily on an elaborate series of guidelines about how to disclose COI in educational activities. But a funny thing happens on the way to CME programs: even with full disclosure, they continue to be commercially biased. Why is that? Why doesn't disclosure solve the problem?
Business school researchers at Carnegie Mellon University conducted two experiments to answer these questions. Undergraduates from the university were asked to estimate the number of coins in a glass jar. Some were assigned the "estimator" role and others, the "advisor" role. In the CME world, the advisors correspond to hired gun speakers, and the estimators are physicians in the audience.
Here are the results:
1. In the first experiment, advisors were paid to give erroneous advice about the number of coins in the jar. Specifically, they were asked to exaggerate the number of coins (bias high) or to mimimize (bias low). Crucially, the estimators were warned ahead of time that the advisors had these incentives to give bad advice. But even with these disclosures in mind, the estimators followed the biased advice.
2. In this variation, some advisors were paid to give accurate advice, and others were paid to give high advice. As expected, the advisors who had an incentive to give high advice succeeded in influencing the estimators. But here's the interesting twist. A third group of advisors was paid to give high advice, and was told that the estimators would be warned about their incentive to bias the answer upward. The result? Advisors who knew their bias was disclosed actually provided more erroneous advice than the others. In other words, disclosing the COI actually makes hired guns more likely to provide biased information.
The authors speculate that disclosure worsens bias for two reasons. First, disclosure gives the advisors "moral license" to exaggerate. To quote from the paper: "When their conflict of interest is disclosed, people feel less of an obligation to protect the advice recipient." The other issue is "proactive exaggeration." Since advisors who disclose their COI worry that their advice will be discounted by the audience, they will tend to exaggerate their advice to make up for it.
This is quite an intriguing paper, and deserves to be studied by regulating bodies in all advice-giving industries, including medicine. It may well be that disclosing COI has the unintended effect of encouraging people to give worse advice than they otherwise would.
74 comments:
- Supremacy Claus said...
Why on earth would a Left wing ideologue collaborate with a racist examination? What employer or licensing body requires going out of the way to submit to a racially discriminatory examination, devoid of scientific validity?
I love the Left. They say, you must disclose. When people disclose, they claim, disclosure results in worse advice.
They condemn racism. Then the hypocrites support racially biased examinations, designed to further exclude the small fraction of minority in a specialty.
All of it is subjective, and destructive. None of it has the slightest scientific validation of prevention of any harm.
It is about attack any alternative authority, and solely about centralizing power in their hands. It is as if the 100 million people killed by the Left, and the utter failure of the Left taught intelligent people nothing. - March 19, 2008 at 1:56 PM
- Supremacy Claus said...
Dan: You will have to do worse than 99% of applicants to fail.
This exam has nothing to do with quality. It has to do with getting fees and intimidation of people by heinous, anti-scientific hierarchies. They are as bad as the lawyer Bars.
A series of class action litigation should hold them accountable for their racial discrimination, as quasi-governmental organizations. To deter. - March 19, 2008 at 2:12 PM
This fascinating study reminds me of the drug/war period film, "Who'll Stop the Rain," when the Michael Moriarity character recounts to Nick Nolte how American pilots in Vietnam often dropped their bombs on elephants rather than engage the Vietcong ... the metaphor being [something like] "In a world where elephants are pursued by men in flying machines, everybody has to get high."
Equally bizarre -- in a world where industry/economic disclosure of potential conflict of interests -- whether rigorously delivered or not -- has no influence on bias -- and may, in fact, worsen the bias, IS IT IN ANYONE'S BEST INTEREST to require CME for medical professionals? (Yes, even the pharma companies are sick and tired of this debate!)
This goes to the heart of my belief for many years now; that Category 1 and Category 2 CME should be merged and a "CME HONOR SYSTEM" be adopted -- therein eliminating the necessity for industry-sponsored programming. Even without all of the economic "incentives," and "ACCME-oversight," physicians will continue to read clinical literature as a matter of necessity, will attend meetings in order to collaborate and socialize with friends and colleagues, and will continue to stop in at Grand Rounds to stay current with what's what at their respective institutions. Medicine moves too quickly not to stay current. To do so risks malpractice and patient referrals, among other things.
In 1997, when the FDA endorsed the ACCME's regulations as de facto insurance that "industry-sponsored educational activities are independent and nonpromotional," the agency unknowingly created a multi-billion dollar CME free-for-all. For all its good intentions, this has backfired, as countless experts have attested. Someone needs to put an end to this bizarre and costly war. - March 20, 2008 at 12:41 PM
- soulful sepulcher said...
James, I always appreciate your comments here. I think a good point is how you say doctors must stay current for care and for new clients; and personally I'd rather not have a doctor influenced by pharmaceutical funded anything.
I had a candid talk with my psychiatrist and asked him if he thinks he is at all influenced by the pharma reps that come there. He said no. Then thought for a few minutes and said, actually yes, because he just realized a Lexapro rep was there and he just rx'd to patients. I know that is not the CME topic, but along the same thought I have, though it may not make sense here. - March 21, 2008 at 5:35 PM
Just remember the premise of reciprocity. When people do for you, you will inherently want to return the favor or act of kindness. That is what reps prey on. Give docs samples or trinkets, and docs will instinctively want to reply by writing for that med. Give docs money, and Faustian consequences will play out.
also remember, evil thrives when good men stay silent. - March 22, 2008 at 9:37 AM
Part of the problem is that there is no way of getting CME for perusing the peer-reviewed literature.
Years ago I had a trial subscription to SKOLAR. If I had a clinical question I would log on, look up full text articles, and then type up a statement about what I had learned and how much time I had spent. I would then get accorded Category I CME for that. This was GREAT and I learned a ton. Unfortunately after my trial ran out I was informed that I couldn't purchase an individual subscription, and now the service itself seems to have vanished. It would be nice to have something like that and I would willingly pay for it as it would increase my clinical effectiveness more than enough to be worth it. - March 22, 2008 at 4:35 PM
- Supremacy Claus said...
I love the Bud Light commercials of the Superbowl. I love their accessories. I love their models. I love everything about their promotional campaigns.
I get a bad headache from drinking Bud Light. What amount of money or other consideration would make me drink Bud Light?
If a patient does well on a medication not being promoted, what sandwich or pen would make the doctor prescribe the promoted medication against the patient's interest? Stephany has to ask the additional question of whether her doc would ever prescribe a promoted medication she told him failed or harmed her with side effects. She has not done so, because of her left wing bias. Her doctor tries to force her to take a harmful or previously ineffective medication. He does so because the company gave him a sandwich or a pen. Would she take that medicine once home?
This movement is left wing bashing of clinicians by academic twits, and attacks on pharmaceutical companies by left wing media and politicians.
If a drug company takes out ten full page ads in the NY Times, I bet all articles on this subject stop. I have never seen an article critical of Saks' Fifth Avenue in that biased, Commie People's Daily rag.
The pharmaceutical companies have generated great value for the economy. The left wing politicians bashing them have generated massive debt for the economy. There is just no comparison between their added value to our nation. - March 22, 2008 at 6:26 PM
- soulful sepulcher said...
- This comment has been removed by the author.
- March 23, 2008 at 12:02 AM
- Supremacy Claus said...
Steph: Did you ever see this commercial?
http://www.youtube.com/watch?v=bOuI3eVUQY8 - March 23, 2008 at 11:22 AM
Joe said:
Part of the problem is that there is no way of getting CME for perusing the peer-reviewed literature.
