Antidepressants & the Politics of Health
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Antidepressants & the Politics of Health David Healy. All Trials GSK House of Common. All Trials GSK House of Common. If treatments work , they could be made available for free, they would enhance national productivity, and encourage innovation.

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Antidepressants the politics of health david healy

Antidepressants & the Politics of Health

David Healy


Antidepressants the politics of health david healy

All Trials

GSK

House of Common


Antidepressants the politics of health david healy

All Trials

GSK

House of Common

If treatments work ,

they could be made available for free,

they would enhance national productivity,

and encourage innovation


Antidepressants the politics of health david healy

We are not in favour of placing anonymized individual patient-level data (IPD) in the public domain in an unrestricted manner…

specific individuals sd be provided with controlled access to IPD through carefully managed and secure “safe havens”.

Access should be facilitated by an independent “gatekeeper” responsible for insuring that the data … makes a useful contribution to scientific understanding

Page 4


Antidepressants the politics of health david healy

We are not in favour of placing anonymized individual patient-level data (IPD) in the public domain in an unrestricted manner…

specific individuals sd be provided with controlled access to IPD through carefully managed and secure “safe havens”.

Access should be facilitated by an independent “gatekeeper” responsible for insuring that the data … makes a useful contribution to scientific understanding


Antidepressants the politics of health david healy

Stone and Jones Nov 17th 2006: FDA


Antidepressants the politics of health david healy

EVIDENT BASED MEDICINE


Antidepressants the politics of health david healy

EVIDENCE

BASED

MEDICINE


Antidepressants the politics of health david healy

Efficacy

6 Week Trials

Rating Scales

2 positive out of 10 trials

100 publications

Accentuate the positive

All effect down to alcohol

Mexican alcohol

Gin, whiskey, beer, wine & rum

Scotch, Irish & Japanese whiskey

NICE Guideline endorsed

Cost-Utility Analyses ++

Take life long - NNTs


Antidepressants the politics of health david healy

Side Effects

6-8 week trials

10% or more?

Anecdotes – Disregard

Pregnancy

Suicide & Violence

Dependence - illness

LFTs - depression

Prescription only Med

Amphetamines

Risk laundering

Stockholm syndrome

Legal liability


Antidepressants the politics of health david healy

All RCTs do harm

Some may also benefit


Antidepressants the politics of health david healy

R.A Fisher,

Design of

Experiments.

Edinburgh:

1935.

Randomization

Statistical

Significance


Antidepressants the politics of health david healy

  • Statistical Significance means

  • You know what you are doing

  • You get the same result each time


Antidepressants the politics of health david healy

  • Statistical Significance means

  • You know what you are doing

  • You get the same result each time


Antidepressants the politics of health david healy

  • DRUGS

  • 100 Effects

  • Surrogates

  • Individual Patient

  • FERTILIZERS

  • 1 Effect

  • Hard Outcomes

  • Population Effect

Logically Ungrounded

Placebo Fertilizer?


Antidepressants the politics of health david healy

Louis Lasagna

Placebo Response

Controlled Trials

Informed Consent - Confidentiality


Antidepressants the politics of health david healy

Thalidomide

Randomized

Controlled

Trials

Efficacy

&

Safety


Antidepressants the politics of health david healy

The days when a company would go to skilled doctors and give them a new drug and ask them to try it on some different patients seem gone. Is this cause for celebration or depression?

In contrast to my role in the 1950s which was trying to convince people to do controlled trials, now I find myself telling people that it’s not the only way to truth.

LOUIS LASAGNA


Antidepressants the politics of health david healy

Streptomycin – Because of RCTs

AntibioticsPenicillins

DiureticsFurosemide

HypoglycemicsMetformin

AntihypertensivesThiazides

AntihistaminesDiphenhydramine,

Chlorphenamine

AntipsychoticsClozapine, Haloperidol

AntidepressantsImipramine

Minor TranquilizersDiazepam

StimulantsDexamphetamine, Ritalin

SteroidsPrednisone

ContraceptivesCOC – The Pill

Chemotherapies

AnticonvulsantsValproate, Phenytoin

AnalgesicsMorphine, NSAIDs

VaccinesPolio, Smallpox


Antidepressants the politics of health david healy

EVIDENT BASED MEDICINE


Antidepressants the politics of health david healy

CONFOUNDING


Antidepressants the politics of health david healy

RANDOMIZED CONTROLLED DISEASE TRIALS

Mild-Mod Depression SSRI Suicidal Acts:

