Dangerous Drugs

What Big Pharma doesnt want you to know
Part one: Dangerous drugs

Over-the-counter drugs
2 7 OTC drugs: medicines dark side Death by aspirin
Drugs for depression

11 15 19 21
The great depression myth The great Prozac conspiracy SSRIs: bad prescribing habits SSRIs: discontinuation syndrome
Drugs for children
23 Kiddie killers 28 Puffers get blown out 29 The kiddie upper takes tumble
Antibiotics
31 Life after antibiotics 35 Antibiotics: definitely not kids stuff
WDDTY publication
Drug-induced disease
36 40 46 47 51 52
Medicine and the elderly The damaged brain: how drugs cause dementia Anticholinergic drugs: the stupid pills Diabetes: epidemic by prescription HRT: the latest cancer risk The big cure-all unmasked
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OTC drugs: medicines dark side

Over-the-counter remedies are thought to be safe because they can be easily purchased from pharmacies and stores, but its an unregulatedand boomingmarket of medications that can be every bit as dangerous as prescription drugs
TC, or over-the-counter, drugsremedies that you can buy in pharmacies and stores without a prescriptionare the dark side of medicine. Many of the active agents in the OTC drugs that are sold every day have never passed any safety trials, so no one knows what happens to consumers once they walk out of the store with their medications. There are more than 100,000 different OTC remedies available for us to self-medicate a range of common ailmentsincluding migraine headaches, insomnia, stomach pain and indigestion problems, arthritis, general aches and pains, and coughs and coldsas well as products to help us lose weight and stop smoking. Because we can walk into any highstreet pharmacy or chemist and buy them with a minimum of fuss and questions asked, we believe they are safe for us to take. And because we think they are safe, we are much more likely to take several OTC drugs in combination, even though they may well share some of the same active agents, thereby increasing the amount of each agent we are taking every time. Indeed, the US Centers for Disease Control and Prevention (CDC) has also reckoned that around half of all children under the age of three years are regularly given an OTC preparation, such as Tylenol or Calpol. Their potential dangers appear to become the subject of public concern only when they affect a celebrity, such as Hollywood film actor Heath Ledger, who died in 2008 after overdosing on OTC sleeping pills, to which he had become addicted. Tragically, many hundreds of thousands of people suffer the same fate as Heath Ledger every year as a direct result of an OTC drugbut their deaths are never recorded as such because there is no monitoring system in place. Researchers at the Eastern Virginia Medical School reckon that OTC painkillers that contain aspirin are, on their own, responsible for 20,000 deaths and 100,000 hospitalizations every year in the US. Yet, not only are these drugs never suspected of being the cause, but most patients who need hospital care dont even bother to mention that they were taking such drugs as aspirinso harmless are OTC drugs thought to be. As the lead researcher and gastroenterologist of the above report, Dr David Johnson, has said: This reflects a common misperception that these medications are insignificant or benign when actually their chronic use, particularly among the elderly and in those with conditions such as arthritis, is linked to serious and potentially fatal GI [gastrointestinal] injury and bleeding (Proceedings of the Annual Scientific Meeting of the American College of Gastroenterology, October 15, 2007, Philadelphia, PA).
active ingredients, such as codeine, that have never been subjected to any rigorous safety tests. In the UK, a regulatory framework for OTC drugs came into existence only in 1971 and, in the US, in 1962so any active compound that was introduced before those dates has never been tested. This means that agents such as aspirin, codeine, dextromethorphan (DXM), paracetamol (acetaminophen in the US) and diphenhydramine have never passed any proper safety trials, and yet they are found in many popular household OTC brands such as AlkaSeltzer, Calpol, Tylenol and Vicks. Double trouble The OTC market has been earmarked as the next major happy-hunting ground of pharmaceutical companies. Over the next few years, we are likely to see many more powerful drugs that up to now, have only been available from the doctor and only with a prescriptionput on the shelves for everyone to buy. Thousands of prescription-only drugs have already made the transition to OTCa process known as Rx to OTC in the US and as OTC switching in the UKand many more are expected to follow suit as patents expire on a host of blockbuster prescription drugs. One example from last year was the switching of Novartis Prevacid 24HR, a heartburn remedy and the first proton-pump inhibitor to obtain OTC approval in America since 2003. As a prescription drug, it was among the top five best-sellers in the
In fact, millions of people may well be addicted to OTC drugs, especially those that contain codeine, which is a controlled substance derived from opium. However, its a major social problem that remains invisible, as the UK governments All-Party Parliamentary Group on Drug Misuse is discovering. Dr Brian Iddon, the crossparty group chairman, said: Our inquiry has only scratched the surface of this problem. Yet, it isnt clear how his enquiry can ever go deeper, as there are no records of who is buying these drugs and how often, although one place that the enquiry could start is with a self-help group of 4000 people registered on a website because of their addiction to Solpadeine, an OTC concoction of codeine and paracetamol (BMJ, 2007; 334: 9178). Very few people who are regularly self-medicating realize that the drugs they are taking invariably contain
2 WDDTY Dangerous drugs
Think twice about these OTC drugs