No so, Joe. JAMA and AMA Archives journals offer online CME to subscribers and AMA members for reading articles (http://cmejama-archives.ama-assn.org).
For background on AMA's efforts to provide CME for reading articles, see my article:
Altus MS.The journal's role in educating readers [meeting report]. Science Editor 2002;25:10 (www.councilscienceeditors.org/members
/securedDocuments/v25n1p010.pdf). - March 24, 2008 at 10:47 AM
Dr. Carlat wrote:
"Lacking any urgent CME news..."
Although the following article is not urgent reading, it is essential:
"Effectiveness of Continuing Medical Education"
/evidence/pdf/cme/cme.pdf) - March 24, 2008 at 3:05 PM
Michael -- That is an ambitious document from The Johns Hopkins Evidence-based Practice Center. Thank you for letting me know about it.
I have been experimenting the last six months with a site called brainscieneblogs.com. It's not a blog -- but one of the domains we own -- so I shuffle information through it on a daily basis that is both promotional and scientifically noteworthy -- hoping to glean some sort of trend in how people are reading and what, if anything, gets a response. (So far, the only trend I see is that there is a clear need for clinical information in Spanish.)
As a writer, my question for you (and Stephany, Joe, et al.) is how would you advise someone today who wants to make a legit contribution to the medical literature, AND make money? I had a drink with an old friend who does a lot of work for Disney interactive and I was unable to explain to him clearly the profound shift in medical marketing and where things might be heading. It sounds terribly naive -- but I have a strong feeling that we are missing the forest for the trees somewhere in all of this. What is your sense? Is there any kind of future left for media, medicine, and marketing? It just might be time for radical measures. Care to lay it out there? —j - March 25, 2008 at 11:13 PM
- soulful sepulcher said...
James, this is a wide open provocative question that I am going to take seriously and come back with real ideas. The Disney connection, it could be part of your answer.
- March 26, 2008 at 12:25 AM
Please allow me to catch up after a few weeks of blogless solitude as I just read that Therapy First is no longer commenting due to Supremacy Claus' "directed' remarks. First, though TF's blanket reference to novel antipsychotics as "poison" is pushing it, his underlying point -- that the atypicals could be marketed someday as anxiolytics -- is valid. Though my opinion is just that, we all lose when someone like TF signs off. And the entire blog is degraded by off-hand, personal remarks, such as "your parents had a great sense of humor or were dirty hippies;" no matter how tongue-in-cheek it was meant.
Because of chat room shenanigans these days between kids, schools and parents are grappling with formalizing written rules on internet conduct in order to prevent emotional fallout from potentially hurtful anonymous "chats." Let's not fall prey to the same syndrome. I hope that TF will reconsider. His expertise will be greatly missed.
ps--thanks Stephany - March 26, 2008 at 12:55 AM
- Michael Rack, MD said...
"No so, Joe. JAMA and AMA Archives journals offer online CME to subscribers and AMA members for reading articles (http://cmejama-archives.ama-assn.org)."
So the choice is to pay $1100 per year in AMA membership fees and get CME from them, or get biased info from Pharma-sponsored CME. I'll take the free Pharma-sponsored CME (but will also stay current by reading peer-reviewed journals, for free, in the medical library of the local medical school- U of MS). - March 26, 2008 at 8:26 PM
To James la Rossa JR.:
Thank you for your words of support in this blog. I have read Supremacy Claus's comments since I stopped commenting here, and I hope he reads this: you are ridiculous and your anonymity blinds you. It is a shame on two counts you stay involved in this blog I believe has incredible importance to the trials and tribulations in psychiatry: you do not offer genuine and responsible criticisms to what Dr Carlat has to offer, and Dr Carlat should consider banning you from this blog site.
This site is not mine to speak for, but if I ever have one in future times, save your typing and cranial energies for others who find your comments of value.
I am a psychiatrist who has been practicing for 15 years now, and at times I feel like I am one of a dwindling few who seem to care that the principles we accept as medical school graduates are applicable to the real world of clinical care. Medication has a valid and crucial role to care, but IT IS NOT THE ONLY ONE we offer as physicians. If any of you out there reading this blog are clinicians, do you really believe the biopsychosocial model is outdated or minimally applicable to the patients you treat? I sense that Dr Carlat believes in a multidisciplinarian approach. That's why I subscribe to his newsletter, that is why I correspond to him, and that is why I look for kindered spirits in this bleak world of "biochemical imbalances".
However, I am not interested in banter with people who do not engage in responsible debate. You, Mr SC, write like an idiot! As long as your comments get validity on this site, I will not participate.
To people like Mr la rossa, stephanie, Dr Altus, I read your comments and digest them. Thank you for your time and energy in supporting blogs like this. I believe if we expose the fraud that is psychopharmacology gone wild, we will restore responsible care for our patients and gain respect from our colleagues and the public at large.
Sorry for the rant Dr Carlat! - March 26, 2008 at 9:13 PM
- Supremacy Claus said...
TF: I forget what you said, but weren't you signing off before? You are signing off again. You can't control yourself.
I suggest the following. Stop leaving. Come back to stay permanently. Start posting facts to persuade. Feel free to call me names, because I love it. Debate your points by participating, not by leaving.
Appeal to scientific studies, personal factual experiences, logic and common sense. Those are all good. Authoritarian ipse dixits. Not good.
Think of psychiatric disorder as people do of diabetes. The treatment involves medications of a miraculous nature, diet from the environment, and lifestyle changes as in exercise. No one disputes this multi-factorial approach. But each has 100's of validated scientific studies. Anyone arguing by authority in diabetes management has to expect skepticism.
I like you because your extremism forces me to return to basics in justifying remedies. I have to think, how does this get explained to a Fifth Grade class? It is a great intellectual challenge. And, it is of relevance to the medico-legal environment, an interest I have. - March 26, 2008 at 11:04 PM
- Supremacy Claus said...
TF: You may start a blog, literally in one minute, for free. Use an alias. Go here. It's one of the best.
Let me know if you decide to do so. I would like to visit periodically. - March 26, 2008 at 11:09 PM
- soulful sepulcher said...
- This comment has been removed by the author.
- March 26, 2008 at 11:44 PM
TF: I did not get off a plane last night to suffer through SC's unwillingness to meet you in legitimate discussion, only to have you justify SC's tongue-lashing with such a dopey posting. SC is radical, yes, but he is very informed -- in case you hadn't noticed -- and there is something lawyer-like about how he is thinking. (You'd be surprised by how much psychopharmacology good lawyering takes these days! And, for the record, Carlat is much too smart to get involved in this, other to feign sympathy to one and all alike.)
So, let's get on with it, shall we!? "Full Disclosure = MORE BIAS?" Any further comments? If not, sit tight. The new day will dawn, my dear doctor, no matter how badly we may fight it. - March 27, 2008 at 3:16 AM
About last night. Your comment that "The facts abandoned the Left 100 years ago. Thus only personal attacks remain. These include the extermination of 100 million people to persuade. Failing to persuade by facts, the Left wants to parse for personal attack."
Supremacy Claus: Being 'right' is what seems to drive you. You play the lawyer, here -- not me. If I have a degree and you don't, it matters little or nothing (to me). If experience teaches us anything, it teaches us that knowing the words is just the start. You're obstructing our search for a valid methodology to talk about medicine by using words like "extermination" in the same context. The 20th Century is defined by that word. Why go there in a discussion about psychiatry? Seeming to have all the answers does not make you right. Seeming to have all the answers does not warrant a response. Suffice it to say that this wouldn't be the first time you fell out of favor. - March 27, 2008 at 3:52 AM
- soulful sepulcher said...
