In my post of August 31, 2011, Plausible Deniability, I illustrated how
doctors under the sway of pharmaceutical companies widely distribute a completely invalid
“take home message” to readers of journal articles and those who listen to
academic-sounding presentations, while simultaneously providing themselves with
an “out” so that they can deny doing just that.
Some of these strategies have been created from information gathered
from the drug company marketing departments' intensive research into physicians and the way they think (see post: Physicians As Unwitting Research Subjects, 1/3/12).
Apparently, these strategies are widely
disseminated to physicians and researchers working with Pharma. They are just too common. A great example occurred in a rebuttal to a
letter to the editor that I and several of my partners in crime (Peter I. Parry,
Robert Purssey, Glen I. Spielmans, Jon Jureidini, Nicholas Z. Rosenlicht, David
Healy, and Irwin Feinberg) managed to get published in the June 2012 issue of
the Archives of General Psychiatry. The Archives is considered one of the two top
journals in psychiatry.
The letter was highly critical of a
study that was published in a previous issue.
The article was one I blogged about in a previous post (More Disease Mongering in a Respected Journal, 8/13/11).
The gist of our published letter was described in that post, and I will
not repeat it here.
However, let me use the rebuttal to our letter, printed in the same issue of the Archives, to
illustrate how the authors avoid actually addressing the criticisms in the
letter and deny that they meant to conclude from their "study" that which was highly
implied by their journal article.
The latter issue is what I previously referred to as plausible
deniability.
Please keep in mind that when
journals publish letters to the editor that are critical of one of their
published studies, they allow the authors of the original study to respond to
the criticisms, but that is where it ends.
They do not give letter writers the chance to respond in the journal to
the rebuttal. (It is a situation similar to that of reporters at a presidential press conference who are not allowed to ask follow-up questions). So I’m doing it here. Next to what they wrote in said rebuttal, I will
provide my own commentary.
We are pleased to respond to the points raised by Allen
et al, some of which take material out of context and quote news media articles
beyond our control. For example, the letter states that “The message is that
almost half the patients with a major depressive episode have undiagnosed
bipolar disorder and are ‘not receiving necessary mood stabilizer treatment.’” The authors are well aware of
exactly how the news media were going to interpret their study. Ditto doctors who read the article. The drug companies have apparently taught these authors that readers will routinely ignore the disclaimers that they list next in their rebuttal – a case of plausible deniability.
The article is designed to give a very specific “take home
message.” The success of this strategy
is illustrated by those very news stories over which they are now saying they
have no control. Of course they don’t
need to have direct control to achieve this goal.
Our actual
statements are: "Based on
these studies and the major differences in treatment guidelines for MDD [major
depressive disorder] and bipolar disorder, we recommend that, among patients
with MDEs [major depressive episodes], the presence of bipolar features,
including all those with significant predictive value reported in this study,
should be investigated carefully before a decision is made to prescribe
antidepressants. If patients exhibit bipolar symptoms that impair everyday
functioning, treatment with a mood stabilizer or an atypical antipsychotic may
be useful." The take home message from what they “actually said:” exactly what
we said it was. This paragraph subtly equates "bipolar
features" with agitation seen in major depressive disorder - a fact nowhere in
evidence.
This conflation is even more pronounced in the abstract of the article (the short summary at the beginning of the article which is usually the only thing that most busy physicians actually read). The introduction states " Many
patients with major depressive episodes who have an underlying but unrecognized bipolar disorder receive
pharmacologic treatment with ineffective regimens that do not include mood stabilizers."
This sounds like the article is going to demonstrate unrecognized signs
of bipolar disorder and will "orient" anyone who reads the whole thing
to think along those lines.