Theyre household names and they may well be in your medicine cabinet right now. Yet, despite their popularity, you may want to think twice before you start popping any of these products. N Advil or Motrin (ibuprofen): These are painkillers that can also reduce fever, but they can also cause stomach pain and dizziness. Their prolonged use can lead to ulcers, raised blood pressure, kidney and liver damage, and even stroke and heart attack. N Aleve (naproxen): A painkiller that also reduces inflammation, this can cause stomach pain, and its prolonged use can bring about the same adverse effects as Advil (see above). N Aspirin (acetylsalicylic acid): One of the first non-steroidal antiinflammatory drug (NSAID) painkillers, its preeminent position has been challenged by newer, and supposedly safer, agents such as ibuprofen and paracetamol (acetaminophen in the US). However, it is still considered a firstchoice remedy for migraine and as a preventative for heart disease. Yet, it causes gastrointestinal bleeding, Reyes syndrome in children and can be a major cause of stroke in the elderly (see box, page 4). N Benadryl, Tylenol (diphenhydramine): These drugs are primarily intended to ease gastrointestinal problems, although older patients also use them as sleep aids. They are increasingly being linked with cognitive impairment, causing confusion, agitation, memory loss and incoherent speech. N Contac (pseudoephedrine): This decongestant causes dizziness, nervousness and sleeping problems. It should be avoided if you have high blood pressure, diabetes, prostate problems, thyroid disease or a heart condition. N Nurofen (codeine, methylmorphine): This painkiller contains codeine, a controlled substance that can become addictive in chronic users. Codeine is found in many OTC remedies and, depending on the formula, can cause nausea, euphoria and rash. Codeine is an opiod, a family of agents that can lead to fatal respiratory depression. Codeine metabolizes into morphine, and this can be passed through a mothers breast milk in lethal amounts. N Nytol (diphenhydramine): This is a sleep aid and, like most OTC remedies for insomnia, its an antihistamine, which promotes drowsiness. Common side-effects, which especially affect older patients, include dizziness and forgetfulness, constipation and blurred vision. However, these remedies can be fatal if you become a chronic user and you regularly overdose, as happened to Hollywood film actor Heath Ledger. Overdosing is common as the body becomes adjusted to the recommended dose. N Solpadeine (paracetamol, codeine): This is one of the most popular OTC painkillers in the UK. Although it is supposed to be taken for no more than three days, many people become addicted to it. The combination can cause drowsiness, and serious liver and kidney damage, especially if taken together with another OTC remedy that contains paracetamol. Other sideeffects include constipation, rash and nausea. N Sudafed (phenylephrine): See Contac (above). N Tylenol (acetaminophen): This was promoted as a safer alternative to aspirin, but it can cause kidney failure, and several prescription drugs that contain this agent are now being closely monitored. Tylenol also contains codeine, a controlled substance in most countries. Its reckoned that acetaminophen is responsible for 100 deaths and 56,000 emergency-ward visits every year in the US alone. N Vicks, Robitussin (dextromethorphan): These cough-and-cold remedies contain DXM, a chemical that is similar to morphine; indeed, some teenagers deliberately overdose on them to get a high. The US Drug Enforcement Administration (DEA) has classified DXM as a drug of concern, but has done nothing to restrict its sales in stores.
US, with annual sales of $3.37bn in 2008and yet, it has now become an OTC remedy that is being marketed directly to the approximately 50 million Americans who suffer from frequent heartburn (www.reuters.com/ article/idUSLE40551720090514). As a result of this refocusing, the OTC marketalready worth around $7.8bn in the US this year, and consistently growing by 8 per cent annually since the early 1990sis set to double by 2023, according to the World OTC Pharmaceutical Market Analysis & Forecasts, 20082023 (www.piribo.com/
publications/otc/world_otc_pharmaceutical_ market_analysis_forecasts_20082023.html).
Although the prescription drugs market is far more lucrative, the pharmaceutical industry is being forced to change its strategy. The industry is reaching a significant watershed as scores of big-selling proprietary drugs are soon to lose their patents, which would allow a wash of cheaper me-too generic drugs from competitors onto the market. To counter such an event, a drug company often adopts a double-pincer move by, on the one hand, supercharging the prescription drugsuch as by increasing its potency or making a minor change to the formulation which would then allow it to extend its protective patent while, on the other hand, making the original drug available in the OTC marketplace. The types of drugs that are expected to make the switch include gastrointestinal remedies, cholesterollowering agents, osteoporosis treatments and contraceptives. Also, the pharmaceutical industry is fiercely lobbying drugs regulators such as the US Food and Drug Administration (FDA) to extend the categories of agents that can be sold as OTC. Its a battle theyre expecting to win, and new categories are likely to be included in the OTC arena, says industry analyst group Kalorama ( www.fiercehealthcare.com/story/studyrecession-could-pump-mkt-over-counterdrugs/2009-04-20).
However, the battle is already all but over in the UK, which is known to operate one of the most liberal druglicensing regimes in the world, where cholesterol-lowering statin drugs were allowed to be sold without a prescription as early as 2004.
WDDTY Dangerous drugs 3
Whos at risk?
As with most drugs, the young, the elderly and those who are pregnant are most at risk from the side-effects of OTC remedies, although any userespecially any chronic usercan suffer an adverse reaction. Around 71,000 preteenagers are rushed to an emergency ward in the US every year after being poisoned by an OTC drug, such as cough syrup (Am J Prev Med, 2009; 37: 1817), while many teenagers are deliberately overdosing with DXM, which is found in cough medicines, to experience a high. From 1999 to 2004, there was a 15-fold increase in cases of DXM poisoning and over-doses among young Americans aged nine to 17 years (Arch Pediatr Adolesc Med, 2006; 160: 121722). The under-12s who take aspirin are also at greater risk of developing Reyes syndrome, a rare and often fatal multiorgan disorder (BMJ, 2002; 325: 988). Yet, ironically, acetaminophen is promoted as safe for children. However, the drugs regulators are now beginning to realize that its even more dangerous than aspirin, and can cause life-threatening liver problems (JAMA, 2009; 301: 23156). Pregnant women who take an NSAID (non-steroidal antiinflammatory drug) like aspirin increase their risk of miscarriage by 80 per cent. The risk is even higher when the drug is taken at around the time of conception or for more than one week. These drugs are thought to suppress the production of prostaglandins, fatty acids that help to ensure that an embryo is successfully implanted in the womb (BMJ, 2003; 327: 368). Women who take any drug that lowers their folic-acid levelsincluding OTC preparations such as NSAIDsrun a far greater risk of giving birth to a child with a birth defect. Also, the risk of cardiovascular defects increases by 240 per cent and that of oral clefts, by 160 per cent (N Engl J Med, 2000; 343: 160814). OTC cough remedies that contain DXM are another cause of birth defects. One studyalbeit in animals, so it may not apply to humansfound that DXM is so powerful that just one dose can result in a birth defect, and can affect the embryo even before the pregnancy is known. So, all women who are pregnant, or who are planning to become so, are advised not to take any OTC cough medicine that contains DXM (Pediatr Res, 1998; 43: 17). Women in general who use an OTC slimming aid that contains phenylpropanolamine will dramatically increase their risk of stroke. In one study of 702 women who had suffered a stroke and who were compared with 1376 healthy controls, an OTC appetite suppressant was found to increase stroke risk by more than 16 times, while women who had taken an OTC cough or cold remedy that contained phenylpropanolamine were more than three times more likely to suffer a stroke (N Engl J Med, 2000; 343: 182632). Nursing mothers should also avoid any OTC remedy that contains codeine. As this agent metabolizes into morphine, it can pass from the breast milk to the babyat levels that can be fatal to the infant. However, the elderly are perhaps at the greatest risk of suffering an adverse reaction to an OTC drug, partly because they are generally taking more of them and their immune systems are less able to cope, but also because it is usually part of a drugs cocktail that includes prescription medications, too. Also, aspirin is often part of the health regimen in the elderly, who take it is a preventative against heart disease and stroke. But a study from Oxford University suggests that the drug has a paradoxical effect among the over-75sand is, in fact, a cause of stroke resulting in either disability or death. The researchers have discovered that aspirin had caused a sevenfold increase in stroke in the elderly patients who participated in their study. As research team leader Professor Peter Rothwell said: There are elderly people who take aspirin as a lifestyle choice, and, in that situation, the trials have shown theres no benefit. And what our study suggests is that, particularly in the very elderly, the risks of aspirin outweigh the benefits (Lancet Neurology, 2007; 6: 48793). In addition, OTC sleep aids are a significant cause of falls in elderly people. Falls and complications after falls are the fifth most common cause of death in the developed world. Researchers from the University of British Columbia in Canada reviewed 22 studies, involving more than 79,000 elderly participants who had falls, and found that prescription and OTC sedatives and anti-depressants were mainly responsible for the accidents (Arch Intern Med, 2009; 169: 195260). However, both the elderly and the young are at special risk from OTC sleep aids that contain antihistaminesand diphenhydramine in particular. While the drugs can cause abnormal muscle spasms and blurred vision in the general population, they also cause nervousness and, paradoxically, insomnia in the very young and in older adults (Pharmacotherapy, 1994; 12: 4926).
The British drugs regulators were undeterred by the dubious safety record of statins, which lists heart failure, liver and kidney damage, and a potentially fatal muscle-wasting disorder known as rhabdomyolysis among their side-effects. In 2001, one statin, Baycol, was withdrawn from the market after 31 people died because of rhabdomyolysis in the US and after being linked to around 100 deaths
worldwide (http://news.bbc.co.uk/2/hi/europe/
1481178.stm;http://news.bbc.co.uk/2/hi/busines s/2916979.stm).
As a spokesman for the pharmaceutical market research company Piribo states: The worldwide OTC market will see a remarkable period of dynamic change. Ageing populations and rising incidence of lifestyle diseases, as well as the need to reduce healthcare costs, will open up new
therapeutic areas for OTC switching. This explosion in OTC sales is also fuelled by consumer demand. More and more people are looking to selfmedicate, which they consider to be inexpensive, convenient and safe, compared with a visit to the doctor, which might involve a more careful review of the problem. Consumer demand for the heartburn remedy Prilosec became so great in 2004 that
pharmacies were out of stock for most of the year. Although manufacturer Proctor & Gamble increased its production, it wasnt until 2005 that shelves were replenished (Berenson A.
Where Has All the Prilosec Gone? The New York Times, March 3, 2005).
The history of OTC drugs

