The Conflation of Chronic Sadness With Major Depression

When I bring up with many other professionals the idea that major depression is now over-diagnosed by relabeling what used to be called dysthymia as "mild' major depression, a lot of them seem to disagree. Or they just tune out. “That’s just your opinion,” I might hear. Well, luckily the DSM-V now provides evidence that I am on the right track. In the DSM-V, the term “dysthymia” has been replaced! It is now called Persistent Depressive Disorder. 

As I have discussed in many previous posts, my opinion about major depressive disorder is that it is more of a brain disorder than mere unhappiness. The word depression itself is a symptom, not a disorder. It is in the interest of drug companies to conflate chronic psychological unhappiness with major depression so they can sell more antidepressant drugs to people who will not actually benefit from them.  Now,  it is also possible to have both, which is called double depression.

While many of the criteria are the same for the new diagnosis as the previous criteria for dysthymia, there are subtle differences that obscure the difference between that disorder and major depressive disorder. In a percentage of people with the latter disorder, it may become chronic. This is seen in the new definition of the disorder, which reads “This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. These disorders should not be consolidated.

There is one additional change which is telling. The only specific criteria for the disorder that has been changed has gone from “The disturbance is not better accounted for by MDD or MDD in partial remission” to “Criteria for Major Depressive Disorder (MDD) may be continuously present for 2 years, in which case patients should be given comorbid diagnoses of persistent depressive disorder and MDD."  Double depression has nothing to do with the length of the major depressive episode.

Drug companies have enlisted academic psychiatrists to become “key opinion leaders” in order to push this idea, and have even advocated the use self report surveys designed to screen for major depression (therefore having a lot of people test positive who don’t really have the disorder  – false positives) as diagnostic instruments.

This has led to a host of articles in the popular press that seem to indicate that antidepressants are nothing more than placebos. Nothing could be further from the truth, but a lot of psychiatry critics like Robert Whitaker have seized on “research” articles (which do a crappy job of making the correct diagnosis) that seem to show this to be the case.  After all, since most anti-depressants are generic,  it's better for drug companies' bottom line if instead of those drugs, expensive new anti-psychotic drugs can be recommended instead.

The critics also use the fact that we don’t know exactly what causes major depression to dismiss the whole diagnosis. The incorrect hypothesis that the condition is due to a “chemical imbalance,” which is sometimes advanced by clinicians, must mean that it is not a real disease. Dumb. Clinicians have often used this oversimplified idea to convince resistant patients to take the medications. Researchers rarely if ever actually said that a chemical imbalance was the cause of the disorder.

Of course, it’s not always easy for clinicians to tell the difference between dysthymia and major depression in a given patient, but in most cases it’s fairly straightforward.  There is nothing that stops anyone from being chronically unhappy when they are not having an episode(the euthymic state) of major depression. And major depression is episodic with normal-for-them baseline mood periods in between episodes.

A good clinician will define a response to antidepressants as good if the patient returns to their baseline. They don’t have to be in a good mood to have had a good response, but may just need psychotherapy like any other dysthymic patient. Nonetheless, many of these patients who have double depression are mislabeled in the literature as “treatment resistant,” which means that docs are encouraged to add still more drugs to antidepressants to “augment” them. There are of course patients who actually are treatment resistant and need this augmentation, but in my 45 years of practice this was a relatively small contingent.

Briefly and in an oversimplified manner, distinguishing the two disorders has to do with the “three P’s” – persistence, pervasiveness, and pathological. (You can tell if a study employs the correct definitions by seeing how the diagnosis was made with their subjects. The P’s are emphasized in an excellent diagnostic interview called the SCID). Persistent: this is the duration criteria. An episode has to last at least two weeks. Admittedly, the two-week criteria is arbitrary, but is put in so clinicians don’t make the diagnosis after too short a period.  The “everything is bipolar” crowd routinely poo poo's the duration criteria.

Pervasive: the symptoms have to be present nearly all day every day no matter what goes on in a patient’s life. This means that if a patient were to win the lottery, it wouldn’t cheer him up all that much.  Pathological: this means that the ways that the patient reacts to any stress is different from the way they might react if they were not in an episode. See the lottery statement. Also, if a lover were to, say, break their heart, this would not always make a whole lot of difference in how bad they feel.

