Fluoxetine in the treatment of depression with comorbid substance abuse disorders

Twenty to 30% of adolescents diagnosed with Major Depressive Disorder are also diagnosed with at least 1 comorbid substance abuse disorder. Moreover, reported drug use has been found to be a predictor of suicide attempts in adolescents, with a positive relationship being found between the number of drugs abused and the likelihood of a suicide attempt.

Fluoxetine (you may know it better as Prozac) is the only antidepressant that the FDA approves for use with children and adolescents, and fluoxetine has been found to be effective in reducing depression and comorbid substance abuse disorders in adults. Findling et al., publishing in the Open-Access Child and Adolescent Psychiatry and Mental Health, decided to study the effects of fluoxetine in adolescents with depression and comorbid substance abuse disorders.

The study originally included 18 patients in a fluoxetine experimental group and 16 adolescents in a random, double-blinded control group. Of the subjects, 26 reported that the depression started before the substance abuse and 6 reported simultaneous depression and substance abuse. Urine screens were used to assess drug use throughout the experiment.

At the end of the study, 12 subjects remained in the fluoxetine group and 13 remained in the placebo control. Both groups had reduced symptoms, but the placebo group had a greater mean reduction in symptoms. Fifty percent of the participants in each group met the criteria for remission. (There is a great graph in the article showing the difference in scores between the two groups, but I’m working off an old computer and can’t get a really good screengrab.)

This study gives us some good data, but it is important to keep in mind the small sample size and low statistical power of the study. I like that the authors didn’t let this study become part of the file drawer problem. It is just as important to see that a psychological or medical intervention is not effective as it is to see that something is effective.

Findling, R., Pagano, M., McNamara, N., Stansbrey, R., Faber, J., Lingler, J., Demeter, C., Bedoya, D., & Reed, M. (2009). The short-term safety and efficacy of fluoxetine in depressed adolescents with alcohol and cannabis use disorders: a pilot randomized placebo-controlled trial.

UPDATE: I just read in one of John’s posts on PsychCentral that the FDA just approved Lexapro for use in children, despite some misgivings. So fluoxetine is not the only SSRI approved for children. Check out John’s post for details about the controversy.

 Child and Adolescent Psychiatry and Mental Health, 3 (1) DOI: 10.1186/1753-2000-3-11

Traumatic Brain Injury

Following the death of Natasha Richardson from a head injury, MSNBC is running a bit of information about Traumatic Brain Injury that they pulled from the CDC. It’s some good info for anyone who is interested in brain trauma.

Can doctors learn something from a snake oil salesman’s pitch?

A co-worker of mine is going through some medical tests, and she is complaining. She says that doctors order too many tests, and that it is killing her to pay for all of them because she hasn’t hit the deductable on her health insurance yet. I point out that they only order so many tests because if they miss something, they open themselves up to malpractice lawsuits, and then their premiums go up. Doctors order extra tests for the same reason we look both ways before we pull out into an intersection while driving: they do not want to pay more for insurance.

There was an article in the Washington Post a couple of days ago talking about alternative medicine, written by a Dr. Manoj Jain. He states that a number of his co-workers who get both conventional and alternative medical care complain that doctors are too brief with patients. One of his nurses told him:

Judy summarized her experiences without mincing words. A conventional doctor “listens to my symptoms and is quick to prescribe a medicine or to order tests. My instructor listens to my story and works with me.” I asked her for another example.

“Well, do you remember two weeks ago, when I had a terrible cold, followed by a cough, low-grade fever and lots of sinus drainage, and I came to your cubicle? In less than a minute — listening to my symptoms — you said, ‘You have sinusitis’ and called in antibiotics.” The drugs worked, but she thought the encounter was a little too quick. “I am not criticizing you, but that is how conventional doctors work.”

Myself, I prefer doctors to give quick answers. But Dr. Jain points out that the placebo effects are powerful things, and that they can make the difference in quality of care.

Dr. Jain does not come off as being soft on alternative medicine, although he may be a bit of what the bloggers over at Science-Based Medicine call a “shruggie.” He seems to attribute the power of alternative medicine to the interest that practitioners take in their patients, compared to then”15-minute office visits, recurrent insurance denials and unnecessary diagnostic tests to avert malpractice suits” that patients see in conventional medical care.

Jain is not really talking about medical practice. He’s talking about the pitch (ironically, he refers to alternative medicine as “snake oil” in the title. Snake-oil is all about the pitch). He refers to alternative practitioners as “good used car salesmen…with little scientific proof,” but he doesn’t see that as a bad thing, and thinks that some of the pitch of alternative medicine can help doctors relate better with their patients, and help the patients trust conventional treatment more than they currently do.

