This book is also available in English as The Logic of Care but the cover is not as good. By Annemarie Mol, it is an extraordinary book on the meaning of care – making sure, for instance, people with diabetes know to prick the side of their finger, not the pulp which is rich in the touch receptors we may need if diabetes causes eyesight problems – or perhaps just even in the dark. The subtitle is – the problem of patient choice.
Folk, who have been and are depressed, have heard doctors tell them for decades that depression is just like diabetes. Going on antidepressants is just like starting on insulin – you may need to take your meds forever.
Take 1
This idea has been beyond irritating for most folk. Endless repetition of the mantra, however, along with increasing numbers of people on treatment for decades, many of whom claim the meds have saved their lives and they cannot contemplate coming off them, has worn down resistance.
When they launched, SSRIs were clearly no good for severe depressions like melancholia. Making a difference in melancholia is how the tricyclic antidepressants (TCAs) had announced themselves 3 decades earlier – See I Come to Praise SSRIs. In the 1980s when the first SSRIs were peeking above ground, the received wisdom was TCAs produced a benefit in melancholia in 2 to 3 weeks, and that it seemed to make sense to stay on them for 3 months or so.
Along with the SSRIs, Guidelines, supposedly based on Randomized Controlled Trials, began to peek above ground. When Antidepressant Guidelines first got written by groups like the British Association for Psychopharmacology, at the behest of some key figures, nothing to do with controlled trial evidence, 3 months became 6 months and later 12 months.
Figures, who knew, when almost no-one else did that company trial data pointed to withdrawal problems, spun the rationale for 12 months as preventing relapse. The high rates of withdrawal in trials when folk were swapped to placebo which cleared on restarting treatment were spun as evidence for relapse prevention.
After that, it was just a matter of holding the line as the difficulties coming off the SSRIs normalized the idea of being on them for years. It became increasingly unlikely anyone on treatment would bump into a doctor asking – Why on earth are you still on those drugs? This was before Dee Mangin coined the concept of Legacy Drugs.
Take 2
Decades ago, pre SSRIs, a young and fit friend developed diabetes. It came on soon after an emotional shock – a broken relationship.
Years later I got interested in Catatonia, which can be triggered by emotional shocks like relationship breakups. Our physiology goes haywire in catatonia – temperature, heart rate, blood pressure and blood glucose can vary dramatically in a few hours from a dangerously slow heart rate to a dangerously fast one. This is like the effects from running out of a sauna in Finnish woods and plunging into an ice cold lake.
Much more recently, a colleague told me of a man he diagnosed with diabetes and offered him meds but also suggested he try losing weight, getting fit and eliminating carbs. His patient did just this and his diabetes disappeared. This was before recent studies showed that this approach can apparently get rid of diabetes in around 50% of us.
However, when my colleague went into his computer to remove diabetes, the diagnosis entered on the first consultation, the computer wouldn’t play ball. It insisted diabetes can’t be cured. Googling this you’ll be told – Yes diet and weight loss can make a big difference, but it only brings about remission, not a cure.
This inability to remove a diagnosis can be added to the increasing number of us who now have diagnoses of pre-diabetes in our records. These diagnoses have consequences for how insurance companies view us. If we are diagnosed with almost anything and are not taking the treatments mandated for these conditions, we risk finding it more costly to get insured
Googling stress and diabetes, you’ll be told – Stress can not cause diabetes. It might add to your problems if you have diabetes but no it cannot cause diabetes.
Before you can open your mouth, you also get told – If you don’t control your blood sugar you will go blind, lose a leg or a foot, die prematurely from a heart attack or a stroke. Getting your blood sugars down will sound like a medical emergency.
Along with an emphasis on taking medicines, there are cautions against dieting and exercising. Combining anything that might also lower your blood sugar with your medicines, which it is assumed you will be taking, risks causing dangerous hypoglycemia.
Take 3
There is an interesting historical footnote here. We now distinguish between Type 1 and Type 2 Diabetes (T2D). While there can be genetic inputs to Type 1, and gluten sensitivity may add to your problems, it is primarily viewed as an autoimmune disorder. Type 2 is commonly thought of as lifestyle based, linked to our ultra-processed foods, obesity, and lack of exercise.
From this you might get the impression that Type 1 diabetes has been with us for ever but type 2 hasn’t. Sweet smelling urine was described by the Egyptian and Greeks over 2000 years ago – you instant reaction like mine may be surely this must have been Type 1. But it was only around 1890 that diabetes was linked to the pancreas, which is the organ attacked and destroyed in Type 1 Diabetes.