These issues are not seen with good doctors, who not only know how to take a complete bio-psycho-social history but actually still do them.

Drug Abuse and Drug Companies

As most readers will know, opiate abuse and overdoses have increased dramatically in recent years, and it’s all over the news. Some of the public may even be aware of the role of drug companies and drug distributors in the process – the latter being recently profiled on an episode of Sixty Minutes. Let’s look at the role of the drug companies.

A Pharma executive, a billionaire, was arrested in October on charges of bribing doctors to prescribe opioid painkillers. (http://fortune.com/2017/10/26/john-kapoor-insys-therapeutics-arrested-net-worth/). The Department of Justice arrested Insys Therapeutics founder John Kapoor, 74, in Phoenix. Kapoor was charged with using bribes and fraud to prop up sales of a pain medication called Subsys, a fentanyl spray typically used to treat cancer patients suffering excruciating pain. Fentanyl is 50 to 100 stronger than morphine, and contributed to the overdose deaths of pop stars Prince and Tom Petty.

When it comes to drugs of abuse, the lunatics seem to have taken over the asylum in medicine these days. In their push towards huge profits, dangerous drugs are being hawked when cheaper, less toxic, and less addictive alternatives are available for treating some conditions. And as discussed in this blog, whole diseases such as “adult adhd” have been invented out of whole cloth.

For those readers who may not know, potentially addictive drugs are referred to by the Drug Enforcement Agency (DEA)  as “scheduled” drugs. Schedule I drugs are the illegal ones. Schedule II drugs are those with the highest abuse potential: narcotics and stimulants. Schedule  IV drugs are those considered to be of low potential for abuse. If you didn’t know how the drugs were scheduled, you certainly would never know it from listening to presentations by doctors working with Pharma.

Pharma hires doctors to do research on as well as give talks to other doctors about their products, totally with the goal of increasing sales – if patients do happen to benefit in some way, all the better – but that is hardly a requirement. The slides that are presented during the talks are furnished entirely by the drug company after being approved internally; the doctors giving the talks are not allowed in most instances to use their own slides.

Pharma is particularly known for employing what they call “Key Opinion Leaders” (KOLs) to give promotional talks to doctors around the country. The more academic credibility they seem to have the better – that is one source of determining who might be a KOL. But it is not the only one.

Pharma can actually get any given doctor’s prescribing records from the pharmacy industry (unless the doctor “opts out” of allowing his or her data to be mined in this way. Most docs are not even aware of this option—and having the information publically available is the default position). Pharma then uses this data to see if prescriptions for their products increase after one of their KOLs makes a presentation. 

Those doctors that make the best salesmen are hired again and again, while those who do not measure up are dropped.

A colleague of mine has taken a course required in Tennessee for licensure that discusses the “proper way” to  prescribe drugs of abuse. The course was sponsored by our malpractice carrier. According to him, one year the leader of the course scolded the doctors present for not prescribing enough opiates to people with chronic pain. 

The doctors were told how much suffering they were causing these patients by withholding these medications. Just one year later, after the “opioid crisis” hit the news, the same course was given. Only this time, the doctors were scolded because they were prescribing these “suddenly” dangerous and highly addictive substances to their patients with chronic pain!

I have discussed in previous posts how the risks of that class of medication (Schedule IV) have been wildly overblown in the medical literature and in public news stories. As well as being classified as “low abuse potential” by the DEA, they do not cause intoxication, and have next to no side effects compared to just about any other class of meds in most patients. I am not saying they are never abused, but usually only by people that mix them with opiates and alcohol. 

And of course any individual can have a bad reaction to any drug. It seems benzo’s are never discussed without the admonition that the “are addictive,” or have a few side effects in (some) patients – while drugs like amphetamines (Schedule II) that are abused far more often, and have more potential adverse or toxic side effects, are enthusiastically pushed.