In psychotherapy, we occasionally see news stories that point out that what we call the therapeutic alliance, the bond that forms between a therapist and his client, is a better indicator of successful therapy than the use of any particular technique. This is old news that gets rehashed as “news” every time a new study is released. The client wants a therapist who will take time to listen to his client, male recommendations, and work with the client. It shouldn’t be stress-free because there is no change without stress, but it shouldn’t be contentious.

Doctors may be able to take some lesson from this. Perhaps If doctors could spend more time with each patient, talk to them more, and make the same recommendation they would have made in five minutes under the current system, patients would feel better about their care.

Of course, the question is how do you fit that into the current system?

JAMA editor DeAngelis is actually Joe Pesci, circa Goodfellas

Okay, my hiatus is over. Class is finished, and I’ve got three weeks to kill with work, blogging, and playing Lego Batman because I’m just that kind of geek.

Of course, the first blog I check when I come back is Mind Hacks, because it is one of the best psychology blogs out there, and I found the first story a bit troubling. I followed it back through all of the sources, and now I’m presenting it here. Furious Seasons has reported on this story, twice, so I also recommend you read that site for anything I may have missed.

In 2008, Robinson et al. published a piece in JAMA testing the use of the antidepressant escitalopram (Lexapro) versus Problem-Solving Therapy as a treatment for post-stroke depression. More specifically, Robinson et al. were testing whether either Lexapro or therapy would prevent depression within the first year after a stroke, stating that depression occurs in more than half of stroke patients. They studies the effects in a randomized, controlled, partially double blinded experiment. (Let me explain: it is virtually impossible to double-blind a therapy comparison, especially when one is comparing the effects of therapy with medication. What Robinson et al. did was blind the Lexapro trial with a placebo group. And when I say virtually impossible, I mean impossible, but I want to leave myself open in case I’m wrong).

Robinson et al. found that fewer people in the Lexapro group (8.5%) were diagnosed with depression after 12 months, compared with the therapy group (11.9%) and the placebo group (22%). These results were paraded through the media.

However, this is not as simple as it seems. Jeffery Lacase and Jonathan Leo published a letter in JAMA in October, stating that, while the study states that while the study finds that the Lexapro results were statistically better than placebo and the therapy results were not, the study did not assess whether the Lexapro results were statistically better than therapy. In a response in the same issue, Robinson et al. stated that “a Cox proportional hazards test did not demonstrate a significant difference between the two treatments.”

This month, Leo and Lacase published an article in the British Medical Journal (BMJ) stating that Robinson et al. did not make full financial disclosures. Specifically, Robonson did not mention that Robinson had a financial relationship with Forest Laboratories. Forest, for those who may not know, makes Lexapro. This seems like a pretty big deal. Robinson chalks it up to an “erroneous recollection” of the dates that he worked for the Forest speaker’s bureau. I don’t buy this. JAMA asks for disclosures going back five years, in this case between 2003 and 2008. Robinson states that he worked for Forest in 2004 “and perhaps 2005.” This is well within the reporting window.

If it were me, and I don’t think I’ll ever have to worry about pharmaceutical money as a lowly counselor and psychologist, I think when I filled out the disclosure form the first thing that popped in my head would be that I worked for the company that is making the drug I am supporting, not that I got money from a bunch of other drug companies.

And I’m not criticizing doctors who take money from pharmaceutical companies. From what I read, if this practice stopped it would almost halt medical research. The NIH only gets about $12 from Congress (as opposed to the billions we use to stop those pesky potheads from getting stoned and passing out while watching anime terrorizing their neighbors. What I’m criticizing here is the non-disclosure. Even if the results of the study are spot-on, it makes things look shady.

But this isn’t the end. Leo received a phone call from JAMA editor Phil Fontanarosa, who, depending on which side of the story you hear, either banned Leo from ever publishing in JAMA again, or, as a spokesperson says, ” It was something along the lines of not setting a good example for students. He didn’t say he would be banned. He didn’t think Leo was taking a very good approach by taking this confidential process within JAMA out to media and another medical journal. It’s just not the way things are handled here.”

JAMA’s Instructions for Authors state that it is best to submit a letter within four weeks of original publication.  It is unlikely that Leo’s article would have been published anyway. In fact, Leo stated that he warned JAMA about the lack of disclosure 5 months ago.

