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Why the drugs don't work
The problem isn't that doctors are too quick to prescribe
anti-depressants, but that they have stretched the label of depression
to cover the full range of human unhappiness.
According to new official guidelines issued by the UK's National
Institute for Clinical Excellence, GPs must be more cautious about
prescribing anti-depressant medications (1).
Prescriptions for drugs in the Prozac group (selective serotonin
reuptake inhibitors, SSRIs) increased from 6.5million in 1997 to
19million in 2003. These drugs should now be reserved for patients with
moderate or severe or prolonged depression, while those with milder
forms of melancholy or symptoms of anxiety should be referred for
counselling or cognitive behavioural therapy.
In response, doctors' representatives have complained about the chronic
shortage of counsellors and psychotherapists. We leave aside here the
considerable doubts whether such techniques are more effective than
medication, and whether they have less adverse consequences, and instead
focus on a prior consideration: the question of the diagnosis of
depression and how widely it is applied (2).
In the new guidelines, the prevalence of depression is expressed in
terms of the proportion of people who are believed to be affected 'each
year': one in 15 women, one in 30 men. These figures stand in marked
contrast to the headline-grabbing estimate of 'one in four' (the
lifetime prevalence of depression) that featured in the 2003 Department
of Health campaign Mind Out for Mental Health (3). If a quarter of the
population is being urged into their GPs' surgeries to seek treatment
for depression, this is likely to lead to the excessive consumption of
whatever form of treatment is available. Even if the adverse effects of
any particular treatment are relatively rare, the number of people
affected will inevitably be substantial.
The origins of the current situation can be traced to the launch in 1992
of the Defeat Depression campaign, sponsored jointly by the Royal
College of Psychiatrists and the Royal College of General Practitioners
(4). The main aims of this campaign were to 'educate practitioners,
particularly GPs, about the recognition and management of depression';
to 'educate the general public about depression and the availability of
treatment'; and to 'reduce the stigma associated with depression'.
A diagnostic term formerly restricted to patients so severely afflicted
by melancholy that they might require hospital admission was now adapted
to cover a wide range of responses to existential distress, resulting
from workplace dissatisfaction, marital disharmony, bereavement or other
losses. According to David Healy, psychiatrist and historian of
anti-depressants, 'depression as it is known or understood by the public
in the 1990s, was all but unknown as recently as 35 years ago' (5). He
estimates that the promotion of depression by the psychiatric profession
- and its ready acceptance by the public - resulted in a one
hundred-fold increase in prevalence over this period.
The Defeat Depression campaign, which was actively promoted by
pharmaceutical companies, was particularly concerned to tackle the
'public's failure to recognise the value of drug treatments'. It
produced some three million leaflets in its first two years, and though
the campaign provided information about 'talking treatments' and
'alternative treatments' such as St John's Wort, its main effect was to
encourage both GPs and their patients towards anti-depressants. It was
not surprising that sales of Prozac, first marketed in the late 1980s,
grew exponentially in the 1990s, nor that this pharmaceutical
blockbuster was rapidly followed by a range of similar SSRIs.
Though Defeat Depression was planned to last for only five years, its
propaganda is still readily available on the internet. In 2001, it was
complemented by a further Royal College of Psychiatrists campaign,
Changing Minds, which focuses on the third aim of the earlier campaign —
challenging the stigma of mental illness, which the psychiatrists claim
still leads to the under-diagnosis of depression (6).
The compulsory admission to mental hospital of the former heavyweight
boxing champion Frank Bruno in September 2003 provided a major boost to
the campaign, when tabloid newspapers were obliged to withdraw
disparaging comments. In fact, the Bruno episode confirmed that, far
from being stigmatised, a diagnosis of depression is not only socially
acceptable, but even creditable. (A cynical publicist such as Max
Clifford might even recommend such a course of action as a way of
rescuing a flagging celebrity career.)
In his 1963 classic Stigma: Notes on the Management of Spoiled Identity,
the American sociologist Irving Goffman exposed the ways in which
contemporary society discriminated against those who were different,
regarding their differences as signs of moral inferiority (7). But today
things have become reversed: we celebrate difference and particularly
cherish the status of victimhood, which is held to confer a certain
moral authority.
In popular culture, the outsider of the 1960s has become mainstream: the
geek, the freak and the damaged have all now won public approval (8).
