Monday, February 15, 2010

Placebo effect

As I was leaving Montreal Saturday, a handsome man somewhat younger than me plopped down beside me on the train. From his reading material, I inferred that he was a physician. Yep indeed he is! Goody, I love doctors and he turned out to be quite talkative. I was on the 'slow' train stopping at every little place so our trip was quite long but we filled the time discussing our work (when I did work)from our very different perspectives. He is a psychiatrist in an emergency ward and though he does have a private practice, most of his patients are experiencing psychiatric emergencies. I on the other hand, spent a lot of my time synthesizing drugs that could be used as antipsychotics primarily targeting schizophrenia but also manic depression. I was quite removed from patients although occasionally we would see patients in special learning environments so there would be a human side to our work. Ultimately we were to help these people (while making lots of money for our shareholders). But aside from the actual process of making and purifying these substances, my focus was seeing how well they bond to various receptors and behaved in our screens. Preclinical work: way, way down in the trenches. So many hurdles to overcome before anything from my hands ended up anywhere near a patient. He, of course, was a heavy prescriber of our (not just our company's but of the industry in general) psychiatric meds given that many of his patients are experiencing acute crises and talk therapy just won't do the trick for them. We spoke of influence peddling: how so much of his knowledge is influenced by 'our' drug reps. And the awful side effects: you fix one problem with a drug and another pops up. Messing around with ones neurotransmitters is a risky business. For instance, many antidepressants can cause an increase in anxiety. We discussed the irony that antidepressants can contribute to suicidal behavior. A profoundly depressed person may want to die but it just is too much effort to go about doing anything about it. As the depression very slowly lifts (the neurotransmitters change quickly but it takes much longer for the behavior to change-don't quite understand it)the patient reaches a dangerous point in that he is still depressed but now he actually has the energy to kill himself. But the biggest conundrum is the placebo effect. This is a huge problem in proving efficacy. Newsweek had a cover story on it last week with its lead article claiming that since antidepressants don't work any better than placebos, antidepressants don't work. Any evidence to the contrary is anecdotal. But for me, I was surprised that the placebo effect is so strong in depressed people. I would think that they would be so pessimistic about their situation that the thought mainly going through their head is that their situation was hopeless and nothing, nothing was going to help them. Yet they do improve: on drugs and on placebo! He attributed the effect to that people really do want to get better, even depressed people. We are fundamentally optimists. And as for the proof that antidepressants work (zillions of anecdotes not withstanding), it is true that for the first few months, there is no difference between drug-treated and controls, but as you extend the timeline, differences do appear. Oh Grasshopper, we have trained you well!
So what can I contribute to all of this discussion? He had no idea how drug companies select targets, how we can actually measure changes in neurotransmitter levels, how patents are our friends and enemies, how do we decide what areas to exploit, what does a medicinal chemist actually do anyway? I told him that most of my work was like his basic organic chem lab. I never took organic chem lab. In what universe would a pre-med student not take organic chem lab? We actually made lidocaine in ours! In the Canadian universe. Besides it's not useful to MY work. Yes it is!!!! I then blathered about how organic chemistry is fundamental to understanding biochemistry, pharmacology, etc subjects very germane to the physician, I would think at least.

Naomi is loathe to learning anything that she probably won't need in the future. She extends this argument to about anything so consequently, is content to learn nothing. Sadly many people have this attitude. As you may have guessed, I take the opposite approach. I read about everything regardless of its immediate usefulness. I do draw the line at memorizing baseball stats as someone in my house may not. For instance, last night I researched those bizarre hills of the Montreal area. The area around Montreal is basically a plain but there are 6 or 7 distinct hills including the eponymous Mont Royale and another overlooking Beloeil. They seem to be rounded cones suggesting to me, extinct volcanoes. Claire said they weren't but I wasn't convinced. But they are the result of volcanic activity but very, very long ago. 250 million years not like the more recent Mt. Ranier and its ilk. I also learned the Beloeil was the site of the biggest Canadian train disaster ever. There was a swing bridge over the Richelieu river left open to let barges through and the conductor ignored the stop signal. Oops! Someday this information will be useful, someday!

Toward the end of our journey, a young woman appeared before us and said that she had been eavesdropping with interest to everything we said. She is a law student on a project to mount a defense that in a nutshell was: Prozac made me kill him! Did she even had a chance? I said I was not in a position to answer that, I might be able to tell her how to make Prozac but Dr. Cute One might be of more help. Yes indeed, people on antidepressants might display more psychotic behavior. It didn't cause the the psychosis but the lifting of the depression may give them the energy to act out their underlying craziness. I did tell her of a local man, a chemistry teacher, who killed the superintendent of the school system then blamed his antidepressant for it. I don't think that defense saved him.

An interesting talk and he was so cute!

Steve barely made it in time to pick me up caught up in tunnel traffic. No traffic at all at the bridge. Lesson learned: don't cross into Canada in the tunnel on a Saturday night. The Hiram Walker fire filled the air with smoke with only one firetruck there to deal with it as opposed to the entire fleet of Longueiul's finest to deal with the smoke alarm. We were on Riverside Drive quite a while on route to the bridge. At night, Detroit looks quite impressive especially this one building that appeared to have a light show displayed on its side.

Steve will leave to New York soon. When he returns I will go to Boston. We are two ships just passing.


Teri B. said...

Boy do I know about two ships passing...speaking of which--mediterranian cruise, maybe? Anyway, you might want to prod Ms. Naomi to take a child development class...particularly one that talks about infant development and mirroring...maybe she can see the possible connection to her life???

Sue in Italia/In the Land Of Cancer said...

That would be cool..where are you anyway? Dallas? I see that I have a Sanata Monica reader using a Dallas hotel internet provider but you are teaching classes.....


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