The Wall Street Journal reports that Leo then received a not-so-friendly call from JAMA editor-in-chief Catherine DeAngelis. Le states that DeAngelis first called his supervisors to try to get him to retract the BMJ piece. Leo characterized DeAngelis as “very upset.”

When WSJ attempted to contact DeAngelis, she gave a remark that could have come from one of the mobsters in one of Scorsese’s best:

“This guy is a nobody and a nothing” she said of Leo. “He is trying to make a name for himself. Please call me about something important.” She added that Leo “should be spending time with his students instead of doing this.”

When asked if she called his superiors and what she said to them, DeAngelis said “it is none of your business.” She added that she did not threaten Leo or anyone at the school.

Of course, with all of the attention this is raising, I would guess that the story isn’t over.

Lacasse, J., & Leo, J. (2008). Escitalopram, Problem-Solving Therapy, and Poststroke Depression JAMA: The Journal of the American Medical Association, 300 (15), 1757-1758 DOI: 10.1001/jama.300.15.1757-c
Robinson, R., Jorge, R., Moser, D., Acion, L., Solodkin, A., Small, S., Fonzetti, P., Hegel, M., & Arndt, S. (2008). Escitalopram and Problem-Solving Therapy for Prevention of Poststroke Depression: A Randomized Controlled Trial JAMA: The Journal of the American Medical Association, 299 (20), 2391-2400 DOI: 10.1001/jama.299.20.2391
Robinson, R., Jorge, R., & Arndt, S. (2008). Escitalopram, Problem-Solving Therapy, and Poststroke Depression–Reply JAMA: The Journal of the American Medical Association, 300 (15), 1758-1759 DOI: 10.1001/jama.300.15.1758-b

Washington DC mental health privatization sparks controversy

In Washington DC, public officials are attempting to privatize the provision of mental health care by transferring patients to private clinics and closing public clinics. This has sparked some controversy in the area.

According to The Washington Post, the city plans to close their six clinics and enter contracts with 30 private clinics by 2010. The city argues that this will save money, which will allow them to provide services for more people.

Critics are arguing that the public clinics provide a higher level of care than private clinics, who are worried about profit and the bottom line. They argue that doctors make less in private clinics and have a larger client load, prompting many doctors to leave.

Apparently DC was court ordered to provide mental health care through clinics after a 2001 court order which restricted confining patients to hospitals. The city says that it was never meant to be a perminant plan, and they are behind their orignial schedule to privatize the system.

Ken Duckworth, the medical director for the National Alliance on Mental Health, thinks this is a bad idea, asking ”If the government doesn’t take care of the most severely ill people, who will?” It’s an interesting question that everyone in and around the field has been asking since the days of deinstitutionalization.  The real question is to what extent should the government be involved in the provision of healthcare versus paying for health care.

In West Virginia we have two hospitals that are owned and operated by the state. local services are provided through private non-profits throughout the state. Prestera serves Charleston and Huntington, United in Clarksburg, Eastridge in the Eastern Panhandle, and Westbrook in Parkersburg. So I’m kind of unfamilliar with the concept of public health care. I don know that private groups can do a good job with public money, so I’m not nearly as alarmed by this as some of the critics are. And if this frees up money to provide services for more poeple, I definately see it as a positive.

Should Alcoholics Get Liver Transplants?

I just read a blog post on Psychology Today concerning whether alcoholics should be allowed to have liver transplants. I was surprised, because I thought that, for the most part, organs weren’t given to alcoholics and drug addicts. Maybe I just watch too much House and Scrubs, but don’t the transplant boards in local hospitals who decide who does and does not go on the transplant typically frown on addictions? If you’re a doctor and you know about these things, please comment.

I took note of the last paragraph in this article:

The public understanding of addiction lags behind that of other mental disorders. Telling an alcoholic to “stop drinking” is like telling a victim of depression to “cheer up” or an anxiety sufferer to “calm down”. In the past few decades, great progress has been made in recognizing diseases like depression, anxiety and posttraumatic stress disorder for what they are; medical conditions deserving of sympathy and treatment. We still have a long way to go with addiction.

I can’t really get behind this rationale. Alcoholism and drug abuse certainly lead to some severe physical and psychological dependence issues, but I don’t see it as a disease in the same sense as the others. In the end, every time you drink, even the first time you drank, you make a choice. Now it’s certainly not as easy as “stop doing that,” but that does not mean that it isn’t a choice. You can’t say the same thing for depression and anxiety.

Andrew Wakefield A Fraud?

