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I can appreciate you might be fatigued with this topic, but let’s face it: for virtually everyone, health care today means going to the doctor and coming home with a prescription.

In your heart of hearts, you know your prescription is made up of a chemical and carries a boatload of potential side effects you hope won’t kill you. Take a full bottle of the stuff, all the pills at once, and you might die on the spot. Oh, I’m sorry, aren’t those bottles generally labeled “Poison”? So, fingers crossed, you swallow a pellet of whatever chemical’s been prescribed and hope for the best.

When the FDA was created in the 1920s to protect us from snake oil salesmen, who would have ever guessed that snake oil–now known to be high in both antioxidants and omega 3s–is actually better for you than most prescription drugs?

The reality is that some of us will die as a result of prescription drugs. As an occasional prescription-writing physician, imagine my perpetual discomfiture scribbling what might later appear on your death certificate. You could be part of this shocking statistic: correctly taken prescription drugs are the fourth leading cause of death in the US.

Since I keep my own prescription-writing to a minimum I don’t lie awake at night stewing about this. Ironically, though, if I neglect to write certain prescriptions I can be sued for failing to abide by the professional standards of good medical practice. So the system does get you both coming and going.

Fortunately, instead of actually dying from these chemicals, we get side effects. Listen to them all in every TV drug ad, spoken so quickly that death–the ultimate side effect–comes out “dith,” like a little spritz of the announcer’s saliva. Thus with every prescription, we hope we’re spared weight gain, vomiting, skin rashes, or the humilities of a marshmallow penis. Nobody wants their sex drive or ability to have an orgasm to become a remote memory.

We just want to feel better.

So whenever I see an article by Marcia Angell, MD, former editor of the New England Journal of Medicine (who resigned because she so disliked the influence of Big Pharma on her journal) and now in the medical ethics department at Harvard, I always get a sinking feeling. That’s because she’s also the author of The Truth About Drug Companies: How They Deceive Us and What We Can Do About It.

“What piece of feel-bad information will Dr. Angell tell me today,” I muse. “How, yet again, has my profession botched up everything?”

The latest from Dr Angell
Her two-part article reviewing three recently published books highly critical of the entire psychiatry profession and its coziness with Big Pharma appears in the last two issues of the New York Review of Books. I summarize Dr Angell’s not-for-the-beach summer reading and my own gut-wrenching moments in these bullet points:

All psychiatry now owes its existence to the pharmaceutical industry. Talk therapy? Freud? Analysis? History! (Though this I already knew.)

Virtually all classes of psychiatric drugs were given FDA approval on evidence that would trigger an ironic chuckle out of any 6^th grader working on her science fair project. For a typical antidepressant, your average pharmaceutical company submits approximately eight double-blind placebo-controlled trials (meaning neither patient nor doctor allegedly knows which was medicine and which was dummy pill). For most of these drugs under review, six of the eight studies showed the drug was not superior to the placebo, but the company was allowed to suppress these six tests and publish only the two favorable ones. To gain access to the suppressed studies, you need to invoke your rights under the Freedom of Information Act.

Practicing physicians will see only the two favorable studies, published in “reputable” journals that receive millions in advertising from Big Pharma. As a reader of these journal articles myself, I am led to believe the drug really works.

The guinea-pig patients who volunteer for these studies receive nice financial rewards for their effort. They make themselves available for multiple trials, which is why they’re called “recyclable volunteers.” Not surprisingly, although they’re not supposed to know if they’re taking actual drug or placebo, they do know within a few days…because the drug gives them side effects and the placebo none. To please the investigator and get re-hired for the next clinical trial, they’re skilled at reporting what the investigator wants to hear. “I feel better” when taking the drug, “I feel nothing” when not.

When a group of researchers was actually studying just the placebo effect–not in relation to any particular drug–they tried changing the rules slightly by giving patients a placebo that also contained a harmless chemical to deliberately induce side effects—called an “active” placebo. When the researchers pitted this “active” placebo against a typical antidepressant, the two pills produced exactly equal results. Both the antidepressant and the active placebo relieved depression.

