Wednesday, August 20, 2008

Michael Phelps: Mom gives "tips" for ADHD

A nice story in the popular press. Good Housekeeping has an interview with Michael Phelp’s mom, Deborah Phelps. The focus of the story is on her experience raising a son with ADHD, and her subsequent involvement with (yet another phony citizen’s advocacy group that is merely another front for Big Pharma’a multiprong marketing efforts) “ADHD Moms.”

The story (as long as the link stays active):
http://www.goodhousekeeping.com/names/real/deborah-phelps-interview

Mom’s group:
http://www.facebook.com/ADHDMoms

The man behind the curtain:
http://www.mcneilpediatrics.net/mcneilpediatrics/index.html

The man behind the man behind the curtain:
http://www.ortho-mcneil.com/ortho-mcneil/

Well, the story is truly nice. This single mom really took care of her son, despite his high activity level. And no dad in the picture.

The story gets her views on treatment of ADHD. Plus some tips.

But in the article is evidence of our culture’s misguided beliefs regarding treatment of mental disorders: When asked about “treatment,” Ms. Phelps acknowledges the role of Ritalin. Then, secondly, when asked for “tips” on how a parent can cope with ADHD, Ms. Phelps has a handful of hard-won wisdom: “Make a task list….I posted a task list on the refrigerator and gave him stickers when he completed his responsibilities.”

“The pool itself helped, too. ADHD children need parameters.”

“Treatment.” “Tips.” Get it?

Meds Vs. Therapy. Therapy lost this one: demoted to “tip” status.

Where did Ms. Phelps come up with the idea of a behavioral chart with stickers as rewards and recognition? In therapy, we call that “treatment.” Straight out of the handbook on treatment for kids. Sticker chart. Treatment.

But in the common view, the view that Big Pharma wants you to believe, the pill is the treatment, and the behavioral strategies are “tips.” Like: to avoid lint when cleaning windows, use newspapers instead of paper towels. To keep your guacamole from turning brown, squeeze lemon on it. Use ammonia to clean your diamond. Those are tips. Clever ideas, take ‘em or leave ‘em.

The truth is that children need to have rules and expectations. ADHD interferes with this. Pills help. But no pill will get your child to complete chores.

Kids, especially boys, need to burn off energy. And it is better if it is in some kind of activity with rules and parameters, rather than just running the streets or running mom ragged around the house. A pill will never make a kid take the trash out on trash day, or make a kid complete a homework assignment. Or stay in his chair through a whole class period. For someone with ADHD, it will help. It will get a kid in the range for performing the behavior, like a footstool can help Michael’s mom reach for something on the highest pantry shelf. But the footstool won’t get the can or whatever down for you.

Is this a big deal? What’s the big diff? Well, I think it is a big diff. If the doc says to take the meds: it will cure your kid’s ADHD problem, well, you are gonna be sorely disappointed. Cuz the kid is still gonna fail to have follow-through or stick-to-it-iveness or respect or to stay in his chair. The meds can get the kid in range, then you need some more “treatment” to achieve these goals.

But when this component of treatment is never mentioned, or is labeled as a “tip,” versus “treatment,” what degree of adherence do you think you are gonna get?

Well, rant off. What would be nice to hear in the future is: Ms. Phelps: how did you learn all of these behavioral strategies? How did you find the therapist or counselor who guided you to develop your first sticker chart? Did you believe in the chart idea at first? How long before you saw it work its magic? How many target behaviors did you have on it at each time? This is what the single moms raising kids with ADHD really need to hear.

Monday, August 18, 2008

If Meds Don’t Work…Add Another!

I was browsing the new TIME magazine when a bizarre advertisement caught my attention.

This is for Abilify, an antipsychotic from Bristol-Myers Squibb.

Here is the deal: if you are taking an antidepressant, and you still have “unresolved symptoms,” the physician should add Abilify.

Am I missing something here?

If your antidepressants aren’t working, maybe you should start talking to your physician about how to find a decent therapist. As in: talk therapy is an effective treatment for depression. “Behavioral Activation” is also a decent intervention: getting off the duff and getting active. Exercise is an effective intervention for depression. Any of these, with or without an antidepressant, will help improve things.

