Medications can be beneficial and safe lives; however, some may not work as well as promised. In some cases, they may do more harm than good as illustrated by the following examples.
- There is weak or no evidence of effectiveness for the long term use of any opiod (morphine, fentanyl, oxycodone, methadone and hydrocodone) in the treatment of chronic pain (Perlin, 2015). As the Center for Disease Control and Prevention reports, “Since 1999, the amount of prescription painkillers prescribed and sold in the U.S. has nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report. Over prescribing leads to more abuse and more overdose deaths.” More than 16,000 people a year die from prescription drug overdose (CDC, 2016). For a superb discussion of the treatment of chronic pain, see the recently published book by Cindy Perlin, The truth about chronic pain treatments.
- Selective serotonin re-uptake inhibitor such as Paxil and Prozac (SSRI) are much less effective than promised by pharmaceutical companies. When independent researchers (not funded by pharmaceutical companies) re-analyzed the data from published and unpublished the studies, they found that the medication was no more effective than the placebo for the treatment of mild and moderate depression (Ioannidis, 2008; Le Noury et al, 2015). In addition, the SSRIs (paroxetine and Imipramine) in treatment of unipolar major depression in adolescence may cause significant harm which outweigh any possible benefits (Le Le Noury et al., 2015). On the other had, exercise appears as effective as antidepressants for reducing symptoms of mild to moderate depression (Cooney et al., 2013). Despite the questionable benefits of SSRI medications, pharmaceutic industry to posted $11.9 billion dollars in 2011 global sales (Perlin, 2015).
- Why are you prescribing the medication?
- What are the risks and negative side effects?
- Do the benefits outweigh the risks?
- How do I know when the medication is working?
- What will you do if the medication does not work?
- How many patients do you need to treat before one patient benefits?
- Can you recommend non-pharmaceutical options?
The important questions to ask are:
- How many patients need to be treated with the medication before one patient benefits?
- How many will experience negative side effects?
The data can be discouraging. As Daniel Levitin, neuroscientist at McGill University in Montreal and Dean at Minerva Schools in San Francisco, points out, it takes 300 people to take statins for one year before one heart attack, stroke or other serious event is prevented. However, 5% of all the people taken statins (the of drug of choice to lower cholesterol) will experience debilitating adverse effects such as severe muscle pain and gastrointestinal disorders. This means that you are 15 times more likely to suffer serious side effect than being helped by the drug. Nevertheless, the CDC reported that during 2011–2012, more than one-quarter (27.9%) of adults aged 40 and over used a prescription cholesterol-lowering medication (statins) (Gu, 2014).
Before making any medical decision when stressed, watch the superb 2015 TED London presentation by neuroscientist Daniel Levitin, How to think about making a decision under stress.
CDC Center for Disease Control and Prevention (2016). Injury prevention & control: Prescription drug overdose. http://www.cdc.gov/drugoverdose/
Cooney, G.M., Dwan, K., Greig, C.A., Lawlor, D.A, Rimer, J., Waugh, F.R., McMurdo, M., & Mead, G. E.(2013). Exercise for depression. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub6.The Cochrane Library. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004366.pub6/epdf
Goter, R. & Peper, E. (2011). Fighting cancer: A nontoxic approach to treatment. Berkeley, CA: Noreth Atlantic Books.http://www.amazon.com/Fighting-Cancer-Nontoxic-Approach-Treatment/dp/1583942483/ref=sr_1_2_twi_pap_2?ie=UTF8&qid=1452715134&sr=8-2&keywords=gorter+and+peper
Gu, Q., Paulose-Ram, R., Burt, V.L., & Kit, B.K. (2014).Prescription Cholesterol-Lowering Medication Use in Adults Aged 40 and Over: United States, 2003–2012. NCHS Data Brief No. 177. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention National Center for Health Statistics.http://www.cdc.gov/nchs/data/databriefs/db177.pdf
Ioannidis, J. P. (2008). Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials?. Philosophy, Ethics, and Humanities in Medicine, 3(1), 14. http://peh-med.biomedcentral.com/articles/10.1186/1747-5341-3-14
Le Noury, J., Nardo, J. M., Healy, D., Jureidini, J., Raven, M., Tufanaru, C., & Abi-Jaoude, E. (2015). Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. http://www.bmj.com/content/351/bmj.h4320.full
Levitin, D. (2015). How to stay calm when you know you’ be stressed. TEDGlobal London Talk http://www.ted.com/talks/daniel_levitin_how_to_stay_calm_when_you_know_you_ll_be_stressed
Perlin, C. (2015). The truth about chronic pain treatments. Delmar, NY: Morning Light Books, LLC. http://www.amazon.com/gp/product/B0160UEQB2/ref=dp-kindle-redirect?ie=UTF8&btkr=1
Robin, E.D. (1984). Matters of life & death: Risks vs. benefits of medical care. New York: W.H. Freeman and Company. http://www.amazon.com/Matters-Life-Death-Benefits-Medical/dp/071671681X/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=&sr=
One Computerized tomography (CT) scan of the abdomen and pelvis will expose you to more radiation than the residents of Fukushima, Japan absorbed after the Fukushima Daiichi nuclear power plant accident in 2011. –Consumer Reports, March 2015, Vol.80 No.3, 39.