This blog is fairly young as blogs go, and this is my fourth post about the vaccine/autism controversy. Why? Two reasons: When I first started working in human services, I did in-home care for people with mental retardation and developmental delays, part of thew Medicaid Waiver system. I saw first-hand what behavioral interventions can do to enhance quality of life. Second, and I’ve mentioned this before, I fell for it. When I read Robert Kennedy’s article Dangerous Immunity, I initially believed that autism could be caused by mercury poisoning. Then a couple of studies were published which refuted this, and I saw it as a blip on the research radar, not realizing until just last year that this contoversy was still going on.

Now information is coming out claiming that Andrew Wakefield not only took money from anti-vaccine interests before and during his research into the defrauded Autism-MMR link, but that he outright lied about the time of onset in his autism patients to enhance the link with MMR. David Gorski at Science-Based Medicine is covering this story is quite nicely, and over at Pharyngula, PZ Myers mirrors my sentiment from my first post on the issue:

Will this revelation matter? Not one bit. The anti-vaxers have ignored all the evidence that they are wrong so far, so one more demonstration that one of the primary promulgators of this nonsense was an outright fraud won’t change a thing, I’m afraid. This is still a clear-cut case where delusions can kill.

Of course Age of Autism hasn’t said anything about this yet. It doesn’t matter, because they have new explanations now. But I would like to comment on a comment made in an AoA article about Paul Offit:

These “ad hominem” tactics finally failed this election. Perhaps they will start to fail in this realm as well as people wake up to this essential fact:

–People like Offit have an obvious and huge profit motive
–People like JB and other autism parents have nothing to gain other than making their child’s suffering not be for nothing

If that isn’t enough to wake others up, they might as well stay asleep until they develop Alzheimers from all the Flu vaccines they will take unquestioningly.

First off, my grandmother died from Alzheimers, so fuck you. If you want to make shit up to prove your point, become a priest. Second, and I’ve said this before, I’ll bet J.B. Handley and David Kirby make more money off of selling “cures” for autism than most of the skeptics who point out that vaccines don’t cause autism will make off of their vaccine-specific persuits. How much would Handley and Kirby stand to loose if they admitted that autism is not caused by vaccinations?

Exploring Placebo

The newest issue of Scientific American Mind has a pretty interesting article on placebos. Although CAM isn’t mentioned specifically, what the highlighted studies suggest has a lot to say about the power of alternative medicine and the overall abilities of the human mind.

The article looks at two different types of placebo; Conditioning placebos, in which real medicine is paired with a second stimulus and the medicine is removed, leaving a second stimulus that provides relief, and Expectation placebos, in which a sham stimulus works because it is similar to a previous effective medications (such as an injection followed by a similar saline injection) or because the patient believes that the sham treatment will work.

The gist of the article is that expectation placebos only seem to work on subjective symptoms, like pain. Conditioning placebos can actually have physiological effects, everything from immunosupression to, in one case, shrinking tumors.

Of course, none of this answers the question of whether placebo treatment is ethical. Consider alternative medicine, for example. Or alternative therapy. One alternative psychotherapy, the emotional freedom technique (EFT), involves tapping on acupressure points on the body while repeating statements that remind one of their problem. Proponents point to horribly-designed studies and argue efficacy. Most likely, the effects are the result of placebo, distraction, and cognitive reprogramming.

So if we can say that placebo is effective, is it ethical to use placebo to treat mental or physical disorders? I say no. First, because the placebo effect is not as reliable as standard treatment. If I were a therapist, I wouldn’t want to hang my success rate on whether someone believes that tapping can solve all of your problems. Second, placebo is unpredictable. If someone believes in the efficacy of a treatment, then becomes unconvinced, it could cause serious problems.

Of course, psychotherapy has its own issues with placebo. With research showing that the therapeutic alliance is more important than any particular therapeutic school of thought, belief plays as much of a role as anything else.

More on Vaccines

I can’t stay away. I picked up the new issue of U.S. News & World Report last night, which contains an article titled “A closer look at vaccines” by Deborah Kotz. The article doesn’t appear to be available online, but the U.S. News website has a companion piece about taking a flexible approach to the vaccination schedule, with Dr. Lawrence Rosen of the American Academy of Pediatrics Section on Complimentary and Alternative Medicine taking the pro stance and Dr. Margaret Fisher of the AAP Section on Infectious Disease taking the con stance.

I find the article biased. Kotz touches on adverse reactions early, but saves the tidbit that the VAERS (the Vaccine Adverse Event Reporting System) is not necessarily the most accurate way of tallying incidents caused by vaccines for the last page. Kotz spends a lot of time talking about Hannah Poling, and discusses the way in which vaccines caused her autism, but the article ends up reading like mitochondrial disease caused by vaccination is common.

