Antidepressants, Alzheimer’s and Brain Injuries: making bad worse

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What we knew:lights-1088141__340

  • Use of antidepressants with Alzheimer’s patients increases the risk for falls and hip fractures
  • There is a protein found in the brain cells of persons with dementia and brain injuries that causes the Axon in the cell (electronic message transmitter) to swell and shut down. This protein is absent from normal cells. Elimination of the protein can cause the axon to start functioning again. (References are in previous blog.)

What the University of Eastern Finland has added to what we know:

  • Use of antidepressants with Alzheimer’s patients results in an increased incidence of traumatic brain injuries among these patients

The mechanism for the injury is probably falling. With slower mental processing and thus slower reflexes, these patients are less able to protect themselves when falling. That means a higher rate of concussions.

This ties back to another previous post on this blog — “deprescribing”. Drugs may have a value in one stage of a person’s life and be counterproductive at another stage. Doctors know how to prescribe drugs, but there are few protocols (apart for drug interactions) regarding when to stop taking a drug.  There is a group in Canada developing guidelines for deprescription, and while NIH has published articles on the topic, I’m not aware of any similar projects to develop guidelines in the US. Some US physicians appear to be doing this on an ad hoc basis.

I suspect deprescription is not a popular topic among pharmaceutical executives, but it needs to be addressed. Continuation of unnecessary medication is just one of many factors that bloats medical costs in the US — and why spending level no longer indicates quality of care. Unnecessary medication poses risks to some patients.


Sources:

  1. Heidi Taipale, Marjaana Koponen, Antti Tanskanen, Piia Lavikainen, Reijo Sund, Jari Tiihonen, Sirpa Hartikainen, Anna-Maija Tolppanen. Risk of head and traumatic brain injuries associated with antidepressant use among community-dwelling persons with Alzheimer’s disease: a nationwide matched cohort study. Alzheimer’s Research & Therapy, 2017; 9 (1) DOI: 10.1186/s13195-017-0285-3
  2. University of Eastern Finland. “Antidepressant use increases risk of head injuries among persons with Alzheimer’s disease.” ScienceDaily. ScienceDaily, 9 August 2017. <www.sciencedaily.com/releases/2017/08/170809073627.htm>.
  3. Gurusamy Sivagnanam, “Deprescription: The prescription metabolism,”
    J Pharmacol Pharmacother. 2016 Jul-Sep; 7(3): 133–137.
    doi:  10.4103/0976-500X.189680
  4. http://deprescribing.org/
  5. http://www.drjohnm.org/2014/10/to-deprescribe-adding-a-new-verb-to-the-language-of-doctoring/
  6. Joaquín Hortal Carmon, IvánAguilar Cruz, FranciscoParrilla Ruiz, “A prudent deprescription model,” Science Direct, Medicina Clínica, Volume 144, Issue 8, 20 April 2015, Pages 362-369.

 

Drug Profits in the US: Who Gets What?

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Conflicts-of-interest in the distribution of prescription drugs are driving health pillsinsurance costs higher in the US.

The Wall Street Journal analysis uses the example of the EpiPen, a drug used to counter life-threatening allergic reactions.

The example illustrates two points about prescription drug distribution in the US:

  • Who the players are
  • How the system misfires

The bottom line is that many consumers are being incentivized to use the more expensive brand name product rather than much less expensive generic version. Insurers are eating the costs of the brand name version, which in turn shows up in insurance rates for the following year.

To be clear, this is the private sector misfiring on its own, with tacit permission from Congress.

Pharmaceutical distribution in the US involves six players. The profit percentages are based on the EpiPen example and will vary for  other drugs and insurance plans. In that example, at a list price of $300, the actual money changing hands with insurance is $220. (The consumer without insurance is out the full $300, but that’s another issue.)