I just took a look at med works media and now i understand why you said here once before nemeroff was a good guy; he's one of an interesting advisory board you've got going there.
So your question about how to make money from your bulletin? How much does yours generate directly to you via subscriptions, and does your editor board get any kick backs from that amount?
Because then it opens a broader circle of thought considering Thase and Nemeroff and pharma funded research, etc. extraction of anyone associated with pharma makes sense doesn't it?
Maybe I've got the honest CME mixed up with Psychopharmacology Bulletins goal?
Bear with me while I attempt to sort this out, as a non professional. The entire industry is quite interesting indeed, how you all are quite connected.
Also there's the "peer reviewed" aspect where doctors see that and take it for concrete thought; and I have a problem with how that influences doctors who read an abstract reviewed for example by Nemeroff [disclosure issues] and even Manji, considering he's on the advisory board of CABF which takes a stance that childhood bipolar exists and promotes psych meds for use in children at ages the meds are not approved for--also that site receiving pharma funding.
My point is how far is the hand in the cookie jar here? - March 27, 2008 at 7:21 AM
- soulful sepulcher said...
and, as Carlat commented on the PBS Frontline program 'the medicated child'-- "you don't know who you can trust"; though Carlat probably said more in the interview that's the snippet that got on camera, and really is a provocative statement isn't it?
When for example, doctors [such as Dr.Bacon in that program] read peer reviewed journals, they end up telling clients/patients/parents of children they medicate, that this is peer reviewed information and dosing schedule comes from that, [for example] and yet the consumer, parent et al typically do not read abstracts, journals or for example pharma-bulletin's fine print where it states none of you are accountable for those details.
BUT then where does the accountabilty come into play?
I'm a rare parent who does pick up journals when they are left at a doctor[neurosurgeon's office for example]waiting area and reads it.
How honesty can play into this just seems unattainable to me.
After researching for a decade, the names that come up are familiar to me. Same ones, etc. Nemeroff was called a "super noun" here by [James] and he is far more than that in this industry. - March 27, 2008 at 7:34 AM
- Supremacy Claus said...
Off label use gets driven by patient responses. These are independently discovered by doctors across the nation. There is no greater scientific validity than simultaneous confirmation of a benefit by 1000's of independent practitioners. They have not spoken to each other. No bribe can induce these docs to endure the negative consequences of continuing an ineffective or harmful treatment. They have been rewarded by the relief they experienced from patient improvement. Prescription tracking services document that effect in millions of patients, and define the standard of care better than regulation or delayed academic studies.
Jim, I want to be fair to you. The author of this character is a doc. He had legal training. Not a lawyer. See what he learned in law school on the blog. I guarantee, you would have never been told that stuff by anyone except an outsider from a different intellectual culture. To reassure you a bit, he loves the lawyer. There is no greater love than one great enough to correct.
And he likes TF. He will gladly reveal anything he wants to know about the author of this fictional character, privately. He's just playing with him.
That being said, all this FDA regulatory gotchas, all these consumer fraud lawsuits, all these hand wringing journal disclosure requirements by quasi-governmental owners, all are lawless. They violate the half dozen Supreme Court decisions holding a presumptive deference to clinical decision making. They interfere with the patient doctor relationship. The most famous such case was Roe v Wade, of course. - March 27, 2008 at 7:57 AM
Dear Supremacy Claus:
I have often thought this issue of "information regulation" is a true exception in medicine and would better be decided by lawyers and not doctors. I concur with you that so much of the quasi-governmental regulations governing disclosures are violative of federal law. (And as constitutional law has been muddied by two weak Supreme Court benches in a row -- the States are proving more than willing to take their swing; it's easy $$ after all.) But as long as industry "allows' itself to be regulated in such a manner, this debate will rage on.
WHAT YOU WRITE IS ENORMOUSLY SENSIBLE: "Off label use gets driven by patient responses. These are independently discovered by doctors across the nation. There is no greater scientific validity than simultaneous confirmation of a benefit by 1000's of independent practitioners. They have not spoken to each other. No bribe can induce
these docs to endure the negative consequences of continuing an ineffective or harmful treatment. They have been rewarded by the relief they experienced from patient improvement. Prescription tracking services document that effect in millions of patients, and define the standard of care better than regulation or delayed academic studies."
What regulators seem to be saying is that FACED WITH ENOUGH INDUSTRY-INFLUENCED INFORMATION, DOCTORS CAN'T BE TRUSTED TO TREAT PATIENTS EFFECTIVELY, SAFELY, AND ECONOMICALLY. I think it is high time to call that bluff. Let's do away with mandatory CME requirements for physicians and let nature take its course, so-to-speak. Thank you by the way for explaining yourself. - March 27, 2008 at 3:20 PM
Stephany: Supremacy Claus suggests that some of medicine's self loathing is artificially generated by people who care more about regulating the masthead than the quality of the medical information. Forgive the seeming harshness here, but some of your comments may prove his point.
Psychopharmacology Bulletin was published from 1962-1999 by the National Institute of Mental Health. When we took it over, we tightened it up in both look and content, as the Government Printing Office had gotten lax in the journal's management. As publisher, I applied the most simplistic of historical axioms; that in publishing, information rules: the best info rises to the top. And except for a publishing hiatus in 2004/2005, Bulletin has continued to make its way in an increasingly turbulent atmosphere -- the very atmosphere that creates so much hair-pulling on professional blogs like this one.
One dilemma which has increased is that there are so many advertising -sponsored publications available for free to doctors, that journals like Bulletin -- which is not funded by industry -- are in danger.
Even so, a cursory look at our site has you thinking otherwise. You mention things like "kick backs, and hands in cookie jars," which would put any good journal in the toilet and the publisher in prison -- so I assume you are being figurative and not literal. What causes you to think these things is the composition of the men and women on our editorial board. Are some of them too closely allied with industry? Your answer is yes. What goes unnoticed, though, is the fact that someone like Bulletin's editor, Michael Thase, continues to work with us without compensation when he can be spending that time working for a well-paying manufacturer. Doesn't this say something about the commitment he has to the field?
You can't dismiss those journals you see in waiting rooms full of "notorious" names because the editors sit on pharmaceutical advisory boards. There would not be any journals left. The question for you is -- do you believe that doctors can choose for themselves what to read, and, thus, how to treat patients, or are those big-name docs with pharmabucks galore just too smart for the average practitioner? At some point, you have to get past the masthead and read the study and decide for yourself. I hope you can stay open-minded in the meantime. Cheers, j. - March 27, 2008 at 4:43 PM
- soulful sepulcher said...
James, I am open-minded and was asking pointed questions to you, per your question here ---thinking outloud. You've answered my questions, and as far as masthead and all of that, like I said, bear with me as I know nothing about how you do things, am trying to understand for clarity. I was merely interested in yes, how you were wanting to know could ppl make money from the publications and remain afloat in this new age world that does hold scrutiny.
The topic certainly doesn't take over my life, I like learning. Thanks for the input and feedback. Also, thanks for clarifying Thase not being paid, the way you wrote makes it appear I should have known more than I do.
I appreciate being in this discussion at all, thanks for including me. - March 27, 2008 at 7:33 PM
- soulful sepulcher said...
- This comment has been removed by the author.
- March 27, 2008 at 7:45 PM
- soulful sepulcher said...
- This comment has been removed by the author.
