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Wednesday 26 June 2013

Readings: Anxiety Disorders in The Anatomy of Melancholy

A Condensed Edition
I’ve been reading a bit from The Anatomy of Melancholy by Robert Burton (1577-1640), a contemporary of Shakespeare. He was a scholar at Oxford University and spent most of his life writing and rewriting the book, which is something of a dog’s breakfast of observations, anecdotes, humourous asides, and advice for those afflicted by melancholy - what today we would call depression.

Although much of the content is only tangentially related to the subject of depression, Burton reveals the motivation behind the work in his preface:

"I write of melancholy, by being busy to avoid melancholy. There is no greater cause of melancholy than idleness; no better cure than business."

Essentially it was a self-help book: by occupying himself with its creation, Burton strove to extricate himself from the depression he himself experienced.

One of his passages is striking for its descriptions of anxiety-related conditions, paralleling modern observations about the same conditions.  Here’s a passage, broken up by my interruptions:

Montanus [2nd century Christian convert who believed himself a prophet] speaks of one that durst not walk alone from home, for fear he should swoon or die. 

This sounds intriguingly like what today we would call agoraphobia. Directly translated as "fear of the agora (marketplace), in fact it is a fear of physical symptoms overtaking a person while they are away from home. It is the symptoms that are feared, not the marketplace.

A second fears every man he meets will rob him, quarrel with him, or kill him.

Paranoia perhaps – or hypervigilant stress?

A third dares not venture to walk alone, for fear he should meet the devil, a thief, be sick; fears all old women as witches, and every black dog or cat he sees suspecteth to be a devil, every person comes near him is malificiated [possessed, I think, though I may be mistaken], every creature, all intend to hurt him, seek his ruin; 

Supernatural fears seem to be somewhat less common these days, but may find their counterpart in fears of alien abduction, etc. And it is not uncommon to hear a fearful person describe strangers as malevolent beings ready to judge or harm them.

another dares not go over a bridge, come near a pool, rock, steep hill, lie in a chamber where cross beams are, for fear he be tempted to hang, drown, or precipitate [throw] himself. 

Now this is interesting! Burton, referencing Montanus, describes the thinking underlying most fear of heights, which is actually a fear of loss of impulse control. Notice that he is not saying the person wants to commit suicide: They fear throwing themselves off the height on impulse. They don't want to do it. But they worry they might anyway, on impulse.  This is exactly what people with fear of heights report - a sense of being drawn or tempted over the edge. In effect, they aren't afraid of heights, nor of falling (no one fears that the bridge might be unsound and about to collapse). They are afraid of jumping.

If he be in a silent auditory, as at a sermon, he is afraid he shall speak aloud at unawares, something indecent, unfit to be said. 

This is a fairly standard obsessive thought seen in many with OCD. I'll start to yell or say inappropriate things in a play, or at a concert, or in church. They don't generally do it, but there is a fear that they might.

If he be locked in a close room, he is afraid of being stifled [suffocated; unable to breathe properly] for want of air, 

This is the core fear underlying most cases of claustrophobia. It isn't the enclosure, usually, it is the sense of being unable to breathe - despite conscious knowledge that there is plenty of air and that suffocation is not a real danger.

and still carries biscuit, aquavitae, or some strong waters about him, for fear of deliquiums [essentially, fainting], or being sick; 

This describes the habit of many people who suffer panic attacks of carrying objects as safety aids. Common ones these days include cell phone, anti-anxiety medication, water bottle, and so on. many who suffer panic attacks of compulsively carrying safety aids (water, cell phone, antianxiety medication) in the event of an attack. Aqua vitae and strong waters, in Burton's case, essentially means booze. And indeed some folks with anxiety problems do this too.

or if he be in a throng, middle of a church, multitude, where he may not well get out, though he sit at ease, he is so misaffected. 

This describes a person who manages to suppress the desire to flee but only with great distress.

He will freely promise, undertake any business beforehand, but when it comes to be performed, he dare not adventure, but fears an infinite number of dangers, disasters, etc.

Every therapist has seen this: the person who fully understands the idea of facing one’s fears and selects a task that seems perfectly reasonable to them in the office, but never winds up being carried out.

*   *   *

Burton may not have managed to cure his own mood disorder, but he certainly had an understanding of many aspects of anxiety and its manifestations.