What people are increasingly figuring out is that the pills just really do not work. Not like we are lead to believe” You have this biological illness called depression. It is caused by some imbalance (or deficit) of serotonin. If you take these pills, the serotonin levels will be restored, and you will no longer be depressed.”

Right. If I had a dollar for every time A psychiatrist played out this tired story, I would be as rich as…as a pharmaceutical company.

So, apparently Bristol-Myers Squibb comes up with a great idea – antidepressants never work that well – so let’s figure out a drug to augment.

To figure out a bit more info, I found the website equivalent of the print ad:
http://www.abilify.com/

Sure, if it helps some people, I guess that is what we want: less depression. But sad to see the reinforcement of pills as the answer, especially pills as the answer when pills don’t work. Is some pharmaceutical company out there currently studying a third category of pill for augmenting the antidepressant/antipsychotic combo if that leaves you with “unresolved” symptoms?

It doesn’t make sense. The ad, and much of this physician-directed and pharmaceutical-directed message fails to ever suggest: Try therapy when the meds fail ya.

Even scarier – the side effects of Abilify must be wicked. The disclaimers and cautions are very prominent on this ad. Seizures, anxiety, and more. Especially a shockingly clear statement about meds being associated with increased suicide risk, paired up with explicit direction to talk to the doc if you start thinking about hitting the gaspipe. All this, plus, very clear warnings that this pill is off-limits to the youngsters. Quite a scary ad, really.

Now consider the side effects of talk therapy: Increased confidence. Greater insight. Increased interpersonal effectiveness.

Take your pick: meds versus therapy.

Wednesday, August 13, 2008

Meddy-Go-Round: multiple 'trials' of meds cuz they ain't workin

I hate to hear people tell me stories of being lead by some physician to get on psychiatric meds for some behavioral or emotional problem, when the problem truly ought to be addressed with therapy. There are a lot of conditions and problems out there, in my opinion, where therapy should be first line of treatment. Largely due to efficacy, and due to the lack of bad side effects, and the range of good side effects of decent therapy.

But, for a couple reasons, getting started on pills is preferred over doing the good, hard work of therapy. Some other time, I will blog about the three main reasons why, tragically, we end up on pills instead of in the therapist’s office. MedsVsTherapy, and too often, meds wins.

So, what happens when you get put, inappropriately on meds?

Well, you have just jumped on the Meddy-Go-Round. You probably will not enjoy the ride. However, like some merry-go-rounds, this is difficult to get off.

The term “meddy-go-round” popped into my head one day, as I was thinking about this common problem. It seems to fit the problem really well. I remember the days when I was a wee lad. Binghamton, New York was the home of the merry-go-round. As a kid, my family would travel over to this happy land of shoe factories and merry-go-rounds, and spend some time visiting my grandparents. The coolest thing was when we kids could get loose of the adults and head down to a nearby park, where it seems they were always running a classic merry-go-round. We would just wait for the next turn, get on, and ride. When it was done, get on another bejeweled horse, and you are riding again. Over and over.

When you go to the doc’s office for some problem: a kid is noncompliant, you are depressed, you can’t sleep, you have stage fright, whatever – well, the old saying about the hammer and the nail applies. So, the doc provides an answer for you, and writes out the prescription. Maybe you are unsure, but you give it a try.

Well, maybe the meds work for a while. Maybe they don’t work at all. Or maybe the side effects are so bothersome that you would rather go back to your familiar problem. But no. when you go to the doc, you hear one of three things: raise the dose, switch to another med, or “augment” with another med. You have now jumped on for your second go-round on the meddy-go-round.

When this new regimen of pills fails to solve your problems, you go back to the doc. The doc asks: how is your depression? Still glum? Well, let’s try another. You start to wonder, “when are we gonna start talking about my problems?” But the doc is firmly in control, socially speaking. You are on the doc’s meddy-go-round.

And so it goes. The next trip on the meddy-go-round. The doc has you try another prescription. Or raises the dose. Or augments.

Tragically, as this goes on, you get into believing that your problem will be solved by pills, because surely the doc would not keep trying you on one prescription after another unless the doc was really sure. You buy into this idea that multiple trips on the meddy-go-round are necessary to find the right pill, or right combination of pills. Maybe. But, maybe not. However, how often do people hear the 'maybe not' from their doc?

