Readers respond to OTC antidepressants, personalized medicine, restoring trust in public health, and more

STAT publishes selected Letters to the Editor received in response to First Opinion essays to encourage robust, good-faith discussion about difficult issues. Submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay.

On “not looking away,” by Patrick Skerrett

A recent First Opinion newsletter drew attention to Carlinville, Ill., which was taking in a refugee family at a time the world is witnessing a growing number of global extremist conflicts and civil wars, killing and displacing vast numbers of innocent children and adults.

For more than 20 years, my wife and I have spent increasing time in the rural village of Conques in south-central France, which is comprised of about 300 homes. In 2016, the people of Conques took in, housed, and provided work opportunities for a family (a mother, father and four children) from the Sudan. I have seen these children grow into their teens, prospering emotionally and educationally.

The village also hosts, several times a year — for respite and spiritual recovery — groups of 20 or more young men and women who escaped from torture and ransom camps in Ethiopia, Eritrea, Sudan, Somalia, tribal Kenya, and the Republic of Congo, and who are now leading impoverished, though safe, lives in the outskirts of Paris, thanks to Limbo, a French nongovernmental organization.

Conques and Carlinville live by an ethos of intentional acts of kindness. A kindness that begets more kindness and nurtures hope. They also embody the message of “On Not Looking Away,” an essay by Sandro Galea, the dean of the Boston University School of Public Health. Never Look Away is a message as enduring as the King James Bible: “Open thou mine eyes, that I may behold wondrous things out of thy law”.

By not looking away, we open our eyes and minds to the possibility of the safer, kinder world that eludes us today. That’s where we can start.

— Lloyd I. Sederer, M.D., Adjunct Professor, Columbia/Mailman School of Public Health

“A nation with too few pediatricians could see health care costs soar,” by Sallie Permar and Robert J. Vinci

Pediatric care is at a pivotal moment, calling for a critical examination of academicians themselves and their actions that inadvertently keep pediatricians away from the communities they are trained to serve. The traditional emphasis on training, compensation structures, and financial incentives within academic settings has contributed to a concerning trend: an increasing number of pediatricians are being drawn away from community-based practice. This shift not only impacts the accessibility of pediatric care in underserved areas but also raises questions about the equitable distribution of health care resources.

Academic institutions must reconsider their approach to pediatric training. The focus should extend beyond hospital-based care to include comprehensive community-oriented pediatrics, preparing medical students and residents for a wide range of environments. Additionally, compensation incentives and loan repayment offerings currently skewed towards specialists and hospitalists need to be reevaluated. By creating more equitable incentives that also value primary care and community-based practice, we can encourage more pediatricians to serve where they are most needed.

The growing divide between C-suite compensation and the earnings of pediatricians directly involved in patient care reflects broader systemic issues within health care. Academic centers, while achieving record profits, must reassess their financial priorities to ensure that resources are allocated in a manner that supports the core mission of pediatrics: to care for all children, irrespective of where they live.

Addressing these challenges requires a collective effort to shift the focus back to relationships, continuity of care, breaking silos, re-engaging community-based care and moving from fee-for-service to value. This involves reimagining our own training programs for medical students and residents for them to understand the “why” of pediatrics. Rewards are much greater than compensation. Only by making these systemic changes ourselves can we begin to bridge the gap between academic pediatrics and community health care needs, ensuring that every child has access to high-quality, compassionate care.

— J. Michael Connors M.D.

***

Drs. Permar and Vinci have clearly pointed out the impact that a reduced number of pediatricians will, eventually, have on the health care system for all Americans. It is beyond time for the policy-makers to recognize the impact of childhood health on the health of adults.

The only thing I would point out is that the authors’ use of the word “reimbursement” is incorrect. Pediatricians are not “reimbursed” for anything — we are paid for the services we provide to the nation’s children. And the major reason that fewer medical school graduates are choosing to enter pediatrics as a career is that pediatricians are not PAID appropriately for the incredibly valuable services we provide to children, as discussed by Permar and Vinci. This is unsustainable given the costs of medical education and practice operation.

