Public health VERSUS individual health

“Public health and individual health”  pointed out that “public health” deals in statistics and averages, and some public-health policies and practices can bring actual harm to some individuals unless physicians recognize the danger and treat each patient as the unique individuals that they are.

It seems that things are even considerably worse than I knew.

“How medical care is being corrupted”  reveals that some insurance companies have taken it on themselves to reward doctors for choosing particular drugs and treatments and penalizing them for not doing so. The article is no outsiders’ radical rant: it is by two physicians at Harvard Medical School and is published in the New York Times.

The insurance companies have financial considerations as their prime motive, and their criteria are inevitably statistical and “on the average”. To drive doctors into practicing by the insurance company guidelines means driving doctors not to treat their patients as unique individuals.

Half a century ago already, health-insurance considerations brought into being the damaging belief that “high” blood pressure represents a risk of cardiovascular disease or adverse events, because blood pressure correlates with such events. But it correlates only because both blood pressure and risk of cardiovascular problems both increase with age, naturally and inevitably. No correlations ever prove causation, furthermore. For half a century, medical practice has continued the absurd practice of defining “hypertension” independently of age, thereby classifying as “illness” levels of blood pressure that are perfectly normal at a given age. Something like 75% of American seniors are being exposed chronically, lifelong, to the continuing negative “side” effects of blood-pressure-lowering drugs for no good reason and with no expectable benefit.

The present direct incentives to doctors to harm their patients seems a natural, normal, progression of allowing health-care policies to be determined by the financial marketplace.

You get what you pay for.

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Damning psychiatric drugs with very faint praise

The effectiveness of psychiatric drugs has been questioned in innumerable books and articles, see for example What’s Wrong with Present-Day Medicine.

It would actually be surprising if psychiatric drugs did work reliably and with high efficacy, since psychiatric diagnosis is itself an art, certainly not a science. Saving Normal by Allen Frances (William Morrow [HarperCollins], 2013) and The Book of Woe by Gary Greenberg (Blue Rider Press [Penguin], 2013)document in exhaustive detail the lack of sound basis for the classification of mental illnesses used in the Diagnostic and Statistical Manual of Mental Disorders (DSM), specifically in its latest version, the DSM-5.

The insurmountable problem is that no distinct cause has been found for any of the peculiar or unusual behaviors and symptoms that are described as mental illness, insanity, craziness, psychosis, or the purportedly more specific labels manic-depression (bipolar), schizophrenia, etc.

Applying the label “mental illness” presupposes an understanding of what is not mental illness. However, human behavior and mentation vary enormously, and there are distinct cultural influences. Some things are regarded as crazy in some societies but not in others, and in a given society what is regarded as crazy may change over time; for example, early DSMs labeled homosexuality a mental illness but recent ones do not.

In absence of identified causes, all mental illnesses are defined on the basis of collections of symptoms that are matters of degree and not specific to any one label. The criteria for the “Inattention” part of attention-deficit disorder (ADHD) (DSM-5, p. 59 ff.) describe behavior quite typical of teenagers, for instance. DSMs are replete with loose criteria that call for satisfying only several of some set of listed symptoms, for more than some specified period of time, to degrees that are judged excessive. Diagnoses are therefore inescapably subjective and thereby arbitrary. A given individual is often given different diagnoses by different psychiatrists.

Treatment can hardly be more specific than diagnosis, and the labeling of psychiatric drugs is no sounder than are the diagnostic labels. It is criminally misleading to describe these medications as anti-anxiety pills, anti-depressants, anti-psychotics, atypical anti-psychotics, mood stabilizers, selective serotonin re-uptake inhibitors (SSRIs), etc., because they do not have the specific influences implied by those labels. Anti-depressants cause suicide in some people; anti-anxiety drugs in one culture are used as anti-depressants elsewhere; SSRIs are not selective in their effects even though they are designed to target a particular neurotransmitter, and so on.

All psychiatric drugs are mind-altering. They are distinguished from “street” drugs like Ecstasy or LSD only in their legality, not in being better understood or more specific in their action.

This not to deny that psychiatric drugs can be useful at times. But so have been insulin-shock and electric-shock treatment and surgical lobotomy. The point is just that these are all purely empirical treatments. Employing them successfully requires a background of experience and good diagnostic intuition; applying them routinely on the basis of formulaic diagnosis à la DSM can be highly damaging. That is perhaps the main theme of Saving Normal, which deserves to be given considerable respect since the author, Allen Frances, is a distinguished psychiatrist who was the lead organizer of DSM-IV (Arabic numeration supersedes Roman numbers with the fifth edition).

Frances’s book attempts a tightrope path, on the one hand acknowledging the lack of scientific basis for labeling and on the other hand not wishing to undercut the authority of the psychiatric profession. One consequence of attempting this impossibility is that he defends the use of psychiatric drugs by asserting that drugs used in general medical practice often have no better record of success than those applied in mental illness. The latter contention cites “Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses” by Stefan Leucht et al., British Journal of Psychiatry, 200 (2012) 97-106.

But that review shows only that many drugs don’t do what they’re claimed to do. It isn’t much incentive to taking an anti-depressive, for example, if you’re told, “Of course it doesn’t work, but then your anti-cholesterol drug doesn’t prevent heart disease either”. The data cited by Leucht et al. report, for example, that blood-pressure-lowering drugs overall reduce mortality by 4% although “significant reduction of mortality has not been shown for all of them”. Aspirin reduced stroke mortality by 1%, but heparin did not. Statins reduced 5-year mortality by 1.2%. Digitalis reduced hospital admission by 8% but did not reduce mortality.
But those numbers don’t even take into account possibly unpleasant “side” effects: for example, some 10% of people taking statins experience muscle weakness within a few years; aspirin causes internal bleeding in some people.
What Leucht et al. have documented is that medications used to prevent illness, by contrast to medications used to treat actual illness, have such a poor record of success as to make their use very doubtfully recommendable.

The claim that psychiatric drugs are no less effective compares apples and oranges: the data given for the psychiatric drugs is for treatment, not for prevention. In general medicine, of course there are conditions for which there is simply no really good treatment, namely, conditions brought on by aging — cardiovascular disease, cancer, organ failures — and it is hardly worth pointing out that drugs attempting to treat those don’t do a very good job; but that is no reason to use psychiatric drugs that are no better.

The authors’ Declaration of Interest is worth noting:
“In the past 3 years S.L. has received fees for consulting and/ or lectures from the following companies: Bristol-Myers Squibb, Actelion, Sanofi-Aventis, Eli Lilly, Essex Pharma, AstraZeneca, MedAvante, Alkermes, Janssen/Johnson & Johnson, Lundbeck Institute and Pfizer, and grant support from Eli Lilly. W.K. has received fees for consulting and/or lectures from Janssen-Cilag, Sanofi-Aventis, Johnson & Johnson, Pfizer, Bristol-Myers Squibb, AstraZeneca, Lundbeck, Novartis and Eli Lilly. All authors work in psychiatry.”

The authors have a clear bias toward the use of drugs to treat mental illness, and that alone already brands their article as biased. This is hardly a reliable assessment of the efficacy of psychiatric drugs or a recommendation for their use.