Type 2 Diabetes may go back to the Greeks also. Until a little over a century ago, diabetes was viewed in medical circles as a form of male hysteria – something linked to stress. It’s not just a modern sin.
After its discovery in 1922, insulin created the distinction between Type 1 and Type 2 diabetes. It was life-saving for Type 1. But by the 1930s it was clear there was a non-insulin dependent diabetes. Pharmaceutical companies began looking for treatments for this. Why chase medicines for T2D? Because that’s where the money was.
The first hypoglycemic drugs, carbutamide and tolbutamide, came onstream in the 1950s. Tolbutamide was put into a clinical trial in 1961, one of the biggest trials the NIH had ever conducted, comparing it to insulin, phentermine (a weight losing stimulant) and placebo. This trial had real outcomes – life or death – rather than a surrogate outcome – lowered blood sugar.
The results shaped the way drugs are regulated today. It became clear that a trial with life and death as an outcome might take 10 years to run. So FDA quietly abandoned this idea for licensing trials, substituting the quick fix of surrogate outcomes instead.
When the results of the trial became clear, things weren’t done so quietly – there was real consternation Tolbutamide was linked to far more deaths than insulin, phentermine of placebo – more than the number of US troops that had died in Vietnam. Industry created key opinion leaders and wheeled them out to rubbish these ludicrous results. How could a drug doing something obviously right be causing deaths? Lots of other trials had been done none of which found this crazy result. (Short-term trials).
Pharmageddon has a lot more about this key clinical trial.
Take 4
If depression is like diabetes, which kind? The mention of insulin hypnotizes everyone into thinking it’s Type 1 diabetes. Not surprisingly, this seems a ludicrous idea to most people.
Nine out of every ten cases of diabetes are Type 2. Before plunging in we probably should also say Type 1 Depression – melancholia or endogenous/ vital depression – is at most 1 in 10 cases of depression, possibly more like 1 in 20 or even 1 in 100 cases. Pre-SSRIs, Type 2 Depression used to be called anxiety or neurosis, which very few people viewed as a medical disease that would need lifelong insulin or anything.
So if we are comparing the common cold of mental health (T2Db) to the common form of diabetes, should we be telling people it’s like having Type 2 diabetes (T2Da)?
There is considerable evidence both conditions can be triggered by stress. While meds may be helpful, both it seems can be managed by lifestyle approaches. Whether or not the lifestyle measures like weight loss and exercise actually help a lot or just a bit, T2Db certainly and T2Da more often that we though often clear up in a few months with or without meds.
Quite apart from getting a diagnosis in your records that might not be helpful to have, perhaps the key point to think about before starting meds for either T2Da or T2Db is this. One of the key things that happens when you take a med is you take a gamble on control.
Before taking a T2Da med, you have a degree of control over your blood sugar. Once you start a T2Da med you relinquish some or maybe all control. You hand it over to the drug. Throwing in your own helpful dietary and exercise maneuvers risks causing hypoglycemia, which can cause dementia. Hypoglycemia is also more likely to land you in hospital than hyperglycemia.
Before taking a T2Db med, you have a degree of control over your mood. Once you start a T2Db med you relinquish some or maybe all control. You hand it over to a drug that may compromise your efforts to exert as much control as you would like ever again.
If it’s an SSRI, given the doses currently used, it will begin to convert muscles into fat. You will likely gain weight. Trying to exercise will become more fatiguing than it was. Your bones will thin. Your balance may be compromised.
There is a good chance you will end up in a prescribing cascade, getting a mood stabilizer like olanzapine to manage SSRI linked problems, which can trigger T2Db.
There may be good grounds to take a med for either T2Da or T2Db, but a good doctor should at least get you to think about your options.
S/he really should also tell you that you may not be able to get off your meds – T2Da or T2Db.
And let you know you are more likely to get a heart attack or stroke, to end up in hospital or dead prematurely as a result of your T2Db meds than you would by leaving a T2Db unmedicated – Antidepressants and Premature Death.
In brief, because Depression is so like Diabetes,
you should think about avoiding meds if possible.
NB
Melancholia on the other hand is not very like insulin-dependent diabetes. In the pre-treatment era, most cases of melancholia cleared up naturally in 5 to 6 months. It was not a particularly recurrent disorder.