And I do mean pushed, as in supplied by pushers masquerading as drug companies. I recall a “grand rounds” (a major lecture at an academic department in a medical school) from maybe 18-20 years ago in which the KOL was saying that about 18% of all adults should be on high doses of speed, that the reason that many of the parents of kids diagnosed with ADHD were substance abusers was because, "If you had a kid with ADHD, you'd drink too," and that kids who had ADHD could concentrate intensely on video games in an arcade despite multiple and pervasive loud distractions all about because that is "not concentrating." (I always wondered what the heck it supposedly was). I kid you not.

As another amazing example of drug pushing, one news service for psychiatry called MDLinx devotes a whole e-mail newsletter to articles extolling the use and virtues of drugs like Adderall and Concerta. Some recent examples:

MDLinx Psychiatry 3/13/18 - Ranked, sorted, and summarized by MDLinx editors from the latest literature.

IN THE NEWS SHP465 mixed amphetamine salts effective, safe for ADHD in adults Liz Meszaros, MDLinx, 03/08/2018

Researchers investigate the link between ADHD and risk of self-harm Paul Basilio, MDLinx, 02/23/2018

Study of 23,000 people links ADHD with genetic signature for delay discounting. Paul Basilio, MDLinx, 12/11/2017

They also have a section of their more general psychiatric newsletters also devoted to this goal that is called the ADHD Resource Center: A collection of articles and features related to ADHD with articles like:

AAP Experience - American Academy of Pediatrics              National Conference & Exhib Conference Of course, none of these Pharma sales mechanisms would matter that much if there were not already a ready market for abusable medications. That market is growing, and adverse childhood experiences and family dysfunction are a huge part of that problem. Still, as Steppenwolf used to sing, “G-d damn the pusher man.”

“Expert” Doctors Who Shill for Big Pharma Get Greedier

In several posts on my Family Dysfunction and Mental Health Blog (8/7/12, 6/19/12, 3/6/12, 2/21/12,  1/31/12, 10/19/11, 8/31/11), I describe in detail the propaganda and truth-twisting techniques used by the “expert” doctors who shill for Big Pharma (referred to by Pharma as key opinion leaders). They use these techniques in order to sell high-priced, brand-name drugs when cheaper drugs would be just as effective, and, in many cases, psychotherapy would be even more effective. 

In a sense, many of the shills (though certainly not all - some really don’t realize how much they themselves have been influenced) are willing to sell out the well-being of psychiatric patients for money. So the fact that their greed is now being used against Big Pharma in Australia, and most likely everywhere else as well, should not come as much of a surprise.  When it’s done to Pharma instead of for them, the drug companies then squeal like little piggies.

Irony, thy name is Pharma.

Thanks to Ken Harvey, a colleague in Healthy Skepticism, for a heads up on the following story:

Megan Reynolds (http://www.6minutes.com.au/news/latest-news/transparency-will-expose-demanding-doctors) a journalist for the Australian website 6minutes, (a daily pdf newsletter sent to Australian GPs and other healthcare professionals) reported the following on October 2, 2012:

“Demanding doctors with ‘unreasonable’ expectations are driving up the costs of medical educational events, a Pharma industry insider says.

In a submission to the ACCC (Australian Competition and Consumer Commission) the next update to the Medicines Australia's Code of Conduct, an anonymous 'player in the pharmaceutical industry  ‘supports full disclosure of sponsorship payments as he says under the current system of self-regulation, ‘Key Opinion Leader’ doctors are coercing Pharma companies into contravening the Code.

The 'insider' says some doctors demand $1-2k or more for a brief talk based on company-provided slides, in addition to business class airfares of up to $15,000.

Key Opinion Leaders also enjoy holidays as extensions of their conferences, and sometimes never turn up to meetings they are sponsored to attend, as they are 'probably off motoring around Europe somewhere!' he claims.

But companies are reluctant to complain about such demands for fear of alienating doctors of influence, who they claim often pit companies against each other in bidding wars for their services.

‘The Code needs to be stronger to help companies deal with these situations and know that any company that does not do the same thing will be exposed. Until that happens everyone is afraid to be the odd ones out,’ he writes.

He urges the AMA to set industry honorarium fee rates to stop bidding wars, and limiting doctors to just one sponsored event per company. He adds that most doctors as well as the public would be shocked by the amount of ‘paid comment’ to be revealed by transparency.”

Drug companies demanding transparency.  Now there’s a switch!