  • The consumer who buys the drug ($35 out of pocket)
  • The plan sponsor or insurer who pays much of the cost of the drug ($185)
  • The pharmacy, which earns 7% on the drug (in this case, $16)
  • A wholesaler, which may take a 1% profit on the drug ($3)
  • The drugmaker (62% or $137)
  • The pharmacy benefit manager (PBM, 8% or $18)

(The numbers are approximately and don’t add up because of other markups, discounts and rebates involved in the prescription process.)

The benefit manager is the player with which most consumers are unfamiliar. His/her job is to design benefit plans and negotiate discounts and rebates with drugmakers that are distributed to pharmacies and wholesalers.

The benefit manager is potentially subject to a conflict of interest. In the EpiPen case, the Journal asserts that the benefit manager receives a higher fee for designing plans that promote the use of the more expensive brand name drug. Thus a plan may

  1. Feature the same out of pocket cost (copay) to the consumer for the brand name as for the generic, even though the actual cost of the two is quite different; or
  2. Offer a lower copay for the brand name.

An attentive pharmacist will recommend that the consumer buy whatever is less expensive — the pharmacist has no direct concern with what the insurer pays, and may not in fact know. CVS, for example, does not provide that information it its staff.

This isn’t the first time that analysts have flagged conflicts of interest with PBMs. The issue has arisen previously with regard to

  • Major pharmacy chains having in-house PBMs
  • PBMs owning mail order pharmacies.

In both cases, the PBM has an interest in maximizing its own revenue rather than minimizing costs to insurers, plan sponsors or consumers.

How can this happen? Pretty easily actually, if the plan sponsor or insurer is inattentive to what the benefit manager is doing.  With the myriad of drugs on the market, this inattention is understandable if not excusable.

Interesting question: Who’s better at policing drug prices — traditional insurers or large companies running self-insured drug plans? Or is there a different?

What you need to consider:

  1. As a consumer, it’s in your interest to buy generic drugs even if the brand name has the same copay — if the brand name and copay are equally effective. Someone is paying the higher price for the brand name, and that extra cost will show up in insurance rate increases in your future.
  2. Drug companies may offer coupons for both brand name and generic products, but may only distribute the coupons for the brand name. You may have to ask to get the coupon for the generic.
  3. You always need to ask the pharmacist if a generic is available for any brand name prescription. Ignorance can hurt you.

 


Sources:

  1. Jonathan Rockoff, “Behind the Push for High-Price EpiPen,” The Wall Street Journal, 7 August 2017, page B3.
  2. Applied Policy, “Concerns Regarding the Pharmacy Benefit Management Industry,” November 2015. http://www.ncpa.co/pdf/applied-policy-issue-brief.pdf
  3. Brian Friedman, “Big pharmacies are dismantling the industry that keeps US drug costs even sort-of under control,” Quartz, 17 March 2016. https://qz.com/636823/big-pharmacies-are-dismantling-the-industry-that-keeps-us-drug-costs-even-sort-of-under-control/
  4. http://www.pbmwatch.com/conflicts-of-interest.html

Situational American Morality

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A new study from the University of Illinois at Chicago has implications for both politicians and advertisers — and should scare anyone who cares about ethics.

The study involved having consumers

. . . read a political monologue about federal funding for Planned Parenthood that they believed was previously aired over public radio.

Respondents were randomly assigned one of two feedback conditions where upon completion they were informed that the monologue they had just read was either true or false.

Consumers were then asked whether they felt the monologue was justified. The bottom line:

  1. If the consumer agreed with the monologue, they were less critical of it, regardless of whether they were told it was true or false.
  2. If the consumer disagreed with the monologue, they were more critical of it regardless of whether they were told it was true or false.

In other words, in today’s America, it doesn’t matter if someone is telling the truth or lying as long as the consumer agrees with what they are saying. Functionally, that’s a blank check for a politician or advertiser to say anything as long as it includes something the consumer wants to hear.

Unfortunately, this “culture of lying” has consequences. It affects where people want to live, work and spend their money.