From Princess Diana to Frank Bruno, celebrities who reveal their
vulnerabilities and embrace psychological disorders are the authentic
popular heroes. Now that even madness and disability have become
fashionable, the campaign against stigma serves to promote the expansion
of psychiatric diagnosis to cover more and more people and a wider range
of behaviour.
Given the particular concerns expressed
in the new guidelines about the prescription of anti-depressants to
young people (because of an apparent increase in risk of self-harm and
suicide), it is interesting to note that the Changing Minds campaign
emphasised that doctors should be alert to the diagnosis of depression
'at any age, even in children and young people'. Just as the Defeat
Depression campaign encouraged GPs to prescribe anti-depressants to
adults, the subsequent campaign had the effect of increasing the
medication of children.
Having sponsored campaigns that encourage a substantial proportion of
the population to embrace the labels of mental illness — and their
doctors to treat them accordingly - the authorities are now baulking at
some of the consequences. If millions of people are taking mind-altering
drugs to help them to cope with every exigency of life, then it is
inevitable that some will commit harm to themselves or others while they
are taking these drugs.
It is unlikely that it will ever be resolved whether the drugs cause or
increase the risk of such behaviours. But rather than now telling GPs to
stop prescribing anti-depressants, it might be more constructive for
doctors and psychiatrists to ask whether it is beneficial either to
individuals or to society to label a quarter of the population as being
mentally ill.
Dr Michael Fitzpatrick is the author of MMR and Autism: What Parents
Need to Know, Routledge, 2004 (buy this book from Amazon (UK) or Amazon
(USA)); and The Tyranny of Health: Doctors and the Regulation of
Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA).
(1) GPs get new anti-depressant rules, BBC News, 6 December 2004
(2) Therapy Culture, Frank Furedi, 2004
(3) Therapeutic Pi, by Michael Fitzpatrick
(4) Defeat depression, on the Royal College of Psychiatrists website
(5) The Anti-Depressant Era, David Healy, 1997
(6) Changing minds, on the Royal College of Psychiatrists website
(7) Stigma: notes on the management of spoiled identity, Irving Goffman, 1963
(8) Arrested Development, Andrew Calcutt, 1998
Dr Michael Fitzpatrick
8 December 2004
Moms find less joy in child care
Most women enjoy being with their children less than they say they do, a
new survey of women's moods has found. The study of 909 U.S. working
women, published in this week's issue of the journal Science, also
revealed that the daily commute is the low point of women's days, while
“sexual intimacy” is the high point. The study used a new method for
assessing quality of life, which researchers say is more accurate than
the conventional approach of asking people to generally report how much
they like various activities.
Norbert Schwarz, a psychologist at the University of Michigan and an investigator in the study, said that under the conventional assessment system, women typically insist that being with their children is their greatest joy. But using the new Day Reconstruction Method (DRM), described in the Science report, Mr. Schwarz said, “Women indicated spending time with their children is a mixed bag — that they represent some of their best moments and also some of their worst moments.” Mr. Schwarz explained that DRM involves breaking the day into a sequence of episodes and rating each moment or activity as a kind of snapshot. He said the women were told to think of their day “as a continuous series of scenes or episodes in a film” and to give each event a name to help them remember it. The women then rated their activities for positive and negative associations. A positive score of six was the strongest and zero was the weakest. Participants gave intimate relations the highest score, at 5.10. That was followed by socializing, at 4.59, and relaxing, at 4.42. They ranked taking care of their children at 3.86 — below exercising, watching television and preparing food. The ranking for child care was not far ahead of activities at the low end of the scale, such as housework (3.73); employment (3.62); and commuting (3.45). The researchers also analyzed those with whom working women most want to interact and found that it is their friends (4.36), followed by their relatives and spouses. Being with their children was their fourth choice, with a score of 4.04. However, the women said they would prefer interfacing with their offspring rather than with their boss (3.52) or being alone (3.41). “In truth, spending time with your children is not always as good as you remember it,” Mr. Schwarz said. By forcing women to recall specific time frames in a day's experiences, they may have to face situations “where they were trying to do something and found their children distracting,” he added. “Saying that you generally don't enjoy spending time with your kids is terrible, but admitting they were a pain last night is quite acceptable,” he said. The study was funded by the National Institute on Aging and also involved researchers from Princeton University, the University of Californiaat San Diego, and Stony Brook University in New York. “We conclude that positive effect and enjoyment are strongly influenced by aspects of temperament and character, such as depression and sleep quality, and by features of the current situation,” the report said. “In contrast,” it said, issues such as income and education “have surprisingly little influence on ... reports of life satisfaction” and the enjoyment of a regular day.