Regulators on both sides of the Atlantic have been slow to regulate OTC drugs, as well as the active agents they contain. In the US, alcohol, cocaine, marijuana and opium were regularly included in therapeutic concoctions without the need for any special licence, and that only changed with the passing of the US Federal Food, Drug, and Cosmetic Act (FFDCA) of 1938. Yet, even then, this piece of legislation failed to distinguish between drugs that were available only by prescription and those that were sold in stores. The situation was clarified only slightly in 1951 with an amendment to the act that defined prescription drugs as those that were habit-forming, toxic, unsafe or used only under a doctors supervision. In other words, a drug could be sold over the counter if it was none of the above although, even today, many OTC drugs are, in fact, habit-forming and toxic, and possibly unsafe. The laws only began to tighten up in 1962 with the thalidomide scandal in the UK and yet another amendment to the FFDCA of 1938 in the US. The latter then required that OTC drugs should be both effective and safe, an amendment that has been little more than window dressing, as no reporting system was created to confirm either of these qualifiers. In the UK, the College of General Practitioners set up a Register of Unexpected Toxicity in the wake of the thalidomide scandal, which caused 5000 appalling deformities in newborn babies in the UK, and around 10,000 cases worldwide. One year later, the British did what the British do best: they set up a committee which, in 1963, suggested that the problem of drugs monitoring and regulating could best be served by the creation of a new committeethe Committee on Safety of Drugs (CSD)which, in turn, comprised four subcommittees. However, despite all these committees, the OTC market was still not covered and was not regulated until 1971, when the Medicines Commissionthe main statutory advisory body set up under the UK Medicines Act of 1968began its work to monitor all drugs.
To make the switch from prescription to OTC, the drug manufacturer will often reduce the dose level or change the formulation to produce a weakened version for the mass market. Nevertheless, these smaller dosages can still be lethal, and is certainly addictive, as the few statistics that are available demonstrate. Indeed, our drugs watchdogs are at pains to point out that there is no such thing as a safe drug, and they urge consumers to read the label before taking any medication. But as OTC regulations are far less rigorous than they are for prescription remedies, the demands and guidelines for the manufacturer regarding the inclusion of patients information are hardly onerous. For example, the safety sheet that comes with the prescription-only version of Motrin, a painkiller that contains ibuprofen, includes possible side-effects such as oedema, blurred vision, nausea, heartburn, diarrhoea, gastric ulcer with bleeding and/or perforation, dizziness, nervousness, rash and tinnitus. In contrast, the label on the OTC version of Motrin merely mentions that ibuprofen may cause stomach bleeding, and the list of sideeffects has been omitted. Hidden interactions The OTC drug manufacturer also doesnt have to make any mention of the fact that the remedy can interact with other drugs or remedies, including vitamins. Paracetamol (acetaminophen) is a common painkilling agent found in hundreds of OTC remedies and, yet, none of them mentions that it can increase bleeding, possibly to a dangerous level, if taken in conjunction with the blood-thinning drug Coumadin (warfarin). The FDA is also becoming increasingly concerned about prescription drugs that contain acetaminophen, and one of their advisory committees last year went so far as to recommend that all drugs that combined this agent with narcotics should be immediately removed from the market.
The committee argued that the chances of overdose and severe liver injury were high, and that the risks far outweighed any benefits that such drugswhich include Vicodin and Percocetoffered. Also, the report stated that acetaminophen, which is commonly used to reduce fever, had been linked to 56,000 emergency room visits, 26,000 hospitalizations and 458 deaths during the 1990s in the US. Yet, no one recommended that any OTC drug containing acetaminophen be taken off the market (http:// news.health.com/
2009/06/30/fda-panel-urges-ban-vicodinpercocet/).
Acetaminophen is even suspected of being a cause of autism. Its found in the childrens OTC remedy Calpol, which is regularly used by parents to reduce fever, which also commonly occurs after receiving the MMR (measlesmumpsrubella) vac-cine. In one study of 83 children with autism who were compared with 80 healthy,
non-autistic controls, the children who were given an aceta-minophencontaining remedy were six times more likely to develop autism after the vaccine, and nearly four times more likely to suffer regression in their development, compared with the controls. The children who had been given ibuprofen to treat fever after the MMR vaccine had no autism (Autism, 2009; 13: 1234). Most cough medicines include dextromethorphan (DXM) and, yet, the warningif there is one at allis woefully inadequate. Although one OTC preparation, Robitussin, mentions that it shouldnt be taken with any prescription antidepressant known as an MAOI (monoamine-oxidase inhibitor), it doesnt state that the interaction is, in fact, life-threatening. DXM also interacts with other antidepressants such as Prozac, Paxil and Zoloft (all of which are SSRIs, or selective serotonin-reuptake inhibitors), to produce a serious condition
known as serotonin syndrome, which can trigger symptoms such as muscle twitches, fever, nausea, dizziness, confusion, shock and coma. DXM sideeffects, even when not mixed with another drug, include impaired judgement, loss of coordination, dizziness, nausea, hot flashes, hallucinations, brain damage, seizure and death. Again, virtually no OTC drug that contains DXM mentions these possible adverse effects. Drug manufacturer Merck, which also publishes The Merck Manual of Medical Information, says: Often, the labels of OTC drugs do not list the full range of possible side effects. As a result, many people assume that these drugs have few, if any, side effects. For example, the package insert for one analgesic (not named) cautions people not to take the drug for more than 10 days for pain. However, the possible serious side effects that can occur with long-term use (such as life-threatening bleeding from the digestive tract) are not mentionednot on the box, bottle, or package insert (www.merck. com/mmhe/print/sec02/ch018/ch018a.html). Americas Generic Pharmaceutical Association (GPhA) recognizes the double standards that now apply to prescription and OTC drugs, and is calling for the same approval process for all drugs, irrespective of the way in which they reach the marketplace and consumers. While FDA-approved prescription drugs are subjected to a rigid application-based approval process . . . other products are marketed either under a minimally regulated system or no regulatory system at all. Specifically, numerous OTC drugs have been on the market for years and some predate the laws that require proof of safety and effectiveness before marketing . . . [so] the unregulated OTC drug market continues to fall between the cracks, an association spokesman says (www.gphaonline.org/
media/press-releases/2009/02/12/fdastandards-and-foreign-inspections).
Double blind With the OTC market becoming the new focus of Big Pharma, it is imperative that it is protected by the same regulatory framework that
controls prescription drugs. While it is forgivable that the consumer might believe OTC drugs are safer, its not acceptable that our drugs regulators should also share the same view. In fact, the regulators know that OTC drugs are every bit as dangerous as their prescription counterparts, even though they may be acting otherwise. Why else do OTC drugs not have to list all of their possible adverse effects, or any of their possible interactions with other drugs and medications. But worse than that is the fact that the OTC market is completely invisible. Nobody knows who is buying these drugs or what happens to them afterwards. This is because theres little incentiveand almost no fundingto investigate the dangers of OTC drugs. However, the little that has been done uncovers a worrying picture, with aspirin alone causing around 100,000 deaths worldwide every year. The OTC market is truly medicines dark side, but its time that light be shed upon it.
Bryan Hubbard
Death by aspirin
Aspirin may be a major killer, and one that none of us even suspects
spirin is the ultimate lifestyle drug, and is seen as one of our great allies in warding off heart disease. With the encouragement of health guardians around the world, we pop 100 billion pills of this just-in-case drug every year, and 37 per cent of them are taken by healthy people as part of their daily health regime. Its the inexpensive and readily available magic bullet that can protect us against cardiovascular disease, mankinds greatest killer. The humble aspirin can, according to its proponents, reduce blood pressure and help thin the blood, so lowering the risk of stroke and heart attacktwo functions that today dwarf its original purpose as a painkiller, an antiinflammatory and antipyretic (feverreducer). Best of all, it appears to be a relatively benign drug. The American Association of Poison Control Centers receives reports of just 59 aspirin deaths in the US each year, while researchers put the mortality rate for all painkilling, nonsteroidal, anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen and naproxen at around 7600 deaths a year (Scand J Rheum Suppl, 1992; 92: 214). Either way, doctors argue that these figures represent an entirely acceptable risk compared with the many thousands more who might otherwise have died because of heart disease. But scientists are now discovering that we have all been dramatically and catastrophically misled by the assurances of the medical community. Far from being benign, aspirin may be a major killer in our society, and one that is never suspected. The new claim centres on the drugs well-documented side-effect of causing seriousand, in some cases, fatal gastrointestinal (GI) bleeding. But researchers in a separate study have discovered a new, and worrying, sideeffect of aspirinit may be a major cause of stroke among the elderly. Because of its widespread use, researchers warn that these little pills
may soon overtake hypertension (high blood pressure) as the major cause of stroke. What studies now tell us In the first of the new studies, researchers reckoned that the drug is killing 20,000 Americansand sending another 100,000 to hospital every year just because of GI problems. Astonishingly, each of these deaths and reactions is slipping under the radar, and is not being associated with aspirin at all.
The story of aspirin