As an Airbnb host, we’ve been getting an earful from foreign travelers who don’t want to live here as well as workers who are asking for transfer back to their home countries. We have a doctor who views the level of medical errors in the US as unacceptable and disgusting. We have the Irani who says that, if she becomes ill, she will return to Iran for treatment rather than seek treatment in the US. We have a mother from Europe who is leaving so her daughter won’t become “Americanized”. We have the black teacher who grew up in the US and now works in Saudi Arabia, and says that her quality of life is better there than it ever was in the US.

We have the realtor from Kansas who lives in an American enclave near Mexico City and has seen a 41% increase in sales to Americans moving south this year. Mexico claims that it has 2 million Yanquis living there, most undocumented immigrants. South Korea has close to 1 million Yankee civilians; there are other large pockets in UK, Saudi Arabia, Costa Rica, Australia and other countries. The US Government itself is mum on the number of Americans leaving the country. (All of these numbers exclude military and government personnel stationed outside the US.)

A primary complaint among expats is that they want to escape what the US political culture has become. That brings us back to our topic — the moral acceptability of lying.

For some of us, lying remains unacceptable regardless of the excuse.


Sources:

  1. Allison B. Mueller, Linda J. Skitka. Liars, Damned Liars, and Zealots. Social Psychological and Personality Science, 2017; 194855061772027 DOI: 10.1177/1948550617720272
  2. University of Illinois at Chicago. “We tolerate political lies for shared views, study suggests.” ScienceDaily. ScienceDaily, 3 August 2017. <www.sciencedaily.com/releases/2017/08/170803145640.htm>

Jumpstarting Yourself

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If you read, every once in a while, you’ll find something and say, “why does that just apply to X? Why wouldn’t that work for Y, Z  and W?”

Sometimes, the topic is medical — like noticing that the same protein is involved in both Alzheimer’s and concussions. (See previous blog.) Sometimes, the topic is far more universal.

Science Daily reports on a mind-training technique that improves the performance of athletes. (1) From the brief description, the program uses a step method (what program these days doesn’t?) and meditation to enable athletes to exclude mental distraction and focus on performance. Athletes who have gone through the program have been able to improve performance and importantly maintain the improvement over time.

The authors talk about enabling the athlete to block out distractions such as anxiety.

The basic premise is that half of athletic performance is mental and that conventional sports training ignores that aspect of the game.

I can certainly accept that. Great athletes have the ability to pay attention at a greater level than others. It’s said that legendary hitter Carl Yastrezmski could see the spin on a fastball and legendary racer Dale Earnhardt could see the wind coming off the car in front of him. The difference from others is in their uncanny ability to focus.

What could you do with that ability?

The larger questions is: what human activity isn’t at least 50% mental? That rule seems to apply to everything including sex.

  • Great levers aren’t great because of some physical attribute but because of their ability to focus on their partner.
  • Great teachers can sense what their students needs, whether the student is a visual or oral learner or requires some other form of coaching and instruction.
  • Great leaders don’t just have vision about where to go, but the ability to motivate their followers or employees — knowing what will get them going.

We even know that the ability to survive and recover from serious illness is largely mental. Part of the sales pitch for supplemental insurance is about removing financial distractions to enable patients to focus on recovery.

And who doesn’t have distractions like anxiety?

So, who wouldn’t benefit from “mindfulness training”? The authors focus on athletes because of the money to be made there, but the concept applies to everyone in all aspects of life.

I’m not endorsing the book or specific method that’s the subject of this citation. However, there’s a lot to be said for improving the ability to focus and exclude distractions. The ability to focus can improve everything you do. There are a number of roads to that goal — including meditation and tai chi. Which method will work for you is something you learn by trying. So try.

There’s even an app for that!  (4) No, I’m not endorsing that either, at least not until I try it myself.