— Jesse Hackell

“Does addiction make you un-American?” by Giorgi Minasovi and Jonathan JK Stoltman

Change the law if you need to help people. However, be sure they want the help and are willing to do the work it takes to be a productive member of society, as well as assimilate to our culture.

—Nicholas Antos

“Personalized medicine: We’re not there yet,” by Edward Abrahams and Christopher Wells

Bravo for this essay.

I recently sent a letter to our clients who are storing cord blood progenitors for personalized, predictive, and precision medical applications about fiscal issues downstream in the utilization of these cells for new therapies. My worry is that these putative stem cells may become underutilized because of costs in the future when new therapies using stem cells become available. I have invited our clientele to join me in finding solutions to this impending problem. This essay supports my assertion that the fiscal issues that might hinder the usefulness of personalized medicine need to be dealt with at the same time as we continue our progress towards large-scale implementation of this innovative field of medicine. This compelling essay is timely and should be widely read in order for the appropriate actions to be put in place before the issue is upon us.

— John Akabutu, M.D. University of Alberta and the Canadian Cord Blood bioRepository

***

Spot on! Just read The Age of Scientific Wellness by LeRoy Hood, M.D., and am having biome gene sequencing done!

— Paul Snyder

“The time has come for over-the-counter antidepressants,” by Roy Perlis

Yikes, where do I start with this one? The absolute gall of Perlis to cite the STAR*D trial after the researchers involved were exposed for grossly misrepresenting the clinical data…to not disclose his numerous ties to drug companies…to downplay the very real risk for violence associated with antidepressants that have been explored in Dr. David Healy’s work…to overstate psychiatry’s understanding of “mental illness” and it’s supposed biological/genetic origins…but worst of all, to steer people toward what’s ultimately a temporary band-aid instead of toward lasting healing for folks in dire need. Shame on you, Perlis.

— Maxwell Thompson

***

I have read with interest Dr. Perlis’s article supporting the over-the-counter availability of antidepressants. Although increasing access to psychiatric care is a national priority, this proposed solution is likely to have disastrous consequences.

Antidepressants have tangible risks associated with short and long-term use that extend far beyond suicide risk. As a class, SSRIs are clearly associated with an increased risk of bleeds and reduced sodium levels which can lead to confusion and delirium in vulnerable persons. Patients with a vulnerability to bipolar disorder may develop mania when taking antidepressants for self-diagnosed depression or anxiety. Daily use of antidepressants for at least 4 weeks is associated with dependence (not addiction) that may lead to severe withdrawal symptoms in at least 50% of patients who stop treatment. There are also several critical interactions between antidepressants and several non-psychiatric drugs. For instance, fluoxetine, paroxetine and bupropion can render tamoxifen ineffective in preventing breast cancer recurrence.

Although antidepressants are not controlled substances, they are not benign medications and warrant a comprehensive clinical evaluation with an appropriate risk-benefit analysis.

— Bryan Shapiro, M.D., UC Irvine Medical Center

***

The recommendation for OTC availability of SSRI’s is based on the assumption that these drugs are safe and effective, as Prof. Perlis claims. However, efficacy is, on average, below common criteria for clinical significance. Together with the known common harms, for example sexual dysfunctions for up to 80% (compared to ca. 13% on placebo), or withdrawal issues, this creates a problematic harm/benefit ratio for the majority of patients. Thus, it is not surprising when a recent study found that, for most people, SSRI’s would not meet criteria for a smallest worthwhile difference, when compared to no treatment. Even high-ranked psychiatrists such as David Nutt recently wrote that “Even the best-performing antidepressant drugs show modest efficacy, non-negligible side effects, discontinuation problems and high relapse rates, highlighting the need for new, improved treatments.”

Furthermore, the claim that, for adult patients, “there is clear evidence that taking antidepressants does not increase the risk for suicide” is problematic, as it is based on short-term clinical trials only. In longer-term clinical trials and in observational studies, there was in increased risk for suicidal behavior for antidepressants. A statement such as “there is clear evidence that taking antidepressants does not decrease the risk for suicide for the average patient; rather, there is evidence that there is an increase of suicide risk” would be more in accordance with the evidence. This is astonishing for a drug that is claimed to effectively reduce depression, one of the most important risk factors for suicide.

