Before You Take That Paxil

I'm bringing Paxilback (yeah)
Generic brands just don't know how to act (yeah)
I pop a couple with that water back (yeah)
Bottomless coffee and a half a pack

The Gray Kid: PaxilBack

A very interesting "debate"¹ over the issue of screening new mothers for postpartum depression erupted in the blogosphere this week. The original point of contention is the Melanie Blocker Stokes MOTHERS Act (H.R. 20: Melanie Blocker Stokes Mom's Opportunity to Access Health, Education, Research, and Support for Postpartum Depression Act). The bill proposes "To provide for research on, and services for individuals with, postpartum depression and psychosis." The full text of H.R. is here.

In one corner is J. Douglas Bremner M.D., a professor of psychiatry and radiology at Emory University. He writes a blog called Before You Take That Pill, named after the title of his book.² Dr. Bremner is a very prolific physician scientist, with numerous publications in the field of biological psychiatry. In addition, he receives millions of dollars in funding from federal agencies that include the NIH, the Department of Veterans Affairs, and the Department of Defense. He specializes in researching the neurological and physiological effects of PTSD other conditions resulting from trauma exposure. He is the Principal Investigator on a clinical trial of Early Intervention for PTSD, which involves administration of the SSRI antidepressant paroxetine (generic for Paxil³) or placebo to Iraq War veterans with PTSD.

In the other corner is John M. Grohol Psy.D., CEO and Founder of the mental health site PsychCentral. After training to become a clinical psychologist, Dr. Grohol was the first to establish an online mental health portal (in 1995), and he has published on internet use and social support. He runs the flagship World of Psychology blog and hosts a number of other blogs that highlight different concerns in mental health and psychology. PsychCentral reprints pertinent press releases on its News page, has an Ask the Therapist advice column, runs online support groups (forums), and posts comprehensive information on symptoms and treatment of mental disorders, psychotropic medications, and clinical trials.

I found the whole debate rather interesting because it involved a role reversal of sorts, with the prescribing psychiatrist warning of the evils of over-medication, and the therapy-favoring clinical psychologist vilified as a tool of the pharmaceutical industry. It all started when Bremner published this post, Motherhood is Not a Medical Disorder. Here he argued that the MOTHERS act is a bad idea because it mandates screening [I could not find that particular clause in H.R. 20] and pathologizes motherhood.

First of all, there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum depression. So to screen all moms as if giving birth is a risk factor for depression is ridiculous. And whenever you start screening the general population, you get into problems with over-identification of people and an increase in the number of people that go on antidepressants. I am opposed to mandatory screenings of the population, like Teenscreen, which are bonanzas for the pharmaceutical industry, but a major intrusion into the privacy and autonomy of American citizens.

Note the passage in bold [my addition]. Grohol took exception to that claim (and others therein) and responded with Bremner’s False Claims about Postpartum Depression. Some considered this post to be very controversial (note the 120 comments), and others found it to be a very well-reasoned summary of the published literature (I fall into the latter camp). Grohol states:

My BS alert goes off whenever someone tries to change the argument from a reasonable effort to help increase education and information about a stigmatized mental health issue, to hyperbole, suggesting that a piece of legislation is trying to turn motherhood into a psychiatric disorder. It goes off again when a professional makes an extraordinary claim like, “there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum [sic] depression.” Really? Absolutely no evidence? That’s quite a strong statement, and easily proven false with a literature review.

He then proceeds to provide a literature review strongly suggesting that risk factors other than a prior history of anxiety and depression can predispose a new mother to postpartum depression. He explains further:

Now, I understand Bremner’s point — let’s not medicalize and catastrophize ordinary motherhood. I agree. And of course a woman’s pre-birth depression or anxiety is strongly correlated to postpartum depression. But not exclusively, as Bremner claims.

Bremner claims, with no evidence, that all mental health screenings are simply pharmaceutical sales tactics to help increase prescriptions. That’s ridiculous. When I worked in community mental health, we ran annual mental health screenings in the clinic — with no funding from any pharmaceutical company — because it reduces stigma, decreases misinformation and increases education about mental health issues in the general population.

I don't want to (or need to) detail all the points pro and con. You can read 120 comments on that post or one of Bremner's followups (Motherhood is STILL Not a Medical Disorder: Response to Critics and Mommy Wars: John Grohol is Blocking My Comments from His Website So I Am Commenting Here).⁴

In the past, I have disagreed with Grohol over his view that mental illness is not a "brain disease" analogous to other medical ailments. And I have defended Bremner's right to be a poopy head say what he wants on his own blog⁵ (but also noted that referring to a rival's opposing statements as "retarded" isn't the best way to make a reasoned argument)⁶.

Just an observation, but the benefit vs. harm of treatment for psychiatric disorders is one of those volatile issues in which the adamantly opposing sides are never going to change each other's minds.

Footnotes

¹ Complete with vitriolic flame wars in the comments.

² From Amazon:

In Before You Take That Pill, Dr. J. Douglas Bremner, a researcher and clinician at Emory University whose study on Accutane and depression made headlines, offers an inside look at the pharmaceutical industry, as well as a scientifically backed assessment of the risks of more than three hundred prescribed medications, vitamins, and supplements.

³ Bremner used to be a paid consultant for GlaxoSmithKline, the makers of Paxil^®, but not any more.

⁴ It seems unlikely that Grohol deliberately blocked his comments, because of such things as spam filters and comment moderation.

⁵ However, using Emory University letterhead to post a "doctor's letter" asserting the medical necessity of smoking in a bipolar person [even if it was meant satirically] may not have been a bright idea.

⁶ Oh yeah, I also made this comment over at David Dobb's excellent blog, Neuron Culture.