Excessive or inadequate? Confusion about medication is common

By Gil Ross — Aug 03, 2015
What s a person to do, when on the one hand it s clear that many Americans are being under-treated for a dangerous condition, while on the other, too many of us are getting way too much care. The lesson: especially when it comes to our health, too much is as bad as too little.

depressed moonToday I came across two health-related articles that present starkly different approaches to dealing with illness and uncertainty about diagnoses and treatments that I was unable to avoid considering them in tandem.

The first is part of The Conversation, a blog site within Science 2.0 written by Dr. Ray Moynihan, senior research fellow at Bond University in Queensland, Australia. His article is entitled We re Overdosing on Medicine: Time to Embrace Uncertainty Instead. As the title indicates, Dr. Moynihan s main point is that we in the developed world anyway are increasingly intolerant of the normal vicissitudes of life, especially the aging process. And he emphasizes that aided and abetted by doctors and pharmaceutical companies for reasons of their own, diseases of aging which were normal aspects of getting older are now given disease-y sounding names, accompanied by indicated drug treatments.

A related matter that Dr. Moynihan calls to our attention is the problem of excessive medical testing, which leads to overdiagnosis: identifying abnormalities found most often on screening imaging tests that might (or might not) be cancerous or otherwise dangerous but are quite often of no clinical significance and would be better off having never been detected. This leads directly to the conception of Choosing Wisely, a program adopted by several medical specialty societies to advise the public about tests, procedures, and drugs that they should avoid because they yield more misinformation than useful data. Among these are routine screening mammograms for younger women, PSA testing routinely (especially to be avoided in the over-70 age group), and even such treasured mementos as the routine annual physical, EKG, Chest Xray, and Pap test.

As the author puts it:

Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation. But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, aging and death. A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing.

The reverse side of this debate is covered very eloquently by Dr. Richard A. Friedman, professor of clinical psychiatry at Weill Cornell Medical College, in his op-ed in the New York Times, Teenagers, Medication and Suicide. His statistics-laden but poignant essay reveals the tragic inadequacy of the delivery of healthcare to our young people with depression (and/or drug and alcohol abuse, which often go hand in hand with other mental illnesses).

He notes how common suicide has become among our 18-25 year olds. And about one out of 11 in that age group experienced a bout of major depression over the previous year. Now the third leading cause of death in that age group and rising, 90 percent of suicides have a diagnosed mental health condition yet only one-fourth of them were being treated by a psychiatrist.

Friedman points a finger at the excessively precautionary FDA, which slapped a black-box warning on antidepressants for teens in 2004, and was later extended to young adults. This hyper-precaution was based on flawed and ambiguous data which was exaggerated and exploited by then-attorney general Eliot Spitzer, and which we criticized in our Dispatch at that time.

Dr. Friedman writes, the FDA s warning was alarming to the public and most likely discouraged many patients from taking antidepressants. Physicians, too, were anxious about the admittedly small possible risks posed by antidepressants and were probably more reluctant to prescribe them.

What the public and some in the medical community did not understand then and perhaps still don t know is that the risk of antidepressant treatment is minuscule: In the F.D.A. meta-analysis of some 372 clinical trials involving nearly 100,000 subjects, the rate of suicidal thinking and behavior was 4 percent in people taking antidepressants, compared with 2 percent in people taking a placebo.

This very small risk of suicidal behavior posed by antidepressant treatment has always been dwarfed by the deadly risk of untreated depression: 2 to 15 percent of depressed people actually commit suicide.

A few years after the warning, a student who had been on antidepressants, but had stopped them some months earlier, shot thirty-two of his classmates (and himself) to death at Virginia Tech in 2007. My op-ed in the Wall Street Journal pointed out that the shooter s unmedicated state very likely had a lot to do with his psychotic decompensation, and again called for a reassessment of that excessive warning.

There s no black-or-white answer to these complex medical questions. One thing we ve learned (or should have learned) over the past few years is that medical guidelines are rarely black and white, and are (or should be) amenable to revision when reliable new data comes in. Yes, Americans are too demanding of doctors regarding preventive testing and eager to take pills or even have surgery to protect themselves from...who knows what? And yes, Americans are not getting enough cholesterol-lowering medication and not getting enough effective blood pressure treatments and are not being diagnosed and treated for mental ailments as much as optimal. A talented musician said it best: It s been a long time coming, but you know, a change is gonna come. (RIP Sam Cooke).