Hat tip to Rick Lippin MD

Well I felt a LEETLE bit guilty for photo-shopping the faces of the heads of the major healthcare lobbying groups onto the bodies of animals, after the son of one of these personages commented on the post, basically saying that I had no proof that the Advanced Medical Technology Association (AMTA) was against the public option for healthcare insurance. I mean, I am sorry for photo-shopping the head of your dad ontop of a dog, but when you are talking about the gang of four healthcare interest groups, there is room for only, well, four, which turned out to be the American Hospitals Association (AHA), American Health Insurance Plans (AHIP), American Medical Association (AMA), and the Pharmaceutical Research and Manufacturing Association (PhRMA). The AMTA signed on to a letter pledging to voluntarily reduce medical spending by a trillion over the next decade, which was clearly a crumb to get the bogey of public option insurance off their back. I can see that AMTA would not care about that, but, hey, maybe they should come out and say that, as I said in my comment.

There was an excellent article this week in the New York Times Magazine which raised the much dreaded R word, namely “rationing”, which my e-friend Rick Lippin MD has been raising for quite some time now.

The fact is that if you viewed the United States as a PERSON, it would be seen as a histrionic female draped over the arms of a much stronger male (probably a Republican), complaining that her proper needs were never fully taken care of.

In other words, the average American is not able to think rationally when it comes to questions of the economics of healthcare (or much else, for that matter).

Consider the fact that our healthcare outcomes are second to last in the industrialized world, and that we spend twice as much as any other country. As Obama adroitely pointed out this evening in his televised address, if you could get a car for six thousand less a year, and it worked just as well, wouldn’t take it? But that is exactly what we are paying extra for for healthcare that gives us no added value.

Do you want to pay $6,000 per year more for healthcare, just so your doctor can drive a Mercedes, when it does nothing to improve the health of you or your family?

I didn’t think so.

And the next time they start blabbering about socialized medicine or you don’t get to choose your own doctor, put some cotton in your ear.

Obama was talking tonight about actually getting some medical experts to tell him what does and does not work. I mean, if you had termites in your house, wouldn’t you want to know what does and does not work to eliminate them? Why should it be any different for healthcare? The British have the National Institute for Clinical Excellence, which is a body of experts who say what actually works. NICE has been villianized by those who are against rationallity in healthcare, but hey, why don’t we get some witches in here to do the job?

Rationing? The near-dead 90 year olds don’t get chemotherapy that will cost $40,000?

Rationing? People with cancers that DEFINITELY WILL KILL YOU like esophageal, certain lung cancers, or metastisized melanoma, don’t get drugs that cost $50,000 and might extend life for a month?

They talk about rationing in Europe. But the REAL rationing takes place here in the ole US of A. Those without insurance who go to the ER have a 37% increased death rate. In terms of cost, that is $5,000 that could have saved the life of a young person that would have had a lifetime of productivity and giving back to the economy.

Rationing? Don’t spout off if you don’t know what you are talking about.

from @pharmawars

Those who have been following this blog know that last month I was told to remove the name of my university from this blog and then a few days ago my university backtracked and said I could use the name (not the letterhead, which I never disputed). The incident attracted the attention of the American Association of University Professors (AAUP) and the Foundation for Individual Rights in Education (FIRE) who wrote a followup article on it here after the reversal of the decision as well as abel pharmboy on scienceblogs. There was also a humorous post by Margaret Soltan on University Diaries, who follows university politics, here, where she wrote a limerick (she is an English professor I think, so that makes sense). My friends perform it below. That’s Billy Tauzin in the middle, head of PhRMA, with of course the always lovable lolcat:

This rather chowder-headed article (”PTSD has Unreliable Diagnostic Criteria“) by David Wilson and Peter Barglow has several weak points that I thought I would address. First of all the use of the term “Unreliable”. Reliability in science doesn’t refer to whether or not you can count on your brother-in-law to return the lawn mower he borrowed. It means whether two clinicians will come up with the same diagnosis (Inter-rater reliability) or whether the same diagnosis will come up when the person is assessed at two different time points (test-retest reliability). The authors use the term in neither of these senses, but rather just throw it out there and hope that it sticks to something.

Their first critique is that the diagnosis is based on human judgment and the criteria have changed several times in different versions of the DSM.

Like so what? And isn’t that true for other diagnoses?

The next set up the straw man that there is a high degree of overlap with other mental disorders in terms of symptomatology. As I have written in my book Does Stress Damage the Brain? it shouldn’t be surprising that mental disorders, including depression, borderline personality disorder, dissociative disorders, and depression, that have in common a link to psychological trauma, shouldn’t have overlapping symptomatology. That is why I call them trauma spectrum disorders.

