Friday, May 09, 2008

Drug money and DSM

Tara Parker-Pope's blog about DSM, the psychiatric bible, and ties to Big Pharma, hits on a point of particular interest to anyone who's had experience of an eating disorder.

The truth is that there are few if any medications that have been shown to help treat an eating disorder, especially in the acute phase of the illness (and isn't that when you want them to help?). Psychotropic meds do not seem to help when someone is severely malnourished through anorexia or bulimia. (There are a few atypical anti-psychotics being looked at for treatment, but the jury is still way out on those.)

Despite the accumulating evidence that meds are not the first-line treatment for eating disorders, pretty much every doc you'd see for an e.d. will prescribe an SSRI, or several.

In my daughter's case, she had bad reactions to nearly everything she was put on, which meant more suffering was piled on top of what she was already going through. Oh, and we had to pay big bucks for it, too.

Of course, my daughter was never officially diagnosed with anorexia nervosa. I'm not sure why; she certainly met all the diagnostic criteria listed in DSM-IV. Parker-Pope's piece suggests that such criteria tend to be overly inclusive and vague. I don't think that's true for eating disorders--on the contrary. My daughter's psychiatrist-in-training diagnosed depression with secondary EDNOS--eating disorder not specified. I don't know if it made a difference in her treatment, but it did saddle her with a diagnosis that was completely inaccurate. I don't know how that might affect her down the road.

Any doc treating eating disorders should know that depression is a typical presentation when someone is acutely ill with AN, and it usually goes away with weight restoration.

I know from friends who are psychiatrists and M.D.s that it's increasingly tough to steer clear of drug money and influence. Even if you refuse the free dinners and concert tickets and cutesy pens and other freebies, as Parker-Pope points out, much of the research in the U.S. is being paid for by Big Pharma. For those of you think that's all right because, after all, everyone wants the Best Thing, think back a month or two to this report about cholesterol-lowering drugs. Drug companies will in fact behave unethically if the bottom line is at stake.

Personally, I don't want Big Pharma writing the rulebook for psychiatric disorders. I'm just not sure how to stop them.


kimbo said...

I agree with your point about ED treatment programs just handing out antidepressants like candy.

My daughter (who also never had an official diagnosis of Anorexia, but was dumped into the EDNOS neverland) suffered from depression before the onset of the ED. She had horrible reactions to every medication we tried. It was not until we got her into the ED program at the Mayo Clinic that we found something that worked for her, thanks to a genetic test that Mayo has developed to help determine which SSRI's will work best for each individual. It is a simple blood test and, I understand it is not expensive. You don't have to be a patient at Mayo in order to have the test done. Here is a link to this lifesaving test:

Once the test results came in, they put her on an SSRI that we had not tried and her depression began to lift. Treating the ED without treating the underlying depression that seems to occur in over 90% of AN cases is like putting out a forest fire with a garden hose. While medication is not the only solution, if the proper medication can be found, it jump starts the treatment.

Here's hoping that others can benefit from one of the few medical advances that helped us in our daughter's recovery.

Harriet said...

I think it's quite different to have depression or another condition that predates the eating disorder. In that case recovery from the e.d. won't fix the underlying problem.

Depression is almost always a physiological byproduct of starvation, though, so for people who did not have a preexisting depression or anxiety condition, recovery can and often does cure the depression. I'm glad you found something that helped your daughter.

I'm curious about that test and will look into it. I have anxiety disorder and have tried many kinds of SSRIs, none of which have helped. I wonder if it would be good for someone like me to take.

Fay said...

I have a question, and please forgive my ignorance. Has medical marijuana ever been tried, as a treatment / appetite stimulant for EDs? I'd think it might do a lot of good, but boy, does Big Pharma NOT like marijuana one bit.

Long-time reader, big-time lurker. Thanks. :)

Fiona Marcella said...

"pretty much every doc you'd see for an e.d. will prescribe an SSRI, or several" - not with a child in the UK they won't. Quite how much this is because UK doctors are wonderful humanistic people who've read all the research and are up to date on effective treatment and how much it's because children in the UK don't pay for prescriptions I'll leave you to judge.

