Drug companies have aggressively and unlawfully marketed off-label use for decades, with the most egregious examples being psychiatric drugs.
Pfizer were fined $2.3bn for off-label promotion of Bextra, Geodon, Zyvox and Lyrica. Eli Lilly were fined $1.4bn for off-label promotion of Zyprexa. GSK were fined $3bn for a slew of misconduct, including off-label promotion of a dozen drugs. AstraZeneca were fined $520m for off-label promotion of Seroquel. Abbott were fined $800m for off-label promotion of Depakote. Novartis were fined $422m for off-label promotion of Trileptal.
Despite these huge fines, the unlawful marketing continues. I don't think we're taking the issue nearly seriously enough. For years, drug companies have been telling (and even bribing) doctors to prescribe drugs with serious side-effects to vulnerable patients based on no real evidence.
There's a deep malaise at the heart of the pharmaceuticals industry. Marketing has become the core function of many drug companies. Blatantly fraudulent marketing is endemic. Drug companies are chalking up billion dollar fines as a cost of doing business.
I urge you to read the GSK settlement agreement. They admitted to promoting the prescription of Paxil to children, while having no evidence of efficacy and hiding evidence that it increased the risk of suicide. They admitted to hiding evidence that Avandia increased the risk of congestive heart failure and myocardial infarction. They admitted to bribing doctors to prescribe half a dozen drugs for off-label use.
This level of corruption would be outrageous in the developing world, let alone the richest country on earth.
Thats because antidepressant is just one of the many activities of such class of drugs. Its like saying that Viagra is a pulmonary hypertension drug, prescribed for something else. Indications are not binary things.
Similarly, most OTC sleeping pills are just first-generation antihistamines like diphenhydramine with a different brand name on the label. Incidentally, diphenhydramine is also an SSRI, and the discovery of that fact led to the development of Prozac and its derivatives.
As true as that might be, I strongly believe depression as a disease/condition should only be diagnosed (and thus treated) if there is no real cause for the symptoms.
Being sad and unable to leave the bed because (your dog died | you are morbidly obese | you are going to die in 3 months) doesn't qualify as depression.
Respectfully: the entire mental health profession and the DSM-5 explicitly disagree with your belief.
Conflating depression with "being sad" is to misunderstand what depression is, what sadness is, and how we qualify depression diagnoses. Sadness is natural and healthy. Depression is natural and unhealthy.
While the word 'depression' is abused in pop culture, showing enough symptoms of major depressive disorder over a long enough timeline is the literal textbook definition of being depressed.
Not getting out of bed because your dog died is arguably a natural reaction to sadness. Not getting out of bed for three months, refusing to eat because you're trying to die, cutting off lifelong friends, and undergoing severe personality changes because your dog died is really, really, something else.
And, on a personal note, distinguishing between what is and isn't a "real" cause for a feeling is a pretty offensive judgment and implies a very dismissive attitude towards peoples pain... I mean, someone who is unable to function in society 15 years after their kid died doesn't get to be depressed because they have a "real" reason to feel bad? And people who kill themselves from a major cognitive imbalance don't have a "real" cause for feeling that way? Bleh. That's a half step removed from "suck it up" or "snap out of it".
The DSM-5 criteria for Major Depressive Disorder are extremely broad. Many serious, thoughtful psychologists and psychiatrists believe that we are at real risk of pathologising normal human emotion.
Code 296.21 designates the apparently paradoxical diagnosis of Mild Major Depressive Disorder, with the following description of severity:
Few, if any, symptoms in excess of those required to make the diagnosis are
present, the intensity of the symptoms is distressing but manageable, and the symptoms
result in minor impairment in social or occupational functioning.
Essentially, the DSM-5 creates a specific diagnostic category for people who are basically OK but slightly sub-par. That's not inherently dangerous in isolation, but it does interact very dangerously with the persistent malpractice of the pharmaceutical industry. Someone who might just need some low-intensity psychotherapy or some peer support might end up on an indefinite SSRI prescription.