Here is a variation in the trips upon the meddy-go-round. Antidepressants are commonly prescribed for depressive type problems, and a range of other things. Well, the problem here is that for many people, the antidepressants actually do have an effect for a brief, shining moment. The mood lifts. The world again has color. You have found a solution.

But then, it happens: the magic wears off. After about five months, the pills no longer work. Maybe four months. Maybe six. But that fleeting period of normalcy really convinces you that pills are the solution. So, you get on the meddy-go-round for yet another trip.

This happens, in my opinion, because the antideprssants, the SSRIs, do have an effect on your mind, as do other drugs including alcohol. And, like other drugs including alcohol, at first your brain, and body, are naïve to the effects of the SSRI. They have their impact.

But with time, the body adjusts – the body does not like foreign substances upsetting the balance. So, the brain recalibrates itself back, as close as it can, to normalcy in the face of this foreign, upsetting substance. You get tolerance. Just like with alcohol.

No one ever talks about this phenomenon. It is simply noted, and dismissed with the comment that it was close, but not quite the correct pills. Onto the next bottle of pills. The next trip on the meddy-go-round.

Tragically, the change in the brain as it compensates to the influence of this foreign substance causes withdrawal problems in some people when they go to quit the pills. There is a lot of talk on the web now about the difficulties getting off of SSRIs. Especially Paxil, but others also. This is just evidence that, like alcohol, your brain has adjusted itself to get back to normal in the context of constant foreign substance.

Ask yourself: how much BETTER are you on the meds? Are you where you hoped to be when you sought treatment? Like so many people, are you still having your same problems AND taking meds? Does that make sense? Think about it, and start searching the web. Start reading up on non-pharmacological treatments for what ails ya. Maybe you will be able to finally get off the meddy-go-round. You will catch a lot of difficulty from the physician, but it might just be a good move.

Sure, this short-term response is good for getting someone out of a depression. Often, therapists note how it is great for getting someone into the range of functioning where they can get engaged in decent therapy. And, pills work for some people. But all too often, they simply don’t but somehow you get caught on this meddy-go-round, trip after trip.

Same thing for kids and behavior problems. Well, these pills did not make junior start to complete his homework and start to talk to me in a decent tone. So, let’s try some other pills. Folks, let’s get real. There is no pill that makes a kid talk to you respectfully, stop listening to angst-ridden music, stop stealing your smokes, and start completing homework. No pills will achieve that. Maybe it is time to think about getting off the meddy-go-round.

Friday, August 8, 2008

Pharmeducation

Darn!
I wrote that other blog, Meducation, and spontaneously came up with that term Meducation. I posted my blog. Then, I went to see if anyone else had applied the label "Meducation" to the Big Pharma role in CME education. I found a zillion web entries for "meducation."

Darn! I really wanted to coin a term today.

I don't think anyone has used the term "pharmeducation" to refer to Pharma-developed or sponsored CME. It is kind of hard to tell how the term was used in one manic post [google "whypsychopsdrugsemfcontrolbad" and give me your opinion).

However, "meducation" has occurred as a clever neologism to many, for many explicative and expository demands.

So, I devoted a couple more brain cells to the effort, and came up with "pharmeducation."

When googled, this basically led me to: someone's email (to mr. pharmeducation: sorry for all the dumb emails you may now receive), and to an online pharmacy site that seems to either be very slow to load, or very slow to load malware onto my computer. No thanks, online drug store: I have great health insurance and docs who will provide me with any samples I need (worthy of another post one day).

So, I am claiming to be the innovator of the term "pharmeducation" as a euphemism for Physician Continuing Medical Education that is tainted by conflict of interst from Big Pharma.

Darn. I still kinda like "meducation."

Meducation: Could CME exist without Big Pharma?

Recently, I had to get some continuing education hours to meet my CEUs (continuing education requirements) for psychologist license renewal. I have a “membership” with Medscape, an organization that reports medical news, features, content, and provides continuing medical education (CME) content for physicians. Since the content areas of psychology and psychiatry overlap, and since free CEU are better than dollar CEUs, I thought I would check out Medscape’s “free” CME offerings in the area of psychiatry.

So, I log in to Medscape. I click on the CME button. I click on the choice for “Psychiatry.” I select the option for CME articles published in the recent 12 months.

