“This test will improve your choice of antidepressant by at least 50%” the salesman claims.
I’m skeptical. I ask him how much it costs. Given his evasiveness, I ask five times before I get an answer: “Two thousand dollars. But don’t worry. Insurance will pay for it.”
Sure. And if that do, a very big if, who ultimately pays the bill? Everybody.
The real question is – is it worth it?
How many people can I treat for a year for two thousand dollars? I can buy forty to fifty lightboxes from Amazon that in many studies do better than anti-depressants – and that’s for people who do not have seasonal depression. Their cost will be the time in front of the boxes, plus electricity.
I ask the salesman for the studies behind this “fantastic test.” They arrive within a week.
The test does show “improvements” in those “carefully selected” by their testing and formula. The people behind it are well established psychopharmacology academics.
Yet the sample sizes are small. The “big improvements” are described in percentages, not absolute numbers. Most folks know that increasing the success rate of a treatment from one to two percent does “double the success rate,” but is less exciting for the 98% of people for which it does nothing. The data only look at depression scale treatment scores, with improvements that are not clinically wonderful and disregard most of what happens to someone who’s depressed. Patients are followed for short periods. And:
1. The test is based, as are others, on how well people metabolize the drugs in the liver into other metabolites – not on their ultimate effectiveness. Yes, it is useful to know to know who rapidly over or under-metabolizes any drug. Yet in many patients, particularly the large number with intercurrent medical issues and those of a “certain age,” the side effect profile of drugs requires you to start low and go slow.
2. Liver metabolism is just one part of how drugs are metabolized and used.
3. Many common drugs are not covered in the test.
4. Why are we so focused on drugs?
If All You’ve Got Is a Hammer
For decades Big Pharma has operated on a relatively simple platform:
A. Find a disease, preferably a chronic one requiring lifetime treatment. If you can’t directly improve the disease, find a “risk factor” that causes the disease B. Find a drug target C. Develop the drug and test it in a population that stacks the deck in your favor D. Demonstrate it is at least a tiny bit better than placebo E. Market the heck out of it.
This process works extremely well for bottom lines. Our public health is a different story. Drug company disinterest in antibiotics – if they work well there may not be enough use to recoup investment – has now led to proposals to give “prizes” of a billion dollars or more so that antibiotic resistant bugs won’t kill us in the tens of millions.
Yet what of depression? What of an illness often calculated to have the second biggest economic impact of all? Some newer antidepressant tests are defining a different story.
Big Inflammation and Big Data
British publications have been awash with of a study showing how to “aggressively treat” depression. It’s only looked at on 140 people, but the authors are very excited, as are journalists.
What are they looking at? Inflammatory markers. People with high inflammatory numbers don’t respond to “standard” treatment.
There’s no clinical trial, no long term results. As time and chance rule life, we will have to wait to know the real results. But this study also links with another, supposedly demonstrating that Google searches can predict who is most likely to get pancreatic cancer – before it’s diagnosed.
What these two seemingly unrelated studies highlight is:
1. Many illnesses have systemic effects on people, varying from physical symptoms to changes in family and economic life.
2. Health is a much bigger proposition than medically defined disease. If inflammation is a large “risk factor” for illnesses ranging from depression to cancer to heart disease, than public health provisions to improve human immune expression should be important for all of us.
3. In the future to study what causes illness, one who will have to get outside the small silo of physical and mental symptoms listed on checklists.
4. To treat illnesses, one has to move way beyond checklists.
Because as in the treatment of depression, standard medical therapy leaves much to be desired. Drugs, even when appreciably better than placebo, do just so much. Psychotherapy trials often claim better results. So do trials with light therapy. Treatments like cognitive-behavioral therapies have useful, generalizable effects well beyond the symptoms of depression, as do light therapies and exercise.
The effects of depression on families, children, and economic life are also critical, and when fully addressed help families as well as communities.
For the issue is health, not medical treatment. If populations are generally healthy, they see less depression, cancer, heart disease and stroke.
And just as big data looks far and wide for factors involving health, so should we who practice health care. We should spend our money wisely, comparing actions involving communities and lifestyle with clinical tests like anti-depressant metabolism profiles.
Those are the clinical trials that really need our consideration.