Several meta-analyses have indicated that SSRIs are not significantly more effective than placebo in mildly depressed patients, with a significant frequency of adverse events. Most SSRIs have known "discontinuation effects" (e.g. withdrawal symptoms), making SSRIs a distinctly questionable choice for mild or short-term depressive episodes. Despite this, there has been a vast increase in the number of SSRI prescriptions, with most of the growth occurring in patients who historically would not be considered sufficiently impaired to warrant drug treatment.
10% of Americans over 12 are currently taking antidepressants, rising to a staggering 23% of middle-aged women according to the National Center for Health Statistics. There is a huge racial disparity, with 13.6% of non-Hispanic whites taking antidepressants versus 3.9% of non-Hispanic blacks. Less than a third of people taking a single antidepressant have seen a mental health professional in the past year.
Something is seriously wrong with the way we diagnose and treat depression; I lay the blame almost entirely at the door of pharmaceutical marketers.
> The DSM-5 criteria for Major Depressive Disorder are extremely broad.
You're making a justified/not justified appeal to the scope of diagnosis, not that diagnosis exists/does not exist on the basis of "reasons". As a taxonomy the code system in the DSM is broad, inclusive, and tries to hit a meaningful subset of behaviour in range of darned tricky, poorly defined, near-impossible to STEM-style research, and abuse prone issues.
More importantly, the reason there will be a DSM-6, DSM-9, and DSM-111 is because these codes will specialize and refine themselves over time...
> Essentially, the DSM-5 creates a specific diagnostic category for people who are basically OK but slightly sub-par... might end up on an indefinite SSRI prescription.
The fact that a diagnosis exists or not is orthogonal to treatment method. The DSM is like the Dewey Decimal system of "head stuff", inclusion in it's indexing is proof and support only of inclusion in its index. Mein Kampf is as much a book as my self-published wookie fan fic, IOW ;)
Crappy medication from crappy doctors is a big deal, and crappy use of prescriptions kills a lot more people than any of the fun drugs... Regardless, bad treatment or good treatment do not hinge on subjective qualitative judgements of your experiences. That's how priests operate, not doctors.
> Something is seriously wrong with the way we diagnose and treat depression;
The US is a notorious abuser of pharmaceuticals across the board, with notoriously bad diet, nutrition, weight, and health system... Something is seriously wrong with the way you treat all your sick people, and design your cities, and make your food, and treat your environment...
There is especially something wrong with how you advertise pills constantly as though they can heal with powers otherwise reserved for healing lepers and converting water into nicely refined chianti...
This still doesn't mean you are only by-textbook-defition depressed if you have a "reason". You don't have to justify leukaemia, schizophrenia, bulimia, aspergers, or chronic asshole-itis, why should depression be any different? If you're statistically abnormal, you're statistically abnormal. No one in crushing pain needs to convince, debate, warrant, or validate anything for a doctor and healthcare system to understand that their anamnesis correlates with a particular taxonomy. In fact, that's kind of a jerky thing to demand of someone experiencing psychic distress and looking for help...
I haven't conflated sadness with depression. I was in fact stating the opposite.
Unfortunately I am very aware of most of the symptoms of depression as I have suffered it myself in the past. And yes, I did take antidepressants. I am not against their use at all, only against misdiagnoses.
15 years of mourning the death of a loved one is of course abnormal, as I have stated already in another response around this thread, but... is it depression? Or is it lack of coping mechanisms? Maybe learning to face reality is better than depending on a daily dose?
Not a doctor, but: it seems the real problem with your claim is that it's patently absurd to say that a symptom can only be a symptom if it has no cause. Symptoms present themselves that we might find the cause of the problem.
Do you mean no cause other than a chemical imbalance? I still think that's shaky ground, but I don't really know enough to say.
> Maybe learning to face reality is better than depending on a daily dose?
Anti-depressants are one tool for treating depression, but they’re usually not meant to be the only tool and ideally people would usually not end up on them indefinitely.