 


Sources:

  1. American Psychological Association. “New mindfulness method helps coaches, athletes score: Sessions can help athletes at all levels develop mental edge, psychologist says.” ScienceDaily. ScienceDaily, 4 August 2017. http://www.sciencedaily.com/releases/2017/08/170804091350.htm.
  2. https://greatergood.berkeley.edu/mindfulness/definition
  3. https://www.pocketmindfulness.com/6-mindfulness-exercises-you-can-try-today/
  4. https://itunes.apple.com/us/app/the-mindfulness-app-meditation-for-everyone/id417071430?mt=8

The Groupthink Epidemic

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Groupthink, a term coined by social psychologist Irving Janis (1972), occurs when a group makes faulty decisions because group pressures lead to a deterioration of “mental efficiency, reality testing, and moral judgment”.  Groups affected by groupthink ignore alternatives and tend to take irrational actions that dehumanize other groups.  A group is especially vulnerable to groupthink when its members are similar in background, when the group is insulated from outside opinions, and when there are no clear rules fGroupThink-300x141or decision making. (1)

Simply, this is how companies, governments, investors and families and individuals drive themselves over cliffs:

  • Bad mergers
  • Bad proposed laws or invasions
  • Investment fads
  • Poor decisions about marriage, divorce of having kids
  • Suicide bombers

just to name a few examples.

The process is pretty simple.  You surround yourself with people who share your opinions and use that agreement to reinforce your beliefs regardless of any contradictory information. Then you make important decisions based on those beliefs. Then you just have to wait for the crash.

No one is immune from groupthink. In fact, human nature tends to encourage it. Most people are conflict-adverse. They don’t like tension. They don’t like disagreement. So they gravitate to people who share like opinions and don’t say anything if they disagree.

Companies make merger decisions based in part on groupthink, which helps to explain why 90% of them fail. Spend a lot of money to buy a company, then sell it cheap when the merger fails. Great for shareholder value.  Examples:

  • 2008 Arby’s acquisition of Wendy’s. That merger lasted 3 years.
  • Also in 2008, Bank of America’s purchase of Countrywide financial. “The bank paid just $2.5 billion for Countrywide, a deal that ended up costing the bank more than $40 billion.”(2)
  • The combination of K-Mart and Sears. Yep, that’s worked.

Politicians and generals make bad decisions on a regular basis.

  • How about the 2003 invasion of Iraq, looking for phantom weapons of mass destruction. Despite the evidence, some people still believe they were real, instead of the imagining of disgruntled Iraqi emigres who wanted the US to toss Sadam.
  • What about the current debacle over healthcare reform? Clearly a group in the Trump administration felt that Congress would submissively obey their demands.

The fiberoptic cable investment bubble of the late 1990s is an example of groupthink. It was mathematically impossible for demand to double every year, but during the bubble, no one thought about it.

Marriages can begin or end influenced by groupthink. In this case, it’s called peer pressure, but that may not be as good a term. Being surrounded by people who think a marriage or divorce should happen increases the odds that it will happen.

Suicide bombers? How does anyone with any intelligence convince themselves that there are 46 virgins waiting to greet them in an afterlife? By surrounding themselves with people who share the fantasy and drawing strength of conviction of peers. To some extent, that’s how every religion and political movement works.

How do you avoid groupthink?

  1. Recognize that smart people will have different points of view on virtually any important issue.
  2. Surround yourself with smart people, not “yes people”.
  3. Listen to differing points of view. Encourage debate. Understand the values that are competing in any decision.
  4. Avoid labels that antagonize. They inhibit open discussion.
  5. Find data that both support and contradict. Don’t ignore data that disagree. Instead, figure out how it makes sense and how it changes the decisions you need to make.
  6. Read Kuhn’s “Structure of Scientific Revolutions.” This thin book should be required reading for anyone with a brain.

Above all, remember, humans don’t do perfect. If you think something is perfect, you’re missing something important. If you think you have all the answers, you’re wrong. Unless you’re a god, of course.