Aspirin holds an unusual place in trademark law. As Aspirin with a capital A, it is a protected brand, owned by Bayer, the German pharmaceutical giant. As aspirin, it is a generic drug that can be used in countries where Aspirin is not trademark-protected. Around 50 other over-the-counter preparations contain aspirin, using either the name or ASA, an abbreviation that stands for Aspirins generic name, acetylsalicylic acid. Aspirin was the very first drug in the family of NSAIDs (non-steroidal, anti-inflammatory drugs) when Bayer began marketing it in 1899, along with another of the companys discoveries, heroin. Its principal ingredient is salicylic acid, derived from the bark of the willow tree and from the herb meadowsweet. It was recognized by Hippocrates as a pain-reliever and an antipyretic (fever-reducer) as long ago as in the 5th century BC . Chemists at Bayer were successful in synthesizing salicylic acid with the common chemical acetic anhydride, so giving Aspirin its generic name. Despite its widespread use and popularity, no one understood how the drug worked until 1971, when the British pharmacologist John Vane found that aspirin suppresses the production of prostaglandins and thromboxanes, hormones that regulate many physiological functions. Today, we globally consume around 35,000 tons of aspirin every yearamounting to around 100 billion tabletsa figure that is increasing annually by 15 per cent. Aspirin continues to be viewed as a benign painkiller, which has helped to fuel its growing use at a time when bad news and scares have hounded some of the other NSAIDs and COX-2 drugs. Most recently, the COX-2 painkiller Vioxx was withdrawn from the market after it was found to cause heart problemssome fatal. It was the subject of the largest civil lawsuit in history until its manufacturer Merck settled with a $4.85bn payout. Aspirin has been dogged by its own fair share of side-effects. The most common are stomach bleeding and other GI problems, but added to that are stroke, anaemia, ulcers, liver damage, hives, wheezing, tinnitus, chronic catarrh, headache, confusion and hypotension (low blood pressure) followed by collapse. Asthmatics have also died from a severe attack after having taken aspirin.
Researchers at the Eastern Virginia Medical School made their alarming discovery when they interviewed patients at a clinic that specializes in GI problems. They found that one in five patients was taking aspirin or some other painkilling NSAID, but the fact wasnt being reported to the medical staff because it wasnt regarded as significant. This reflects a common misperception that these medications are insignificant or benign when actually their chronic use, particularly among the elderly and those with conditions such as arthritis, is linked to serious and potentially fatal GI injury and bleeding, said Dr David Johnson, one of the Virginia researchers. If the researchers death and injury rates for the US is correct, this could mean that the worldwide aspirin and other NSAID death toll is 100,000 individuals every year. Whats more, a further 500,000 of us will need hospital care to treat a serious reaction to the drug, such as the result of a GI reaction (Proceedings of the Annual Scientific Meeting of
the American College of Gastroenterology, 15 October 2007).
Is it truly a heart helper?