Ireland can lay claim to very few pharmaceutical developments but in 1922 just as insulin was being discovered in Toronto, metformin was discovered in Dublin. It took a long time before anyone realized it could benefit many cases of T2Da, along it now seems with nervous disorders, epilepsy, PCOS and a range of other problems.
Another among the many Annemarie Mol books linked to taking back control of what we do is this fascinating book on Eating.
Peter Selley says
The data back up what you say, according to an NHS survey
Thinking about the last 12 months, to what extent do you agree or disagree with the following statement? ‘My diabetes is a constant worry’
61% with Type 1 and 37% with Type 2 agree
https://diabetessurvey.co.uk/ppt/NDES_National_Report_Public.pptx (powerpoint)
annie says
I take an interest in my long-time neighbour’s health and there is no escaping it as at 88, his ‘girlfrend’, and full-time companion tells all. He has for a long time been a Type 2 diabetic. Managed, with a medication, but in the last year he has had to start measuring and plotting his pricks, sending in results frequently. So lots of appointments hours away. Then he had a dizzy spell and I sat with him waiting for the ambulance, since his ‘partner’ had called the ambulance from a phone conversation she had with him. At the hospital he was deemed ok. A little while later she took him to the hospital again, sweating, dizzy, confused. He was told that it was very, very difficult to see if he had had a heart attack as he was a diabetic. He went off to a Glasgow hospital by helicopter. There, he was told he had heart damage. He was put on heart medication. Since then, he is very dizzy and walking is problematic. They keep changing his medication due to his dizzying symptoms.
In his early 80s, he was walking miles. His diet was mostly carbs, sweet treats and loads of salt. His calf muscles have now become so tight he can’t walk far. He is currently nonplussed ‘all I do is go from one hospital appointment to another. I never used to have all this carry on.’
The guy was a fitness fanatic, weights, a home cycle bike, always active. He wants to go to Texas to see his son and family.
Another neighbour had diabetes and had his big toe amputated and retreated in to misery.
‘One of the key things that happens when you take a med is you take a gamble on control.’
‘You hand it over to a drug that may compromise your efforts to exert as much control as you would like ever again.’
Many of us figure that bother doctors too much, and your life is completely turned on its head. When it is likely best to leave things well alone. At 74, I am on one lone 5mg. Amlodipine. I could probably chuck that if I made more effort. Every year I am invited for a health check for ‘bloods, blood pressure, and cholesterol. This year I had three calls. Two polite requesting my attendance. The third was more crispy ‘Would you call the surgery!’
My thoughts were if they saw an increase in blood pressure, I wouldn’t be inclined to take more medication. I would sort it. Cholesterol, it went up slightly a while ago, we might give you a statin. No you won’t, I will sort it.
I feel a stab of guilt not attending my health check. But, is it better for me to take control?
If I do have to go to see a doctor for something else, will they say we can’t treat you, if you don’t come..
Patrick Daniel Hahn says
My mother’s brother – my Uncle Phillip – was a bodybuilder as a young man. I’ve seen pictures of him from back then – he could have turned pro. But he quit and got fat, and in his sixties he developed Type II Diabetes. His doctor told him he could avoid going on insulin if he would lose a ridiculously small amount of weight – fifteen pounds. Not fifty – fifteen!
He said “No. my chief pleasure in life is eating. Gimmer my insulin.”
He died soon after, of ischemia.
Patrick Daniel Hahn says
So much of modern medicine consist of suppressing the body’s natural response to disease and stress. If you eat too much, of course your body will try to get rid of excess sugar in the urine. But the medical profession calls that Type II Diabetes. So what happens if you take a drug to force your cells to take up even more sugar (and presumably store it as fat)? Where does that excess fat go? To the liver, the heart muscle, to the coronary arteries? Could this explain the link between these drugs and liver failure, heart failure, and heart attacks?
Patrick Daniel Hahn says
As part of his settlement with GlaxoSmithKline, Eliot Spitzer required them to post all their clinical trial data on a website. Steve Nissen of the Cleveland Clinic noticed that GSK’s own data showed their blockbuster drug Avandia was killing hundreds of people a month.
Dr. Nissen once told me that none of the oral hypoglycemics had been shown to reduce the rate of death. That’s hasn’t stopped these drugs from becoming a fifty-billion-dollar-a-year-industry.