The authors refer to a study of patients being treated with medication for depression where those with and without a history of trauma had similar rates of co-morbid PTSD at 78%. Given the overlap of symptoms between PTSD and depression and the strong link between depression and trauma this really isn’t all that surprising. They cite another study in which healthy college students were divided into those with a DSM defined trauma and those without. The ones in the group without trauma had higher levels of PTSD. A traumatic event is defined in DSM as a threat to self or or personal integrity, or the sudden death or injury of someone close to you, experienced with intense fear, horror or helplessness. Obviously an event like a death of a parent can be very traumatic for a child, even if it doesn’t happen suddenly. In fact, in this second study, 2/3 of the students noted death of a parent or someone close to them as a ‘non-congruent’ trauma. Furthermore the paper did not specify whether the required “fear, horror or helplessness” was assessed, so we have to assume that it wasn’t. These papers were in an issue of the Journal of Anxiety which ran a series of troll-ish articles which I have previously taken on here.

The authors go on to tackle some other non-issues, like the fact that a re-analysis of data from the Vietnam War showed lower rates of PTSD than previous estimates. So what? This was largely because DSMIII did not require functional disability for the diagnosis. There are still 236,000 veterans with PTSD, as we wrote in a letter to the Editor of Science in 2007.

The authors go on to set up the straw man that not all veterans with PTSD can be confirmed to have been in combat. So what? There are other possible traumatic events that occurred in Vietnam, and some may have experienced PTSD from other events. It stands to reason that this could happen in some instances.

The authors go on to claim that cases of PTSD are related to searching for financial gain. To state that all veterans are faking their symptoms to make money is ridiculous. If they don’t like psychiatry, why don’t they go work in a different field?

I posted a comment on John Grohols web site at 4 pm Atlanta time when there were 32 comments; now there are over 50 and he hasn’t approved mine so I am going to write from here (currently 9:11 pm local time). All I can say is thank god for the internet which finally will spell the end of censorship by large entities. I am not sure what he had an issue with but assuming there was not a glitch maybe he didn’t like the fact that I said that many of these so-called patient advocacy groups receive funding from pharmaceutical companies and with their emphasis on screening and identification of cases are a bonanza for drug companies increasing their market share. It is not only for post-partum depression (PPD) but for other disorders and I know because I have been there but I don’t want to throw rocks at any particular organization.

Moving on to the comments under John Grohol’s psychcentral post on my original post and followup on Motherhood is not a Medical Illness (I know I am paranoid but having my website hacked into and comments disabled right after I made this post seems like an eery coincidence), relating to his (what I consider) impugning me that I have an agenda, am against use of psychotropic meds, or am trying to sell my book, I have the following response: 1) I don’t know what agenda he thinks he has; 2) I am not against psychotropic meds, in fact prescribe them, I only believe that people have the right to be informed and to decide for themselves the risks and benefits and not get railroaded into things by the government (i.e. mass screening as with the Mother’s Act), doctors, or other entities; 3) my book sells for one cent (yes!) on amazon, and as authors like Gina Pera (who setting aside for the moment some of her strident commentary on the topics at hand, which I don’t always agree with necessarily, wrote a very nice book on ADHD, thank you very much) can attest, you get all of your payment in advance, and unless you get on the best seller list (which I am not) you never get payments related to how much it actually sells. And the amount authors get pales in comparison to the tens or hundreds of thousands that psychiatrists get consulting or being on speakers bureaus for pharmaceutical companies. We don’t write books to make money, we do it because we are passionate about our topics. There’s a difference.

Moving on to the specific issues, Grohol stated that I cherry-picked a single paper to pick a fight with him about whether there were more risk factors for PPD than merely a prior history of depression or anxiety. He, somewhat condescendingly IMHO, described me as a “prestigious researcher” (thanks for the compliment, John), implying that I hadn’t done due diligence. Or maybe shut up and sit down, go back to the lab, etc. Well, he made a series of statements about so-called risk factors for PPD and I went after the few that looked most relevant. The risk factor of substance abuse turned out to be women who were actively abusing cocaine or drinking a six pack a day while pregnant, which can cause harm to the fetus. I originally said they should get a slap up side the head rather than worrying about PPD screening, and I took it down cuz it wasn’t politically correct (violence against women and all) but I think I am gonna put it back there. As for “abuse” most of those were men who abused their pregnant wives, which is another story altogether. The studies of childhood abuse didn’t show an association for the most part after controlling for depressive symptomatology. We can argue the details, but I guess the point is that I think he is making statements and then giving a string of references and getting up on a bully pulpit about science and not expecting a rebuttal cuz noone will read them. So far, no good.

Again, NO to the MOTHER’S ACT.

After I wrote this post yesterday called “Motherhood is Not a Medical Disorder” about the Mother’s Act, which advocates for widespread screening of moms for post-partum depression (PPD), something I don’t think is a good idea because it medicalizes a normal stage of life, increases the chances that people will be but on antidepressant medications that they may not need and that may have side effects, and represents yet another intrusion into privacy, I got this response from John Grohol at psychcentral (”False Claims by Bremner”).