Aspirins popularity today is more to do with its ability to protect us from cardiovascular disease (CVD) than as a painkiller, for which it has been superseded by newer kids on the block such as ibuprofen. Around 37 per cent of the 100 billion aspirin pills swallowed every year are taken as a preventative against heart disease and stroke, while 23 per cent of users are arthritis sufferers who take it for its anti-inflammatory qualities. Only 14 per cent of users take it to relieve a headache. Its principal role as an anti-inflammatory and antipyretic began to change when Dr L.L. Craven, a GP working in California, discovered that it was providing benefit to his heart patients (Mississippi Valley Med J, 1953; 75: 3844). More recent trials have confirmed its role as a preventative agent, and particularly for heart patients. In 1998, the US drugs regulator, the Food and Drug Administration (FDA), widened the scope of aspirin to encompass its new role, especially among those who had had a heart attack, stroke, angina, or bypass surgery or angioplasty. Since then, two meta-analyses have concluded that aspirin can reduce the risk of cardiovascular disease by 13 per cent (Arch Intern Med, 2000; 160: 31237), and heart attack by as much as 32 per cent (Heart, 2001; 85: 26571). Despite these glowing recommendations, however, many groups remain cautious and recommend that healthy people not use aspirin as a prophylactic just-in-case. The US Preventive Service Task Force is still not convinced and, despite the meta-analyses, says the data are insufficient to make any categorical pronouncement (Ann Intern Med, 2002; 136: 15760). The European Society of Cardiology suggests that those at high risk of heart disease should take aspirin only at a low daily dose of 75 mg. Similar cautious voices have been raised concerning aspirins ability to prevent stroke, despite the seemingly impressive research. The Antiplatelet Trialists Collaboration (ATC) prepared a series of landmark trials that appeared to establish aspirin as an important agent for treating stroke. Yet, within a year, its findings were being questioned. The Thrombosis Research Institute analyzed the third arm of the ATC trial, which focused on the efficacy of aspirin in reducing venous thrombosis and pulmonary embolism after surgery. The Institute declared that some of the ATCs conclusions were not justified, and that several of the studies included in the meta-analyses werent of a high-enough standard (BMJ, 1994; 308: 12137). Worse, the ATC researchers had also played down the issue of side-effects such as internal bleeding. Without them, said the Institute, the true riskbenefit ratios couldnt be worked out. In the face of these criticisms, the ATC researchers moved away from their earlier effusive position and instead suggested that aspirin was not the complete solution, but should be seen as part of a range of measures. The ATC studies were an interesting object lesson in how the myth of the healing powers of aspirin always manages to outpace the actual studies on which it has been founded. Nevertheless, despite the legend, there is only a handful of research to support the theory that aspirin can prevent heart disease and stroke. Even used as a preventative by heart patients, the evidence is thin on the ground. The editorial team of a prestigious peer-reviewed journal once stated that aspirin seems as effective as any other single agent or combination of agents (BMJ, 1994; 308: 712), which is saying far less than aspirins advocates believe
Currently, none of these deaths is even recorded as an aspirin fatality. Equally worrying is the drugs effect among the over-75s. Far from protecting them against stroke, it appears to be causing just such an attack that is either fatal or results in disability. Researchers at Oxford University have discovered that the drug has caused a sevenfold increase in intracerebral haemorrhagic strokebleeding within the brainduring the past 25 years among groups of elderly patients who participated in their trial. Research-team leader Professor Peter Rothwell says that aspirin may soon replace high blood pressure as the leading cause of intracerebral haemorrhagic stroke, especially among the over-75s. There are elderly people who take aspirin as a lifestyle choice, he says, and, in that situation, the trials have shown theres no benefit. And what our study suggests is that, particularly in the very elderly, the risks of aspirin outweigh the benefits. In Rothwells study, researchers assessed the records of stroke victims between 1981 and 1985, and again
between 2002 and 2006. While the overall rate of stroke caused by high blood pressure had dropped by 65 per cent between those two periods, the rate among the over-75s remained the
same, mainly because there had been an increase in the number of strokes among patients taking blood-thinners such as aspirin. The team discovered that the
use of these drugs had increased dramatically and especially among healthy people who were taking the drugs as a preventative. From 1981 to 1985, only 4 per cent of patients were taking a blood-thinner, but this had risen to 40 per cent between 2002 and 2006 (Lancet Neurology, 2007; 6: 48793). In fact, the true dangers of aspirin have been known for some time, although no one has been prepared to do anything about it. Scientists from the West Midlands Regional Health Authority in Birmingham were among the first to raise the warning flag 12 years ago, when they did an investigation into the reasons why people were in hospital for treatment of bleeding peptic ulcer. At that time, they discovered that 12.8 per cent of the 1121 patients being investigated were regular users of aspirin, which they defined as five days a week for at least a month. When they compared these patients against other patients with the same prob-lem, but who were not regularly taking aspirin, it was evident that taking the NSAID had increased the risk of hospitalization for bleeding peptic ulcer by 2.3 times at a low dose of just 75 mg, and by up to 3.9 times at the more standard dose of 300 mg (BMJ, 1995; 310: 82730). The 300-mg dose is the recommended level for just-in-case, or prophylactic, use against heart disease. These researchers didnt track the progress of patients after identifying their cause of hospitalization, but one group of scientists didand came up with a horrifying picture. Of those who were being treated in hospital for serious upper gastrointestinal bleeding or perforation, 10 per cent had died. Who are most at risk? This alarming scenario was derived from an analysis of 12 studies published between 1980 and 2000. Those who were especially at risk were older individuals, and there were around twice as many men as women who ended up in hospital (J Clin Epidemiol, 2002; 55: 105763). So, as well as age and gender, people who take several NSAIDs in combination also increase their risk of having a serious GI reaction. In a separate study, researchers who
examined patients records from databases in the UK and Spain found that 60 per cent of those who suffered a GI reaction from an NSAID were aged over 60, 13 per cent were using several NSAIDs in combination, and 6 per cent had a recent history of peptic ulcers, even though patients with pre-existing GI problems should not be taking any sort of NSAID in the first place (BMC Medicine, 2006; 4: 22). But perhaps the most lethal drug combination is an NSAID with an SSRI (selective serotonin reuptake inhibitor) type of antidepressant such as Prozac, Zoloft or Paxil. In fact, this is a common drug cocktail, especially among arthritis sufferers, who are often given an NSAID to ease their joint pain and inflammation, and an SSRI to ease their mild depression. When these two drugs are taken concomitantly, the risk of upper GI haemorrhage increases by 6.3 times. Translated into everyday usage, a patient has to take the combination just 82 times before suffering a serious gastrointestinal adverse reaction. Such an event would occur less than three months into the treatment, assuming the combination is taken daily. Researchers from the University of East Anglia made this discovery when they carried out a meta-analysis of four trials involving a total of 153,000 patients who were taking either an SSRI or an NSAID, or a combination of the two types of drug. Patients who took just the SSRI increased their risk of a GI reaction 2.4 times, and those taking just an NSAID had a 3.2-times greater risk (Aliment Pharmacol Ther, 5
October 2007; doi: 10.1111/j.13652036.2007.03541).
coated, which allows the tablet to transit through the stomach to the small intestine before releasing the medicine, or buffered, where the standard pill is coated with a substance that neutralizes stomach acid. But again, far from reducing the GI risk, these coatings appear to increase it. Researchers from the Boston University School of Medicine interviewed 550 hospital patients who had major upper gastrointestinal bleeding about their aspirin use. To their surprise, they found that those who had regularly taken buffered aspirin were at a slightly greater risk of developing GI problems than were those taking regular aspirin tablets. At doses greater than 325 mg, patients taking the buffered tablets were seven times more likely to develop GI problems whereas the risk was increased nearly sixfold with the standard pills (Lancet, 1996; 348: 14136). Aspirin: still a wonder drug? Extraordinarily, the popular use of aspirin seems to be immune to any bad news. This may be because aspirin is still perceived as being a wonder drug. Every year, its estimated that around 3500 studies are carried out on the drug, and researchers seem to consistently come up with new health problems that they believe it can solve. Its been claimed to fight cataracts (Arch Ophthalmol, 1992; 110: 33942), and cancers of the prostate, colon, pancreas, upper GI tract, and lungclaims that usually no one is able to replicate and so are, eventually, forgotten. This is, of course, in addition to its more traditional, and accepted, uses as an antipyretic to reduce fever in cases of rheumatic fever, as an antiinflammatory in cases of rheumatoid arthritis and osteoarthritis, and as a painkiller for minor aches and pains such as headache. But if the risks of regularly taking aspirin outweigh its benefits among healthy over-75s, as suggested by Oxfords Professor Rothwell, then should healthy individuals of any age be taking it? Not according to Charles H. Hennekens, former chief of preventive medicine at Brigham and Womens Hospital in Boston, and one of aspirins main advocates. Yet, even he believes it
Lead researcher Dr Yoon K. Loke commented: Before I did this study, I didnt worry at all when I saw patients who were on combinations of SSRIs and NSAIDs. Now that I have seen the fairly substantial excess risk, physicians should review the patients chartsdo they need to be on these drugs at all, or are there safer alternatives? Gastrointestinal problems with aspirin have been known for a long timeeven if the actual severity and extent have only recently been revealedand manufacturers have tried to reduce the risks by either producing a version that is enteric-
is wrong for any healthy individual to take aspirin as a preventative as the risks are simply too high. A 30-year-old womans risk of a heart attack is typically very small, and remains so even over the next 30 years. Aspirin would give her no benefit and it could cause gastro-intestinal effects or dangerous bleeding, he says in a Food and Drug Administration (FDA) report. Children aged under 12 should also no longer be given aspirin because of the very real danger of Reyes syndrome, a rare, often fatal, disorder primarily seen in children recovering from a viral illness and associated with aspirin use (BMJ, 2002; 325: 988). If the healthy should not be taking aspirin, this suggests that nearly 40 per cent of daily aspirin use is inappropriate, and may even be endangering thousands of lives without any realistic benefits. Nevertheless, it should be part of the daily health regime of anyone who has a heart problem, says the American Heart Foundation. It estimates that between 5000 to 10,000 of the 900,000 lives lost each year to cardiovascular disease in the US alone could have been prevented had the patient taken a daily aspirin. It points to research that suggests that aspirin can help to prolong the lives of people who have suffered a stroke or heart attack, or recurring blockages following heart bypass surgery or angioplasty to clear obstructed arteries. But these positive claims have to be countered with the more recent findings that the drug could be killing 20,000 Americans every year because of GI complications alone, a figure that may well increase if stroke victims are also included. But no drug is a substitute for a sensible lifestyle. A healthy diet that is rich in vegetables and fruit, moderate exercise, and stress- and cigarette-free living can do more for the healthy individual and the recovering patient alike. As the FDAs Debra Bowen says: Physicians really need to look at aspirin in the context of complete care, as part of a whole treatment plan for people at risk of heart attack or stroke. Its a view shared by Dr Peter Coleman, deputy director of res-earch for the Stroke Association in the UK.
He says: If you are healthy and have a low risk of heart disease or stroke, the increased risk from side-effects of aspirin are likely to outweigh the benefits of preventing stroke. Aspirin is as close as medicine has ever come to producing a magic bulletand one that appears to be Teflon-coated, too. Neverthe-less, given these latest discoveries, its an ideal that is apparently as far away as ever.
Bryan Hubbard
The great depression myth

SSRI drugs sell on the basis of the false chemical imbalance theory
very year around the world, we take $13bn (6.6bn)worth of antidepressants, and more than 80 per cent of those is an SSRI (serotonin selective reuptake inhibitors) such as Prozac, Paxil and Zoloft. SSRIs are among the best-selling drugs in medicine, and their enormous success is based on the chemical imbalance theory, which proposes that people are depressed because they are low in serotonin, a brain chemical and neurotransmitter that acts on the nervous system. An SSRI redresses such a chemical imbalance by helping to promote serotonin, and can treat not only depression, the manufacturers claim, but also other psychiatric problems such as social anxiety disorder and obsessivecompulsive disorder. The SSRI signalled a revolution in mental care. Suddenly, clinical and severe depression wasnt something that the sufferer just had to endure or learn to get over. Instead, heres a simple remedy to hand: a chemical to treat a chemical. As a result, weve become a Prozac Nation, as Elizabeth Wurtzels best-selling book says. The pharmaceutical industry has been the major promoter of the depressionserotonin theoryfor obvious reasons. Yet, astonishingly, the concept has never been actually proven since it was first postulated in 1967and not because there havent been many attempts to do so. Given that the theory remains unproven, its not surprising that the SSRI antidepressant is far less effective than the drug companies are claiming. In a meta-analysis of both published and unpublished trials so far, researchers found that the trials, usually funded by the drug manufacturer itself, either put an unwarranted positive spin on the results or were suppressed if the results were not positive (N Engl J Med, 2008; 358: 25260).
Whats the idea? Its generally accepted by doctors
as well as the general publicthat severe depression is the result of a chemical imbalance nd, especially, low levels of the neurotransmitter serotonin in particular. Joseph Schildkraut was one of the pioneers of the general theory that chemical imbalances cause depression and, in 1965, he postulated that depression was associated with low levels of a neurotransmitter. These imbalances caused mood swings, and the problem could be corrected by drugs, he believed. Two years later, researchers zoned in on serotonin as the neurotransmitter responsible (Br J Psychiatry, 1967; 13: 123764). But this acceptance has far more to do with aggressive marketing by the drug companies, who sell their SSRIs on the basis of the theory, than research from neuroscientists, who have triedunsuccessfullyfor 40 years to come up with conclusive evidence to support the theory. Researchers who analyzed the cerebrospinal fluid of clinically depressed and suicidal patients couldnt find any differences in their serotonin levels compared with healthy controls. Even participants in medical trials whose levels of serotonin were deliberately lowered failed to become depressed (Pharmaco-
psychiatry, 1996; 29: 211). Similarly, depressed people who were given huge increases of serotonin failed to witness any improvements in their condition (Arch Gen Psychiatry, 1975; 32: 2230). Not only has neuroscience been unable to prove the theory in independent studies, it has found plenty of evidence to suggest that depression and other mental disorders are the result of far more complex factors than a simple neurotransmitter deficiency. The lack of substantiating evidence isnt helped by the fact that no one knows what an ideal serotonin level is supposed to look like, let alone the profile of a pathological imbalance. There is not a single peerreviewed article that can be accurately cited to directly support claims of serotonin deficiency in any mental disorder, says Jeffrey Lacasse, a PhD candidate from Florida State University and coauthor (with neuroanatomy professor Dr Jonathan Leo of Lake Erie College of Osteopathic Medicine) of the essay Serotonin and Depression: A Disconnect Between the Advertisements and the Scientific Literature

