Tuesday, February 21, 2006

Prozac OTC?

Aspazia left a comment with some questions, pertaining to my last post.  Since the response is way to long to fit into a comment box, I've responded here.  Note that the response might not make a lot of sense unless you first read the original post, and the comment, here.

Yes, the term hysteroid dysphoria is attributed to Donald Klein, from the late 60's. At this point (year 2006), it is more of historical and sociological interest, than medical interest. As for the question of whether MAOIs or Prozac would be better for treating rejection sensitivity, the answer is the predictable one: it depends on the patient, and to some extent, on the doctor.

I am confident that the magnitude of the therapeutic effect is greater with MAOIs, and that a higher percentage of patients will respond. But at least 30-35% will stop taking an MAOI because of adverse effects, compared to 10-15% with Prozac.  

From the psychiatrist's perspective, the judgment about which is "better" will depend upon a number of factors.  MDs who see a lot of young, relatively healthy patients, with clean diagnoses, and without a long history of multiple medication trials, will naturally see Prozac as the better choice for their typical patient.  MDs who see patients with multiple diagnoses (e.g. depression and panic disorder and PTSD), patients who have had multiple trials on modern antidepressants, will tend to think of MAOIs as better.  That's because there is no point in starting yet another trial of yet another SSRI in such a patient.  (If that was going to work, it would have worked already.)  

Some younger psychiatrists have little or no experience prescribing MAOIs, and would need to do their homework before doing so.  Some will do their homework, while others will not.

Psychiatrists vary considerably in their practice patterns, thus there are systematic differences in their patient populations.   It is important to keep this in mind when listening to a psychiatrist talk about his or her own experiences.  This is because it is impossible to know what conclusions can be drawn from those experiences, unless you know something about the population of patients among whom those experiences occurred.  

As for whether patients can pressure doctors into prescribing antidepressants, I would like to think that it would not happen very often.  It is pretty easy to say to someone, "Look, I know you think this would be best, but I really have to prescribe according to my own judgment..."

A bigger concern is that it is fairly easy for someone to come in and give all the correct answers, to manipulate the doctor into prescribing an antidepressant.  There is no good defense against that.  As a physician, one has to assume that the patient is acting in good faith, and the suspicion level is going to be low unless the patient seems to be fishing for a controlled substance.  

Make SSRI's available without a prescription?  First you would have to get a company that would be willing to sell them without a prescription, and I tend to doubt that anyone would do that in the USA; the liability issues would be horrendous.  But I realize that is a different issue.  Assuming that a company would do it, would it be advantageous for society?  The issues I see are these:

1. Selling antidepressants over the counter (OTC) might do something to destigmatize depression, and mental illness in general, and there could be benefit there.  

2.  It could trivialize mental illness, which would be bad.

3.  A lot of people who don't need them would end up taking them.  Most of those people would suffer no harm, except for the wasted money, and would stop taking them after a while.

4. Some people with bipolar disorder would became manic or hypomanic, and that would be a problem; in some cases, it would be a big problem.

5. Some people would try to abuse them.  Most of those people would get no appreciable effect, and would stop, no harm done.  Some would combine them with other substances, and that could be very dangerous.  

6. Some people report that antidepressants intensify the effect of alcohol.  That is not directly dangerous, assuming that the person does not intentionally overdose, but it can be hazardous because the person may not realize how much impairment there is.  (Of course, that can happen with alcohol alone, but it is more likely to happen with some kind of CNS drug involved.)

7. Some people who need treatment, but who for some reason will not see a doctor to get treatment, might end up getting beneficial treatment.  While not optimal, that would be more good than bad, except for #8...

8. Some people who are at risk for suicide would try to treat themselves in isolation.  Isolation is very bad for persons who are suicidal.  Self-treatment almost certainly would be a bad idea, and could have disastrous consequences.

Policy wonks may have some way of estimating the magnitude of those good and bad factors, and coming up with some kind of pronouncement about whether the good would outweigh the bad.  Personally, I would be highly skeptical of any such analysis.  So, to answer the question about whether SSRIs should be available OTC, I would not attempt a numerical analysis.  Rather, I would rely on the following kind of judgment:  
  • In general, it is a bad idea to make a radical change in how a medication is used, unless the likely consequences can be anticipated and quantified.
  • Selling antidepressants OTC would be a radical change in how they are used.
  • The likely consequences cannot be anticipated, nor quantified.
  • Therefore, it would be a bad idea.
I realize that that is a simplistic analysis, but even so, it pretty much sums up what I think about the idea.

(Note: The Rest of the Story/Corpus Callosum has moved. Visit the new site here.)
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Thanks for this analysis. The reason I asked about making Prozac and other SSRIs OTC was bound up with David Healy's argument in Let Them Eat Prozac. He argues that the current system, wherein you have to rely on a physician to write a prescription for a drug, particularly one like Prozac is that you tie it up with politics and profits. The pharmaceutical industry wants to make money, lot's of money. It can only make drugs for diseases (according to FDA guidelines). It is therefore invested in seeing depression as a disease that is widespread, hence profitable. PMDD, Social Anxiety, Eating Disorders etc. are all profitable diseases as well.

But, many people prescribed SSRIs would not have been prescribed them, I take it, when the only available medication was MAOIs or imprimine (sp?). The side effects of those medications were crappy and a patient could overdose. SSRIs side effects are more tolerable, so you can more casually write out prescriptions for these drugs than the older antidepressants. Now, you have more people than ever saying they are depressed and on antidepressants. The majority of these prescriptions are written by GPs not psychiatrists.

The majority of people on these SSRIs are women with private insurance. Not surprising since that is who Big Pharma is marketing these drugs too. Sure, being stressed out and dealing with multiple responsibilities does make women prone to have symptoms of depression. Also, being the victim of a sexual assault or shitty childhood etc. Depression is a dimensional disorder and so better, cleaner drugs seem to lead us to include more people in the category of depression requiring treatment than we did before. Many of these people might benefit from a less stressful world. But, shit, who has the time or drive to change the world when you are stressed out. Why not just get a pill to deal with it.

So, back to the OTC thing. If you have all these profits being made from selling these drugs to women with insurance, is this right? How do you take the politics out of it? OTC.

I have put this together rather quickly, but hopefully my point comes through!
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