A reader of this blog named Laura Fisher left a comment about “doctors as bureaucrats” — meaning they care more what their employer thinks of them than what their patients do. A scary and plausible idea. I asked for details. She replied:
I live [and practice psychiatry] in a small [Utah] college town that is 80% Mormon. Almost all the docs in town are employed by an outfit called Intermountain Healthcare which owns most of the hospital beds in this and a few surrounding states. Once you get the doctors on the payroll, they really must take instruction from the employer–and they sure as hell do. The doctors who refuse to take instruction that is ethically or morally conflicted or repugnant are typically subjected to “peer review” as a means of punishment, either by hospital medical staffs or by state licensing boards. If you want  details on the abuses of “peer review”, you should find plenty of information on the website of the Association of American Physicians and Surgeons.
The typical patient I see has been jollied along for years [by IHC doctors], sometimes decades, without any of his physicians taking the time to review his/her medications effectively. There isn’t a billing code for actually taking the time required to deliver good care, so the patients do not get good care. Some of them get good surgeries. Some get bad surgeries. Often a patient has had a surgery or procedure that he or she did not need. Often the surgery creates new needs for expensive pharmaceuticals. Most often he or she is on a pharmaceutical which is causing psychiatric effects. Either no one has thought of this, including psychiatrists, or no one other than the patient has thought of this and the patient is afraid to discontinue medications for fear of alienating the doctors he needs to stay on good terms with and for fear of unanticipated withdrawal syndromes. The docs who are seeing these salt of the earth working-class patients are young physicians who are not familiar with the old-fashioned notion of the doctor-patient alliance as being somewhat sacred, private and full to the brim of ethical obligations on the part of the physician. These docs check out at quitting time. I have seen them fail to save a sick person at risk of death when one of their colleagues is responsible for putting the patient in that predicament. They refuse to answer questions from patients about whether or not a given treatment change would help that patient, apparently because that doctors employers’ treatment guidelines don’t include answering such questions or choosing different treatment and because that doctor’s professional society leaders are reading from the same page where treatment is conveniently canned such that even nurses can dole it out pretty successfully.
I have seen depressed patients whose depression completely resolved when he or she stopped taking the statin they were on. I have also been interested in the statin users apparently having a higher risk for infections and therefore cancers. Duayne Graveline wrote a very short book (Lipitor, Thief of Memory) on his personal experience with transient global amnesia. This short book is great introduction into the statin subject. The best book I have found on the statins is Fat and Cholesterol are Good For You by Uffe Ravnskov. There is an International Network of Cholesterol Skeptics and their website is marvelous. If you look at this material you are going to learn that it is a poor idea to interfere with cholesterol because we have to have it for brain function.
Don’t forget to read The Trouble With Medical Journals by Richard Smith and The Emperor’s New Drugs by Irving Kirsch.
Statins and memory loss. Thanks to JR Minkel.
I have not read The Emperor’s New Drugs (yet), but I’m familiar with Kirsch’s other published work. The trouble with Kirsch is that he doesn’t go nearly far enough. His hypothesis is that antidepressant drugs are essentially glorified placebos. That view is correct, as far as it goes, but Kirsch doesn’t realize (or, at least, doesn’t emphasize) the harmful effects of antidepressants, particularly when they are taken over the long term.
For a more-comprehensive look at antidepressants (and other psychiatric drugs), see, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker.
Alex, I am happy that Kirsch has taken the time to compare antidepressants with placebos and non-treated controls. I would say the main problem with his work is that the studies he examines do a poor job of matching clinical practice, where non-working antidepressants are stopped and a new one tried. A comparison of placebo and the usual clinical practice hasn’t been done. Such a trial is likely to show a larger effect of anti-depressants.
For those interested in the adverse effects of the SSRI drugs, see Joseph Glenmullen’s Prozac Backlash (especially focused on involuntary tics caused by these drugs and the importance of withholding such drugs from patients with Parkinsons’s) and Let Them Eat Prozac by David Healy (all about suicide and bizarre homicides in people who became suicidal or homicidal only on an SSRI drugs, and of course this comes to mind whenever a normal person shoots up a shopping mall or a classroom or an induction center. Healy is not exactly easy to read by has written extensively on the history of psychiatric drug development.
As to “long-term” use, the suicides and homicides happen quite early on.