High-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had a significantly lower 30-day mortality when admitted during dates of national cardiology meetings (70% survival when doctors attended meeting as compared to 60% survival when doctors did not attend the meetings). –-Jena et al, 2014.
There are so many questions
I feel healthy but worry that cancer could be lurking in the background, should I do a preventative body scan?
I sometimes have slightly higher blood pressure especially when the doctor measures it. It is probably borderline, should I go on medication?
Should I have my PSA tested?
I am a healthy fifty year old, should I have a mammogram?
Should I have an annual physical?
In the quest to stay healthy or prevent disease, we are bombarded by information that preventative testing would save lives and improve health. Only in the United States and New Zealand allow direct to consumer medical advertising which tends to increase excessive drug use and medical testing (Liang & Mackey, 2011). The messages imply that medical screening and testing (e.g., body scan or stress tests) can identify early stages of a disease and implying that earlier treatment will improve quality of life and survival. Similar messages encourage basically healthy people to take drugs for borderline conditions (e.g., borderline hypertension, osteopenia, increased cholesterol levels. What is not shared is the possible risk of unnecessary medical interventions or the harm caused by drug or treatment side effects especially when they are used for a long time period. When unbiased research such as the Cochran Reviews are done, even the annual physical exam appears to offer no benefits (Krogsbøll et al, 2013). Similarly, mammograms and PSA testing for a healthy population appears to offer no benefits and may increase risks. It is truly difficult to accept that an annual health check up is worthless or that a routine mammogram or PSA test may do more harm than good since for many years the public message has been the opposite: to get more screening and testing. There are many reasons for this approach such as:
- Genuine belief, although not evidence based, that an early intervention and more testing would reduce suffering.
- Financial incentives for the parties that perform testing and preventative screening or encourage increased drugs sales for borderline conditions for which the risk and benefits are not well documented.
- Fear of lawsuits by medical providers. If a patient develops an illness which possibly could have been diagnosed by screening, even though the screening may not have affected the actual outcome, the health professional could be sued.
Become an informed consumer
When you have a symptom and do not feel well, see your doctor and get diagnosed, it may safe your life. At the same time be an educated consumer and when unexpected findings are discovered and not related to your specific symptom/complaint, ask questions before agreeing to have more tests or treatments. Ask your provider some of the following questions which were initially outlined by Dr. Eugene Robins (1984):
- Why are you doing this test or procedure?
- What are the risks and what are the benefits?
- What are the risks of treatment and what are the benefits of treatment?
- How accurate is the test?
- How will the test results change the treatment strategy?
- Are there less invasive strategies that could be used? Be very careful of exposing yourself and especially children to CT scans. It is estimated that for every 1000 children who have an abdominal CT scan, one will develop cancer as a result (2015, Consumer Report, March 16).
To be able to navigate the complexities of diagnosis and to understand the risks and benefits of treatment and testing, read the recent two articles in the New York Times, Can this treatment help me? There is a statistic for that, How to Measure a Medical Treatment’s Potential for Harm and the superb book, Over-diagnosed-Making people sick in the pursuit of health, by Drs. H. Gilbert Welch, Lisa M Schwartz, and Steven Woloshin who are professors at Darthmouth Institute for Health Policy and Clinical Practice. This book is a must read for every patient and health care provider.
