The Double Standard on Depression

One of Eli Lilly’s key objectives, when they were marketing Prozac in the early 1990s was to get employers to reimburse for anti-depressants. Some leaders of the National Association of Manufacturers had expressed reluctance to underwrite “mental health benefits” in the Clinton Health Plan; they had to be convinced that a workforce on Prozac would be in their interests. Lilly funded a study by an MIT economist that Tipper Gore and Fred Goodwin of the National Institute on Mental Health ballyhooed at a press conference (also funded by Lilly) and Daniel Goleman publicized in the New York Times in December ’94 (without mentioning Lilly). “Depression Costs Put at $43 Billion,” said the headline.  “The cost of days lost from work is about $11.7 billion,” Goleman reported, “and impairment from the symptoms while people continue on the job costs $12.1 billion more.” Add to this “earnings lost to suicide… about $7.5 billion.”

To make Prozac a blockbuster, Lilly spread the word that clinical depression was abroad in the land. They were helped by the NIMH (whose top officers retire and get hired by the drug companies the way Pentagon brass get hired by the arms makers) and the National Mental Health Association (a non-profit funded by pharmaceutical companies) and freelance opportunists like Dr. Peter Kramer (author of Listening to Prozac), and Dr. Douglas Jacobs, creator of National Depression Screening Day. The ultimate goal of all these promoters was to get the American people to take a simplistic test for depression -a test designed to convince almost any honest adult that he or she is a candidate for Prozac. The test is based on criteria set forth in the Diagnostic and Statistic Manual, the so-called “bible” of the American Psychiatric Association. The drug companies influenced the drafting of the DSM so that the definition of depression would apply to as many people as possible -i.e., would maximize the potential customers. See “The Drafting of DSM-III,” a great book by Kirk and Kutchens.

This is how doctors are taught to detect depression: “The presence of depressed mood (5) or loss of interest (6) and at least four other symptoms over a two-week period is required for the diagnosis of a major depressive episode. 1) Changes in appetite and weight 2) Disturbed sleep 3) Motor retardation or agitation 4) Fatigue and loss of energy 5) Depressed or irritable mood 6) Loss of interest or pleasure in usual activities. 7) Feelings of worthlessness, self-reproach, excessive guilt 8) Suicidal thinking or attempts 9) Difficulty thinking or concentrating.

Is there a single adult in America who could not qualify for a diagnosis of depression? The criteria are vague and all-embracing. Losing weight? You’re depressed. Gaining weight? You’re depressed. Sleeping too little? You’re depressed. Sleeping too much? You’re depressed. Going too slow? You’re depressed. Going too fast? You’re depressed… The all-important fifth criterion -“Depressed or irritable mood”- used to define depression is a syllogism. And even when the external causes of a patient’s “depressed or irritable mood” may be obvious -loss of a job, a relationship on the rocks, kid trouble, etc.- the resultant diagnosis, “Clinical Depression,” will imply that his or her internal psychological condition was causal! Is there such a thing as a double syllogism?

“Loss of interest or pleasure in usual activities” can be associated with physical aging and/or deteriorating quality of life. For example, you may no longer take pleasure in swimming at a beach after you’ve noticed human shit bobbing in the waves. You may not find driving as pleasurable now that there’s bumper-to-bumper traffic and the ride that once took less than 20 minutes takes more than an hour.

The definition of “clinical depression” can never be rigorous and the whole concept -the medicalization of unhappiness- is a misdirection play, pointing away from the real causes, insecurity and loneliness. Insecurity is a function of the rich/poor system, compounded by looming ecodisaster and personal health problems. Loneliness is almost everybody’s lot in a socioeconomic system that breaks up families geographically.  Prevention -which nobody ever talks about- would involve changing the system to encourage social stability. But in the meantime….

In this mean time, marijuana is the anti-depressant and anti-anxiety medication of choice for millions of Americans. That’s the statistical fact at the heart of Dennis Peron’s famous line, “In a society where they give Prozac to shy teenagers, all marijuana use is medical!”   Prop 215 explicitly established the right to obtain and use marijuana in the treatment of any condition for which it provides relief. The medical profession and the government recognize depression as a serious, disabling illness for which Prozac, Wellbutrin, et al can be prescribed to provide relief -and were prescribed to some 2.5 million Californians last year. “What’s sauce for the goose is sauce for the gander,” as the old saying goes. Californians have every right to use marijuana in the treatment of depression.

This may be a winnable fight.  U.S. employers were losing $3,000 per year per depressed worker, according to the 1994 MIT study. The biggest impact of depression, more costly to employers than absenteeism, was “the effects of poor concentration, indecisiveness, lack of self-confidence,” i.e., dawdling.  Most employers probably assume that widespread marijuana use would lead to even more dawdling. Just wait till they find out it’s a performance enhancer!