Actually, just because there is a reason for you to be depressed doesn't mean that you don't have depression. Depression can cause abnormal responses to life's events. Not to mention the fact that a life event - death of a loved one, death of yourself, or a bad situation - can cause an episode of clinical depression. The basics with mental health is that it needs to be abnormal and/or cause problems doing basic life stuff.
So back to your example: Not leaving the bed because your dog died can be a red flag of depression. Or cause it in a few people (death of significant other, parent, or child is probably more likely to cause it though). This is especially true the longer the person has the symptom - none of us would blame a person for taking a couple days off, but you should be able to function at work a few days later.
It doesn't matter if obesity is the cause of the depression if the state of mind keeps them from doing self-care.
And I don't know why it would be bad to let some terminally sick person to take happy drugs. It seriously doens't matter at this point because they will probably be dead. Might as well enjoy what you can of the rest. This is probably a bad example all around and likely hard to diagnose properly.
Any active medication has side-effects. But if the depression—even though it may have an unknown cause—prevents a person from functioning in life, then the medication might be worth it. But it's a judgement call to be made by the patient, with proper guidance by his/her care team. In many cases, increasing the risk of a severe disease 20 years from now is preferable than losing job/house/life. It's easy to criticize these patients or their care team as doing too little but sometimes, a baby step is the only realistic step that can be taken, and there may even be some urgency associated with it.
Having said that of course, it's important to follow-up and continue to dig deeper in what can be done from a mental health perspective. An antidepressor may be the band-aid to regain sanity and some stability, and from that place, the next steps can be taken. The key is to not give up in that journey towards health, but that is easier said than done.
Disclaimer: not a doctor, just a patient advocate.
In my opinion, inability to cope with whatever is going on with life is still not depression. It is, however, something that can and should be addressed (possibly through therapy).
In fact, I believe using antidepressants for such cases is counter-productive, making people rely on pills to feel alright instead of acquiring the adequate coping mechanisms or mental processes.
Giving drugs (whatever their legal status) to terminally ill patients is acceptable, but it's still not treating any illness known as depression.
> In my opinion, inability to cope with whatever is going on with life is still not depression. It is, however, something that can and should be addressed (possibly through therapy).
Okay, so it can be addressed, using therapy, like depression. What would you prefer to call it?
In the first two cases, it’s an extreme and unreasonable reaction (assuming it goes on for a while, rather than just being for a day or so), and could well be depression. On that basis, depression could only be diagnosed in people who have perfect lives, ie nobody.
I recently started suffering from chronic headaches that usually start in the morning when I wake up, and come and go throughout the day. After getting an MRI and ruling out a brain tumor, we've been trying a variety of medications to take care of it.
The most successful so far is an anti-depressant. Duloxetine. SNRI. I do have some of the side effects - my libido is markedly decreased, but it was fairly high to begin with, so I'm probably at about low-average now. I can still get in the mood on demand, and still want to initiate several times a week, so I'm more than happy to make the trade off to not have a basically constant headache 80% of my waking hours.
Off label prescription is a pretty common thing. Personally, I'm glad for it.
Have you looked into teeth grinding during the night/throughout the day? I know, it seems like an obvious thing to look into (your dentist can tell if you've been grinding your teeth within the first couple minutes of an appt), but this unconscious behavior can cause low dull headaches throughout the day. An oral appliance (i.e. night guard) can have a tremendous positive impact on preventing daily headaches.
When I started taking duloxetine, I've experienced most or all of the side effects in the first ~4 weeks. After that they all went away. A friend of mine also had the same experience.
This is a small data point but who knows, not sure how recently you started taking the meds but there is a chance all the side effects will vanish :)
I’m curious if you’re tracking your blood pressure? Both before and after starting the medication. Did you see any change? I’ve wondered if there’s a relationship between blood pressure and headaches.
Some anti-smoking drugs are actually just antidepressants sold under a different brand name. It’s literally exactly the same drug with a different name stamped on the pills, but it’s easier to get people to take the drug if they think it’s a “pill to help you quit smoking” and not an “anti depressant”
I was prescribed buproprion to help me quit tobacco. It was extremely effective. I don't think the reduction in aniexty was the main driver though. In my experience, I physically felt sick every time I tried to smoke. It was a really unpleasant experience, but it helped immensely.