After a moment, a long list pops up.

I start to browse for a couple topics to round out my CEU hours.

I notice a pattern. See if you notice a pattern to the curricula offerings:

“Effectiveness of Second Generation Antipsychotics: A Systematic Review of Randomized Trials.”

“New Data in the Recognition and Management of Bipolar Disorder.”

“Augmentation Strategies in Treatment-Resistant Depression.”

“Improving Remission in Depression: Focus on Augmentation Strategies.”

“Improving Mental Health Outcomes: Focus on Atypical Antipsychotics.”

“Optimizing Management of Bipolar Disorder in Children.”

Patterns of Pharmacotherapy and Treatment Response in Elderly Adults with Bipolar Disorder.”

“Improving Remission in the Treatment of Major Depressive Disorder: Assessing the Augmentation of Traditional Antidepressants with Atypical Antipsychotics.”

“Pediatric ADHD: Guidelines for Initiating and Monitoring Treatment.”

Wow.

Meducation.

In all, across approximately 125 CME course in psychiatry posted to Medscape in the past year, it really looks like the “atypical antipsychotics are good for everything” message is coming through loud and clear in about 75% of the articles offered.

From reading on this topic lately, I knew that Big Pharma was really pushing atypical antipsychotics, and their puppet spokesmen psychiatrists were promoting expansion of the borders of whom to diagnose and/or treat. But a peek into some of these articles shows a very consistent, coordinated campaign.

The term “obvious” comes to mind when thinking of Chik Fila’s EAT MOR CHIKN campaign. The Big Pharma campaign to get everyone diagnosed and hooked up to the antipsychotics is a bit more subtle, but equally consistent, sustained, and coordinated. Multi-pronged: radio, billboard, television, print, etc.

EAT MOR CHIKN
EAT MOR CHIKN
PERSKRIB MOR ZIPRECKSA
PERSCRIK MOR ZIPRECKSA
PERSCRIB MOR ZIPRECKSA.

What if the obesity CME was sponsored by Chik Fil A, and breaded, fried chicken sandwiches were recommended as the nucleus of recommended diet for just about every diet-related condition? Wouldn’t we begin to wonder if we were being “sold” a bit strongly? What if your physician was recommending fried chicken sandwiches as a remedy for your obesity, or cholesterol, or hypertension, as he or she wrote out a prescription, with a Chik Fil A pen, for you to eat one Chik Fil A sandwich per day?

Meducation.

This brought home the issue that some other psych med bloggers have been noting: Big Pharma uses Key Thought Leaders (Big Pharma-sponsored psychiatrists) and Continuing Medical Education as marketing tools.

Because of FDA rules, Big Pharma cannot even hint that a med ought to be prescribed for some application, such as depression augmentation, unless the med has been FDA-approved for that application. However, Big Pharma can: 1. sponsor a particular physician’s research and 2. sponsor continuing medical education.

Did you catch that? That is how Big Pharma sponsors off-label use of their products while not violating, but side-stepping, federal law. Well, this is no revelation. Many people have noted this.

It just struck me as I went to get my CEUs. I just was struck by the extent to which Big Pharma has grown to control CME as I hunted for a couple free CEU hours for myself. Well, I guess it is true that you get what you pay for. I clicked away from Medscape and went and found some psychologist-intended CEUs.

There are, currently, many related controversies and emerging issues regarding the role of Big Pharma and COI. One debate is framed this way: Can the continuing medical education system survive without Big Pharma sponsorship?

Huh?

http://www.accme.org/index.cfm/fa/home.home/home.cfm

Folks, here is the source. Of the money made by providing CME, over half is from Big Pharma providers. If you analyze the situation in different ways to get at the portion of CME “sponsored” by Big Pharma, you realize that closer to 90% of CME is supported by Big Pharma, an entity with a clear stake in the game.

The extent, and the tradition of the Big Pharma-sponsored lunch, is so entrenched in the medical system that some people actually wonder if we could still hold the requirement that practicing physicians ought to continue to receive education following licensure.

So, debate is everywhere. However, from my point of view as a licensed psychologist, and from the point of view of all of the other clinical professions where CME (or CEU or whatever it might be called) is required, we just cannot figure out what the issue is.