(2015). Overexposed. Consumer Reports, 80(3), 37-41. http://www.consumerreports.org/cro/2015/01/when-to-skip-ct-scans-and-x-rays/index.htm
Carroll, A.E. & Frakt, A. (2015). How to Measure a Medical Treatment’s Potential for Harm. New York Times, February 2.
Frakt, A. & Carroll, A.T. (2015). Can This Treatment Help Me? There’s a Statistic for That, New York Times, January 26.
Jena, A. B., Prasad, V., Goldman, D. P., & Romley, J. (2014). Mortality and Treatment Patterns Among Patients Hospitalized With Acute Cardiovascular Conditions During Dates of National Cardiology Meetings. JAMA internal medicine. doi:10.1001/jamainternmed.2014.6781 http://www.drperlmutter.com/wp-content/uploads/2015/01/Cardiac-outcome.pdf
Krogsbøll, L. T., Jørgensen, K. J., & Gøtzsche, P. C. (2013). General health checks in adults for reducing morbidity and mortality from disease. JAMA, 309(23), 2489-2490. http://drkney.com/pdfs/WAC_A_061913.pdf
Liang, B. A., & Mackey, T. (2011). Direct-to-consumer advertising with interactive internet media: global regulation and public health issues. JAMA, 305(8), 824-825. http://jama.jamanetwork.com/article.aspx?articleid=645713
Robins, E. D. (1984). Matter of Life & Death: Risks vs. Benefits of Medical Care. New York: W.H. Freeman and Company
Welch, H.G., Schwartz, L.M., & Woloshin, S. (2011). Over-diagnosed-Making people sick in the pursuit of health. Boston: Beacon Press.
Factors that support brain development and contribute to the possible development of ADD/ADHD is the focus of my recently article, Support Healthy Brain Development: Implications for Attention Deficit/ Hyperactivity Disorder, published in Psychophysiology Today,9(1), 4-15. The article takes an evolutionary perspective of development and suggests that our lifestyle interacting with the digital devices has implications for our health. This blog extracts some parts of the published article. For the complete article with references see: http://biofeedbackhealth.files.wordpress.com/2014/04/support-healthy-brain-development-psychophysiology-today.pdf
In class, he fidgets, every auditory and visual stimulus distracts him– he gets up, talks to other students and disrupts the class. Nothing seems to hold his attention, he looks at the page and moments later turns around and disturbs the boy behind him. At home, he grabs his food and leaves the table. He is continuously distracted. The only thing that seems to capture his attention is his computer games.
ADD/ADHD has become an epidemic in the last 30 years. Now one in seven boys by the time they reach the age of 18 have received this diagnosis according to the Centers for Disease Control and Prevention, as shown in Figure 1.
Figure 1. Rate of office-based visits per 1000 US population aged 5 through 18 with diagnosis (Dx) of ADHD and rate of use of medication (Rx) for boys and girls. Redrawn from: Sclar, D. A., Robison, L. M., Bowen, K. A., Schmidt, J. M., Castillo, L. V., & Oganov, A. M. (2012). Attention-Deficit/Hyperactivity Disorder among Children and Adolescents in the United States Trend in Diagnosis and Use of Pharmacotherapy by Gender. Clinical pediatrics, 51(6), 584-589.
The increase in ADD/ ADHD diagnoses cannot be explained by genetics alone. It may depend upon the interaction of genetics and the environment. It may develop into a disorder as a result of disrespecting and not understanding our evolutionary background during our development. We attempt remedy them with medications (e.g., Adderall, Concerta and Ritalin) that provide an 8 billion dollar revenue stream for pharmaceutical companies. Yet, there is little or no evidence of long term benefits. Self-mastery approaches such as Neurofeedback have demonstrated long term benefits in improving reading, writing, and mathematical scores as well as decreasing impulsive behavior. Neurofeedback training teaches children how to control their brain function.
Our modern lifestyle has compromised the healthy development of the brain and behavior. To prevent this we need to support those factors that during the course of evolution increased survival, reproductive fitness and promoted healthy brains.
1) Breast feed children at least for one year and concurrently introduce new foods slowly after 6 or 8 months to reduce the risk of developing food allergies.
2) Respect the importance of face-to-face contact to provide safety, develop empathy and nurture social connection.
3) Encourage motor development such as crawling, playing in nature, and physical movement that occurs while playing games support brain development instead sitting and being entertained by smartphones, computers, tablets or TV screens. Physical movement during play– without being distracted by the overwhelming rapid changing stimuli shown on LED and TV screens–is necessary for brain development.