This conflation is even more pronounced in the abstract of the article (the short summary at the beginning of the article which is usually the only thing that most busy physicians actually read). The introduction states "
They assert that “The study’s findings are based on a
‘bipolar specifier’ requiring ‘no minimum duration of symptoms’ and ‘no
exclusion criteria,’ ” and that “Any subject who came to psychiatric attention
with an angry, agitated, or elated response to environmental triggers or
psychoactive substances might have met criteria for ‘bipolarity.’ ”
The criteria, stated in the “Methods” section of our
article,1(p793) were (1) an episode of elevated mood, an episode of irritable
mood, or an episode of increased activity with (2) at least 3 of the symptoms
listed under Criterion B of the DSM-IV-TR
…The minimum duration of symptoms required for a hypomanic episode was 1
day. Here the
authors are flat out contradicting themselves! I quote from the original article itself: “No minimum duration of symptoms was required and no
exclusion criteria were applied.” (page 793).
And exclusion criteria in the article do not exclude active drug
abusers, which we brought up and the authors just ignore in their rebuttal.
We assessed the
duration reported for hypomanic episodes in 5 groups. Among subjects with major
depressive episode with hypomanic episodes, 7.8% reported episodes of 1 day’s
duration; 2 to 3 days’ duration was more frequent than 4 to 6 days. Even if they did have a minimum duration
criteria, the DSM criteria for even a hypomanic episode is
four days. Really, one day? In patients
who met criteria for major depressive disorder?
Riiiight.
…associated
with (3) at least 1 of the 3 following consequences: unequivocal and observable
change in functioning uncharacteristic of the person’s usual behavior, marked
impairment in social or occupational functioning observable by others, or
requiring hospitalization or outpatient treatment. Neither the article nor the rebuttal tells us how
the study doctors made the determination that there was an unequivocal “change in functioning uncharacteristic of
the person’s usual behavior. “
Especially since under their rules you only have to agitated for a day,
and if you took cocaine or had a big fight with your mother, you might have an
unequivocal change in your “usual” functioning. What the phrase is supposed to
mean is that the patient’s functioning has unequivocally changed under any
and all environmental contingencies.
They would have to be more reactive than they usually are to all unpleasant situations
to a similar degree.
So how do would the study doctors know this? Did they take the patient’s or a family
member’s word for it? I can tell you
beyond a shadow of a doubt that patients rarely really understand what
psychiatrists mean by this phrase. The
only way a doctor can know this is the case is to observe the patients several
times over several weeks, both during and outside of the specified time
period.
Even a close approximation would require taking an extensive psychosocial history including evaluating current environmental stresses as well as an exploration of the nature, past history of, and current status of the subjects relationships with spouses, lovers, parents, and children. Maybe they did that, but I doubt it, because doctors like these tend to denigrate the importance of such factors in favor of “disease” explanations. And it would take a LOT of time.
Even a close approximation would require taking an extensive psychosocial history including evaluating current environmental stresses as well as an exploration of the nature, past history of, and current status of the subjects relationships with spouses, lovers, parents, and children. Maybe they did that, but I doubt it, because doctors like these tend to denigrate the importance of such factors in favor of “disease” explanations. And it would take a LOT of time.
No exclusion criteria for manic/hypomanic episodes
associated with antidepressant or other drug use were applied. So people who got agitated from a
side effect of an antidepressants were not excluded by their own
admission. Someone gets a side effect
from a drug, and that proves they are manic?
Importantly, the initial eligibility criterion was that
patients have presented to clinical settings for evaluation and treatment of a
major depressive episode per DSM-IV-TR
criteria. These sequential criteria, applied by senior psychiatrists in each
country, are entirely inconsistent with the assertion that the psychiatrists
conducting the assessments enrolled “any subject who came to psychiatric
attention with an angry, agitated, or elated response to environmental
triggers.”