- March 27, 2008 at 8:11 PM
maybe it is hypocritical for me to say this, but your comments are of value in this blogging fest. You ask good questions and bring up important points as someone who is on the receiving end of treatment. So don't leave if you are really invested.
At least Mr SC was a bit transparent in a recent posting, so for what it is worth, Thank You.
Maybe I'll stick around for now, but I hope people will keep this civil and productive. One further detail to my backround I'll offer:
I became a psychiatrist so I could offer a full compliment of services for patients, but I never had any agenda to just push pills.
And yet, I see a good number of colleagues who do just that. Do I have a right to be judgemental? No.
But, do I do a service by not challenging the status quo. Equally, NO!
Face it folks, every physician should have this motto above his or her door: the road to hell is paved with good intentions. That is what pharmacology is about if you as the prescriber are not careful.
Well SC, I guess I'm in again!!! - March 27, 2008 at 8:33 PM
- soulful sepulcher said...
well thanks I think TF. My comments should be important feed back for psychiatrists. I'm not that far out of "your league".
I've taken this to my blog, so I don't clog up Carlat's with it. - March 27, 2008 at 11:28 PM
Stephany: I stand corrected. What you say rings true:
"Rather than take my words here as close-minded, you actually have missed how open-minded and able-minded I am for discussion, and as a consumer I might just have some answers for the troubled industry, being that I've been intensely behind the scenes for 3 years solid, with a sick kid, I've heard a lot, seen a lot, and yeah I read a lot. The best information I get is on the side from ppl complaining to me about the industry."
I might have assumed more than I should have. Forgive me. We would -- as TF first said -- all benefit if you stuck around. Again, please overlook my (often late night) grouchiness. Best regards, james - March 28, 2008 at 3:13 PM
- James M. La Rossa Jr. said...
Stephany: I stand corrected. What you say rings true:
"Rather than take my words here as close-minded, you actually have missed how open-minded and able-minded I am for discussion, and as a consumer I might just have some answers for the troubled industry, being that I've been intensely behind the scenes for 3 years solid, with a sick kid, I've heard a lot, seen a lot, and yeah I read a lot. The best information I get is on the side from ppl complaining to me about the industry."
I might have assumed more than I should have. Forgive me. We would -- as TF first said -- all benefit if you stuck around. Again, please overlook my (often late night) grouchiness. Best regards, james - March 28, 2008 at 4:28 PM
- soulful sepulcher said...
Thank you James.
- March 28, 2008 at 9:05 PM
- Supremacy Claus said...
I am glad to see my left wing ideologue e-friends are back. Debate away.
Now, I suggest Dan grow up. He deleted my remark about this being a left wing, hate speech site, devoid of credibility. Any credibility he may have had, evaporated after his Front Line appearance. It is a misleading, biased, Hate America propaganda outlet from a notorious, foam at the mouth, Commie organ, PBS. This agency provides more balance, and is less vitriolic in its hostility to the US.
http://www.cubanews.ain.cu/ - March 28, 2008 at 10:49 PM
Mr S.C.:
Your comments on the Thursday blog were inappropriate, and the message I would take from the deletion is be more responsible and respectful, or move on to another blog. That's what I have been saying for the past few weeks.
I saw a patient today who asked why she should be on psychiatric medications when she is making significant strides in her therapy.
I told her if she is comfortable and attentive to her functions ongoing, we can look to taper in the near future. Her smile alone was one of the positive moments of my day.
Dialogue is what this career is about. Not as someone wrote in a letter in Clinical Psychiatric News last year, being hydralic operators: going up and down in doses.
By the way Dr C, your quote from Dr Pies in your mailer to get subscribers was impressive! That is a good sales pitch. - March 28, 2008 at 11:32 PM
- Supremacy Claus said...
Jim: You know a little law.
Here, in the US, as opposed to Iran or Cuba, a harm must be shown before the chilling of an activity. We do not prechill here in the US. If one is going to attack an activity, first, show a harm. In the absence of data showing harm from drug advertising or detailing, this verbal abuse by the Left media and its running dogs is unAmerican. The criticisms are baseless, irresponsible, biased ipse dixits. The data will likely show greater awareness of a condition, especially from direct to consumer advertising. Such an increase in awareness will likely result in less impact from the disorders addressed.
For example, "Ah, that's what I have is called, restless legs syndrome. It has a treatment. I will call my family MD." The result? Fewer car crashes caused by sleepy driving.
Here is a harm from these inappropriate and irresponsible, left bias attacks. Patients on the severe end of a disorder will believe the false propaganda, and stop or refuse these treatments. Many patients question their established treatments. The reply is, go ahead, stop for the third time; see if you get a different result.
This effect took place after the wrongheaded black box warnings on anti-depressants by the cowards at the FDA, bullied by the same power hungry, hate filled, left wing crowd.
The family doctors got deterred from treating suicidal young people. Wider treatment by family doctors is one of the few proven methods of reducing the suicide rate, long term. The downward trend of the suicide rate reversed, and hundreds of additional young people died by suicide needlessly, each year since 2004. This is the fruit of left wing hate speech.
Detailing of anti-depressants to family doctors ends. They treat fewer depressed patients. The suicide rate goes up in older age groups. The Left will never take responsibility for this lethal consequence. - March 29, 2008 at 5:53 AM
Mr S.C.:
Your attempts at politicizing this blog site are mystifying at least.
If we were to follow your path, then I guess we should embrace the right wing ideology of stigmatizing and discriminating the mentally ill population as was the case when such mentality was pervasive in the late 40's to early 60's.
Distortion and projection are the main defenses of the extremist, as well as denial. I know you won't accept this suggestion, but it will be made anyway: focus on the point of health care issues and the innappropriate intrusions into this relationship between doctor and patient, and leave the politics behind. It is a shame that some of your valid points get swamped by your pontifications.
By the way, in my opinion the issue of increased suicidality from antidepressants was the byproduct of 70% of prescriptions written by non mental health care providers. When MDs think all that is needed is a RX to treat a mood disturbance, there is a sizeable percentage of patients that feel dismissed or marginalized. People want to talk and be heard; PCPs and family medicine docs by in large don't have or make the time to provide this NEEDED interaction. So, some patients end up acting on these hopeless thoughts. That's the point to MDs like me fighting to eradicate this "biochemical Imbalance" simplicity to our field. That's not a left wing ideology, that's a psychiatric principle.
I hope your reply will be to the point. By the way, DR C, any thoughts from you about this ongoing debate of late? - March 29, 2008 at 10:21 AM
- Supremacy Claus said...
TF: I don't see any political aim in asking for evidence of harm before bashing and regulating a traditional and beneficial practice. Detailing help spread information and benefits patients several ways. The criticism seeks to empower central government and to take away choice from doctors and patients.
The Left does not rebut. It eliminates dissent.
The training and increasing of awareness of family md's is among the rare proven ways to reduce the suicide rate of an area.
Sorry. Could not get the link. Good candidate for industry sponsored CME.
Acta Psychiatr Scand. 2006 Sep;114(3):159-67. Increased antidepressant use and fewer suicides in Jämtland county, Sweden, after a primary care educational programme on the treatment of depression. Henriksson S, Isacsson G.