(PLoS Med, 2005; 12: 12116). The psychiatric bible, The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; published by the American Psychiatric Association), lists the definitions of all psychiatric diagnoses, and does not list serotonin as a cause of any mental disorder. However, the Textbook of Clinical Psychiatry, 4th edn (Hales RE, Yudofsky SC, eds. Washington, DC: American Psychiatric Publishing, 2003) does describe serotonin deficiency as an unconfirmed hypothesis, adding: Additional experience has not confirmed the monoamine depletion hypothesis. The SSRI explosion Nevertheless, and despite the lack of evidence, SSRI drug sales increased by 353 per cent between 1981 and 2000 (Ann Pharmacother, 2002; 36: 1375 9). Indeed, its even anticipated that SSRI sales will peak in 2010 with global revenues of $14.6bn, and Japan is expected to be a major market for growth over the next couple of years, with sales there anticipated to increase by 52 per cent (Datamonitor; at www.marketresearch.
com/search/results.asp?sid=92042647406931770-490552493&query=ssri+future+ use+Japan&vendorid=72&publisher=Datam onitor&cmdSubmitLt=Go).
What can cause depression?

Depression is a chronic and debilitating condition that goes far beyond feeling down or having the blues. While doctors recognize that it can take various formssuch as moderate or severe, or clinicalthey dont know precisely why some people become depressed, other than accepting that it can be due to a complex mix of causes. However, the one thing that is known with certainty is that the oft-repeated theory of a chemical imbalance is simplistic and not supported by any scientific evidence. While patients help groups often point to obvious causes of depression such as death in the family, job loss or chronic illness, WDDTYs scouring through the literature has uncovered many other, often unsuspected, causes. N Hypothyroidism. Around one in five cases of chronic depression are believed to be due to the body producing too little thyroid hormone. One study found that women with even just mildly decreased thyroid function had three times the rate of depression compared with the average (Ann Rev Med, 1995; 30: 3746). To check if your thyroid gland is underperforming, place a thermometer under your armpit for 10 minutes immediately upon waking in the morning. Any temperature below the normal range of 97.898.2 degrees F (36.637 degrees C) may be indicative of an underactive thyroid. N Low blood sugar. This conditionwhich has the medical name of reactive hypoglycaemiais a recognized cause of depression. It can occur after compulsive snacking on sweet or starchy foods and, once these foods and carbohydrates are removed from your diet, the depression may well lift. N Irritable bowel disease. Gastrointestinal problems are a major cause of irritability and depression. One-third of all sufferers of Crohns disease complain of headache, eye problems and depression (South Med J, 1997; 90: 60610). N Coeliac disease. Depression is associated with this gastrointestinal condition, where the inner lining of the small intestine is damaged by eating wheat, rye, oats and barley. N Allergies. One study found that a third of all depressed people also suffer from some sort of allergy such as to certain foods, or hayfever or bronchial asthma (J Affect Disord, 1981; 3: 2916).
The first blockbuster SSRI, Prozac (fluoxetine hydrochloride), was launched in 1986, and is the most widely prescribed antidepressant medication in history, according to its manufacturer, Eli Lilly. Another SSRI, Pfizers Zoloft (sertraline), was the 10th best-selling drug in the world in 2003, with sales of $3.4bn. Before the SSRIs were developed, only 100 people per one million population were diagnosed as being depressed; today, this figure now stands at 100,000 people per million population (Healy D. Let Them Eat Prozac. New York: NYU Press, 2006). The depressionserotonin hypothesis has been actively promoted by drug companies in advertisements to both doctors and the general public, and in seminars to health professionalsand so successfully that it has been widely accepted as a physiological fact. In the US, where drug companies are permitted to market directly to consumers,
Pfizers TV advertising for Zoloft has claimed that depression may be due to a chemical imbalance, and that Zoloft works to correct this imbalance. In the support literature for its SSRI, Pfizer states that scientists believe that it (depression) could be linked with an imbalance of a chemical in the brain called serotonin. SmithKline Beecham, the manufacturer in the US of the SSRI Paxil (paroxetine), has this to say on its website: Scientific evidence suggests that depression and certain anxiety disorders may be caused by a chemical imbalance in the brain. Paxil helps balance your brains chemistry. The idea is repeated constantly by SSRI manufacturers, even though the US drugs regulatory body, the Food and Drug Administration (FDA), has sent out 10 warning letters to them
since 1997. In fact, the Irish Medical Board has banned GlaxoSmithKline from claiming in its patient information that Paxil corrects a chemical imbalance. Nevertheless, the company continues to make the claim on its website and in other countries. However, despite these occasional slaps across the wrist, manufacturers are generally allowed to continue promoting the hypothesis. The SSRIs dont work Not surprisingly for drugs based on a false hypothesis, they arent effective. In a recent meta-analysis of 74 trials involving 12 antidepressants that had been logged with the FDA, researchers from the Oregon Health and Science University discovered that the manufacturers either tried to hide the fact or put a positive spin on any results that suggested that
their drug was not helpful. As for 22 studies that had negative results, the researchers found that none of them had been published, while a further 11 reported positive conclusions that were not backed up by the research findings. Of the published trials, 94 per cent were positive, suggesting that the drug was considerably better than a placebo in treating depression. Yet, the FDAs analyses of the same trials concluded that only 51 per cent presented positive findings (N Engl J Med, 2008; 358: 25260). In a separate analysis of clinical trials involving SSRIs submitted to the FDA, researchers discovered that a placebo, or sugar pill, replicated up to 80 per cent of the benefits of the so-called active agent, and that 57 per cent of all trials, published and unpublished, failed to demonstrate any statistically significant differences between the drug and a placebo (Prev Treat, 2002; 5: article 23;
online at http://content.apa.org/journals/ pre/5/1/23).
Treating depression without drugs