Joyce Howard Price
6 December 2004
Seattle: center to study child medical ethics
Children's Hospital is establishing a new center to examine ethics
issues that arise in the care of children. The Center for Pediatric
Bioethics, the first of its kind, will receive $340,000 a year in
federal funds plus $1 million in startup money from Children's Hospital
and Regional Medical Center, which is affiliated with the University of
Washington
“If you look around the country there are lots of centers for bioethics,
but all of them tend to be devoted more toward general issues,” said Dr.
Doug Diekema, director of medical ethics at Children's and interim head
of the new center. “There really is no concentrated center for the study
of purely pediatric issues.” The center will be host of a pediatric
bioethics conference in July, a sort of unofficial kickoff.
“We hope the center will become a national resource for physicians,
researchers, policy-makers, parents and patients,” Dr. F. Bruder
Stapleton, pediatrician-in-chief at Children's and chairman of the
pediatrics department at the UW, said in a Friday news release.
The center will consider such issues as:
- Can a terminally ill 7-year-old
decline medical treatment?
- Are pediatricians required to tell
parents when a teenager has a sexually transmitted disease?
- Should a 10-year-old be consulted about enrollment in a clinical research trial?
The center's first task will be to hire a
director with experience in pediatric bioethics research, said Diekema,
who is considered an expert in the field.
Caring for children can raise unique questions.
“The largest one is that children can't
decide for themselves whether they want medical care or whether they
want to live or die, so parents are given a lot of deference in
decisions about their children's health care,” said Dr. Norman Fost,
professor of pediatrics at the University of Wisconsin, and director of
the bioethics program there.
Federal regulations are often vague, leaving doctors and hospitals to
flesh out the details.
Medical research, for example, must expose children to no more than
“minimal risk,” Fost said, adding, “People disagree very broadly about
how to interpret that definition.”
Doctors sometimes need guidance about overriding a parent, Diekema said.
For example, what if a parent opts for herbal remedies, many of which
have no proven benefits, rather than mainstream medical care?
“When would it be OK for a parent to make that decision for their
child?” he asked.
Genetic screening is another area of uncertainty, Fost said. The
benefits to children are debatable, he said, especially when symptoms
may not appear until adulthood.
“There are risks associated with labeling children,” he said.
6 December 2004
Source
Study suggests children's diet affect their
behaviour as adults
Feed your children well, or they may turn into thugs when they grow up,
suggests a recent American study.
You are what you eat — yes and we’re talking of a child’s character and
behaviour, not whether he is obese or not.
A study that suggests that young children who do not eat healthily are
more likely to grow up into violent teenagers must have many parents
worried.
Indeed, the poorer their diet, the greater the risk of them turning to
crime and behaving anti-socially, according to the research by the
University of Southern California.
Admittedly, the irresistible temptation of junk food advertisements over
television and other media are partly to blame for poor eating lifestyle
of children.
In fact, many parents are dictated by their children’s eating habits,
such as going to fast food outlets or hawker centres, rather than having
wholesome nutritious meals.
Teenagers, too, often prefer eating out with their friends at cozy
joints and bistros instead of settling for home-cooked food which they
reckon as “uncool”.
During the study, a group of scientists observed the development of more
than 1,000 children in Mauritius over a period of 14 years.
They monitored signs of malnutrition, vitamin and mineral deficiencies
as well as tested the intelligence level of kids from the age of three.
At age eight, 11 and 17, the researchers studied how the children
behaved at school and at home.
Malnutrition link
Among other things, the researchers monitored the children’s traits and
characteristics such as whether they lied, cheated, fought, bullied,
destroyed property or swore.
When the children turned 17, the parents and teachers reported on
anti-social behaviour such as stealing, drug use and destroying
property.
“A link became evident between malnourishment and anti-social or
aggressive behaviour,” said the study’s co-author Prof Adrian Raine.
He said that compared with youngsters who ate well, malnourished kids
showed a 41% increase in aggression when they turned eight.
A 10% rise in aggression and delinquency was recorded at aged 11. By the
time they reached 17, there was a 51% increase in violent and
anti-social patterns.