Sources:

  1. http://www.psysr.org/about/pubs_resources/groupthink%20overview.htm
  2. Huffington Post, “9 Mergers that Epically Failed,” 23 February 2013. http://www.huffingtonpost.com/2013/02/23/worst-mergers-of-all-time_n_2720121.html
  3. “5 Odd Things that Raise Your Chances of Divorce,” Newser, 2 June 2015. http://www.newser.com/story/207687/5-odd-things-that-raise-your-chances-of-divorce.html

Stress and Health

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Everybody has a story.

  • The unreasonable boss or lousy job,ben_franklin
  • The injury or illness
  • Money problems
  • The loved one with an addiction
  • Something.

Most of the stories are real — things with which the person has to deal every day. (A few people make up stories to get attention; that’s a different topic for another time.)

In the lexicon of research, all of these things are stimuli. They’re things that happen that require some kind of response. In physics, Newton’s Third Law makes it easy —

For every action, there is an equal but opposite reaction.

Unfortunately, that doesn’t apply to thought and emotions. Instead, human responses can be —

  • Proportional (optimal)
  • Inadequate (hypofunction/allostasis, or inadequate adaptation to a stimuli)
  • Excessive (hyperfunction).

In neurology, these stimuli are called “stressors.” How you respond to them is the “stress response” or “stress.” Stressors are perceived threats, and the human body reacts to them in ways not unlike when early humans stumbled into the path of a dinosaur. The body releases a variety of hormones that impact almost all major systems in the body.

The stress response is mediated by the stress system, partly located in the central nervous system and partly in peripheral organs. The central, greatly interconnected effectors of this system include the hypothalamic hormones arginine vasopressin, corticotropin-releasing hormone and pro-opiomelanocortin-derived peptides, and the locus ceruleus and autonomic norepinephrine centers in the brainstem. Targets of these effectors include the executive and/or cognitive, reward and fear systems, the wake–sleep centers of the brain, the growth, reproductive and thyroid hormone axes, and the gastrointestinal, cardiorespiratory, metabolic, and immune systems.  (1, emphasis added)

Inadequate or excessive stress reactions are linked to a massive array of both physical and behavioral problems.

  • Physical: Asthma, exzema, migraines, low or high blood pressure, cardiovascular disease, indigestion, diarrhea, constipation, obesity and Type II diabetes, sleep disorders, panic attacks and psychotic episodes. In children, it may be related to stunted growth. In women, osteoporosis.
    • Recent research is placing greater emphasis on the role of stress in cardiovascular disease.(2)
  • Emotional: Anxiety, depression, mental errors, loss of sex drive, OCD, alcoholism, etc.

Dr. Chrousos argues that stress response hormones were designed for limited use (e.g., see dinosaur, release hormones; lose dinosaur, stop release). In the modern environment in which stressors operate continuously over a long period of time (e.g., the bad boss), long term release of these hormones can have profound negative effects on the functioning of the body.

The portion of the brain that controls emotions is the amygdala. Recent research has shows that severe stressors cause physical chances in the amygdala, most notably enlarging it. (3)

What’s Important to Know:

  1. Stress (or the stress response) is inside you. It’s not what someone does to you; it’s how you react.
  2. Some of the stress response is automatic. You don’t tell you body to release hormones. And when someone is chasing you down a dark alley, be grateful that’s true.
  3. However, you may have some ability to influence how long those hormones are released and the damage your body sustains.
    • You can take yourself out of a stressful situation.
    • You can “let go” of something that’s happened after it’s over.
    • You can use meditation, yoga, tai chi or other tools to moderate reaction to stressors.

Keeping the stress reaction alive when it’s not needed hurts you, not the stressor.

 


Sources:

  1. George P. Chrousos, “Stress and Disorders of the Stress System,” Medscape, 2009. http://www.medscape.com/viewarticle/704866
    Dr. Crousos is professor and chair of the Department of Pediatrics at the University of Athens, Greece. With 1,100 articles, he is one of the most quoted doctors and researchers on the planet.
  2. Marlene Busko, “Study Links Stress-Related Amygdala Activity to Future CVD Events,” Medscape, 13 January 2017. http://www.medscape.com/viewarticle/874435
  3. Megan Brooks, “PTSD May Be Physical, Not Just Psychological,” Medscape, 21 July 2017. http://www.medscape.com/viewarticle/883251

 

Coffee Addicts Rejoice!