OBJECTIVE: To consider and evaluate a continuing medical education programme for general practitioners (GPs) on depression in Jämtland county, Sweden, inspired by the Gotland study. METHOD: Interactive seminars were conducted between 1995 and 2002 in Jämtland county. For evaluation, suicide rates and annual sales statistics of antidepressants were compared with national averages. Questionnaires were used for information about attitudes and prescribing habits. RESULTS: The suicide rate in Jämtland decreased to the same level as the national average. The use of antidepressants increased from 25% below the Swedish average to the same level. The selective serotonin re-uptake inhibitors (SSRIs) were preferred because of their tolerability. Suicide issues were considered to be most important in the management of depressed patients. CONCLUSION: A trend towards a greater prescription of antidepressants and fewer suicides after an educational programme on depression for GPs replicated the findings from the Gotland study. The educational programme will be conducted annually and could be a model for other regions. - March 29, 2008 at 12:38 PM
- soulful sepulcher said...
TF: It makes sense to note that medication as treatment only does not work for patients because time has proven meds only don't. If this was true, the hospitals would be empty and you'd all be out of work.
The best doctor is the one who noticed the patient's smile on their face as a result of the conversation: kudos for that, because yes people are in fact motivated by others.
Re: SC-- what is your point anyway? have you been drugged by force? in a psych ward? on meds that didn't work?
The black box warnings are in fact placed there because of REAL adverese events, and some even happen during trials of these medications.
What is happening with the SSRI's now is a marketing dream for pharma, because the average consumer/person does not understand how antipsychotics are slowly entering that mainstream treatment, and patients are now being treated for depression, insomnia and anxiety with antipsychotics such as Seroquel and Abilify.
The person who walks into the PCP office, talks about insomnia or depression won't come out with Prozac; they will walk out with Abilify and never know they are on an antipsychotic created for schizophrenia.
James is in the marketing business and does understand law I'm pretty sure...
Dr. Carlat is counter-detailing Effexor for a good reason.
Smart people want full disclosure, all data access to scientists, no more ghost written papers, and honesty and integrity when it comes to drugs they take.
As a consumer I demand excellence from a profession that treats patient with mind altering chemicals that have physical side effects, adverse events, cause brain damage, etc.
So when I take one of those meds, you can bet your &^% that I want to know the ethics were in place when that med got to the FDA to my house.
Zyprexa is prime example of harm, and death done to patients at the expense of making a buck, and if you want proof of that, go read the Zyprexa documents online at Furious Seasons. Lilly hid data that could have prevented many people from dying and other life threatening permanent damage to their bodies.
Sorry Dr. Carlat for this rant. It's all connected and goes straight back to CME, and who teaches psychiatrists. If it's pharma funded, there's no chance in hell I'd trust it.
I've got a decade of this in my life and have learned a lot and the first thing I learned was to trust myself before anyone else. Doctors often don't know what to do either, and the ones who admit that get my respect more than the ones I've met who would not have these conversations and declare a "3o years in this business" line to me, all the while, they could never figure out why their psych med treatments didnt work on my daughter.
There's a reason for that! now call me Left. Nope. I'm just a mother who pays attention to a defunct system that needs a lot of work and change. - March 29, 2008 at 1:41 PM
SC: Appreciate the use of a health care reference in your rebuttal. Let's be honest though; Sweden is not an american society in attiutudes and expectations, so I do not see the parallel as equivalent as you try to apply. Also, my issue is not just limited to suicidality, but improvement in function overall with time. When I have met people both professionally and personally who received mental health care by a non mental health care provider, there is very rarely a level of satisfaction voiced. So, in keeping with my position, it is not the drugs that lead to a feeling of improvement in the end, but the quality and consistency of the interaction between provider and patient.
By the way, to also reinforce my point from a political position, it is in fact the left that embraces dissent, and the right that dissuades/rebukes it. So, by going just by this typed debate, I still believe you are practicing some level of projection in your arguments. Health care by the providers in the arena is not repressive or tyrannical, but invested in improving those that they serve. Sometimes care can be misguided or benignly clueless, but I firmly believe responsible providers listen and change with credible arguments to the status quo.
You don't see that with people who are financially driven. Pull out what you will to refute that, but deeds speak louder than words, and our society is moreso driven by short term goals than long term ones. The american dream is often a reality of greed and self servedness (if a word).
I do appreciate the rebuttal though. The reference shows you are accessing literature. - March 29, 2008 at 1:46 PM
Stephany: (got the spelling right now)
just caught your latest reply as I finished mine and wholeheartedly agree with your points.
For what it is worth to you, to be a bit naively simplistic, these days I see two types of patients: ones who want to feel better, and ones that want to get it right. I am taking a line from a 'Numbers' episode where the therapist for the Rob Morrow character tells him after Morrow says "so I need a pill", the therapist replies' "if you want to get better, take a pill, but if you want to get it right, face the truth".
It may be a line from a TV show, but I feel art imitates life and that line was on the mark for me.
I have the quote on my door at an addiction program I consult for, and patients who seem to be embracing recovery give me positive feedback about it.
Glad you're still here! - March 29, 2008 at 1:58 PM
Michael Rack, MD, wrote:
So the choice is to pay $1100 per year in AMA membership fees and get CME from them, or get biased info from Pharma-sponsored CME. I'll take the free Pharma-sponsored CME (but will also stay current by reading peer-reviewed journals, for free, in the medical library of the local medical school- U of MS).
There you go! Unlike other professionals, physicians can get continuing education credits for free. Somebody has to pay for it. One concern arising from this situation is about the hidden cost to patients that their physicians are getting their education from biased sources that are invested in the education content and outcome.
1. As a freelance medical writer-editor, some of the work that I do is preparing pharma-sponsored materials CME-accredited purposes. My comment here is against my professional interest.
2. As a patient, I want to know that the drugs my physicians prescribe are the best for my needs. My coment here is for my personal interest. - March 29, 2008 at 3:14 PM
James M. La Rossa, Jr., "wrote" and I reply:
"Michael -- That is an ambitious document from The Johns Hopkins Evidence-based Practice Center. Thank you for letting me know about it."
Reply: You're welcome, James.
"So far, the only trend I see is that there is a clear need for clinical information in Spanish."
Reply: I expect that Elmer Huerta, MD, MPH, director of the Cancer Preventorium at Washington Cancer Institute, Washington Hospital Center, and current President of the American Cancer Society, would strongly agree. See his home page at http://tiny.cc/ZDBoZ and a brief description of his media work at http://tiny.cc/1ya8f. Furthermore, I expect that Dr. Huerta could advise about the future of media, medicine, and marketing, which you note in the next paragraph.
"As a writer, my question for you (and Stephany, Joe, et al.)[SNIP] What is your sense? Is there any kind of future left for media, medicine, and marketing? It just might be time for radical measures. Care to lay it out there? —j"
1. Work as a full-time medical writer-editor in a full-time job at a medical school or other nonprofit organization in which the writer-editor has close contact with the authors of articles and other materials.
2. Work as a full-time writer-editor in a pharmaceutical company in which the head of writing is a committed champion of disclosure of the company's role in developing materials. I know of at least two such champions, both of whom described publicly who they struggle to get their companies to include the names of employees who should be named as authors.
3. Work for or run a medical education and communications company that is committed to ethical practices. For more, read the following:
Woolley KL. Goodbye Ghostwriters! How To Work Ethically and Efficiently With Professional Medical Writers. Chest. 2006 Sep;130(3):921-923. Freely available at http://tiny.cc/fOFEw.
4. Work as a freelance medical-writer editor and accept assignments only working when closely with to-be-named author is in on it as early as possible, and decline assignments when to-be-unnamed authors are involved.
I suppose that the "radical measure" will arise when medical education and communications companies work directly with a medical education provider that is not pharma-funded to develop programs in which the physician-instructors are not also pharma-funded. - March 29, 2008 at 4:12 PM
- Supremacy Claus said...