screening

Run-in/wash out

randomization

drug

pbo

Start

treatment

Stop

treatment

follow-up


Antidepressants the politics of health david healy

RANDOMIZED CONTROLLED DISEASETRIALS

Severe Depression Imipramine Suicidal Acts:

screening

Run-in/wash out

randomization

drug

pbo

Start

treatment

Stop

treatment

follow-up


Antidepressants the politics of health david healy

RANDOMIZED CONTROLLED DISEASE TRIALS

Mild-Mod Depression Imipramine Suicidal Acts:

screening

Run-in/wash out

randomization

drug

pbo

Start

treatment

Stop

treatment

follow-up


Antidepressants the politics of health david healy

Every Time Drug & Illness

Produce the same Outcome

Anti-arrhythmics Arrhythmias

Anti-asthmatics Wheezing

RosiglitazoneDiabetes – heart attacks

Byetta – JanuviaDiabetes – pancreatitis

Antidepressant Suicide

Benefit

It’s the Disease not the Drug if a Hazard

It’s the Drug not the Disease if a Benefit


Antidepressants the politics of health david healy

GlaxoSmithKline - 2006

Paroxetine Suicidal Acts 11 v 0 Placebo Suicidal Acts

N = 2943 N = 1671


Antidepressants the politics of health david healy

GlaxoSmithKline - 2006

Paroxetine Suicidal Acts 11 v 0 Placebo Suicidal Acts

N = 2943 N = 1671

RR > 6.0

Paroxetine Suicidal Acts 36 v 35 Placebo Suicidal Acts

N = 147 N = 147


Antidepressants the politics of health david healy

GSK - 2006

Paroxetine Suicidal Acts 11 v 0 Placebo Suicidal Acts

N = 2943 N = 1671

RR > 6.0

Paroxetine Suicidal Acts 47 v 35 Placebo Suicidal Acts

N = 3090 N = 1818

RR < 0.80


Antidepressants the politics of health david healy

Randomization controls

Fertilizer Confounders

It generates ignorance about ignorance

About Medicines

RCTs give weaker drugs

Standardized care

Fertilizers - no longer Poisons

All RCTs do harm,

some may also be of benefit


Antidepressants the politics of health david healy

MEDICULTURE not MEDICINE


Antidepressants the politics of health david healy

“If one came to the conclusion that the only way to find out the truth about a medication was to use a controlled clinical trial, it would mean not that the pendulum had swung too far but that it had come completely off its hook”

Louis Lasagna

Evidence Based Medicine has become synonymous with RCTs even though such trials invariably fail to tell the physician what he or she wants to know which is which drug is best for Mr Jones or Ms Smith – not what happens to a non-existent average person


Antidepressants the politics of health david healy

Thalidomide

Randomized

Controlled

Trials

Efficacy

&

Safety


Antidepressants the politics of health david healy

August 5th


Antidepressants the politics of health david healy

ALLTRIALS v RIAT


Antidepressants the politics of health david healy

We are not in favour of placing anonymized individual patient-level data (IPD) in the public domain in an unrestricted manner…

specific individuals should be provided with controlled access to IPD through carefully managed and secure “safe havens”.

Access should be facilitated by an independent “gatekeeper” responsible for insuring that the data … makes a useful contribution to scientific understanding


Antidepressants the politics of health david healy

  • Shower

  • Patents

  • Data Exclusivity

  • Prescription-only

  • Status

  • RCTs & Data

  • Evidence v Data

  • Based Medicine

  • Privacy Rights


Antidepressants the politics of health david healy

AbbVie

V

European

Medicines

Agency

Adverse Events


Antidepressants the politics of health david healy

  • Bidet

  • Data Based Medicine

  • Comparative Safety Research

  • Drug Trials

  • Patient Reporting

  • Consumer Pressure

  • [Save Money

  • New Drugs]


Antidepressants the politics of health david healy

AERS v ASRS


Antidepressants the politics of health david healy

THE GUILDFORD FOUR

If their story is right

it is such

an appalling vista

it cannot be

Wrongfully convicted prisoners should stay in jail

rather than be freed and risk a loss of public confidence in the law.


Antidepressants the politics of health david healy

When treatments work

they can be made available for free,

they will enhance national productivity,

and encourage innovation


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