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Snake Oil

Posted by Dr No on 18 January 2010

prozac.jpgYet another study has been published showing that prescription antidepressants are no better than snake oil - that is to say, placebo, or sugar-pill - for treating mild to moderate depression. Yet in 2008 - the latest year that figures are available for - UK doctors doled out a staggering 36 million prescriptions for antidepressants to patients - almost enough for one prescription for every adult.

How can this be? To answer this question, we have to go a bit further than the usual – and highly important – profit motive of Big Pharma. We have to ask the question: why is it so easy for Big Parma to shift 36 million prescriptions a year? The answer lies in the history and nature of General Practice - which is of course where the vast majority of these prescriptions are issued.

Historically, the medical profession had three main branches. First there were the physicians, traditionally university educated learned gentlemen who would arrive and leave by the front door. They provided opinions (diagnosis), and sometimes ‘physic’. Then there were the surgeons, descended from the barber-surgeons (and so not learned, which is why to this day we call surgeons “Mr” rather than “Dr”), who would arrive by the tradesmen’s door, and cut you open on the kitchen table. And then there were the apothecaries – the corner shop chemists who you would visit, to buy pills and potions, and brightly coloured remedies, much of it snake oil.

Over the last century, and particularly with the introduction of National Insurance and then the National Health Service, these three branches of medicine became assimilated into the organisations we see today. The physicians and surgeons became increasingly hospital bound, and provide secondary care, while the apothecaries evolved into a new form of practitioner – the General Practitioner - who would provide primary care in the community, from their own premises. The corner shop chemist became the Surgery on the Corner.

Because a visit to the apothecary was at heart a shopping trip, no appointment was needed, and the encounter brief. The customer would describe their problem, and the apothecary would provide a remedy. Goods and money would change hands. The customer would not expect to come away empty handed…

With the full implementation of the NHS, the payment side of the equation was done at a remove by taxation. But in other respects the encounter remains largely unchanged. That is why general practice consultations – until recently – did not require an appointment, are still short, and why there is so often an expectation – on both sides – that something, usually a prescription, will change hands.

Dr No is not for a moment suggesting that all GPs are closet shopkeepers. But he does think old habits die hard. Until recently, the ‘goods’ were antibiotics. Nowadays it appears they are antidepressants. How else could we get to 36 million prescriptions a year for something that is no more effective than snake oil?


An article in 2005 in the BMJ identified that between 1991 and 2002, prescriptions per head for all antidepressants increased 2.8-fold and the total cost (adjusted for inflation) increased by £310m; the increase was almost entirely due to selective serotonin reuptake inhibitors. These costs could have been used to employ 7700 therapists (26 per primary care trust in England) providing 1.54 million treatment courses of six sessions each a year.

The 6 major SSRI's all seem to act in slightly different ways judging by their propensity for diferent specific side effects.

A study in 2006 found after unsuccessful treatment with an SSRI approx 1:4 patients had a remission after switching to another antidepressant and here's for me the interesting point - "Any of the other SSRI studied in 2006 provided a reasonable 2nd step choice for patients with depression".

This lax approach to the neuro chemical soup in the brains of treated patients (particularly those with less severe forms of depression) gives snake oil salesmen a bad name!

You are right Dr No, this is bed medicine! People do not need all these chemicals whether they work or not inside their bodies. I touched on this subject before:

Oops! Meant to say 'bad medicine' of course. :-)

Government Research / Funding Scandal


Medicine Gone Bad


PoH - AD prescriptions (and so costs) have been increasing year on year since that BMJ study, so the opportunity cost today will be even greater. But, in the real world, drug companies have marketing departments; therapists don't. Big Pharma is heavily involved in all this for sure, but I don't think we should overlook the way the role of the one-time apothecary plays into their hands. Doling out pills "fits" general practice better that talking cures.

The SSRI story is quite remarkable. Like the fact selective serotonin reuptake enhancers are as efficacious as SSRIs (google "tianeptine vs fluoxetine"). How can it be that two drugs that have opposite effects produce the same clinical result - and we still hang onto the "serotonin hypothesis"? Perhaps it is time to call it the "placebo hypothesis"...

Sam - Freudian Slip - it was bed-time - or an allusion to Dr No's bedside manner(!)? And I quite agree about the smile. One of Balint's things was the use (and "pharmacology") of the drug "doctor", and one of Dr No's things is that in many cases one good friend is worth 1000 pills.

I think to understand the rise and rise of the SSRIs it is necessary to remember that old saw

"The road to Hell is paved with good intentions"

You had to have been around then to understand the SSRI phenomenon. I am old enough, as I'm sure Dr No is, to remember the pre-SSRI era and the early media buzz around Prozac. In their early years (late 80s and early 90s) SSRIs were far more than medicines – they were truly a snowballing cultural (as well as medical) phenomenon. I don’t blame the PharmaCos – everyone was part of it. The patients wanted “miracle pills”, the doctors (especially GPs, I think) wanted something to give the patients with persistent low mood, the Pharmas wanted to sell boatloads of pills and the media ate it up. The spin on the tablets was overwhelmingly positive at all levels ("Better than well"), with Peter Kramer's book Listening to Prozac the most famous medical example. A TV show put the singer of the famously gloomy pop group pop New Order on Prozac to see if it changed his songwriting... and so on, and so on.

The whole story has latterly been “recast” as PharmaCo dirty dealing, but that was not how it ran and played at the time.

Perhaps more interesting in the light of Dr No's take on it is how SSRI sales have gone on growing even as it has become more and more apparent (say over the last 5 yrs) that the tablets don't do anything for mild to moderate depression.

ear_pop.jpgDr Aust - certainly the times were different then. They were the times when it was the norm (but not the rule) for the drug rep-ette to turn up at the surgery (apothecary's), sit on the doctor's knee and say "Hello, Big Boy!". Most doctor's hadn't the slightest clue about evidence based medicine (many still don't) and the rep-ette's logoed pencil wasn't the only long hard thing in the room that day.

But there were other doctors - Dr No counts himself amongst them - who were even then deeply dissatisfied with the cosy relationship between Big Pharma and jobbing doctors (that's jds, not JD!). This really is the point of this post: the shopkeeper (ex-apothecary, now GP) was keen to have shiny goodies in the shop-window for his punters (patients); and was not in any hurry to look at all that horribly complicated science as to whether the shiny pills really worked. If the pills looked good, and the CSM said they worked, that was good enough reason for the shopkeeper to stock and sell them. OK - GPs don't sell actual pills to patients (although dispensing practices get close), but the mentality was still there - the shopper (patient) goes shopping, and the shopkeeper (GP) supplies the goods.

And it still is - if the 36 million prescriptions are anything to go by.

I notice there is a Horizon on tonight on pill-popping - BBC2 9pm. Might be interesting...

Even us truly messed up types suffer from inappropriate subscribing - after doing a 5-minute survey in a doctor's office, I was given Prozac, which made me hallucinate. The doctor told me to keep taking it until I could see a specialist . . . I was diagnosed with severe depression and BPD, but after feeding me three or four different SSRIs, they just tacked on the words 'treatment resistant' ang gave up, cut me loose. If it can't be fixed with an SSRI, it can't be fixed?