4) Reestablish circadian (daily) rhythms. Until the 19th century our biological and activity rhythms were controlled by natural light. It is hard to imagine not having light at night to read. When the sun went down, we went to sleep. Light not only illuminates, it affects our physiology by regulating our biological rhythms by blocking melatonin production which interferes with sleep.
5. Support touch and movement with vision and sound to develop the brain. During the first years of life, the baby/toddler integrates the visual and auditory world with touch and movement. Motor development is the underpinning of brain development..
6. Provide constancy and reduce novelty. When reading a bedtime story, the child wants to hear the same story again and again. If part of the story is skipped, the child interrupts and reminds us to read correctly. When the child is stressed, it wants to hear a past story for comfort and safety. Repetition while feeling safe allows memory to create appropriate neural connections. Neural growth depends upon the appropriate level and type of stimuli.Too few stimuli hinders brain development and too many novel stimuli may decrease brain development.
7. Limit hours of watching or playing computer games that trigger orienting and activation. The rapidly changing visual stimuli from these screens evokes the biological reflexes to attend– there is something new and it could be safe, dangerous or life threatening. The physiological processes and the important implications for health and illness have been elucidated by the polyvagal theory developed by Professor Stephen Porges.
Over-stimulation with digital devices has been associated with impaired learning and decreased ability to self-regulate. The flood of novel visual and auditory stimuli trains the brain to react, to react again, and again. The ongoing external novelty captures the child’s attention, instead of directing attention from within.
8. Provide face to face safety as infants begin to explore the world. In the last 50 years we have radically increased the visual and auditory input to a developing baby following the concept of more is better. Babies are now exposed to visual and auditory stimuli which rapidly pass by them without repetition or the ability to interact kinesthetically with them. Babies are often carried on the chest or in baby carriages/strollers facing forward- leading the charge into the unknown–instead of receiving face-to-face reassurance from the parent, touching the parent, or hiding behind the parent for safety.
In a study of 2722 observations of parent-child pairs by developmental psychologist Dr Suzanne Zeedyk, parents talked twice as much to their baby when it faced them than when the baby was facing forward in the stroller. The impact of stress was measured by the decrease in baby laughing. Babies who faced their mother/caretaker while being pushed laughed 90% more than those who faced forward. As babies become older they do want to face the environment as it is more interesting; however, when the infants feel overwhelmed or threatened there is an opportunity to automatically reconnect with the caretaker to feel safe.
In summary, do not park children in front of smart phones, tablets, computer games, and television screens that flood the auditory and visual senses without the ability to integrate the information through touch and movement. Although TV and computer games are superb baby sitters, it is not the same as interacting and playing with a baby and toddler to develop the appropriate motor and emotional control. Let’s create an environment that is in harmony with our evolutionary background–An environment where infants play interactively with objects, explore nature and have face-to-face contact with their caregiver.
Even if the initial conditions during growing up were less than optimum, the brain can change—a process known as neuroplasticity. Thus, nurture inner directed attention by having the child develop skill mastery. Learning these skills can include neurofeedback training, back-to-nature explorations, learning to play a musical instrument, practicing a sport or martial art technique, or participating in yoga and meditation. These and many other practices will change the neural structure: it is never too late to learn, change, and optimize health.
To view or download the whole article with references: http://biofeedbackhealth.files.wordpress.com/2014/04/support-healthy-brain-development-psychophysiology-today.pdf
*I thank Drs. Stephen Porges, Linda Thompson, Michael Thompson, Monika Fuhs, and Annette Booiman for their constructive feedback.
In the late 19th and early 20th century, numerous people with schizophrenia recovered and lived functional lives without receiving pharmaceutical treatment (Whitaker, 2011). The spontaneous recovery has changed since advent of barbiturates and the use of antipsychotic medications. With medication, the initial schizophrenic crises can be more easily managed– patients have less disruptive symptoms although they slow down and often life in a mental fog. Now there is new doubt about the efficacy of long term use of antipsychotic medication treatment as reported by science writer Clare Wilson in her New Scientist article, “Rethinking schizophrenia: taming demons without drugs”. She point out that there have been no long term comparative outcome studies between continued drug treatment and stopping drug treatment except for observing the increase in serious side effects such as tardive dyskinesia.