Dan and TF have a conflict of interest they will not acknowledge.
Medications are cheap and effective. They may be prescribed by non-specialists, with the same reliable effective results.
I have proposed that sertraline and citalopram be available over the counter. In places where they are, there has been no adverse result.
Contrast that with the high cost, labor intensive alternatives, endless psychodynamic psychotherapy. This is a false cult like ideology based on atavistic cult indoctrination still going on in Ivy psychiatric training programs. More priest, less doctor, these left wing ideologues feel unashamed making ipse dixit utterances, defying logic and data. They feel free because they were indoctrination by arguments by authority. They feel no embarassment doing the same to the public.
One has to ask, if medications decrease, will the alternatives make these ideologues more or less money?
That explains the inexplicable, rigid orthodoxies of the left wing ideologues. - March 29, 2008 at 5:17 PM
- soulful sepulcher said...
TF: Thanks, for the feed back. You used this quote:""so I need a pill", the therapist replies' "if you want to get better, take a pill, but if you want to get it right, face the truth".
That is exactly what most typical psych patients do not do, they do not look at themselves truthfully, and get on [hesitantly add this here] a spiritual journey back to themselves.
If a psychiatrist can encourage a patient to go off of medication or use little as possible and offer DBT, CBT and other ideas for recovery, there would be in fact less pill popping.
If you are part of an addiction program, you "get" what I am saying I am sure. Because, in general, I'm not saying mental illness does not exist; oh I've seen it first hand in severe settings; but average people have some sort of void in their life that they try and fill with pills, booze, whatever; and until they take a hard close look at the truth that resides inside them, they will continue to abuse and use what it takes to deny real self.
Sorry, this has gone way off topic, but wanted to reply back to TF. - March 29, 2008 at 5:36 PM
- Supremacy Claus said...
These brand named psychotherapies validly apply to the mildest forms of mental illness. Yet, they have durations of, let's say, 6 months or a year. Those are never practiced nor advocated by the Ivy trained, left wing ideologue. They advocate only cult like interminable therapies. These never work, thus never end. They can make a good, easy living off a few gullible patients. See the great results in Woody Allen.
The products of pharmaceutical companies work for minimally trained practitioners, at very little patient expense, and have 1000's of studies scientifically validating them.
This is unbearable competition to the Ivy trained, left wing ideologue. Thus the vicious attacks in the biased, anti-corporation, America Hater media. - March 29, 2008 at 6:04 PM
Mr S.C.:
in regards to your March 29 5PM posting:
1. where are SSRIs sold OTC in a reliable country? and
2. why do you continually associate me with left wing ideology just because I am a psychiatrist?
These are the generalizations that diminish any reasonable debate. If you truly understand what I have been writing to this blog, I am not one of the usual providers in my field. So, your comments are getting older and more offensive as you continue on in your bashing of my opinion. As I noted last, you did provide a reference that had legitimacy to a rebuttal, so i appreciate such effort. But if you continue this ranting of alleged political positioning, I will just ignore your postings hereon. Everyone here seems to feel speaking freely without providing some transparency is fine; I find that position a bit lame. I don't expect names and addresses, but a little backround nonspecifically is appreciated.
I'm done commenting on this posting, as I feel the Thursday posting is more relevant and important to what Dr C is pursuing, so I hope your dialogues as the group are enlightening hereon.
Good times and good day. - March 30, 2008 at 10:52 AM
- Supremacy Claus said...
SSRI's are sold over the counter all over the world, in Mexico, and in the Caribbean. No evidence of harm reported.
The left wing ideologue refuses to be honest, to admit, garbage, unproven treatments are expensive, ineffective, and compete with proven, cheap, and effective medications discovered and produced by pharmaceutical companies. Dan went to a program that remains psychodynamic. He refuses to be transparent about his indoctrination, his baseless, anti-scientific ipse dixits, and his left wing partisan bias. The hypocrite bashes others for not being transparent.
Citalopram costs $4 for a month's supply at Walmart, a God fearing, right wing company. If I had an anxiety disorder or depression, I should be able to get that off the shelf, without having to submit to endless, garbage treatments by left wing ideologues. I would improve in a month. - March 30, 2008 at 11:32 AM
- James M. La Rossa Jr. said...
WOW. THIS IS GREAT! What a refreshingly honest, passionate, (and yes) intelligent give and take. My only hope is that some of you stop threatening to quit this debate. This is really good stuff.
A few things important to note based on the last dozen postings: Suicide rates -- especially among children and adolescents -- have steadily decreased the last 10-years. Much of the credit goes to Drs. like David Shaffer and John Mann and the American Foundation for Suicide Prevention -- which is heavily funded by the pharmaceutical industry -- and the physician training, public education, (and yes) safer and more efficacious drugs that have, literally, saved thousands of people. Faced with the sheer weight of numbers, we all have much more to worry about if parents STOP giving their depressed kids antidepressants because of the increase in incidents of suicidal ideation in newly dosed patients -- which is getting more attention than it may deserve. The VAST majority of "surviving" parents are left with a LAST wish that they could have had the chance to have their child treated and medicated properly. So, suicides continue to go down in #'s. And while drugs are not the "magic bullet" for suicidal youth that we may have thought, the medications, patient education, and AFSP studies on suicide -- much funded by pharma -- have been critical elements to the reduction in suicides. If you think I sound like a cheerleader, it's because I've had the privilege and horror of having more dinners with more parents of more dead kids than I should admit.
Re. another interesting comment. Would even more kids be alive if SSRIs were available OTC? I made the mistake of "giving" a three-month supply of an SSRI to a friend who was clearly having problems which could have benefited from a "serotoninergic adjustment." What it did was allow him to delay making an appointment with a psychiatrist. Within the first 5-minutes of the appointment, it was absolutely clear that he was in full crisis, which I may have, inadvertently, made worse, by giving him medication.
Lastly, I note DC's latest entry that the APA has announced a 5-year plan of becoming "industry free." Wouldn't that be the greatest irony of all if the new president of the APA -- who has been accused of being too industry-oriented -- is instrumental in liberating the APA from the wiles of big pharma?! Mark my prediction that industry will give up sponsoring medical education before medicine gets the chance to further bite the hand that feeds it. CME HAS FAILED TO PROVE ITSELF A VALID PART OF THE MAKING OF A GOOD DOCTOR! As a last gasp, it has overregulated itself to death. Don't look to the drug industry to save such an unappreciative patient. - March 31, 2008 at 6:28 PM
- Supremacy Claus said...
Jim: Do you manage your cold? Do you manage your pneumonia? Are there any equivalent conditions in psychiatry?
If one has shyness, why does one need the full workup? If one has unrelenting urges to kill oneself, does one need the full workup?
If everyone with a cold demanded the full workup, the system would collapse. Why does anyone think the needs of psychiatric patients are any different from those of any other specialty? The rent seeking left wing ideologues want the shy person to never get well, to continue to stay dependent on bogus, 5 day a week therapy, that is a complete waste of time, and fraudulent.
Organized medicine is an adversary of the clinician. It works only for itself. It dominated by Ivy trained left wing ideologues. In the case of the AMA, an elected president had to rebut the policy utterances of the AMA on the single payer system, in an op-ed in Am Med News, an organ of the jackass AMA. - March 31, 2008 at 7:04 PM
- soulful sepulcher said...
"If you think I sound like a cheerleader, it's because I've had the privilege and horror of having more dinners with more parents of more dead kids than I should admit."-James
James, I wonder out loud here, if you have had dinner with parents who have children who only attempted suicide on or close to after starting anti depressants?