Thursday 20 June 2013

Thank God That's Over: Exodus International Closes Its Doors

This week the largest US sexual conversion therapy organization, Exodus International, apologized for its work and announced that it will be closing.

For over 40 years it has been the figurehead in the “ex-gay movement,” telling lesbians and gay men that with a combination of prayer, support, and therapy it is possible to change their sexual orientation and become heterosexual. Exodus not only provided direct services, it was the umbrella organization for like-minded groups throughout North America.

Perhaps you’ve seen their ads. Over the years, leaders of Exodus and related organizations were portrayed in large print ads in major American newspapers, putting faces to the claim that orientation change was real.

Then, with a regularity that became either tragic or comical, depending on one’s perspective, those portrayed in the ads would come out, admitting that they hadn’t changed at all and renouncing the organizations that they had helped to deceive thousands of well-meaning gay and straight people.

They often seemed surprised by the relatively chilly reception they received in the gay community. Having been prime agents of antigay sentiment for years, here they were, ready to join the club. What’s the problem, guys, what did I miss?

The humour fades when one considers the human lives affected by the ex-gay organizations. People would spend years attempting to become heterosexual,  earnestly lied to by leaders who would proclaim their own bogus changes. “It’s not the program, it’s you: If you tried hard enough, it’ll work!” If they were good enough Christians, they could be changed – so apparently they weren’t. Confusion, guilt, a sense of failure, and depression would often ensue.

At Changeways Clinic we have seen many men and women who have attended ex-gay organizations and have then spent years pulling their lives back together. It has been frustrating to be putting together what agencies elsewhere were merrily pulling apart, but the groups kept going and going.

Now Alan Chambers, the president of Exodus International, has issued a public apology for the damage caused by the organization, and has announced that it will be closing its doors.

Here’s an excellent interview with Chambers in The Atlantic.

Of course, the damage done won't evaporate with the close of the organization. And surely no one is naive enough to expect Exodus or the other groups to take responsibility for correcting that damage -  financially, morally, ethically, or in any other way.

For them it will be enough to issue an apology, look sorrowful, then move on with something new. As even the Atlantic article's title says: "Let's Do Something Different."

I have an even better idea. Just stop. You've done enough.

Wednesday 12 June 2013

Intermission: Time for a Break

So it's been over two years of psychology - more than enough for anyone. This week let's take a break and do something else.

One of the joys of travel is discovering signs, menu items, and misphrasings that provide a welcome jolt. And one of the cardinal rules of travel is that you never point out the problem to anyone who might correct it. Like a pristine campground, your job is to leave it as is for others to enjoy.

Of course, you don't always have to leave home for these. Here are just a few ...
I've always loved this Australian realty firm. I'll take a dozen.

A good Cambodian Buddhist recommendation.

Vancouver. Just the other day I was planning a party
to celebrate the blandness of daily life. Ultimately I went with another tile,
one that exclaimed the tedium of meaningless existence.

So much easier than leashing the tail and dragging him everywhere.

A reminder of the importance of branding. No waiting!

A great anticonsumerist reminder. It turned out
 this was exactly right: I didn't need anything.
A proconsumerist point of view, for balance.

Also available: Chocolate Bypass, Butterscotch Crutch, and Strawberry Eyepatch.

In an airport, is this a hopeful or pessimistic sign to see?
Is it just me, or is calling your restaurant S.O.L. self-defeating?
Okay, time to get back to psychology.

Tuesday 4 June 2013

Medications: Is Depression Still Profitable?

This spring, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, has been released amongst a torrent of criticism. Much has been made of various changes to the diagnostic criteria for individual disorders.

But the louder cries have argued that the revision is driven as much – or more – by the wishes of large pharmaceutical firms than by science or public need. With each succeeding revision of the manual, a larger proportion of the population has been diagnosible as having a mental disorder deserving treatment – often a proprietary drug treatment. The range of human experience deemed “normal” has correspondingly shrunk.

Much of the fury in this most recent debate has centred on the diagnosis of depression – particularly Major Depressive Disorder. More on the issue can be found here. This is a familiar battleground, as the field has undergone years of controversy about the effectiveness of the antidepressant medications (see here, here, and here). In a few short decades, this drug class has climbed to the number two position in overall sales, second only to the cholesterol-lowering statin drugs.