Psychiatrist Wunderlink and colleagues (2113) in the Netherlands have just published an outstanding controlled study. They showed that when the people were assigned to either a medication or stopped medication group, the stopped medication group did nearly twice well over the long term. In the short term, the stopped medication group had a higher relapse rate. However, at the end of seven years they showed significant lower relapse rate and double the rate of having functional lives (e.g., holding down a job and looking after themselves) than the group that continued to take medication as shown in figure 1 and 2.
Figure 1. Long term study showing the benefit of minimal or no drugs after the initial schizophrenic episode as compared to continued medication. From: Wilson, C. (2014). Rethinking schizophrenia: taming demons without drugs. New Scientist, 221(2955), 32-35; based upon the published research by Wunderink, et al, 2013.
Figure 2. Long term out of the ability to hold down a job or look after themselves. Those who were assigned to the minimal or no drug group had a significant improvement in functional recovery. From: Wilson, C. (2014). Rethinking schizophrenia: taming demons without drugs. New Scientist, 221(2955), 32-35; based upon the published research by Wunderink, et al, 2013.
This study points out the importance of not generalizing from short term benefits which are so often augmented by active placebo factors. As the Dutch study showed, there is more harm than benefit from long term medication use in the treatment of schizophrenia. Similar results have also been reported in long term use of sleeping medication—it increases mortality risk by 25%. Long term chronic medication may cause different outcomes than for short term crises use. When medication is taken over an extended period of time, the body will adapt to achieve homeostasis. Namely, it will reduce or increase endogenous neurotransmitters or receptors to compensate for the increase presence of the drug. When the medication is withdrawn, the symptoms are now worse because the neurotransmitter or receptor have been changed and they takes time to regenerate. This process is similar to having a caffeine withdrawal headache. Drinking caffeine, induced vasoconstriction, the body compensates by reducing its own vasoconstriction. Then, when caffeine is stopped, the blood vessels dilate too much and a headache results. It usually resolves itself in a few days as the body rebalanced.
The reported results that the minimal or no drug group did so much better confirms the observations that numerous people with schizophrenia in the late 19th century and early 20th century could regain functional recovery unlike what occurred after the use of antipsychotic medication treatment (for more discussion on this topic see the superb book by Robert Whitaker, Anatomy of an Epidemic.
Finally, this post is a reminder to doubt the benefits of medication for ongoing long term use based upon short term studies.
Whitaker, R. (2011). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. Random House.r
Wunderink, L., Nieboer, R. M., Wiersma, D., Sytema, S., & Nienhuis, F. J. (2013). Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial. JAMA psychiatry, 70(9), 913-920.
The recent book, Anatomy of an Epidemic, by Robert Whitaker is a must read for anyone who is planning or taking medications to treat mood disorders such as depression, anxiety, or panic attacks. His in-depth evidence based book, which reads like a novel, suggests that psychiatric drug benefits are mainly a myth and contribute significantly to creating life-long dysfunction and worsening of the symptoms. He cites study after study demonstrating this for depression, children with ADHD, biopolar disorder, panic attacks, anxiety and even schizophrenia. For example he cites a Canadian study of 1,281 people who went on on short-term disability for depression. Only 19 percent of those who took an antidepressant ended up on long-term disability, versus 9 percent of those who didn’t take the medication.
More importantly, when people are treated for panic attacks with benzodiazepine such as Xanax, the placebo groups does much better in the long term than the drug treatment group after medication is tapered off. Whitaker illustrates this concept by showing the following research data that was part of the FDA approval for the medication.
This Upjohn’s study of Xanax, patients were treated with the drug or placebo for eight weeks. Then this treatment was slowly withdrawn (weeks 9 through 12), and during the last two weeks patients didn’t receive any treatment. The Xanax patients fared better during the first four weeks, which is the result that the Upjohn investigators focused on in their journal articles. However, once the Xanax patients began withdrawing from the the drug, they suffered many more panic attacks than the placebo patients, and at the end of the study were much more symptomatic. Source: Ballenger, C “Alprazolam in panic disorder and agoraphobia.” Archives of General Psychiatry 45 (1988): 413–22. Pecknold, C “Alprazolam in panic disorder and agoraphobia.” Archives of General Psychiatry 45 (1988): 429–36.
This book and the scientific evidence suggests that non-pharmacological treatment approaches should be the first strategy for treatment–it may save your life.