In our family's case, my husband was desperate for our daughter to be given meds, and the docs refused. I personally agreed with the docs - but that hardly improved the parental unity which is such a feature of what we were supposed to be doing! In the end, meds (mood stabilisers, an a-typical anti psychotic, lorazepam and an SSRI ) PROPERLY PRESCRIBED by a specialist psychiatrist and supervised in an inpatient unit helped during re-feeding - and possibly not only because they met the approval of the father and the presciber was one of those rare beasts, someone who met the approval of both parents.

As for the drug companies sponsoring research - it's difficult isn't it? Without their money research might not be done at all, and where would evidence based medicine be then? I do wonder if PART of the problem with the Mandometer People and their "reluctance" to submit evidence and play with the other children is because they are anti-pharma no one will pay them for their studies.

Anonymous said...

Found my way here through Rachel at The F Word.

I'm curious about the evidence/reasoning behind this statement: "Any doc treating eating disorders should know that depression is a typical presentation when someone is acutely ill with AN, and it usually goes away with weight restoration."

In my own experience and that of the many other ED sufferers I've met over the years, I'd say most of us do have underlying problems with depression or anxiety (whether clinical-level or not) that contributed to their disorders. Eating disorders are mental illnesses, after all -- there's a reason (or, more accurately, many reasons) that someone chooses to engage in self-destructive behaviors. Disordered thoughts and behaviors precede weight loss, not the other way around, and weight restoration doesn't cure whatever it was that triggered the ED in the first place.

I know this post is about SSRIs, so I'm sorry for hijacking, but I was curious about this point. Thank you for your attention and your other engaging posts here!

Anonymous said...

Malnutrition, even in the absence of an eating disorder, is associated with depression, social isolation and obsessionality. The Minnesota Semi-Starvation Study is interesting on this topic. The
Biology of Human Starvation by Ancel Keyes is worth looking at.

There does seem to be some association between pre-exisiting anxiety and AN in a many cases (about 2/3) but it is not universal. Starvation (or other eating disordered behaviors) can impact mood and obscure whether or not there are co-morbid illnesses present so addressing ED symptoms is an important first step. Of course if there are other problems, they need to be addressed. That holds for co-morbid illness or issues in a person's life that hold them back from complete health.

I wouldn't characterize my daughter's AN as "choosing to engage in self destructive behavior" (nor would she.) A substantial subset of people with AN were not trying to lose weight at onset. And many, many, many people in our culture diet to lose weight and do not develop eating disorder so I'm not sure if the "intentional" label fits even if people were

Eat Weight Disord. 2007 Jun;12(2):97-100. Links
Unintentional onset of anorexia nervosa.

Brandenburg BM, Andersen AE.
Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
OBJECTIVE: The purpose of this article is to report a series of patients with an onset of anorexia nervosa precipitated by unintended weight loss rather than the more typical onset following intentional dieting, or the occasional iatrogenic beginning. METHOD: Retrospectively, case notes of 66 consecutive outpatient evaluations at an eating disorder diagnostic clinic between 2002 and 2006 were reviewed. RESULTS: Five cases, 7.6%, of inadvertent onset anorexia nervosa were identified. Causes of the inadvertent weight loss were varied: the mourning of a death, a parasitic infection, medication side effects and surgery. None had intended to lose weight. CONCLUSIONS: We postulate that inadvertent weight loss may be as powerful a trigger as intentional dieting to initiating anorexia nervosa in predisposed individuals; self-induced weight loss may not be a necessary precursor to anorexia nervosa.

Harriet said...

bt, anonymous is right. there may or may not be underlying depression/anxiety. but it is absolutely true (as evidenced by Keys' starvation study) that starvation causes symptoms of depression and anxiety. the only way to tell what's underlying and what's not is to cure the starvation and get the patient up to a truly healthy weight and keep them there for at least 6 months to a year. then you can begin to tease apart what's caused by malnutrition and what's underlying.

fay, i'm not aware of anyone looking as marijuana as a treatment, but i doubt it would be useful. anorexia is not a loss of appetite; it's a kind of phobia about eating and gaining weight. anorexics are hungry (even if they don't consciously feel hunger); they just cannot eat. i would hate to add the psychotropic effects of marijuana onto a starved brain.