In my experience, they were quite upfront about the fact that it was an anti-depressant that had the effect of aiding quitting smoking, because it fairly obviously dealt with the predictable effects of trying to quit smoking: anxiety, depression, irritability. You're making it sound like a stealth SSRI channel, and it's not.
I am not sure if all physicans have adequate training on psychoatic drugs, but giving SSRI to a patient with both bipolar and personality disorder can have very negative effects. So if a non-psychiatrist prescribing antidepressant to someone without adequate psychatric evaluation (and evaluation can be off too), you can end up making the patient ill.
So if I were given SSRI to quit smoking, my mental health may get even more worse.
Disclaimer: have bipolar and personality disorder.
I understand. I also understand that even with a psychiatrist prescribing it appropriately, with full evaluation and diagnosis for depression, a particular SSRI can make the patient worse, not better. I've had friends spend years working through various prescriptions (and combinations) to find what worked, and it often included some hellish periods when they felt far worse until they hit on the right drug(s).
That doesn't surprise me the least, there's quite a bit of evidence [0] that many smokers smoke to treat psychological issues. Which would also explain why some people have a much easier time kicking the habit while others struggle really hard just with the thought of giving up.
As somebody who's been suffering from depression his whole life, atop a few other mental issues, it's really disheartening to realize how little we seem to actually know about how the human psyche and brain work.
anti-anxiety meds, to be precise. reducing anxiety reduces the drive to smoke. it was discovered ass a side-effect during clinical trials, that many subjects spontaneously quit smoking.
Yes, drugs have all kinds of secondary effects, and some may be useful for many things. (aspirin being the most notorious)
Once you test something out on enough people it becomes much easier to find these patterns of secondary effects.
It is actually kind of unfortunate that because of the stigma associated with mental illness some patients will refuse to take anti-depressants when prescribed for other conditions where they could be helpful.
Trazadone is one of the most commonly prescribed insomnia medications. It isn't FDA approved for that. It is a decade's old generic antidepressant. The sleep dose is much less than the regulated theraputic dose.
Through mechanisms not fully understood, people with liver disease often experience intense skin itching. Standard dermatology approaches have essentially no effect. SSRIs are one well tolerated treatment.
In neither case is their obvious profit motive or overselling by drug companies.
My ex-wife had intense skin itching. We didn't realize that her transplanted liver had started failing. A neighbor happened to notice her scratching, and happened to know about the liver disease connection, and happened to mention it. After some tests to confirm her liver was failing her meds were adjusted to slow the process down. It failed several years later anyway (she survived a second liver transplant) but without proper treatment it would've failed much sooner.
I always say to be wary of treating symptoms instead of underlying causes. Taking an antidepressant to soothe intense skin itching can kill you, if that's all you're doing for it. Your dermatologist may not know any better, or may not care.
Sure but shouldn't those drugs undergo FDA approval for those uses? You make it sound as if they're very effective without many side effects so (as far as FDA approvals go) it shouldn't be too hard.
This is not in the least remarkable. The article does not mention it, but several maoi inhibitor drugs are effective for common varieties of epilepsy and have been used for decades.
Here's an interesting counterpoint to the anecdote at the start of the story. I have chronic treatment resistant depression. Gone through many different treatments. The thing that works best for me is a treatment I receive for something else. A THF-alpha inhibitor (in my case Etanercept), so I'm in practically the opposite position to the guy in the article.
I suspect there's a link in some form of branch of depression that comes with the autoimmune grab bag of fun.
I am glad that Briggs could heal his ulcerative colitis with an unorthodox treatment.
"On occasions when she stopped taking bupropion, the blood and abdominal pain returned until she started taking the drug again."