Physician investigators (virtually always department heads at prestigious university hospitals) conducting the trials for drug companies seeking FDA approval are paid obscene amounts of money to run these trials. Since psychiatric results are extremely subjective (as opposed to a medicine for high blood pressure, which either lowers blood pressure or doesn’t), the data obtained in these studies can be cleverly manipulated to slide the results through the FDA-approval process.

The DSM (Diagnostic and Statistical Manual of Mental Disorders), a huge manual published by the American Psychiatric Association, codifies psychiatric diagnoses. It can only be described as “loosey-goosey” in its standards. In a recent survey of randomly selected adults, a full 46% of them met the DSM criteria for having at least one, and often multiple, forms of mental illness. Every single time the standards are loosened (like adding “Prone to temper tantrums” to the criteria for childhood bipolar disorder) or a new syndrome is created (like “Social Anxiety Disorder” or “Shift Workers Sleep Disorder”), the eyes of some Big Pharma CEO light up at the thought of owning the patent on the drug for it. For example, just as Abilify was about to go generic, the FDA approved a smaller dose for a different condition (depression instead of schizophrenia), allowing the company a patent extension and the right to sell it for $17 a tablet.

All this leads to a lot of pill swallowing. Right now 10% of all Americans over age six are taking an antidepressant. And there are more Americans taking antipsychotics than cholesterol-lowering meds. Woe betide if you are a wise-ass 11-year-old mouthing off to your teacher—you stand a good chance of being quickly labeled as having bipolar or “oppositional defiance” disorder and for the rest of your incarnation your doctor will be adjusting your drug cocktail. Plus, you’ll probably die young, since the side effects of the meds include obesity, high cholesterol, and diabetes.

Oh, wait. We have drugs for those too.

Despite these grim revelations, every physician (and I certainly include myself) has seen remarkably beneficial effects when depressed or anxious patients take an SSRI antidepressant. So after reading articles like this, we doctors scratch our heads. What can this mean?

Dr. Angell, and the authors of the three books she reviews in this article, suggests these possibilities:

For most people, depression and anxiety are temporary, and were I without your knowledge to deliberately prescribe you a placebo–especially an “active” placebo with side effects–the pill would give the appearance of doing something. Believing you were taking an antidepressant, you’d have just as much chance at feeling better as you would with an actual one. The success rate of the two is the same.

“Getting well,” especially from a mood disorder like depression or anxiety, is highly complex. If a patient is really motivated (“I’ve got to get over the panic attacks or I’ll lose my job”) and has limited choices for treatment (“I can’t afford talk therapy”), then her whole mindset is geared toward that pill working for her. Receiving her own supply of the same pill those smiling people in the TV ads are using successfully could be just the trigger to switch her brain into a more positive mood. This effect is enhanced if she trusts her doctor and he or she has told her that the medicine has worked for many other patients. In other words, the whole healing process is far more complex than just chemicals in a pill.

In reality, surveys show that at least two thirds of patients prescribed antidepressants go off them, reporting “I didn’t feel anything except side effects.” Many never bother to fill the prescription at all and simply tough it out. Doctors don’t know about this two-thirds group and end up giving the meds much more credit than they deserve.

To say that all this is blindingly frustrating to a primary care physician like me is an understatement. Despite this news, I will continue to carefully write prescriptions for antidepressants (though my own preference is for the virtually side-effect-free herbal antidepressant St John’s wort) because despite my limited toolbox of prescription drugs, patients need help and antidepressants do help some patients.

I’ll also continue to rely on JAMA, New England Journal of Medicine, and a dozen other journals to keep me abreast of research in my field.

But with Dr. Angell’s revelations, I will look at the newly released antidepressant Viibryd (supposedly both clinically effective and free of side effects) and wonder, “Is there anyone I can trust?”

Be well,

David Edelberg, MD

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David Tenenbaum says:

August 2, 2011 at 6:18 am

No truer words were spoken than by the medical heritic, Robert Mendlesohn, M.D. when he said, if the drugs you’re taking are pulled off the market don’t worry, the FDA will approve even more dangerous drugs to replace them. If you want to remain drug free, it’s not that difficult. Adopt a a cruelty free lifestyle and go vegan and exercise. A modest investment to avoid prescription drugs and substantially reduce your chances for contracting one of the horrific western diseases.