Anonymous said...

This is a nice full text article on serotonin, state and trait in AN, BN and BED. (Certainly, starvation is bad for the mind as well as the body, no matter what a person's pre-existing mood situation.)

Anonymous said...

Thanks for the responses. I know about the vicious cycle and what starvation does to the brain; I should have acknowledged that in my comment.

What I take issue with is the idea that there is "usually" no underlying problem. The study the anonymous poster cites says that in 7.6% of the cases studied, anorexia was due to a parasite or some other external factor. That's a pretty small number. I would not presume to speak for any individual other than myself, but it doesn't make sense that most people with anorexia are starving by accident. The decision-making process may be warped, but a person can't be unaware that she is skipping meals or losing weight. (To get a little too personal, my mother thought that my anorexia came out of nowhere, too. It didn't. I just didn't let her in on what was really going on.)

None of this negates the importance of weight restoration, of course. It just seemed like this side of the story was missing.

Harriet said...

Hi BT,

Many girls (and boys) set out to diet or lose weight. In fact that's the norm in our thin-driven culture, especially among girls. That is not a sign of an underlying problem. If it were we'd have to pathologize the entire population at this point.

It is very possible to fall into anorexia by accident. If you're genetically susceptible (and we know genetics plays a huge role) then losing weight can trigger a process that very quickly goes from voluntary (I'm going on a diet) to involuntary (I cannot eat). Some people get triggered by inadvertent weight loss--they start running, for instance, and drop weight, or they get sick and lose some weight. For some that seems to begin a process.

We don't really understand what causes anorexia. The causes are complex. What I take issue with is the notion that people who become anorexic are always depressed/anxious/struggling in some way psychologically. Sometimes no doubt this is true. But sometimes it isn't.

We also know for sure that starvation causes symptoms of deep depression and anxiety. It's very hard to know which came first. Starvation can be more subtle--say, someone who's been restricting for a while but not to a very extreme level. The act of restricting, as I've written in another recent comment, seems to set up a feedback loop in the brain that also triggers some of the behaviors we associate with anorexia. So it's very complex.

I'm sure my daughter was restricting for a while before I was aware of it. She didn't just suddenly become anorexic in the space of three weeks. But I also do not believe she was working out some deep psychological ambivalence about growing up or about sexuality, as some therapists would have us believe. I think like most teens she got sick by accident. She started out wanting to be thin, like so many young girls in this culture. She was "careful" about what she ate (meaning she stopped eating dessert, then stopped eating fried foods, then went through a progression). This probably went on for a year or so. It was certainly the message she was getting in health class, that this was a good thing to do. At some point she very subtly crossed some boundary invisible to us and went from being careful to being consumed by what she did and didn't eat. That's what anorexia truly kicked in, I think. But she certainly wasn't depressed or intentional about becoming anorexic.

Anonymous said...

Many people in our culture intentionally restrict calories by dieting. Many people in our culture try to lose weight. Exposure to constant weight loss advice is universal. People who begin to lose weight and nearly always congratulated, even if they were at a healthy weight to begin with. So it's no surprise that many people with anorexia nervosa began their weight loss by intentionally restricting calories--LOTS of people do.

One common misunderstanding is that the Maudsley approach focuses solely on weight restoration. It doesn't. In the second stage of treatment kids gradually resume eating independently. The final part of treatment focuses on getting healthy adolescent development. That might include working through any number of issues. And, of course, any co-morbid illnesses are addressed as well.

As to your feeling that one side of the story was missing, let's remember the post was about SSRIs. Proper nutrition is important to mood. The extent to which that helps will likely vary by individual, but I think it will almost certainly put a person in a better position to address any remaining issues.

Unknown said...

Thanks for nice post on Drug money and DSM.