There is also a bit of information which the antivaccine groups often bring up to make themselves seem less monsterous. This is the “what’s the harm in getting sick?” argument:

Menactra, for example, protects against bacterial meningitis, which strikes about 1 in 100,000 people per year and kills about 1 in 1 million.

Wow! Only strikes 1 in 100,000 ? We should let people get this then! Of course, bacterial meningitis causes irritability, delerium, photo- and phonophobia, and a bulging of the soft spot on the head, as well as rashes and legions. They also don’t bother to mention that 1 in 100,000 means 3030 people per year in the United States. 303 people will die from it. Keep in mind that untreated meningitis has a much higher mortality rate, and that there is a cost for treatment. The article also states:

But [Menactra] also may cause Guillain-Barré syndrome, a temporary but severe paralysis triggered by an overactive immune system, in 1 to 2 teens per million who are vaccinated.

However, from a statement from the CDC:

This finding suggests that the rate of GBS among MCV4 recipients based on the number of cases reported within six weeks of administration of MCV4 is similar to what might have been expected to occur by chance alone. However, the timing of the onset of neurological symptoms (within 1.5 to 5 weeks of vaccination) is of concern.

If we don’t vaccinate, thousands of people will likely get one disease, and about 300 will die. If we do faccinate 300-600 may get a another disease, and far fewer will die. Lets also not overlook cost of treatment. It is great to advocate chickenpox parties if you can afford doctor visits and medication. It’s also great to advocate expanding the vaccine schedule so that children have more doctor visits, which low-income parents have to pay for. This article even advocates giving your kid the thimerosal-free flu vaccine, a recomendation with about as much scientific backing as “stay away from toads to avoid warts.”

The irony is that the “too much, too soon” argument is easily refuted by the same studies which show that the rise in autism is due to the expansion of diagnistic criterial in the DSM-IN in 1994. The reason that the AntiVax people don’t want you to hear that is that guys like David Kirby and JB Handley make too much money lying to you about the dangers of vaccines.

Perhaps this is part of the problem

If I go to my doctor and complain of a sore knoee, the doctor will send me to a joint specialist.

If my doctor hears a heart murmur, she will send me to see a cardiologist.

If I describe symptoms of synesthesia, she will send me to a neurologist.

If I complain about abdominal discomfort, she will send me to a gastrointernologist.

If I describe symptoms of depression and anxiety, she will prescribe me SSRIs and mood stabilizers.

Idon’t hate doctors. If you’ve read this blog so far, you should know that. However, I do have issue with the relative ease many patients have in getting psychopharmaceuticals. I also think therapy is often ignored. These are not grounds to tear down the entire medical establishment. But it is some food for thought, especially considering that psychiatry is a perfectly respectable specialty. (I know, some doctors have issues with psychiatrists, but some doctors also have issues with dentists, and I’ve never had a GP try to clean my teeth.)

When I lived in Parkersburg, WV, I worked in a mental health short-term crisis stabilization unit while I was finishing my RBA. One of our doctors was Dr. Mike Dickerson. Dr. Dickerson was great. He told lots of stories about being a medic in the military, and was a no-nonsense doctor overall. He and I would get into heated discussions, then go off and do it all again a few days later. I learned a hell of a lot from him, but one day I think I really got the point across as it related to medicine and diagnosis.

I had heard a story from a professor that I was passing around the office. This professor used to work as a child psychologist, and she had a client come in who had been seen at another behavioral health clinic. The doctor spent 5 minutes with the child, wrote a prescription for Ritalin, and said “Give him this. If it doesn’t work, he doesn’t have ADHD.”

I had stated that this was sloppy, that the doctor should have spent more time in the diagnosis stage, and that drugs working/drugs not working” should not be the test for ADHD. I still believe this, especially since, according to Skeptical Inquirer, there are at least 8 million kids diagnosed with mental disorders today. Dr. Dickerson stated that this was acceptable, and that it had happened to him. He took his son to the head of the neurology department at Duke University while he lived in North Carolina, and the events transpired the same way. I responded with “Do you know any former heads of the Duke Neurology Department who are working down the steet at the local mental health clinic?”

I know, it’s an argument ffrom authority, but it is a valid point. I think neurologists are better equipped at making these kind of decisions than family doctors who work in mental health clinics because Medicaid doesn’t pay enough to attract a psychiatrist. Dickerson got that point, too, and relented.

Again, we don’t need to dismantle the entire system, we just need to put a little more thought into how we treat mental illness.