Addie says:

August 2, 2011 at 7:07 am

A few years ago I read the statistic that 200,000 people a year die because of doctor or hospital error, the majority of these from side effects of improperly administered prescription drugs. This may be been due in part to the extreme specialization taking over medical professions. In re the FDA: it’s well known that Bush II dismantled it, converting that agency into a political arm of the administration focused on blocking attempts to develop or market abortion drugs and new contraceptives. Unusually large numbers of people were poisoned by salmonella during his tenure because the FDA simply didn’t function. I understand it’s being repaired now, but the process is slow, and Big Pharma icontributes to Democrats too. Anyway the FDA can’t solve all the problems you raise, but an educated, informed public can. Keep up the good work!

Judith Allison says:

August 2, 2011 at 8:16 am

You briefly mentioned cholesterol lowering drugs. I would love to hear your take on statin drugs, Big Pharma’s push to get everyone on them, and any alternative approaches to lowering cholesterol.

Amy says:

August 2, 2011 at 9:20 am

David, I am continually inspired by the courage you have to face uncomfortable facts (and invite us to do the same..) Also really enjoy your wry humor. One of the best blogs on the web. Thank you.

Kate says:

August 2, 2011 at 1:51 pm

I read Whitaker’s “Anatomy of an Epidemic” about psychiatric medications and the damage they can do, and I decided to taper off (under the supervision of a doctor). The fact that I lost my job and my insurance of course, aided my decision to go off the drugs. I’d been on them for six years–I’d call that pretty long-term use. I started using some of Martin Seligman’s positive psychology techniques, and some “whammy” stuff, and y’know–things aren’t perfect, but I’m basically doing pretty well without the drugs. Whitaker says that not only does long term use of psychiatric medication not do much–it can even make you worse.

Gina Pera says:

August 2, 2011 at 11:24 pm

Dr. Angell doth protest too much, IMHO.

I am surprised at how much credence is given to this woman who in my opinion possesses so little credibility. After all, she edited JAMA for a few years, right? Where was her conscience during that time? And what exactly qualifies her to opine as she does, relentlessly and omnipresently?

No, sorry. I don’t see any credibility with Angell. She shows her ignorance about psychiatric conditions and their treatment at every turn. Moreover, she shows her grandiose and uncompassionate disregard for the real-world consequences of her scare-mongering.

There are ways to reasonably call out the problems with our medical system, including many physicians over-reliance on medication. Angell’s is not one of them, in my opinion.

As someone who came only very reluctantly, and with much required proof, to accept the important role of pharmaceuticals in the treatment of ADHD and other conditions, I consider it vital to support patients’ right to take these medications without incurring more stigma. The way I see it, Angell only contributes to stigma, not true illumination. You ask if there’s anyone you can trust, Dr. Edelberg? I’d say there are plenty but they don’t include Angell.

Respectfully yours,
Gina Pera, author
Is It You, Me, or Adult A.D.D.?

August 2, 2011 at 11:34 pm

Dr. Edelberg wrote:

“Woe betide if you are a wise-ass 11-year-old mouthing off to your teacher—you stand a good chance of being quickly labeled as having bipolar or “oppositional defiance” disorder and for the rest of your incarnation your doctor will be adjusting your drug cocktail. Plus, you’ll probably die young, since the side effects of the meds include obesity, high cholesterol, and diabetes.”

I think you exaggerate here, Dr. Edelberg, perhaps out of frustration.

The fact is, many children are NOT being diagnosed with psychiatric conditions when early intervention could make all the difference in their futures.

At the same time, many American children are Vitamin D deficient, exercise deficient, consumers of too much junk food and videogames, and all the rest.

It takes careful doctoring to tease out these factors and address these children in an integrated-health fashion. So, why can’t we blame poor doctoring and parents who put more time and effort into programming their new digital devices instead of feeding and caring for their children. Why must it always be the fault of Big Pharma?