There is a range of strategies that can be adopted to help to overcome depression, depending on its severity, and they dont involve the use of toxicor dubiousdrugs such as the SSRIs. N St Johns wort (Hypericum perforatum). This herb, dubbed Natures Prozac, is a proven remedy for mild-to-moderate depression, although it has also proved effective in more severe cases. In Germany, it has become the standard treatment for depression, and is even preferred over antidepressant drugs. Numerous studies have shown that the herb works. One found that 300 mg three times a day cured 75 per cent of depressed people (J Geriat Psychol Neurol, 1994; 71: 124). Doctors in the UK and Ireland have been opposed to the herb only because it can interfere with prescription drugs. N Diet. Oily fish can ease depression. Tryptophan-rich foods, such as turkey, salmon and dairy, may also help, as may foods rich in vitamin B6, including soy-beans, lentils, meat, poultry, fish, fruit and brown rice. Make sure that you consume plenty of mono- or poly-unsaturated fats, and cut out caffeine and refined sugar, and eat only dark chocolate. N Nutrition. The B-complex vitamins, including B12 and folic acid, can help with depression, as can calcium, zinc and the omega-3 essential fatty acids. N Thought Field Therapy. The TFT technique involves finger tapping on specific acupuncture points around the body at the same time that the patient is generating a negative thought or emotion. The tapping is supposed to release the trapped emotion. However dubious it may sound, the therapy has been tested in several trials, and the early results are promising. N Cognitive behavioural therapy. This form of talking therapy, which is based on the idea that how we think, act and feel all interact with each other, is one of the most successful ways to treat mild-to-moderate depression. Its as effective as SSRI drugs, but without the dangerous sideeffects (BMJ, 2006; 332: 10302). N Exercise. Exercise can be surprisingly effective in combating depression. Even moderate exercise, which involves just walking briskly or jogging for 40 minutes, three or four times a week, can help. Those who already exercise regularly are less likely to become depressed. One study found that moderate exercise was as effective as the powerful SSRI sertraline (Zoloft) (Arch Intern Med,
Other drugs and remedies for depression appear to work just as well asif not better thanan SSRI drug, which serves to further challenge the depressionserotonin hypothesis. A Cochrane review of various antidepressants found that there was no major difference in effectiveness between SSRIs and tricyclics, an older class of antidepressants that was developed in the 1950s (Cochrane Database Syst Rev, 2000; 3: CD002791). In randomized trials, bupropion (Wellbutrin; Zyban), an antidepressant that is more commonly used today as a stop-smoking drug, and reboxetine (Edronax; Norebox) were found to be equally as effective as SSRIs for treating depression and, yet, neither interferes with serotonin levels (J Clin Psychiatry, 1997; 58: 5327; J Clin Psychiatry, 2000; 61 [Suppl 10]: 318). The herbal remedy St Johns wort (Hypericum perforatum) was more effective than an SSRI in one trial involving patients with moderate-tosevere depression (BMJ, 2005; 330: 503), and the SSRI sertraline was even bested by a placebo in another trial involving patients who were severely depressed (JAMA, 2002; 287: 180714). Indeed, exercise was just as
effective a remedy against depression when pitted against Zoloft in a randomized trial of older patients with severe depression (Arch Intern Med, 1999; 159: 234956). SSRI dangers The FDA has issued more public warnings and black-box notices prominent announcements in the drugs literature and patient information sheetsregarding the dangers of SSRIs than for almost any other family of drugs. Although the drugs come with a vast array of adverse reactions, drugs regulators are especially concerned over the SSRI potential to increase the risk of suicide.
The risk was thought to be greatest among adolescents and teenagers, but the FDA has admitted that anyone who takes an SSRI is at greater risk of committing suicide. At an FDA drugs advisory committee meeting held in December, 2006, psychiatrist Dr David Healy told the members: The idea that you would have a risk in one age group but not in another is just wrong. Another psychiatrist, Dr Peter Breggin, also testified, and said: Americas drug watchdog needs to come clean because its been approving depressants as antidepressants. The primary data on suicidality has been generated in short-term controlled clinical trials planned by

drug companies, carried out by drug company hacks, and evaluated by drug company employees at corporate headquarters. If that kind of carefully cultivated evaluation bears such bad fruit, imagine what the real data must show. Despite these very real dangers, doctors continue to prescribe SSRIs to children. In one study, researchers discovered that children as young as six years of age were being prescribed an SSRI, and they were 52 per cent more likely to commit suicide within the following two months. Overall, a child on an SSRI was 15 times more likely to kill himself than one not taking such a drug (Arch Gen Psychiatry, 2006; 63: 86572). In addition to the suicide risk, SSRIs have been linked to a wide range of other adverse reactions. Prozac alone has 242 different sideeffects listed, including 34 problems of the genitourinary tract. In one review of drug reactions, it was found that during a 10-year period, Prozac was associated with more hospitalizations, deaths or other serious adverse effects reported to the FDA than any other drug in America (Moore T. Prescription for Disaster. New York: Dell Publishing, 1998). The most common problems seen with SSRIs are neurological (22 per cent), psychiatric (19.5 per cent), gastrointestinal (18 per cent) and dermatological (11.4 per cent) (Drug Safety, 1999; 20: 27787). Every SSRI manufacturer has active lawsuits pending. Forest Laboratories, which makes Lexapro (escitalopram oxalate) and Celexa (citalopram), has been involved in at least 25 lawsuits recently, says US law firm Pogust & Braslow, and most of these involve cases of unexplained suicide or attempted suicide. Off-label prescribing One major cause of the enormous success of the SSRIs has been offlabel prescribing by doctorswhere they prescribe drugs either to people, such as the very young or very old, for whom no safety trials have ever been undertaken, or for problems for which the drug has never been intended. Although the SSRIs are labelled as antidepressants, the FDA has allowed their use as remedies for eight other psychiatric disorders, including social anxiety disorder, obsessive compulsive disorder (OCD) and premenstrual dysphoric disorder (a severe form of PMS). Despite such a loose definition of an antidepressant, one study found that 75 per cent of all prescriptions for SSRIs were off-label, as treatments for conditions for which the drugs have not been approved (J Clin Psychiatry, 2006; 67: 97282). Lead author Dr Hua Chen, from the University of Houston, said that the findings reveal a significant gap in the US drugs-safety system. Over the years, SSRIs have been prescribed for pain, insomnia, shyness, menstrual discomfort, dementia and restless leg syndrome, and to every age group, including young children, and even to pregnant women, despite evidence that these drugs are harmful to an expectant mother as well as to her fetus (N Engl J Med, 1996; 335: 10105). While its not illegal for a doctor to prescribe a drug off-label, it is not allowed for drug companies to promote a drug for such unapproved uses, although it is known to be a widespread practice and one that has been the subject of a US House Committee hearing. Mind over matter The SSRIs are some of the most dangerous drugs ever developed and, yet, they are probably the least effective. Based on an hypothesis that stubbornly remains unproven, these agents usually fare little better than placebo, which suggests that any benefit while taking them is very likely being generated by the patient himself. Depression can be debilitating, but it can be resolved without the use of these powerful, yet ineffect-ive, drugs. It may be that the most important contribution of SSRIs has been to our understanding of the power and importance of our own minds in bringing about health.
Bryan Hubbard
The great Prozac conspiracy

After 20 years of these so-called miracle antidepressants, psychiatrists are shocked to discover that drug companies withheld information about the risks of this class of drugsand with the tacit approval of the drug regulators.
t all started so promisingly, when drugs like Prozac first came on the market in the 1980s. Here at last, we were told, was a new class of antidepressants that would transform the world of psychiatry. Out would go the old dirty psychiatric drugs of the 1950s, and in would come a set of drugs honed by science to target the biochemical core of depression in the brain. These new drugs had a very scientific-sounding nameselective serotonin reuptake inhibitorswhich neatly morphed into the catchy acronym SSRIs. They are among the most successfully marketed drugs in history, so much so that the brand leader Prozac is almost a synonym for antidepressants, just like Hoover is for vacuum cleaners. But now, some two decades later, the world of psychiatry has finally discovered it has been largely taken for a ride with SSRIs, by both drug companies and lax regulators.
by allowing the transmitting cell to reabsorb them from the synapse (a process that is called reuptake). So, if a way can be found to stop (or inhibit) this reuptake, the synapse would remain constantly bathed in neurotransmitters. But only one neurotransmitterserotoninis involved in depression, which means that only serotonin needs to be selectively isolated from the rest of the neurotransmitter cocktail. So, in the mid-1970s, the pharmaceutical companies set themselves the task of finding a drug that would select out serotonin, and inhibit its reabsorption by the transmitting neurones. Ten years later, the family of SSRIs was created. The first SSRI appeared in the mid1980s from the Swedish pharma company Astra. The drugs chemical name was zimelidine, but it was
quickly withdrawn from the market when patients developed Guillain Barr syndrome (a serious autoimmune condition involving damage to the peripheral nerves). Soon afterwards, a second SSRI, a French drug called indalpine, was also stopped after it was found to damage blood cells. These straws in the wind didnt deter other drug companies, however although the SSRIs hoped-for lack of side-effects had been intended to be a major part of their sales pitch.
Safety and side-effects

