The Depression Industry.

A depressing tale.

This has been a busy week, with one paper submitted and one graduate seminar delivered so this will be short. The seminar may have made history as the first time in this country that a psychiatrist has addressed an audience of philosophers on their field. It seemed to go fairly well and will be put on Youtube in due course, when I get the address, I'll link it here.

The main thing was that they were interested. As you may know, philosophy is under seige throughout most of the English-speaking world as "unnecessary, unprofitable, unmarketable" and so on, so the idea that somebody outside their field actually wants to talk to them was a pleasant surprise. What the powers-that-be in universities don't realise is that all the great scientific disasters in the past few hundred years were eventually exposed by philosophical analysis. If and when psychiatry is dragged back into line, it won't be because of statistical analysis, or some breakthrough in drugs or neurophysiology, it will be because, via the philosophy of science, people start to realise that psychiatry has no basis in science.

Talking of breakthroughs, I see another brilliant discovery has rolled off the drug production line. A brief and breathless article in Psychiatric Times announces the US FDA has approved a "new treatment" for the movement disorders of Huntington's Disease and tardive dyskinesia. Huntington's Disease is a rare progressive genetic dementia, starting mostly in late 30s, which results in jerky movements and rapid cognitive decline. I had the unusual experience in 1976 of finding a new family tree in Perth so I had a fair bit to do with it after that. That family had a rapidly progressive form and the three siblings were all gone by age fifty.

At the time, there was only symptomatic treatment available, tetrabenazine, an older drug of the same class as fluphenazine and some other antipsychotics. It simply masked the symptoms so it did nothing to slow the progress of the disease but it was better than nothing. There were also attempts to use it in what is called tardive dyskinesia, which is a late complication of prolonged treatment with antipsychotics. It was only starting to appear in the mid-1970s so nobody knew much about it. Tardive dyskinesia consists of a variety of repetitive, jerky movements of the body but the first signs are usually around the mouth, with writhing movements of the tongue, lip-smacking and sucking. It is now much more common and can be disabling: I have seen patients in their thirties showing it, bad enough to stop them wanting to go out in public. Tetrabenazine was helpful but, needless to say, it had its own complications, including the distressing condition of akathisia, so it had to be used carefully and only in more severe cases. People needed to take 3 or 4 tablets a day as it was metabolised fairly quickly so often they would only take it when they had to go out.

So imagine my surprise when I read the article above, on a novel treatment for choreiform movements, to find that tetrabenazine has been resurrected and given a new patent. The drug company, Teva Pharmaceuticals of Tel Aviv, Israel, has rather cleverly tweaked the molecule to replace a number of hydrogen atoms with deuterium, giving (drum roll...) deutetrabenazine.

Deuterium, as you may know, is a hydrogen atom with a neutron, giving a molecular weight of two instead of one from its single proton. Two deuterium atoms and one of oxygen gives deuterium oxide, usually known as heavy water, which occurs naturally and can be harvested from the ocean, so there's enough to go around. It's used in nuclear reactors and various other high-powered processes. Adding a few deuterium atoms to the tetrabenazine molecule increases its molecular weight by about 2%, thereby slowing its metabolism so that patients only need two tablets a day. It also allows a new patent and as it is now the only new "treatment" for tardive dyskinesia (which is caused by excessive use of antipsychotics), it's guaranteed to sell, especially in the US where excessive use of antipsychotics is normal.

The listed price for deutetrabenazine in the US is $4,980 (let's say $5000) for 60 tablets, $120 per tablet, so at two a day, that buys just a month's supply. Sixty thousand a year just because you were fed excessive doses of too many drugs for too long by exuberant psychiatrists who didn't have a model of mental disorder and who weren't aware they needed one (and didn't want to be told). That's US$, by the way, so it's about $7,500 a month in AUD. Wow, what a little gold mine. Granted, US Medicare isn't going to pay for it in a hurry, but even if 10,000 wealthy families (out of a million in the US) decide that grannie's twitching and lip-smacking is getting a bit much, that adds up to AUD900 million a year for the managers and shareholders of Teva Pharmaceuticals. They'll be twitching and smacking their lips all the way to the bank.

All they have to do is hope nobody notices that tetrabenazine is still available in Australia. It's made in India, of course, but Indian pharmaceuticals are the equal of anything in the world. Here, it costs (wait for it) a maximum of … AUD320 for 112 of the 25mg tablets. That's a month's supply on a private script; on Medicare, it's $30 a month. Compare that with AUD7,500 a month for the fancy nuclear version. It's cheaper still in India if you buy in bulk. If you have room for 100,000 tablets, it works out at Rs260 for each box of 100 tablets, or the princely sum of AUD4.72. For a month's supply. At that price, it would be far cheaper to buy 100,000 and flush most of them.

So that's what happened when the ethical pharmaceutical industry bumped into raw capitalism: the ethics were mugged and dumped in a rubbish skip. Talking of scams, there is an online newsletter sent around to psychiatrists giving brief summaries of recent papers from the psychiatric journals. Called Depression Research Review, it is a professional presentation, financed by drug companies, and thus a little biased toward seeing depression as a biological illness of the brain. This point is completely unproven, of course, but they don't mention that. As Yogi Berra said, "It's amazing what you don't see when you don't look."

This month's edition has several articles on antidepressants and the elderly, depression following strokes or heart attacks, one on air pollution and anxiety/depression in the UK, and one each on psilocybin (a hallucinogenic drug) and esketamine nasal spray (another hallucinogenic) although they don't explain how you can have a placebo (sugar pill) trial of a hallucinogenic. There is also something called Alpha-Stim AID for Depression. This is a little electronic doodah with clips that are attached to the ears, so it looks like a head set. It delivers a tiny trickle of electricity that goes in one ear and out the other and is supposed to cure all manner of ailments and woes. According to the Alpha-Stim website, 20 minutes of the current of "millionths of an amp" per day will cure anxiety, depression and insomnia. With other attachments, it will relieve "post-traumatic, acute and chronic pain" as well.

The website continues: "Alpha-Stim may seem too good to be true..." which it certainly does. For $1300, what does it actually achieve? According to a paper quoted in the Depression Research Review, nothing. It has no measurable effect, which is probably why it was reviewed in a publication supported by drug companies. Still, I'm sure the manufacturers have made a killing. As for the article on air pollution, it found a higher incidence of anxiety and depression in areas with high levels of air pollution, with the effect more pronounced in men that women. That makes sense, men generally work in dirtier air than women, but the reviewer dismissed this. It's not air pollution causing mental problems, it's because poor people have to live in crappier air than rich people, and they have "... poor nutrition, limited access to healthcare, and pre-existing health conditions." The reviewer concluded: "I suspect the implications for ‘pollution policy’ are overstated…" Of course he would. If you believe that depression and anxiety are genetically-determined diseases of the brain, you're not going to let a bit of air pollution cloud your clear view of things.

It all goes back to the crucial point: mainstream psychiatry doesn't have any understanding of mental disorder, which was the theme of my philosophy seminar. Psychiatrists have an ideology of mental disorder, but no science. That's why there are so many completely contradictory "treatments" available, none of which are leading to any improvement in the community but which are enriching the drug companies. That's pretty depressing but, against the odds, we soldier on.