The statement that 23.2% of subjects experienced elevated or irritable mood triggered by antidepressants did not “define the subjects as having ‘bipolar disorder.’” Rather,it addresses the DSM A criteria, which are essential, but not sufficient, for diagnosis of bipolar disorder. As Figure 1 in our article shows, mood lability while taking antidepressants occurred in 55.8% of bipolar specifier–positive vs 23.0% of bipolar specifier–negative subjects (odds ratio, 1.7;95% CI, 1.4-2.0) and mania/hypomania while taking antidepressants occurred in 37.2% of bipolar specifier–positive vs 3.4% of bipolar specifier–negative subjects (odds ratio, 5.7; 95% CI, 4.4-7.5). Sorry, but with this paragraph the authors are still implying that their subjects MAY be bipolar, and assumes precisely what the article is supposed to show – that a patient who is agitated when depressed could have a manic symptom. So if patients with an agitated depression are more likely to become more agitated on an antidepressant than depressed patients without agitation, that is supposed to show that they might be bipolar? Only by circular reasoning.
The statement that 23.2% of subjects experienced elevated or irritable mood triggered by antidepressants did not “define the subjects as having ‘bipolar disorder.’” Rather,it addresses the DSM A criteria, which are essential, but not sufficient, for diagnosis of bipolar disorder. As Figure 1 in our article shows, mood lability while taking antidepressants occurred in 55.8% of bipolar specifier–positive vs 23.0% of bipolar specifier–negative subjects (odds ratio, 1.7;95% CI, 1.4-2.0) and mania/hypomania while taking antidepressants occurred in 37.2% of bipolar specifier–positive vs 3.4% of bipolar specifier–negative subjects (odds ratio, 5.7; 95% CI, 4.4-7.5). Sorry, but with this paragraph the authors are still implying that their subjects MAY be bipolar, and assumes precisely what the article is supposed to show – that a patient who is agitated when depressed could have a manic symptom. So if patients with an agitated depression are more likely to become more agitated on an antidepressant than depressed patients without agitation, that is supposed to show that they might be bipolar? Only by circular reasoning.
Allen et al view their position as part of a “debate”
about the “ever-widening bipolar spectrum.” We consider data, not debates, as
central to the progress in the scientific understanding of mood disorders. Ha! This is
a brazenly outrageous statement. The “debate” is specifically ABOUT "data" like
theirs – both its validity and what it means.
They make several references to borderline personality
disorder. The BRIDGE study assessed for comorbid diagnoses in all subjects.
Five hundred thirty-two patients (9.3%)met DSM-IV-TR
criteria for borderline personality disorder. This large sample provides an
opportunity to analyze patients who met borderline criteria vs those who did
not. We are completing a manuscript that will provide useful evidence on this
subject. Maybe they
should have said this in the original article.
But we know from the work of Zimmerman and others (My Psychology Today blogpost 12/11/11) that many patients
who have borderline personality disorder are misdiagnosed.
Allen et al cast unseemly aspersions that the BRIDGE
study was a vehicle to promote sales of an antipsychotic drug sold by
sanofi-aventis. sanofi-aventis has no antipsychotic with an indication for
bipolar disorder. Here the study authors are being
complete weasels. The misleading point
is contained in the phrase “with an indication for bipolar disorder.” What they say is literally true - in the United States. Unfortunately, Sanofi does have an antipsychotic drug called amisulpiride (brand name, Solian). In fact, in the United States, it is not FDA-approved for any indication, let alone for bipolar disorder.
However, Solian is approved and widely marketed in Europe and Australia, and at least according to Wikipedia, used for bipolar disorder. (This may be why the study was conducted overseas). In addition, Sanofi also sells a preparation of depakote, which while an anticonvulsant and not an antipsychotic, is widely used in both actual and misdiagnosed bipolar disorder.
However, Solian is approved and widely marketed in Europe and Australia, and at least according to Wikipedia, used for bipolar disorder. (This may be why the study was conducted overseas). In addition, Sanofi also sells a preparation of depakote, which while an anticonvulsant and not an antipsychotic, is widely used in both actual and misdiagnosed bipolar disorder.