These drugs have been immensely profitable for the pharmaceutical industry, and many have questioned whether the profit motive has driven their marketing more than the science underpinning their use. But is the party now winding down?

Medication Development and Patents

It costs a huge amount of money to develop a medication for market. It must go through a series of trials demonstrating its safety and its effectiveness (generally relative to placebo; it need not be shown to be more effective than preparations already on the market). Some drugs get partway through this process and prove to be duds, with the result that the development costs are lost. It’s a risky business.

For a private corporation to bother, there has to be some hope of recovering the development costs (for the successful drug, and for the drugs that never made it to the pharmacy) and making an eventual profit. So the drugs are patented, meaning that the developer has the sole right to produce and market that preparation, and they can pretty well set their own price for it. These patents expire, however, and then other companies can manufacture the same medication, driving the price down markedly through competition.

Once a drug is off patent (generally after 20 years in North America), the profitability is sharply reduced. The motivation to promote the product to physicians and public largely evaporates. (This is why drugs advertised for years as miracle cures suddenly vanish from the airwaves.) A company that has two medications in the same class (two antidepressants, for example), one on patent and the other off, will shift most of its promotional budget to the former.

Many pharmaceutical companies have only a few real “blockbuster” drugs, so the looming expiry of a patent on one of their main moneymakers is ominous. For example, a 2012 article in U.S. Pharmacist estimated that the sales of the antidepressant Lexapro amounted to 59% of the overall sales for Forest Laboratories. The major firms survive by having a pipeline of new drugs (which will have new patents) on the way.

You can see the problem. What if a new drug class is developed, the various companies all go out and make minor variations on these, they promote the medications (and public awareness of the disorders they treat), and then the pipeline dries up, with no new preparations arriving on the market? The high profits associated with the patented medications will vanish with the patent expirations and not be replaced.

What about antidepressants?

This is the situation in which the industry finds itself in the case of antidepressants. In the 1950s there were no antidepressant medications. Then the tricyclic antidepressants came out and rapidly gained a foothold in the market. In the 1980s the selective serotonin reuptake inhibitors (SSRIs: Prozac, Luvox, Paxil, Zoloft, Celexa) began to appear, then a variety of other variations (such as the serotonin and norepinephine reuptake inhibitors (SNRIs: Effexor, Pristiq) and others (Wellbutrin, Remeron). Just when one drug would go off patent, another would appear.

But the flurry of antidepressant development has passed, and most of the patents have now expired. Take a look at the most widely used antidepressants (most dates are USA expiries):

Prozac (fluoxetine) - patent expired 2001
Paxil (paroxetine) – patent expired 2003
Luvox (fluvoxamine) – patent expired 2000
Zoloft (sertraline) - patent expired 2006
Celexa (also Cipramil; citalopram) – patent expired 2003
Effexor (venlafaxine) – patent expired 2007
Remeron (mirtazapine) - patent expired 2010
Lexapro (also known as Cipralex; escitalopram) - patent expired 2012
Cymbalta (duloxetine) - patent expires June 2013
Wellbutrin (also Zyban; bupropion) – patent expires August 2013
Pristiq (desvenlafaxine, a modification of Effexor) - patent expires 2022

Antidepressants continue to be prescribed at rates that some find alarming and well beyond the range of conditions and severities for which there is adequate research support. But with the reduction in cost associated with patent expiry, the overall dollar value of sales has declined from a peak of $15billion in worldwide sales in 2003 – and shows signs of declining further in the years to come. Thomson Reuters Pharma predicts total sales under $6billion by 2016. This is all coming from price reductions associated with patent expiry, not from a decline in prescriptions for these medications.

For example, Cymbalta, the patent for which expires this month, is presently the #2 selling antidepressant in the United States, with overall worldwide sales of $2.7billion. This revenue will not all vanish, obviously, as the medication will go on being prescribed, but the price will most likely drop by 70% or more, eliminating most of the profits for Eli Lilly and most motivation to promote the drug to the public.

And what’s in the pipeline? Not much, apparently. AstraZenica’s TC-5214 crashed and burned in 2012, and development was halted on both agomelatine and aprepitant. Certainly there isn't anything that anyone is describing as a “game-changer” with markedly greater effectiveness than what we have now.

Will this be good for the depression treatment field? Hard to say. Your thoughts?

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