Patrick Daniel Hahn says
Spitzer had an annoying habit of insisting that drug companies operating in the State of New York had to obey the laws of the State of New York. He had an even more annoying habit of insisting that banks operating in the State of New York obey the laws of the State of New York. That’ s why the banks were happy to report him to the feds for not breaking the law, and that was the end of Spitzer’s political career.
annie says
This document is one of the most important in legal history.
“Today’s multi-billion dollar settlement is unprecedented in both size and scope. It underscores the Administration’s firm commitment to protecting the American people and holding accountable those who commit health care fraud,” said James M. Cole, Deputy Attorney General. “At every level, we are determined to stop practices that jeopardize patients’ health, harm taxpayers, and violate the public trust – and this historic action is a clear warning to any company that chooses to break the law.”
https://www.justice.gov/archives/opa/pr/glaxosmithkline-plead-guilty-and-pay-3-billion-resolve-fraud-allegations-and-failure-report
Off-Label Promotion and Kickbacks: The civil settlement resolves claims set forth in a complaint filed by the United States alleging that, in addition to promoting the drugs Paxil and Wellbutrin for unapproved, non-covered uses, GSK also promoted its asthma drug, Advair, for first-line therapy for mild asthma patients even though it was not approvedor medically appropriate under these circumstances. GSK also promoted Advair for chronic obstructive pulmonary disease with misleading claims as to the relevant treatment guidelines. The civil settlement also resolves allegations that GSK promoted Lamictal, an anti-epileptic medication, for off-label, non-covered psychiatric uses, neuropathic pain and pain management. It further resolves allegations that GSK promoted certain forms of Zofran, approved only for post-operative nausea, for the treatment of morning sickness in pregnant women. It also includes allegations that GSK paid kickbacks to health care professionals to induce them to promote and prescribe these drugs as well as the drugs Imitrex, Lotronex, Flovent and Valtrex. The United States alleges that this conduct caused false claims to be submitted to federal health care programs.
That is huge,” Mr Spitzer said.
Karen Barth Menzies, an industry critic and lawyer for Baum Hedlund, said the settlement was a step in the right direction. But she cautioned that as companies are not required to disclose raw data from clinical trials, they can mould summaries to potentially hide negative outcomes in trials.
https://archive.ph/2uUFK
Dr. David Healy says
I should make clear for the record that at the same time GSK were running into trouble with paroxetine/Paxil given for Type 2 Depression and causing suicide around 2004 and after, they were also running into serious trouble with rosiglitazone/ Avandia for Type 2 Diabetes.
D
Harriet Vogt says
I love what feels like a literary conceit – finally making the nonsensical antidepressant-insulin parallel make sense.
‘So if we are comparing the common cold of mental health (T2Db) to the common form of diabetes, should we be telling people it’s like having Type 2 diabetes (T2Da)?’
Bingo.
The way the system refuses to recognise that T2Da can be reversed is significant. Even though its own research has shown that sustained weight loss can result in lifelong ‘remission’ – reversal, no? – there is always the caveat:
‘Benefits of remission and weight loss
‘Staying in remission can be challenging. It is always possible that your blood sugar levels and weight can increase again, and you can go in and out of remission.’
https://www.diabetes.org.uk/about-us/news-and-views/weight-loss-can-put-type-2-diabetes-remission-least-five-years-reveal-latest-findings’-
What they fail to articulate here is that T2Da – just like T2Db – is significantly upweighted to deprivation – and thus the food insecurity and chronic stress that we know are drivers of insulin resistance, as well as despair (T2Db):
‘A Canadian study found that living in poverty at any time during a person’s lifespan increased the risk of type 2 diabetes by 26 percent, Evidence has shown that chronic stress (often associated with the daily experience of living in poverty) impacts on insulin resistance and can contribute to the development of insulin resistance.’
https://committees.parliament.uk/writtenevidence/129467/html/
I’ve questioned a few endocrinologists about the social drivers of T2Da – and why they medicate rather than focus on diet and proper support. The bottom line is really – risk to the system is more reliably managed with drugs. Missing the point. Just like black mothers in the US need universal child care, paid leave – and community support – not pills.
The mouldy leftovers on people’s medical notes are an unforgivable interference in their lives. Perfectly ridiculous that reversed – cured – pre-T2Da – should affect personal insurance costs.
And how about the ‘Active Problem List’ that sits on GP records -and highlights old or even ancient ‘psychiatric’ diagnoses? Cathy Wield was horrified to discover entries from over 20 years ago were termed ‘active problems’. And a marvellous woman, survivor of ‘psychiatric treatment’ ,author of ‘Dark Threads’, Jean Davison, still has her incarceration from about half a century ago listed as an ‘active problem’.