Besides, as I described in my post of 6/12/12, marketing
for off-label uses of drugs for bipolar disorder is unequivocally rampant. Maybe the authors didn’t know
this? NOT.
We know of no evidence that this was the case at any
stage of development and execution of the BRIDGE study. Sanofiaventis ceased
financial support for analyses of the study in 2010. All work subsequently
conducted has been achieved by our local funds. The drug company got out of the
game just in time for the authors to claim they were not biased due to the
funding source. Actually, the original article says “The sponsor of this study (sanofi aventis) was
involved in the study design, conduct, monitoring, data analysis, and
preparation of the report.”
In addition, all of the clinicians recruited for the study received fees, on a per patient basis, from Sanofi-Aventis in recognition of their participation in the study. The key lead authors, all with significant Pharma connections, did not disclose their other pharmaceutical company ties. These authors: Allan H. Young, MD, Jules Angst, MD, Jean-Michel Azorin, MD, Eduard Vieta, MD, Guilio Perugi, MD, Alex Gamma, PhD, Charles L. Bowden, MD.
They should be ashamed of themselves.
In addition, all of the clinicians recruited for the study received fees, on a per patient basis, from Sanofi-Aventis in recognition of their participation in the study. The key lead authors, all with significant Pharma connections, did not disclose their other pharmaceutical company ties. These authors: Allan H. Young, MD, Jules Angst, MD, Jean-Michel Azorin, MD, Eduard Vieta, MD, Guilio Perugi, MD, Alex Gamma, PhD, Charles L. Bowden, MD.
They should be ashamed of themselves.
You like arguing with people don't you?
ReplyDeleteYou got me! Sure do. Especially when someone's arguments are as disingenuous and destructive as these are.
DeletePersonally, I give up on all of this. I'm not a science type, but sometimes I think the DSM should simply be thrown out. I stopped reporting MDD a while ago...and that was because most docs didn't know what it was, and I found it was only useful to report it to psychiatrists, because SSRIs cause MDEs for me. Same with Panic Disorder. No point.
ReplyDeleteExample:
Me: I have ADHD PI, MDD, and Panic Disorder
Doc: What is ADHD PI???
Me: ADHD w/out hyperactivity
Doc: I've never heard of that. I've only heard of ADHD w/out hyperactivity as ADD. You're also depressed?
Me: No...I have MDD though.
Doc: So, you're depressed.
Me: No. It's in remission. I haven't had an episode in years.
Doc: Is it Bipolar Disorder?
Me: No...its MDD.
Doc: Okay, so you're just depressed
Me: The heck are you talking about?
Doc: So you also have panic attacks?
Me: Not anymore. It's been in remission for years.
Doc: I think all of your health complaints are psychosomatic and because you have anxiety. Are you planning on hurting yourself? Do you feel like you want to die?
Me: Huh?
Doc: I have to ask you this. You take Wellbutrin to treat your depression.
Me: No, I take Wellbutrin to treat ADHD
I can't make conversations like that up. Just throw out the DSM now.
It's absolutely appalling that patients suffering from adverse effects of antidepressants are saddled with a diagnosis of bipolar disorder and treated with God-knows-what drug cocktails, thus gratuitously escalating their condition to a serious mental illness further complicated by iatrogenisis.
ReplyDeleteCommon sense would dictate STOP THE ANTIDEPRESSANT and allow symptoms to resolve but does psychiatry respond to common sense?
The entire mythology of antidepressants triggering bipolar disorder, leading to a lifetime of medication, serves no one but pharma sales.
It's beyond appalling. It's a crime against humanity. And the idea of expanding the diagnosis of bipolar disorder to include any kind of emotional upset can only be based in empire-building either by the psychiatrists who promote it or the manufacturers of drugs to treat bipolar disorder.
Uhh...Jane, did you ever think you might be overdiagnosed and overmedicated? You may be over all that stuff.
ReplyDelete