Map of life expectancy at birth from Global Education Project.

Friday, June 26, 2009

Guest post from Les Izzmoor

Les may come around again from time to time. Clearly we need to hear from him. -- C

The new BMJ (i.e., British Medical Journal), which unfortunately gives the commoners only limited access to the stuff they are probably least inclined to read, has several items of interest to us colonists as we yell and scream about rationing and bureaucrats. The tea slurping decolonization monkeys think about these things rather differently than we do; their pinko doctors offer an instructive perspective.

  1. Katy Bell et al find that routine monitoring of bone density in the first three years after post-menopausal women start on the anti-osteoporosis drug bisphosonate is useless and even misleading. Save money, don't do it.

  2. CC Butler and a multitude find that there are big regional variations around Europe in the likelihood that adults with coughs will be prescribed antibiotics, but there is no association with better outcomes. Overprescribing of antitbiotics, as our faithful readers know, wastes money, causes adverse effects (for one thing, it can wipe out the endosymbionts in our throats and intestines, causing opportunistic infections), and of course promotes antibiotic resistance in pathogens. In Europe, of course, there tend to be bureaucrats who could get doctors to stop doing this. They should consider restricting people's personal freedom to waste money, harm themselves, and risk the doom of humanity.

  3. According to SG Thompson and colleagues, routinely screening men age 65-74 for abdominal aortic aneurysm reduces the 10 year risk of death from .87% to .46%, so according to my calculations you could save a life by screening 243 men. They figure this will cost about 7 600 pounds sterling per avoided death, which they deem worth it. Of course, these guys are already getting on so they may not have long to go even if they avoid the aneurysm, but still. Of course, this doesn't save money, it costs money, but we still might want to do it. Rescreening the guys who were negative ten years later, however, is probably not worth it.

  4. Joanna Moncrief and David Cohen argue -- entirely correctly as far as ol' Les is concerned -- that psychiatric drugs, specifically "antipsychotics" and "antidepressants" -- don't really target specific underlying disease processes. No, depression is not a serotonin deficiency and psychosis is not a disorder of dopamine processing. We don't really know what the heck they are. These drugs produce altered mental states which may just happen to make some people feel better, e.g. by suppressing affect they make people with psychosis calmer. That doesn't mean they are treating the disease, however. If patients understood this -- which would first require the drug companies to stop lying about it, although they don't mention that -- they would probably consume less of these drugs, save money, and avoid side effects.

  5. New results in the Archive of Internal Medicine show that people with chronic kidney disease do just fine on lower doses of drugs that increase the red blood cell count. The manufacturers, by the way, have pushed for higher doses. Natch.

  6. Iona Heath is a physician who declines her own doctor's recommendation that she have screening mammograms. She writes that "for every 2000 women invited to screening for 10 years one death from breast cancer will be avoided but that 10 healthy women will be "overdiagnosed" with cancer. This overdiagnosis is estimated to result in six extra tumorectomies and four extra mastectomies and in 200 women risking significant psychological harm relating to the anxiety triggered by the further investigation of mammographic abnormalities. The percentage of women surviving 10 years if they are not screened is 90.2%; it is 90.25% if they are screened. Is this enough of a difference to risk the possibility of significant harm? For me, it is not." If more women were given this information -- which is entirely accurate, by the way -- fewer might choose to be screened.

So we Americans need to clearly understand that meaningful choice requires accurate information. The freedom to choose to waste money and harm yourself out of ignorance is the opposite of freedom, as far as I'm concerned. People need to stop degrading and abusing the word freedom: it doesn't pertain exclusively to rapacious capitalists, it needs to be our common possession.


kathy a. said...

an interesting set of observations!

i understand your position on anti-depressants, which may be widely prescribed for even minor conditions, but depression *can* be a major, painful and hugely disabling condition, for patients and those around them.

yes, so what if the meds are only treating the symptoms, and not a cure? in my experience, doctors are clear that the meds are treating symptoms and not a cure. and yes, sometimes patients don't believe that, and go off their meds when they feel better, only to cycle back into an intolerable and non-functional state. the concerns about side-effects are valid ones, because those can create serious issues as well, but the untreated illness can be just devastating for some segment of the population.

it is not my understanding that anti-psychotics are widely prescribed for people who don't truly need them, but maybe my understanding is inaccurate.

psychosis can be very serious indeed, both for the patient and for those around them. it's not just a matter of affect, either: hallmarks of psychosis include disordered thinking, delusions, hallucinations -- things really outside the range of normal functioning.

on the topic of mammograms, i assume the study addresses screening just to screen, and not folks who have particular concerns like lumps or family history?

thanks for the guest post!

Cervantes said...

Antidepressants actually help about 15% of people who are diagnosed with depression, according to the best calculations; and they are addictive. Cognitive behavioral therapy works better for most people, has longer lasting effects, and no adverse effects. Antidepressants (which aren't really that and are misnamed) should be a last resort.

Alas, so-called antipsychotics are indeed widely prescribed for people who don't need them. The manufacturers have hawked them for bipolar disorder, dementia, and major depression, even in children. People with true psychosis should do their best to get off of them if they can -- the side effects are absolutely devastating.

As for mammography, yes that is definitely true, but what you are talking about is not population screening, it's either diagnosis - in the case of a lump - or screening people known to be at high risk. Those odds are different.

C. Corax said...

My friend astounded me recently by telling me that he's going to taper off as many of the anti-psychotics he's been on as he can. A few years ago, he wouldn't even consider stopping a single drug.

He's suffered psychotic episodes in the past, but according to Oliver Sacks, about one third of people who suffer psychosis will get better, even without treatment. In the case of my friend, there's family history where an ancestor went on to have a normal and productive life. If my friend doesn't give this a try, he'll never know.

Kathy, you might want to check out "Agnes's Jacket" by Gail Hornstein. She definitely has her perspective on the subject, but her studies were done mostly in England, where peer support groups are becoming very popular (and accepted by the health care system) for people who choose to limit or eliminate medication. It's a good read.