Yet I guess I am unimpressed when I hear that symptoms diminish with use of a drug like bupropion. Eventually when the patient gets tired of the side effects they will get off the medication. This will leave them with the return of the illness they used the drug to treat in addition to the damage it caused in other parts of the body. Masking symptoms is sort of psychiatry's gambit so I guess this is nothing new.
Just asked a retired pharmacist and clinical social worker (two family members) about this. They said that there were numerous things that anti-depressants are prescribed for (smoking cessation, OCD, anxiety, etc.) which are NOT off-label uses.
Crohn's can also be improved with Glycine according to someone I know who started taking it for other reasons. A bit of googling then showed there may well be a connection, so the result made some sense. YMMV of course.
Wasn't a dismissal, rather a comment, and technical language aside it stands as true: being happy "solves" problems collaterally, by rendering us oblivious to them.
If you don't want your comments to be read as standard internet snarkytropes, you'll need to distinguish what you mean more clearly. In this case, the trivialization of an entire article to an idiotic tautalogy kind of signals that.
On HN, if you have a substantive point to make, make it thoughtfully; if you don't, please don't comment until you do.
That’s a bit reductive. For example, many anti-depressants affect serotonin reputake, which is now known to be integral to gut function. Further, often these off-label uses are at doses far below the levels required for anti-depressant effects.
A more accurate TL;DR might be something like: allowing off-label prescription is a two-edged sword. One the one hand, it has enabled innovation and the discovery of clinically effective treatments. On the other hand, the benefits are unevenly distributed because few doctors know about them, we know less about the side effects, and knowledge about effectiveness versus placebo is limited.
I would comment that many off-label treatments using anti-depressants do have significant double-blind studies behind them.
I figured it was going to be something like Wellbutrin to quit smoking which, while off-label, kinda makes sense. But IBD? Can’t say I saw that coming. Because I’m not all that interested in the topic I just skimmed, but I gather it is not well understood why such wildly off-label use works? (And “no, go read the article” is acceptable. :-) )
Um... Smoking cessation is not an off-label use of bupropion (Wellbutrin), it's an FDA approved use and it's very openly marketed as such.
As far as the reason it seems to work, that was given as:
>Studies on mice had shown that instead of blocking the action of inflammatory proteins, bupropion appeared to lower the production of those proteins in the first place.
Bupropion also FDA approved for weight loss when mixed with the opioid antagonist naltrexone (brand-name Contrave).
No use "make sense" more or less than any other use use, it's a substance that has lots of effects on the body.
Um... Smoking cessation is not an off-label use of bupropion (Wellbutrin)
It was twenty some years ago when I took it. I obviously haven’t kept up with the latest, but a quick search says FDA approval came shortly after it was prescribed to me. Mea culpa.
Pfizer were fined $2.3bn for off-label promotion of Bextra, Geodon, Zyvox and Lyrica. Eli Lilly were fined $1.4bn for off-label promotion of Zyprexa. GSK were fined $3bn for a slew of misconduct, including off-label promotion of a dozen drugs. AstraZeneca were fined $520m for off-label promotion of Seroquel. Abbott were fined $800m for off-label promotion of Depakote. Novartis were fined $422m for off-label promotion of Trileptal.
Despite these huge fines, the unlawful marketing continues. I don't think we're taking the issue nearly seriously enough. For years, drug companies have been telling (and even bribing) doctors to prescribe drugs with serious side-effects to vulnerable patients based on no real evidence.
There's a deep malaise at the heart of the pharmaceuticals industry. Marketing has become the core function of many drug companies. Blatantly fraudulent marketing is endemic. Drug companies are chalking up billion dollar fines as a cost of doing business.
I urge you to read the GSK settlement agreement. They admitted to promoting the prescription of Paxil to children, while having no evidence of efficacy and hiding evidence that it increased the risk of suicide. They admitted to hiding evidence that Avandia increased the risk of congestive heart failure and myocardial infarction. They admitted to bribing doctors to prescribe half a dozen drugs for off-label use.
This level of corruption would be outrageous in the developing world, let alone the richest country on earth.
https://www.justice.gov/opa/pr/glaxosmithkline-plead-guilty-...