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Coffee might actually be very good for you.

You’ve probably heard some of this online in the last couple of days, but not the full story. That’s unfolded over two years, and Facebook and News sites don’t have that kind of memory.

Here’s a litany of documented health benefits of drinking coffee.

Before I go into the list, there are two one big caveats.

  1. If you drink overly hot beverages of any kind — hot enough to burn the lining of your throat — you can be setting yourself up for Barrett’s Syndrome and esophageal cancer. Aristotle extolled the virtue of moderation, and moderation in this case includes temperature.
  2. It is possible to overdose on caffeine. I knew someone in college who had to be hospitalized due to excessive consumption of caffeine via a carbonated soda, Tab. In fact, caffeine overdose was cited as the cause of death of a teenage in May of this year. (1) That case was also related to soda, not coffee. Aristotle is correct again. Moderation includes caffeine consumption.

However, there are a number of important documented benefits from drinking coffee:

  • People who drink coffee appear to live longer.  In an analysis by researchers at the University of Southern California,

Drinking coffee was associated with a lower risk of death due to heart disease, cancer, stroke, diabetes, and respiratory and kidney disease for African-Americans, Japanese-Americans, Latinos and whites.(2, 4)

Previous research by USC and others have indicated that drinking coffee is associated with reduced risk of several types of cancer, diabetes, liver disease, Parkinson’s disease, Type 2 diabetes and other chronic diseases.(4)

According to one of the lead researchers,

“We cannot say drinking coffee will prolong your life, but we see an association,” Setiawan said. “If you like to drink coffee, drink up! If you’re not a coffee drinker, then you need to consider if you should start.”(4)

  • Coffee-drinkers have better sex.  According to a report from the University of Texas in 2015, males consuming two to three cups of coffee per day reduce their risk of erectile dysfunction.(5)
  • She might actually remember it. Seriously, another study from 2016 supports a role of caffeine helping reduce the risk of dementia among women.(6)

So, enjoy coffee but skip the decaf (unless your doctor says otherwise). Caffeine might actually be good for you.


Sources:

  1. http://www.nbcnews.com/health/health-news/south-carolina-teen-died-caffeine-overdose-coroner-rules-n759716
  2. Marc J. Gunter et al. Coffee Drinking and Mortality in 10 European Countries: A Multinational Cohort Study. Annals of Internal Medicine, 2017 DOI: 10.7326/M16-2945
  3. Song-Yi Park et al. Association of Coffee Consumption With Total and Cause-Specific Mortality Among Nonwhite Populations. Annals of Internal Medicine, 2017 DOI: 10.7326/M16-2472
  4. University of Southern California. “Drinking coffee could lead to a longer life, scientist says: Whether it’s caffeinated or decaffeinated, coffee is associated with lower mortality, which suggests the association is not tied to caffeine.” ScienceDaily. ScienceDaily, 10 July 2017. <www.sciencedaily.com/releases/2017/07/170710172118.htm>.
  5. David S. Lopez, Run Wang, Konstantinos K. Tsilidis, Huirong Zhu, Carrie R. Daniel, Arup Sinha, Steven Canfield. Role of Caffeine Intake on Erectile Dysfunction in US Men: Results from NHANES 2001-2004. PLOS ONE, 2015; 10 (4): e0123547 DOI: 10.1371/journal.pone.0123547
  6. Ira Driscoll, Sally A. Shumaker, Beverly M. Snively, Karen L. Margolis, JoAnn E. Manson, Mara Z. Vitolins, Rebecca C. Rossom, Mark A. Espeland. Relationships Between Caffeine Intake and Risk for Probable Dementia or Global Cognitive Impairment: The Women’s Health Initiative Memory Study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2016; glw078 DOI: 10.1093/gerona/glw078