We all pay for CME that is, generally, free of Big Pharma, and, generally, we all make less than medical doctors. We don’t see any problem whatsoever. Do we like it? Well, generally, people are hesitant to part with their money. Do we manage? Yes.

Of course, you won’t get lunch with your CME.

But seriously: name a profession, outside of “licensed physician,” where the salary levels are so consistently upper middle class that anyone would even think to say that they could not AFFORD CME unless it was provided for free. Who?

Name professions where we DO pay for CME (and lunch is generally not provided). Psychologists. Licensed clinical social workers. Licensed marriage and family counselors. Licensed chemical dependency counselors. Licensed professional counselors. Licensed physical therapists. Licensed occupational therapists. Licensed massage therapist. Licensed Speech/Language Pathologist.

Doc, all of us can manage to scrape up the dollars required for a few CME credits per year. I think that question is now answered.

Tuesday, August 5, 2008

Consumer Reports Sept 08: Meds versus Machine

September 2008 Consumer Reports finds those sound machines are a great alternative to sleep medication.

Big Pharma has been making plenty of money by pushing pills for sleep. Partly this is because we (in general) have gotten into the habit of thinking that we need to run to the physician every time we have some problem. People describe this as the “medicalization” of problems. Take a problem, figure out how it could be a medical problem. Define it that way for others. Provide the medical-style solution (typically pills or surgery). Problem Solved.

So, we all start believing that a problem like insomnia is somehow fundamentally the same as cystic fibrosis. Give it a diagnosis. Give it a diagnosis code. Allow a physician to be “reimbursed” for providing “diagnosis” and “treatment.”

People, let’s get real. If you have sleep problems, you know you have sleep problems. You don’t need a “diagnosis.” Does it make you feel better if a physician tells you that you can’t sleep?”
So, you come home and tell your family:
“Oh, now I know what my problem is. The doctor said I have insomnia 780.52.”
“What is 780.52.”
“It’s the number for my medical condition. It also coincidentally is the cost of getting diagnosed and starting treatment. Thank goodness I have that nice, fat health insurance package.”

[Now, we are all starting to see how we spend so much and get so little for our health care dollar.]

So, Consumer Reports decides to ask a group of everyday people about sleep problems. Things don’t look so good for Big Pharma, because unlike academic researchers, the universities, psychiatrists, other physicians, medical organizations, advocacy organizations, the prominent peer-reviewed journals who accept advertising, the FDA, and other entities, Consumer Reports cannot be “supported” through loads of cash. No conflict of interest.

For those who don’t know, Consumer Reports is the main publication from Consumer’s Union, a magazine-subscription-supported group who evaluate everyday products and services that everyday people are concerned with. Such as sleeping pills, since many of us have problems with sleep. To stay independent, when they test something, they usually go out and buy their own. If they test five different models of toasters, they just send staff out to the store and buy these. Then they run the toasters through tests to see how well the toasters perform. Their criteria are usually the things we everyday people are concerned about: does it burn the toast? Is an inexpensive model as good as an expensive model?

Increasingly, Consumer Reports has branched out from evaluating toasters and lawn mowers. They have gotten more into health care. I think this is awesome.

In April, they conducted a phone interview of almost 1,500 everyday adults in the U.S. to ask about sleep problems, and what people do to address sleep problems, and how well that attempt worked. One weakness of the Consumer Reports strategy is that I can’t readily find details, so I cannot evaluate various potential limits and biases of this study.

Nonetheless, they found that 20% of us are taking these sleeping pills, prescription or OTC, at least once a week to sleep better.

Wow. One in five of us.

The U.S. has 300 million people. One-fourth are under 18. That leaves a guesstimate of 225 million adults. Let’s say the survey failed to be representative of half of that, and that none of that half of us take sleeping pills. That leaves 20% of 110 million people. So, conservatively, well over 20 million people each week are taking at least one pill for sleep. Now, some of them are only paying a nickel for a Benadryl. But some are paying a lot more – for prescription pills. So, there is a lot of money to be made from 20 million or more people per week. A million dollar industry? It sounds like a million dollars-per-week industry.