What Prop 215 Authorized

The San Diego District Attorney doesn’t know — or just can’t stand It — that California law authorizes doctors to approve the use of marijuana as a treatment for “any condition for which marijuana provides relief.” After raids that closed five local dispensaries July 6, DA Bonnie Dumanis said “Our office has no intention of stopping those who are chronically ill with AIDS, glaucoma and cancer from obtaining any legally prescribed drug, including medical marijuana, to help them ease their pain.”  Deputy DA Dana Greisen complained to Channel 10 News that profiteering doctors were approving marijuana use too readily: “The doctors, because they’re giving it to so many people, are basically legalizing marijuana one doctor and patient at a time… It’s being recommended for insomnia, depression, anxiety… The law is being abused on a massive scale.”

Actually, the law is being implemented on a limited scale, given how many Californians are using pharmaceutical antidepressants and how afraid/uneducated most doctors are when it comes to cannabis.  The way to deprive cannabis specialists of revenue, if that were really law enforcement’s goal, would be to remove the fear that constrains other doctors from approving their patients’ use of the herb -mainly, fear of being investigated by the state medical board. So why has SDDA sent a letter to the medical board requesting investigations of four doctors who allegedly issue approvals too freely? The investigations will undoubtedly have a chilling effect on every doctor south of Capistrano Beach who might be considering a more liberal approach. Patients, instead of asking their regular doctors to approve their cannabis use, will continue to seek out the docs who advertise their cannabis consultation services in the San Diego Reader. The cost of lawyers will justify the cannabis consultant’s fee, and the system will grind grimly on.

Are Bonnie Dumanis and her deputies totally ignorant of the relevant history? In 1994 and again in 1995 the California legislature passed and Governor Pete Wilson vetoed bills that would have legalized marijuana for the treatment of AIDS, cancer, glaucoma, and multiple sclerosis -a finite list. After Wilson’s second veto, Dennis Peron gave up on the politicians and decided to change the law by ballot initiative. The measure he crafted, with input from Tod Mikuriya, MD, among others, left it entirely up to the doctors which conditions cannabis could be used to treat.  Thus Prop 215 was and is much more liberal than the bills Wilson had vetoed. There was nothing misleading about what appeared on the ballot: the very first sentence of Prop 215 establishes “the right to obtain and use marijuana for medical purposes where that medical use is deemed appropriate and has been recommended by a physician who has determined that the person’s health would benefit from the use of marijuana in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief.”

The Voters Handbook “Argument Against Prop 215” clearly stated the opposition of the California State Sheriffs Association, the District Attorneys Association, the Police Chiefs Association, the Narcotics Officers Association and the California Peace Officers Association.  “Prop 215 DOES NOT restrict the use of marijuana to AIDS, cancer, glaucoma and other serious illnesses,” they reminded us. “Read the fine print: Proposition 215 legalizes marijuana use for ‘any other illness for which marijuana provides relief.’ This could include stress, headaches, upset stomach, insomnia, a stiff neck, or just about anything.”

It wasn’t fine print, it was the first sentence of the measure that we, the people, read and passed by a 56-44 margin. The district attorney of San Diego ought to read it because it’s the law she’s supposed to uphold.

Accomplia Update

Acomplia, Sanofi’s weight-loss drug that works by blocking cannabinoid receptors in the brain, was approved by British regulatory authorities in late June and promptly offered for sale by on-line pharmacies such as SpeedyHealth.com –28 tablets (20 mg) for $389, which comes to about $336 per pound lost in the first year. Add to cart?… A paper published in General Archives in Psychiatry in April 2001 examined whether Sanofi’s drug blocks the psychoactive effects of marijuana. A team of researchers from the National Institute on Drug Abuse led by Marilyn Huestis gave various doses of the drug or a placebo to 63 cannabis smokers who then smoked NIDA-wanna (2.64% THC) or placebo joints. The authors’ abstract states that only at the 90 mg dose did Acomplia produce “a significant dose-dependent blockade of marijuana-induced intoxication.” But medical-graduate student Sunil Aggarwal has analyzed the paper and discerns a similar blocking effect at 10 mg. “It is not statistically significant per se, but the dose-response blocking curve is,” says Aggarwal.  (20 mg/ day is Sanofi’s recommended starting dose of Acomplia. In clinical studies, higher doses led to an unacceptable incidence of gastrointestinal problems.)  Huestis has reportedly done an unpublished study in which subjects taking 60 mg/day of Acomplia for two weeks did not lose the ability to get “high” when they smoked marijuana.

FRED GARDNER is the editor of O’Shaughnessy’s Journal of the California Cannabis Research Medical Group. He can be reached at: fred@plebesite.com



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Fred Gardner is the managing editor of O’Shaughnessy’s. He can be reached at fred@plebesite.com

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