This is not a challenge, for a debate, just curious. Because I'm one of those parents. - March 31, 2008 at 9:06 PM
- James M. La Rossa Jr. said...
Let's say, arguendo, that pneumonia is equivalent to depression. My guess is that pneumonia would warrant a physician's visit -- regardless of the age of the patient -- both to confirm the diagnosis and to prescribe an antibiotic. Perhaps an OTC purchase would be suggested to manage some of the symptoms. Pneumonia in the elderly would need aggressive treatment lest it become debilitating. Pneumonia in a young person, while, perhaps, not as immediately life threatening, is more troubling, I would think, since it would prompt me to question congenital pulmonary problems, smoking, drug use, obstructions, and the like. Likewise, depression in the young seems daunting to me (said like the guilt-ridden father of young children who live 3,000 miles away). In other words, to use your phrase, I would require the "full workup," -- so I don't get your full meaning. Where I get your point is when you're talking about "episodic" depression (the "cold")-- which you don't hear about as much; your view (again, I'm guessing) being because psychiatry wants people tied to the "illness process" for life. And perhaps there is some truth to that, after all -- wasn't there a day when the "average bout" of depression lasted approx. 16-months after which the patient should start titrating down and off? In your world, that patient should be able to purchase citaloprom, for example, OTC. OK. That seems like a point worth debating. But what about the bacterial illness -- the pneumonia? Is it a totally bogus argument in your opinion to claim that psychiatric illness is always "bacterial" -- always in need of medical intervention, testing, and a prescription medication, because it is both difficult to diagnosis, is dangerous in different population groups for various reasons, and can have more serious implications over time if treated incorrectly? I am not arguing, just trying to understand.
As an ancillary consideration to your view, another question: From a legal standpoint, lowering the standard of care lowers the duty of care the physician is held, which, obviously, limits the physician's liability to that lower (more reasonable perhaps?) standard. Does this play into your thinking as well? Is part of your resentment toward the "Ivy leaguers" prompted by your belief that these psychiatrists inadvertently make themselves (and, thus, you) unfair targets of liability by insisting that drugs like SSRIs remain prescription-only medications?
I won't be in front of a computer again until tomorrow afternoon (PCT), so in the event you get back to me tonight, please forgive me for not being able to write again for 24-hours. Regards, jim. - March 31, 2008 at 10:32 PM
- Supremacy Claus said...
Let's not burden an analogy too heavily. There is some self-triage. I have a cold. I decide to manage it myself. I am short of breath, I need professional help. So it is in psychiatry.
There are now available psychiatry meds over the counter. They are 10 times more dangerous than citalopram, both in normal doses, and in overdoses. Benadryl. Pseudoephedrine. Opiates like dextromethorphan. Caffeine. Alcohol. Nicotine. All intoxicating, addictive, lethal. And ineffective for any psychiatric diagnosis.
I do not hear TF getting all upset by those OTC's. He only gets upset by advertising and potential OTC availability for psychiatric meds that work, are safe, and cost 1/1000 what ineffective phony therapies do. - March 31, 2008 at 11:37 PM
- James M. La Rossa Jr. said...
What you say say, sounds absolutely reasonable, but flies in the face of my personal experience. Almost every person I have have ever known who has suddenly found themselves in psychiatric distress, arrived at that dangerous medical fork n the road because they could no longer trust their own counsel, and had become unable to help themselves. In other words, they could not manage any constructive self-triage. Perhaps you are short- changing how very scared and irrational psychiatric patients can present. Isn't it possible that psychiatry is , quite simply, "trickier" than other branches of medicine and that one of the byproducts of that is that the patient is profoundly confused by his/her own symptomology because it doesn't relate to their understanding of what is and is not "medical illness" and what can be done about it? The medicine of choice for depression on Cape Cod, for example, might be a stiff brandy. That kind of self-triage and OTC remedy just doesn't make the cut sometimes. Why can't you just admit that psychiatric patients are woefully inadequate at helping themselves because it is the thing they think they are doing to help themselves that is often contributing to their illness. You have a very hard job with very high stakes. Why not admit it other than you may prefer, instead, to break the balls of your colleagues (which, albeit, you are very good at)? Would you allow a close associate or friend to walk the isles of CVS looking to for his self-administered "cure" instead of doing everything in your professional capacity to insure that he/she received the best diagnosis and treatment possible? I don't believe you could. I just don't...j.
- April 2, 2008 at 2:23 AM
- Supremacy Claus said...
Psychiatrist is a specialist, like pulmonary medicine.
They want to seek the rent by promoting specialist treatment of transient stress responses, and nuisance symptoms that end with age.
The public has pretty good judgment on who has a mental illness. This judgment is universal. So, it exists in Eskimos (before they got so in touch with modernity), pygmies in the Congo, etc. They are as good as psychiatrists in recognizing mental illness. Those patients recognized by their peers should go to a psychiatrist, as a pulmonary specialist should manage pneumonia that has not responded to the first or second trial of an antibiotic.
You are referring to dangerous or disabling conditions.
I am referring to mild, non-disabling, non-dangerous, yet uncomfortable conditions. Do none of those exist in psychiatry? - April 2, 2008 at 8:07 AM
- James M. La Rossa Jr. said...
Question asked and answered. Thanks.
- April 2, 2008 at 1:09 PM
- Daniel Carlat said...
Here I agree with SC. SSRIs should be over the counter. I do believe the risks are overblown and are certainly lower than a variety of currently available OTCs. I suspect that most psychiatrists oppose this based on financial issues rather than patient safety issues.
- April 2, 2008 at 1:25 PM
You know, I did not want to comment in this posting any longer as newer postings are more important to me. However, while I greatly appreciate Dr C's above response, I disagree solely because our society, our culture, and our essence is too quick fix based to handle the use of medications with potential toxicities.
How many people think:
1. If one tablet may work, then how about two, or three at a time.
2. Why am I not better after one week of these pills; the benadryl reduced my itching eyes, the tylenol ended the headache, the lotrimin cream got rid of the rash.
Hasn't there been a backlash about tylenol toxicity in the past few years? Phenylpropylalamine is gone now; it was the best decongestant for me, but not for women. What about the push to put prozac and phenteramine as OTCs so people could lose weight? Hmmm, sometimes once is too much, eh?
We debated in residency whether some psychotropics should be made accessible as OTC products, and the consensus was BAD IDEA! It is a slippery slope; today it is SSRIs, and tomorrow you will see other products clamor for such designation.
It's not about protecting ourselves to maintain our livelihood, it's about reinforcing the standard of care for depressive and anxiety disorders: medication and therapy and change by the patient as a whole is the intervention. Is that going to be put on the label in the store?
I didn't pick this posting name for nothing: I preach what I was taught; less invasive to more invasive. There is a power in dialogue. I've seen it, I've lived it, I believe in it!
A question: Is Zyrtec making money for its brand name producer these days? I don't know, but I wouldn't be surprised if it was.
Twist this point of view however you wish, SC. I have no hesitation that if I could cure a mental illness tomorrow, I would gladly look for a different type of work in mental health care or medicine in general, knowing that people got better.
Think about it: a committed physician would accept putting him or herself out of business in doing the job. How many business people could say that and mean it!?
I hope you are reading the newer postings in this blog. Important stuff being exposed and raised. I know I sound like a cheerleader; I am glad someone has the time and energy to be public with these issues. I share it with any and all who want to hear it.
Again, thanks for your work Dr C. - April 2, 2008 at 7:31 PM
- soulful sepulcher said...
