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Sunday, Sep. 16, 2012
Japan's depressing increase in psychoactive drug use
In July, the British pharmaceutical behemoth GlaxoSmithKline reached a $3 billion settlement with the U.S. Department of Justice over the company's illegal marketing of several drugs in the United States. One of these, the antidepressant Paxil, was pushed by GSK salespersons for treating children, even though it was not approved for children. Studies show that Paxil is ineffective for younger patients and some believe it makes them suicidal.
Three billion dollars is only a fraction of what GSK makes on antidepressants in a single year, so the fine isn't going to affect it much.
American TV airwaves are filled with commercials for prescription drugs, including antidepressants, and by law these ads have to state possible side effects. Usually, the side effects outnumber the benefits, and if you shut your eyes to the relaxing images of couples walking on beaches at sunset and concentrate on the voiceover, the CMs can be horrifying. But these drugs still sell well.
The impressive sales growth of psychoactive medications in Japan has occurred over a shorter period of time. It wasn't until the 1990s that the word utsu (depression) received wide currency. According to the health ministry, the number of clinics treating depression increased by 140 percent between 1996 and 2008, as the number of people diagnosed with depression jumped from 240,000 in 1999 to 700,000 in 2008. Sales of psychoactive drugs have gone up by 30 percent in the past four years.
The media has portrayed psychoactive drug usage as being out of hand, owing to the lack of alternative treatments, meaning counseling. As with most mental illnesses in Japan, depression was seen as a condition that had been ignored for too long, and drug treatment was a means of catching up with the rest of the world.
A recent article in the Tokyo Shimbun focused on the link between injudicious prescribing of psychoactive drugs and suicide, a connection the health ministry has yet to address formally, even in its campaign to bring suicide numbers down. The paper mentions several cases, including a 37-year-old Tokyo woman who in May was diagnosed with postpartum depression, for which she was prescribed antidepressants, antianxiety meds and sleeping pills. She hung herself in July. The woman's mother said her condition wasn't that bad before she received the drugs, but after she started taking them she deteriorated rapidly. In a survey of 1,016 families who had lost members to suicide, the newspaper found that 69 percent had been taking medication.
Psychoactive drugs can help many mental-illness sufferers lead productive lives, but the problem in Japan seems to be that doctors aren't knowledgeable enough about medications to dispense them effectively. One physician interviewed by the paper said that postpartum depression is usually not serious enough to warrant medication, especially three different types at the same time, and in any case psychiatrists should observe patients for at least two weeks before prescribing anything. Most, however, give out drugs on the first visit.
The GSK suit highlighted the role of money, and money certainly has something to do with how readily Japanese doctors prescribe psychoactive drugs. Counseling, which is supposed to go hand-in-hand with medication, is not cost-effective for doctors who belong to the national insurance system, which recompenses a psychiatrist ¥5,000 for the first 30-minute consultation. With subsequent sessions, payments get smaller, to the point where the doctor will only receive ¥3,300 for a consultation that lasts between five and 30 minutes. In such a situation, there is no financial incentive to talk to a patient for more than five minutes, but in any case psychiatrists who are serious about counseling usually don't belong to the health insurance system. They just charge patients what they want and the patient pays 100 percent. So even if doctors don't directly make money off the drugs they prescribe, medication is an easier means of tackling the problem.
This attitude seems to have pervaded the general population. A recent edition of NHK's in-depth news show, "Closeup Gendai," looked at the proliferation of psychoactive drugs in the treatment of children who have difficulties in school. The announcer prefaced the report with a disclaimer that it is not NHK's intent to "deny the benefits of drugs" in the treatment of mental and behavioral disorders, but what followed was provocative.
The program reported that the number of people under the age of 20 being treated with psychoactive drugs increased from 80,000 in 1997 to 150,000 in 2009. What was shocking is that 39 percent of the children on these medications started taking them prior to entering elementary school and 36 percent started between first and third grade.
Dr. Norihiko Ishikawa, a guest on the program, pointed out that there is no real clinical consensus on how most of these drugs affect developing brains, but the dominant trend in all disciplines is for early diagnosis and early treatment. Medical institutions are pressured to nip burgeoning mental and behavioral problems in the bud.
Moreover, schools understand that these drugs are available and pressure parents of students with perceived developmental disorders to seek treatment, which means medication. One parent told NHK that her son's school wouldn't let him attend classes after she decided unilaterally to take him off his meds, which she felt was doing him more harm than good.
Not all psychiatrists rely on drugs, but what used to be called the "talking cure" never caught on in Japan. Similarly, mental illness has traditionally been treated as an inpatient matter, and Japan has per capita one of the largest mental-institution populations in the world. In such a clinical environment pharmaceuticals leap-frogged analysis as a treatment option. Japan went from the snake pit to Zoloft without even waving at Freud.