But, seriously, folks. We know why we can’t sleep. We watch TV too late. We don’t take time to calm down and relax. We are over-committed. We don’t manage our time well. We drink something with caffeine too late in the day. We get allured into surfing the internet, or talking on the phone, too late into the night. We never get active enough in the daytime to be tired enough to really fall asleep at night. We worry a lot – we worry about money problems, job problems, aches and pains, the leaky roof, the noise in our car, about someone breaking into our home, etc.

“Therapy” for sleep involves assessing and addressing these various problems. Look at that list. You are probably on there. Therapy for sleep is obviously going to be individualized, not one-size-fits-all. For me to address my worries, I will need a different conversation to help me discover these, and address these, than you will need for your worries.

[Oh, excuse me – let’s just re-label the worries as “racing thoughts,” and diagnose ourselves with the bipolar 296.80. Then we can simply be cured with Zyprexa.]

You might need to switch to decaf. Or find a non-caffeinated tea. Sure, it will not be as satisfying, but it is the trade-off for solving the sleep problem. Oh, excuse me – I meant to say “curing” your “insomnia 780.52.”

Any of these methods will take work and effort. The pill companies are gonna try to convince you that it is all much easier – just take a pill and you are done.

The advertisements are sooo peaceful!
http://www.lunesta.com/
http://www.ambiencr.com/

You might be able to get it covered by your insurance, since you have a legitimate medical disorder: “insomnia 780.52.”

What worked for the people surveyed by Consumer Reports?
For those using prescription medication, 75% said the pills worked “most nights.”
Listen to this: what was in second place?

A sound machine. 70% said this worked “most nights.”
http://www.homedics.com/products/soundspa.html

What else worked? OTC meds (57%), making the sleep schedule more routine (50%), and also practicing “muscle relaxation (40%).”

So, why not go with the pill? It is the clear winner. Meds versus therapy, and meds won.

Well, what are the trade-offs?

This problem is so big, I can’t begin to get through it all at once. Sleep-driving. Drug dependence. Rebound insomnia. Tolerance. Oh, don’t worry about these – as Big Pharma says- only use these pills OCCASIONALLY. In other words, people, you are still left with the problem.

The problems with sleep pills rose to a level that the FDA broadcast a special warning last year about them:
http://www.fda.gov/bbs/topics/NEWS/2007/NEW01587.html

The Consumer Reports survey said that for people using pills, half were using strong pills not meant for sleep but meant for other problems: Xanax (anxiety), Darvocet (pain), Neurontin (seizures). Wow. Fifty percent paying big bucks and facing big side effects.

Not to mention the fact that with the pill, you are moving one more step down the path to believing that all of our problems are actually “medical disorders” that need to be treated by a physician, and by a pill or surgery. You are losing the belief that you can use your own abilities, and help from others, to figure out your own problems and solve them. To determine when some are and some are not medical problems.

Insomnia due to some thyroid problem = medical problem. Insomnia because you are wondering if checks are gonna bounce = you need financial therapy. See the difference?

Your physician may or may not. What we do know is that your physician does not have time to diagnose the root cause of your insomnia, and is probably not very good at providing counseling to help you manage your money, and ALSO we know the physician was just visited by his or her best friend, the drug rep. The drug rep just provided a free-lunch talk on the epidemiology, diagnosis, treatment, and third-party reimbursement of insomnia 780.52. Plus, the drug rep left some samples. Mmmm.

Now – how easy is it for the physician to provide you a solution? They just hand you a sample and send you on your way. Oh, and the side-effects issue? Well, uh, that’s up to the pharmacist. Besides, you weren’t gonna use alcohol at the same time, anyway, right?

If you live in a dangerous neighborhood, and can’t sleep because you worry about someone breaking in, the pills will not make the bad guys stay away!! Have you made your home relatively safe? Yes or no. If not, do it, to the best you can. Once it is reasonably safe, then “rest-assured.” We can never be safe. But you can do only what you can do. How safe is it to be intoxicated into somnolence when that burglar or rapist does break in?

So, in Consumer Reports, meds barely squeaked out a victory over behavioral strategies. There is a great body of literature, more “scientific” – ruling out more alternative hypotheses, etc. – defining behavioral interventions as the first choice for most sleep problems. And these are very effective. Plus, with GOOD side effects versus BAD side effects. For example, if you learn Jacobian progressive muscle relaxation (Gurgle that to learn more) to help you sleep, you can then use it to help you with test anxiety, stage fright, etc.