And we know what this means. A psychiatric diagnosis on your records almost invariably diminishes an individual’s authority about their own person – just as, seemingly, a pre-T2Da diagnosis undermines an individual’s credibility as the caretaker of their own body..
Dr. David Healy says
This is a great comment. Thanks
D
annie says
Depression Is to Diabetes as Antidepressants Are to Insulin: The Unraveling of an Analogy?
https://www.tandfonline.com/doi/full/10.1080/10410236.2012.753660
Abstract
The common comparison of depression to diabetes enables the construction of depression as a nonstigmatizing chronic illness that requires medication. We explore, through the use of discourse analysis, how both long-term users of antidepressants and family physicians invoked this analogy in research interviews. Specifically, we show how these participants explicitly or implicitly challenged the aptness of the depression–diabetes analogy as framed either within a generic (and presumably type 1) conception of diabetes or within the model of type 2 diabetes. These challenges include demonstrating how the elements or inferences of the analogy do not correspond, and how the analogy does not have its intended effects. We consider the implications of the unraveling of this analogy for the construction of depression as a chronic medical condition, for the supposed ease of prescribing and taking antidepressants, and for the reduction of stigma.
ACKNOWLEDGMENTS
This research was supported by a standard research grant from the Social Sciences and Humanities Research Council of Canada awarded to the first author. We thank the interviewees for their participation in our research.
Notes
1Up to at least 2006, the depression–diabetes analogy was prominent on publicly accessible websites for common antidepressants. For example, one of the “facts” on the website for Zoloft was that depression “is a real medical condition, like diabetes or arthritis”; the opening sentence from the section on Disease Information from the website for Prozac was, “As with illnesses such as diabetes or high blood pressure, depression can ‘run in your family’”; and in a section titled Understanding Depression from the website for Lexapro was the statement “And, just as there are treatments for conditions like diabetes and heart disease, there are treatment options available for depression.” Before 2012, all of these references had been removed from the websites and replaced by the black box warning about the potential for suicidality and other adverse reactions following use of antidepressants.
Dr. David Healy says
If you click on the link you will see that this is an article from 2013 which may partly explain the odd point about 2012 – Black Box Warnings had been on antidepressants from 2004.
D
chris says
“A psychiatric diagnosis on your records almost invariably diminishes an individual’s authority about their own person ”
It gets worse and goes beyond.
There are downright lies about psych patients and their treatments’ in their records. I was shocked not by the facts of the lies in my own case, but that they had used them in reply to a complaint they pretty much knew would go to the PHSO.
In an astonishing and very informative interview with psychiatrist Michael von Cranach he noted that you could tell the moment a psychiatist had decided to murder the patient by negative value judgments written in the patients notes after more hopeful and positive words re T4.
https://m.youtube.com/watch?v=4YU6CHaTWb0
And in our time a leak happened to the outside world bringing some truth of the circumstance. I’ve no doubt his suffering was horrific beyond their words:
https://www.independent.co.uk/news/health/nhs-mental-health-deaths-black-country-trust-hallam-street-b2857602.html
“According to a leaked internal review into his death, Adrian was left “terrified and confused”, became incontinent and had to be washed, dressed and fed with a spoon. Eighteen days later, while still at the hospital, his physical health deteriorated so badly that he collapsed and later died.”
Where are the police in all this, they have a room in this place where they see/interview the patients. Ofcourse there will be no prosecution of the people who caused this man’s death.
annie says
‘he noted that you could tell the moment a psychiatrist had decided to murder the patient’
It’s a Wonderful Life, until they get their hands on you, at the first negative barb, you should get out of there cos if you don’t it could get worse than your wildest dreams.
It never ceases to reverberate with me that as a ‘suicidal’ patient, I was left to roam the corridors for several hours. I was not missed, no one came looking for me. The fact that the plastic bag in the toilet was in there, not for any rubbish, but for any patient.
When I was at the peak of a fair degree of angst, I walked in to a police station, and the reply was “Good luck with that, we don’t deal in medical matters”. You are left to sue, the chances are fully against you, you can try a group action lawsuit, ie GSK, the judge will throw it out.
Murdering your patient, seems a right of passage. The sad and crazy fact is half the time they don’t even know they have done it, the other half is it will never be admitted.
The prickly heat of lackadaisical entwined with malicious intent.