Prof Raine believed that intelligence levels, rather than social
factors, significantly influenced behaviour.
“Poor nutrition, characterised by zinc, iron, vitamin B and protein
deficiencies, leads to low IQ, which can contribute later to anti-social
behaviour.
“These are all nutrients linked to brain development,” he explained.
The study found that children with higher indicators of malnutrition
were exposed to a greater risk of anti-social behaviour.
Initial findings showed that malnutrition in the early post-natal years
is associated with behaviour problems through the teenage years.
Risk factors
Identifying the early risk factors is a
crucial first step towards developing successful prevention programmes
for adult violence.
Of course, if nutrition is a cause, then parents have a greater
responsibility of ensuring wholesome, nutritious meals for their
children.
However, many school meals are putting the pupils’ health at risk
because they contain too much fat, sugar and salt.
A typical primary school dinner in Britain contained around 40% more
salt, 28% more saturated fat and 20% more sugar than is recommended for
children by food experts.
It is sad that many school foods lacked the vital nutrients needed for
the healthy growth of children, both mentally and physically, in their
tender years.
If children are encouraged to eat healthily in primary schools, they are
likely to demand good quality foods as they grow older.
Needless to say, proper upbringing and good moral education are just as
important as nutritious food in helping to mould a child’s character.
At the end of the day, parents will still have to exercise strict
discipline and monitor their children’s diet to ensure they only consume
food with the highest nutritional value.
After all, they will have to face their children when they grow into
young adults, either as responsible teenagers or thugs.
Choi Tuck Wo
2 December 2004
Source
Smoking pot raises psychosis risk in youths
Smoking pot increases psychosis risk in young people, especially among
those who are already vulnerable to psychosis.
That’s the conclusion of a study of more than 2,400 German teens and
young adults aged 14-24.
Participants’ substance use and psychosis symptoms were tracked for
about four years. Psychologists interviewed participants at the study’s
beginning and end.
The research was conducted by experts from Maastricht University in the
Netherlands, including Jim van Os, a professor in the university’s
psychiatry and neuropsychology department. Their study appears in
today’s edition of BMJ Online First.
At the study’s start, 13 percent said they had smoked marijuana at least
five times. Four years later, about 17 percent of all participants had
had at least one psychotic symptom.
Psychotic symptoms include hallucinations, such as seeing or hearing
things that aren’t really there, and delusions, which are false beliefs
that do not go away with logical or accurate information. Other possible
psychotic symptoms are incoherent speech, confused thinking, and strange
behavior. The most common psychotic disorder is schizophrenia.
Pot smokers were more likely to have psychotic symptoms than those who
didn’t smoke pot. The more pot that participants smoked, the greater
their chance of having at least one psychotic symptom. The risk held
after screening out other influences including alcohol and other drugs.
Pot had “a much stronger effect” on psychotically predisposed
participants, say the researchers. People who have a family member with
psychotic symptoms are more likely to suffer similar symptoms
themselves.
It’s not the first time that marijuana has been linked to psychosis. But
until now, no one knew which came first — the psychosis or the pot use.
Were participants using pot to soothe their psychological problems?
Probably not, say the researchers. Psychotic predisposition wasn’t a
good predictor of future pot use, they note.
Youth may be a particularly risky time for pot use.
Puberty is “a vulnerable period” for pot’s negative effects, say the
researchers, citing studies of lab rats. Pot’s active ingredients may
interact with brain chemicals to create negative psychological side
effects, they say.
In 2002, a study published in the British Medical Journal linked
frequent marijuana use at a young age – more than 50 times — to an
increase in schizophrenia later in life. Similar to the current study,
this previous research showed that the more pot people smoked, the more
likely they were to suffer psychosis.
Another study published in the same issue showed that daily pot smoking
as a teen increased the risk of depression as an adult. When that study
was released in 2004, researcher Louise Arseneault, PhD, told WebMD that
their research suggested that there is a direct causal link between pot
smoking and psychological problems that cannot be explained by tendency
toward mental illness.
Miranda Hitti
4 December 2004
SOURCES: Henquet, C., BMJ Online First, Dec. 1, 2004. News release, BMJ Online First. WebMD Medical Reference provided in collaboration with The Cleveland Clinic: "Psychotic Disorders." WebMD Medical News: "Pot May Cause Depression, Schizophrenia."
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