I find Whitaker very helpful in sorting out what is actually involved in assigning drug efficacy or lack of such. Physician critics of non-discriminant anti-psychotic and anti-depressant use, such as Peter Breggin, M.D., emphasize that the anti-psychotic drugs offer no efficacy advantage over simple sedatives but as associated with a myriad of adverse effects not caused by sedatives.
Perhaps Dr. Roberts is familiar with the STAR-D trials.
I find it interesting that Ms. Fisher is specifically calling out Intermountain Healthcare–they are the poster child for health care reform.
The New York Times did a big article on them almost a year ago:
https://www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html?_r=1&pagewanted=all
Atul Gawande is also a big fan of theirs. He likes to hold them up as a counter example to wasteful medical practice. He mentions them in passing in this New Yorker article:
https://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all&
David
Gary Greenberg did a podcast with Russ Roberts a few weeks ago. He made the same point about Kirsch as Alex, but went further. (From the transcript):
“Basic point: efficacy of these pharmaceutical treatments of depression is that they are very unclear on depression, help some people but so do placebos; but they have this powerful effect that has nothing to do with depression that makes people like taking them. People [specifically, Kirsch] claim the studies showing the drugs don’t really work means that the drugs don’t do anything. The drugs do plenty, but there’s no financial interest in figuring out what it actually is. In fact, there may be an anti-interest. If it only makes you feel more powerful then it’s like Scotch; can’t get your Medicare to cover it, or your employer. Argument for making Prozac over the counter, or making it illegal and let there be a black market for them.”
He didn’t address your point, though, Seth.
https://www.econtalk.org/archives/2010/09/greenberg_on_de.html
(The section starting at 47:58).
Thanks for mentioning the STAR-D Trials, which I knew only a little about. They tried to resemble clinical practice and measured the effect of switching treatments if the first treatment (antidepressant) doesn’t work.
Here is an overview:
https://www.nimh.nih.gov/trials/practical/stard/allmedicationlevels.shtml
Here is a critique:
https://ebmh.bmj.com/content/11/4/97.full
(which fails to make clear what was learned, unfortunately)
Seth, here is a more-recent critique of STAR*D:
“The STAR*D Scandal: A New Paper Sums It All Up”
Does anybody know of a good book that deals with the sociological prejudices regarding diagnosis? Perhaps that unclear, so I will give examples.
A woman with whom I worked has a son who was diagnosed with ADHD. The boy did indeed have a hard time studying in the usual sense of the word. He just couldn’t sit down a read books. However, here’s the thing. The kid was a mechanical genius of sorts. He’s now 19 (and apparently having a brilliant career in the Navy as an airplane mechanic), however, even as a child, the neighbors would ask him to their house whenever they needed something put together.
You see where I am going with this. Different strokes for different folks. We have one model of how people are supposed to be nowadays and, if you don’t fit that model, well, your are labelled as “faulty”. How many of these people on psychiatric drugs are just people who have been prodded out of their proper niche or haven’t found it yet? How much of this is chemical and how much of it is sociological?
Kirsch’s view of the STAR*D trial is described by Louis Menand in The New Yorker:
Source: https://www.newyorker.com/arts/critics/atlarge/2010/03/01/100301crat_atlarge_menand?currentPage=2
Note: Menand has been criticized for his sobriety and lack of extreme opinions; this article is no exception. However, it does contain several cogent observations, and at least a hint of a coming “train wreck”:
Several aspects of Laura Fisher’s comments are factually incorrect in regards to Intermountain Healthcare.
First, Intermountain Healthcare does not own most of the hospital beds in Utah in surrounding states.
Intermountain owns 21 of Utah’s 59 hospitals and operates only about 40 percent the 6,258 hospital beds in the state.
Intermountain owns only one hospital outside of Utah, a small 25-bed hospital in Idaho. Intermountain does not have any facilities in other states besides Utah and Idaho (as noted, a minor presence in Idaho).
Lastly, only about 900 physicians in Utah are employed by Intermountain, out of nearly 5,000 licensed doctors in the state. The University of Utah Medical Center is actually the largest employer of doctors in Utah.
I think those 900 physicians employed by Intermountain would likely have an opinion different than Ms. Fisher.
Given the way she plays loose with the facts I have to wonder about her objectivity and motivations.