"SSRIs should be over the counter. I do believe the risks are overblown and are certainly lower than a variety of currently available OTCs. I suspect that most psychiatrists oppose this based on financial issues rather than patient safety issues.""-Dr.Carlat
Are you serious? if so, which ones would you personally be willing to see OTC available to consumers to use at their own discretion?
I also appreciate TF open-minded therapy first, least intrusive treatment program he/she seems to have in place. As my own doctor said, "no more meds, you won't need me any more" and he was glad to say it! - April 3, 2008 at 1:18 AM
- Supremacy Claus said...
Citalopram 10 mg and sertraline 25 mg. Others are not for amateurs, due to serious drug interactions, cost, or ultra nasty drug withdrawals.
The package insert for users would read below the sixth grade. It would contain the really necessary black box warning, now missing. One in twenty patients gets agitated and restless in the first few days. They should not take the medicine again.
That warning gets added to alcoholic beverages and to anti-histamines too.
As to current ridiculous and irresponsible, left wing bullied warning about suicide? The corporation hate bias shows through (of the left wing bullies and of the craven, irresponsible FDA psychopharmacology committee). Half the people who commit suicide, murder, or who are murdered are drunk. How is that for causing suicidal thoughts? Find me the suicide warning on a bottle of whiskey. - April 3, 2008 at 5:59 AM
- Daniel Carlat said...
I'd agree with SC on which meds to include, although I'd also add Lexapro, which also causes no drug interactions. Might want to consider a few others, like buspirone for anxiety, trazodone for insomnia, and even Ambien for insomnia. Some would argue that Ambien is too abusable and causes too many strange side effects for OTC, but currently many many of my patients depend on some version of OTC benadryl, which can cause oversedation and memory loss.
- April 3, 2008 at 1:55 PM
- Nunya said...
my friend who suffers from depression was prescribed lexapro, and began hallucinating within 3 days. he never made the connection to the lexapro - i did for him. if i hadn't, he likely would have checked himself in to a psych ward because he thought he had become completely psychotic. his personal experience leads me to vehemently argue against lexapro otc. the others i have no experience, so no opinion of.
- April 3, 2008 at 3:43 PM
Maybe I am a bit naive to the purpose of blogs, but this "conversation" is going in a bad direction to me. No one here is going to impact on Rx meds going OTC, but in my opinion even validating this debate only empowers those who are trying to demean and debase psychiatry.
Thanks for the opportunity to participate, but I am out of this discussion. I would hope the comment by anonymous mom would give some fresh perspective to legit concerns of dangers to making meds OTC.
I have to wonder if SC has ties to scientology; there are overlaps in their rhetoric and yours. If I am wrong, sorry for the inference.
Good luck, good times, good day. - April 3, 2008 at 8:42 PM
- Supremacy Claus said...
TF: How do you know no one here will orchestrate getting SSRI's over the counter?
Here is a nice path to that:
Fill in the blanks. Guess who would support that. Correct, HMO's, with their $1000/hour administrative law lawyers.
You will never leave. You are an addict. - April 3, 2008 at 9:21 PM
- Supremacy Claus said...
Dan: It's great you outdo me in advocacy for freedom. I agree with your list of potential psychiatric medications to get placed OTC.
- April 3, 2008 at 11:37 PM
- soulful sepulcher said...
please read stephany's blog. - April 4, 2008 at 1:59 AM
- Supremacy Claus said...
Steph: Your casual association of school shootings with the use of SSRI's is baseless and irresponsible. It gives you the credibility of Holocaust Deniers and 9/11 Conspiracy Theorists. I am curious about your position on those two questions. Did the CIA set off a planned demolition series of explosions that took down Building 7, hours after the striking of the other towers?
That black box warning on SSRI's was placed after intimidation of the FDA by people with your views. If I were the parent of a kid who committed suicide after his pediatrician refused to continue his SSRI due to a black box warning, I would want the addresses of the intimidating extremists, to visit with them.
What do you think of alcohol? That is found in levels above the legal limit in half the suicides, half the murderers, half the murder victims. Many survivors of near misses of those deaths have no recall of their attempts, nor of any reason for them.
Entire stores specialize in nothing else but the dispensing of alcohol. Some of the stores are owned by state government monopolies. Alcohol is legally advertised in all media.
Perhaps, it's not a drug in your world, a food, maybe, an all natural substance? - April 4, 2008 at 6:20 AM
I'm just replying to stephany's april 4 posting: I read it and agree, I tried to post a reply but I don't think it went through.
Stop projecting your BS on me, SC.
I'm beyond annoyed, now at offended. - April 4, 2008 at 10:54 AM
- soulful sepulcher said...
SC- "It gives you the credibility of Holocaust Deniers and 9/11 Conspiracy Theorists. I am curious about your position on those two questions. Did the CIA set off a planned demolition series of explosions that took down Building 7, hours after the striking of the other towers?"
That is completely offensive. - April 4, 2008 at 1:42 PM
- Supremacy Claus said...
Steph: Your anti-scientific, unwarranted remarks on SSRI's are irresponsibile.
Please, answer the question. Do you believe Building 7 was demolished by a preset series of sequenced explosions, perhaps installed by the US government? - April 5, 2008 at 6:56 AM
- James M. La Rossa Jr. said...
I am so sorry not to have seen your earlier question -- "if [I] have had dinner with parents who have children who only attempted suicide on or close to after starting antidepressants? ... Because I'm one of those parents." I lost that post among these 71 comments.
First, I am very sorry to hear that. Your child is lucky to have such a smart and tenacious advocate for a parent.
As a publisher, I am "in the business" so-to-speak, so I don't often speak to personal psychiatric issues. I want to share with you that I lived through my Mother's very serious suicide attempt when I was 16. She never made another, but has been a constant frustration until the last few years because she has switched psychiatrists too readily, and has been non-compliant from time-to-time with her medication. I am very passionate about mental health issues, as you know, so when someone close to me -- who has every resource imaginable at her disposal -- seems to NOT want to get better, it infuriates me and has allowed me to "justify' a certain emotional distance.
So the short of it is that I know what it is like to survive the suicide attempt of someone very important, but my experience did not result in "positive action" such as your advocacy, and ironically, my Mother's attempt was compounded by her non-compliance, whereas it is your deduction that your child was hurt by the drug itself.
This is as far as I can go on this subject, Stephany, but, again, please forgive me for not having seen and responded to your pointed posting to me. With great regard, james. - April 6, 2008 at 3:52 PM
- Supremacy Claus said...
Extremists bullied the FDA Psychopharmacology Committee into issuing a black box warning about suicidal ideas from anti-depressants, against their experience and better judgment. That warning intimidated primary care doctors from writing for anti-depressants after 2004. Their scripts decreased. That reversed the decrease in suicide in that group. It resulted in the suicide of untreated young people by the 100's per year. The ideologues do their work, then refuse to accept responsibility for the ghoulish consequences. They are the cause of the tragic, totally unnecessary loss of 100's of young people a year, and the agony of their loved ones.
The Committee issued a warning to deter. It got its intended result. This Committee has to count among the biggest mass murderers in US history. Their murderous rampage continues today, without the slightest consequence to them, nor to the left wing extremists that forced them. Instead of learning, the FDA is on a rampage. It is issuing unwarranted warnings for all manner of drugs. - April 6, 2008 at 4:46 PM
- soulful sepulcher said...
Thank you James, I appreciate what you have written here to me.
Stephany - April 6, 2008 at 5:33 PM