I think we cede entirely too much responsibility to Big Pharma’s manipulations and don’t look closely enough at ourselves and especially our medical schools.

As for OBESITY, CHOLESTEROL, AND DIABETES, that is the trifecta of untreated ADHD! No, I have no published studies to prove this, but I hear the reports so often in the groups I moderate (for adults with ADHD, and a separate group for the partners of adults with ADHD).

For many late-diagnosis adults with ADHD, they have life-long habits of “self-medicating” with food. Some procrastinate around shopping and meals, so that they don’t eat at regular intervals or eat too much fast food. The sleep issues around ADHD can also contribute to obesity, as can the lack of initiation and motivation that is often part of the ADHD neurobiology.

The irony is that ADHD medical treatment can in fact help people develop healthier habits and reverse these diseases.

Gina Pera

fern says:

August 3, 2011 at 7:51 am

Keep on telling us what we need to hear…as a “geriatric patient with a heart problem’ I often feel like just NOT taking a various RX month after month, especially when they all say may cause …and list effects that are worse then the problems I went in with. The body ages, keep eating good food and doing some exercise, better then most meds. Fern

Mark says:

August 3, 2011 at 8:58 am

Thanks, David. Well said. Your articles bring a smile to my face since I enjoy seeing confirmation of much of what I suspected. I have referred many a friend and family member to the Whole Health Chicago website.

Peter says:

August 3, 2011 at 11:48 am

“Listen to them all in every TV drug ad, spoken so quickly that death–the ultimate side effect–comes out “dith,” like a little spritz of the announcer’s saliva.”

My wife always completes those disclaimers with: “Other than that they’re really great!”

Dr E says:

August 3, 2011 at 1:16 pm

Hi Gina
Concerning your issue of ADHD–as you know I treat a lot of ADHD in both kids and adults and do use stimulant meds with usually excellent results. What I was referring to is an overdiagnosis of bipolar disorder in kids (probably because of loosened diagnostic criteria) and too generous prescribing of meds with side effects of obesity, high cholesterol and early onset diabetes. Most of these alleged bipolar kids actually have ADHD or ADD and do fine when given the right med
Dr E

Melisah says:

August 4, 2011 at 4:10 pm

My mom died when I was 17 due to cardiac arrest which was the result of a hefty cocktail of prescription drugs, taken correctly. Things like symptoms of fibromyalgia (which it itself is a symptom), sleeping disorders, depression, and a few other symptoms that could have been allieviated naturally. Long before I knew anything like what the article above reveals, I vowed I would never, ever go the drug route. Thank God I never did. All of my ailments have disappeared thanks to diet changes and meditation. Thank you so much for this article. Everyone my age (28) thinks I’m crazy because I believe in being natural but folks out there like you help me not feel so alone!

August 4, 2011 at 6:20 pm

——-

Hi Dr. Edelberg — Yes, I know you have been knowledgeable about ADHD for a long time. An early adapter, in fact!

I just wasn’t sure your readers were aware of that, and the nuances involved with these medications.

I’m no psychiatrist but it does make sense to me that bi-polar could present at young ages if we know what to look for. And if the challenges can be addressed at that age, that might prevent more brain-affecting stress, bad habits (such as substance abuse), and even suicide (rather high with bi-polar disorder).

The problem is that so many of our “specialists” see every darn condition now with myopia. They disregard nutrition, food allergies, chemicals in the home, and even the frenzied pace of parents’ work-lives and digital lives.

It’s so hard to find a middle ground these days in medical care. The patient or parent has to be the case manager among so many specialists, it’s mind-boggling.

Jimmy Flatbush says:

August 28, 2011 at 5:17 pm

The human race seemed to have survived millenniums without resorting to taking pharmaceuticals that have worse side effects than the ailment they are supposed to treat.

I recommend that people turn away from our pill popping culture and research exactly what natural remedies can do for you.

I find it hard to believe a government that declares that Americans take too much vitamin D supplements, when in fact over 70% of Americans are severely deficient in this cancer fighting vitamin.

Whole Health Chicago

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