There are also other problematic statements. For example, one neuroimaging study Prof. Perlis referenced found differences between depressed and non-depressed people. However, this could not be successfully replicated. Larger studies and reviews on the biomarkers for depression found that brains of depressed and non-depressed people are remarkable similar, and the tiny differences are not in any way clinically useful for diagnoses and treatment. Perlis also refers to a study which found 100 genes to be associated with depression but missed to mention that very large studies failed to replicate findings on candidate genes, and overall, the variance explained by genes is small.

A minority of patients may clearly benefit from antidepressants, but we don’t know who these are, despite massive efforts to find predictors. The suggestion to provide SSRI’s OTC may create more harm than benefit.

References and more elaborated arguments are available here:

— Martin Plöderl

***

I have suffered with depression since I was a child. I have heard few more reckless ideas. There’s a reason there’s a black box warning on every one of the SSRIs/SSNRIs. I’m that reason. If antidepressants were over the counter, I would be dead. Every single one has made me suicidal. Also without a diagnosis you might be taking your over the counter antidepressant when you really need a mood stabilizer. As someone who struggles with feelings of depression almost every day, it is extremely reckless to publish such an irrational article.

— Jerry Bruno

***

Dr. Roy Perlis responds:

I was distressed that so many of the responses to my commentary elected to spread misinformation about major depression and SSRIs rather than addressing the fundamental concern I raise: access to adequate mental health care, much less excellent mental health care, remains elusive for too many people in the United States.

The COVID-19 pandemic showed how readily misinformation is spread, launching the term infodemic. To its credit, STAT’s First Opinions strives for transparency in debate, but this also allows misinformation — about the effectiveness of antidepressants, for example — to be propagated. Asserting falsehoods about antidepressants poses real risk of harm in dissuading people from seeking treatment. There are real debates to be had about the magnitude of benefit, and who derives greatest benefit, but there’s no debate that many, many people do benefit, or could if they could access care.

I recognize that some people can be harmed by antidepressants, as is true for any medicine. In fact, my colleagues and I were among those who sounded alarms about these risks with SSRIs – including suicidality, switch into mania, bleeding risk, effects on heart rhythms, and weight gain. I have heard directly from many people who experienced harms in the past several days; the common element in most of them is feeling like their physician did not listen, or dismissed their concerns. That is unacceptable.

The very real benefits of these medicines must be balanced against this possibility of harm. In fact, the FDA adds a boxed warning to medications, including antidepressants as a class, to highlight the risk for serious adverse reactions – more than 400 marketed medications have such a warning, including ibuprofen. Any effort to market an SSRI over the counter would require additional protections, perhaps via the FDA’s ‘Additional Conditions for Nonprescription Use’.

I continue to hope that we can have a conversation about why so many people who could benefit from evidence-based depression treatment cannot access it – regardless of what treatment they might choose.

“To rebuild trust in public health: Better communication, fewer mandates, and small wins,” by Tom Frieden

I couldn’t help but feel like “public health” is being blamed for the very high level of distrust. Sure, there were many things public health professionals got wrong. Public health can do all the things suggested in this piece, but it will fail if politicians use the public’s health as a tool for personal gain. Our country is more anti-science now than it ever has been. Is that public health’s fault? I think public health should have been much more conservative from the start of the pandemic and peeled away layers as more info came to light. Pretending SARS-CoV-2 wasn’t airborne was a huge public health fail, in my view. I would argue, however, that much of that had to do with politicians (again!).

Dr. Frieden calls out mandates. The backlash against mask mandates had everything to do with politicians seizing Covid-19 as a political weapon for personal gain. (Interestingly, many of those same politicians have no issue mandating what a woman can/can’t do with her own body.) The prevalence of distrust can’t all be blamed on public health’s shortcomings and this piece made me feel that way. The majority of that distrust is a direct result of power-hungry people looking to take advantage of people’s fears for their own gain. As public health professionals, we should become more involved in politics as it seems that is the crux of public health and where we can make the most impact.

— Grazia Cunningham

If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.