First he grumbles about my pointing out that the psychiatrist quoted in the Time article, Katherine Wisner, MD (you can follow the link to the Time article in yesterday’s post), was on the speakers bureau for Pfizer and Lilly (something not noted in the article but which I found on my own), makers of Zoloft and Prozac, respectively, which as a commenter pointed out are promoted as the two safest antidepressants for pregnant and lactating women. Being on a speaker’s bureau these days means giving “promotional talks”, which translates into working for the drug company to advertise to other doctors, and is relevant. In addition, the psychcentral website has paid ads, most of them for treatment (which includes medications), while this site has no ads. And don’t say I am trying to profit off my book, which now goes for a nickel on amazon.

Grohol further takes issue with my statement that women without a prior history of anxiety or depression are not at risk for PPD and therefore would not benefit from widespread screening. However in support of that he cites Ross et al 2009, claiming that history of abuse and alcohol or substance abuse are risk factors for PPD as well. However a perusal of Ross et al shows that a history of childhood abuse is not in fact a factor, rather only abuse during pregnancy. In addition, it is alcohol and substance abuse during pregnancy that is a risk factor, on the order of a pregnant woman drinking a six pack a day or actively abusing cocaine. That kind of substance abuse is a risk to the fetus, and needs to be stopped.

If you have a man beating his pregnant wife, or a woman snorting cocaine while pregnant, that it is a situation much more serious than PPD, and should be stopped. These extreme circumstances hardly justify mass screening for PPD.

I still say NO to the MOTHER’S ACT.

This recent article in Time Magazine discusses the Mother’s Act, legislation initiated in response to the story of Melanie Blocker-Stokes, who leaped to her death from her hotel room in Chicago three months after the birth of her daughter. Officially known as the Melanie Blocker-Stokes Post Partum Depression Research and Care Act, but referred to as the Mother’s Act, this legislation would require screening of all women post-partum for depression.

The problem with this is the attitude that being a mother is a risk factor for a psychiatric disorder. First of all, there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum depression. So to screen all moms as if giving birth is a risk factor for depression is ridiculous. And whenever you start screening the general population, you get into problems with over-identification of people and an increase in the number of people that go on antidepressants. I am opposed to mandatory screenings of the population, like Teenscreen, which are bonanzas for the pharmaceutical industry, but a major intrusion into the privacy and autonomy of American citizens. In the case of Melanie Blocker-Stokes, she had already been treated with multiple courses of psychotropic drugs and electro-convulsive therapy, so there is no reason to think that her life would have been saved by “screening”. This legislation is typical of much that comes out of an individual tragedy, that results in an intrusion into the personal lives of individuals and the further relinqueshment of individual freedoms to the government.

The article quotes psychiatrist Katherine Wisner MD as stating ”how can you be opposed to something that will help mothers?” But an examination of the fine print from one of her articles here shows that she is on speakers bureaus for Pfizer and Lilly, makers of Zoloft and Prozac, respectively. 

In it is quoted Amy Philo, a leader of the coalition against the Mother’s Act. Her experience was that after her baby choked on his vomit and needed emergency treatment, she became increasingly anxious about his health. Her doctor gave her Zoloft, telling her that it would make both her and her baby happier. After treatment with Zoloft, she started having alarming suicidal thoughts and thoughts about hurting her baby. When she weaned herself off of Zoloft she felt fine. This experience led her to start the United Non-Profits and Individuals for Truth and Ethics (UNITE), a coalition opposed to the Mother’s Act (click here to sign their petition). Time magazine recently corrected a statement that she had post-partum depression and developed thoughts of harm before taking Zoloft, which wasn’t true.

[update: read more on the debate that arose after this post here at Amy Philo's The Bitter Pill blog and my responses to John Grohol's attack on this post ("Bremner makes false claims...") here and here.]

Yes, it’s true. After posting that my university had sent me a letter by courier telling me to take the name of my university off of my blog, there was mounting publicity about the situation, including stories by BNET Pharma, Schwitzer Health News, and Inside Higher Education, followed by other posts including a story last week in the Academic Exchange and this post on the Carlat Psychiatry Blog. The obvious question was why the ban was applied to me and not other faculty from the same institution. In the face of growing media attention I got a sudden letter chalking it up to a misunderstanding, basically, and yes I can identify myself as university faculty. I thought the first letter was pretty clear not to use the university name in any way, but, whatever.

I think this question has important implications for academic freedom because if I can’t say that I am a professor of psychiatry and radiology then people don’t have any basis for evaluating my opinions. If I am reading a blog about legal issues I want to know if that person was trained as a lawyer. My work in the area of medication safety started with the issue of the acne drug Accutane causing depression (taken off the market last week thanks in part to my efforts btw) and continued with a book analyzing prescription medication which they declined to publicize.

The American Association of University Professors (AAUP) and Foundation for Individual Rights in Education (FIRE) both took an interest in the case. After an initial good first step in saying that it was a violation of my academic freedom for the university to block me from identifying myself as a member of their faculty, I think the response of the AAUP was fairly weak, saying that since I didn’t file a grievance that they assumed I felt the issue was resolved. My complaint was about their ban on me identifying myself as a faculty member, especially when it was so arbitrary and unilateral, in what basically amounts to an effort at censorship.

If this isn’t the kind of issue that the AAUP is interested in, then what is?