In addition to suicide risk, SSRI sideeffects include: Insomnia (up to 35 per cent of patients need sleeping pills) Sexual dysfunction (anorgasmia in up to 83 per cent of men; this may be permanent, even after the drug is withdrawn. In bizarre contrast, SSRIs can also cause yawningexcitement syndrome, where patients experience sexual arousal when they yawn, often progressing to orgasm) Akathisia, described by an SSRI spokesman as overwhelming distress and unbearable discomfort, making patients feel like death is a welcome result. It can sometimes be mistaken for worsening depression, prompting some doctors to increase the dosage (J Psychopharmacol, 1998; 12: 192214).
Miracle science In the brain, messages are passed between brain cells (neurones) across a tiny gap called a synapse. This gap is filled with chemicals, which have the job of controlling the communication between brain cells, transmitting information from one neurone to the other. Hence, these chemicals are called neurotransmitters. When one neurone communicates with its neighbour, it floods the synapse with a cocktail of neurotransmitters, one of which is serotonin. By the 1970s, it had been discovered that some prescription drugs can cause depression as a side-effect, a problem traced to low brain levels of serotonin. It was then argued that, if a way could be found to increase serotonin in the brain, it would reduce depression. Its already known that the brain naturally conserves neurotransmitters
Other effects
Nausea Vomiting Diarrhoea Gastrointestinal bleeding Headache Agitation Nervousness Rash Weight gain Lethargy Fatigue Sweating Anorexia Forgetfulness Seizures Anxiety Mania Dizziness Problems in urinating Trembling or shaking Dry mouth Hostility Aggression

The first SSRI to come to market was fluvoxamine (see box, right), but its manufacturer Solvay Pharmaceutical, based in Georgia, lacked marketing clout, making its launch a bit of a damp squib. It took the marketing power wielded by the giant US (and international) drug company Eli Lilly to collar most of the SSRI public relations when it launched fluoxetine in 1987, under the memorable tradename Prozac. Newspapers were quick to swallow the companys sales pitch, with headlines describing Prozac as a happiness pill. Even normally cynical journalists described Prozac as a valuable, quick, emotional fix, and a panacea for the stresses of the 20th century. But the marketing dream soon turned into a PR nightmare as patients began to complain of unpleasant sideeffects such as nausea, sexual dysfunction, insomnia and gastrointestinal bleeding. Worse, Prozac sometimes caused violent, irrational behaviour. In one infamous case, a middle-aged factory worker became homicidal while taking Prozac, killing five people and wounding 12 others at his workplace. In another example of horrific behaviour as a result of taking this drug, a female patient attacked her mother by biting her so viciously that she managed to rip away 20 chunks of her mothers flesh. Eli Lilly was ordered to pay substantial damages. After SmithKline Beecham (now GlaxoSmithKline or GSK) weighed in with their own SSRI, Seroxat (paroxetine), similar side-effects were seen with their drug, too. Even doctors began to express some concerns. Physicians are seeing long-term sideeffects from SSRIs far in excess of what was expected from the clinical trial data, Dr Norman Sussman, a psychiatrist at New York University Medical Hospital, told the press in 1998 (Clin Psychiatr News, 1998; 26: 1). Within a few years, Seroxat was following Prozac into the courts. In June 2001, GSK was ordered to pay $6.4m to the family of Donald Schell, who, after just two days on Seroxat, killed his wife, daughter, granddaughter, and finally himself. Although GSK tried to claim that the drug wasnt to blame, the British expert
Patently profitable
Generic (trade) names citalopram (Celexa, Cipramil, Emocal, Sepram) fluoxetine (Prozac, Fontex, Seromex, Seronil, Sarafem, Fluctin) fluvoxamine maleate (Luvox, Faverin) paroxetine (Paxil, Seroxat, Aropax, Deroxat) sertraline (Zoloft, Lustral, Serlain) Manufacturer Lundbeck Patent expiry date 2002
Eli Lilly
2000
Solvay GlaxoSmithKline
1996 2006
Pfizer
2005
witness Dr David Healy, of Bangor University in North Wales, told the court he had uncovered early SmithKline Beecham documents which acknowledged that serious symptoms of agitation could occur after taking the drug for just a few days. Whistleblower Dr Healy, now a professor of psychiatry at the North Wales Department of Psychological Medicine, has recently been in the news again, after publishing an article in the scientific literature accusing drug companies and their official regulators of dirty tricks (BMJ, 2006; 333: 925). The target of his concern was the fact that the drugs cause some people to commit suicide: indeed, these highly sophisticated drugs apparently can precipitate the fatal behaviour that psychiatrists spend their lives trying to prevent. The first warnings of this effect were sounded as early as 1991, when researchers looked at the placebocontrolled clinical evidence for fluoxetine, and discovered a spike of suicides (BMJ, 1991; 303: 68592). Drug companies glossed over such findings, and even complained that placebo-controlled trials were unethical, as SSRIs were self-evidently both effective and safe. However, as Professor Healy revealed in his British Medical Journal article, he obtained access to some of the original drugcompany data, which gave the lie to their official PR line. He was able to confirm that, in the evidence presented to the licensing authorities,
every antidepressant licensed since 1987 [showed] an excess of suicides. The companies, he said, had obscured the suicide evidence by fudging the data, a practice euphemistically referred to as recoding. When Healy challenged Pfizer (which makes sertraline, marketed as Zoloft) and GSK with his bombshell discovery, they didnt deny that recoding had occurred, but noted that the FDA [Food and Drug Administration, the US watchdog regulatory body] has neither criticised these data or the report as inappropriate, nor required additional analyses. However, documents obtained under the Freedom of Information Act reveal that FDA regulators were fully aware of the recoding but, says Healy, told the pharma industry that they did not see the SSRIsuicide connection as a real issue, but rather as a public relations problem. And yet, no fewer than four clinical studies published between 1990 and 2000 have shown SSRIs to cause an increased risk of suicidality, culminating in a British report entitled Deliberate Self-Harm and Antidepressant Drugs. This was a survey of the Accident & Emergency case notes from one UK hospital area that revealed a five-and-a-half times extra risk of suicides among people taking SSRIs (Br J Psychiatry, 2000; 177: 5516). Slow-acting regulator Healy showed that there has been collusion between the authorities and
the drug companies in putting as good a gloss on the data as possible. For example, the FDA had a backdoor agreement with Pfizer that the sertraline suicide data should be analysed as if it were a constant hazard, even though they knew the evidence clearly shows that suicides peak in the first few weeks of use. This averaging-out is outright manipulation of data, says Healy, because it disguises the true extent of
the suicide problem. His own analysis shows that the latest data for paroxetine indicates as much as a fivefold increase in suicide risk, a statistic consistent with previous findings. Another area of concern is children. Astonishingly, SSRIs have been given to kids as young as two years old, and the figure is rising exponentially for older children, too. For example, sertraline prescriptions for youngsters
What to do instead
Allergies, food intolerance and nutritional deficiency all cause depression. So, first ensure that you are receiving the nutrients you need by taking the following nutritional supplements: N good vitamin B-complex, one which contains 50 mcg of B12 and biotin, 400 mcg of folic acid and 50 mg of all other B vitamins N Vitamin C, 500 mg twice a day N Calcium, 500 mg/day and magnesium, 200 mg/day (both necessary for nerve function). One recent study showed rapid recovery (less than seven days) from major depression with magnesium supplements (Med Hypotheses, 2006; 67: 36270) N 5-HTP (plant-based tryptophan), 200 mg/day. When compared with fluvoxamine, for example, 5-HTP is at least 10 per cent better at reducing depression, anxiety, insomnia and physical symptomsand works faster, too (Psychopathology, 1991; 24: 5381) N Zinc, 15 mg/day N Omega-3 essential fatty acids (EFAs; for example, cod liver oil)) 2 g/day, or EPA (eicosapentaenoic acid) 1 g/day. In one study, taking EFAs for just 12 weeks reduced depression by half in patients for whom all conventional drugs had failed (Arch Gen Psychiatry, 2002; 59: 9139) N St Johns wort, 300 mg three times a day. A meta-analysis of 23 studies showed this herb to work in mild-to-moderate depression, and to be just as effective as the standard drug treatments, but with fewer adverse side-effects (BMJ, 1996; 313: 2538). Check that the tablets contain a standardized content of 0.3 per cent hypericin (the major active ingredient in St Johns wort), as well as 5 per cent hyperforin, recently discovered to be another key natural ingredient (Pharmacopsychiatry, 1998; 31 Suppl 1: 549). Choose solid tablets as they have a much longer shelf-life than capsules. Other alternative treatments include: N Exercise. Get your body moving. A German study showed that 30 minutes of treadmill exercise a day helped reduce major depressive episodes in 100 per cent of patients, of whom more than half experienced substantial improvement. The benefit was particularly marked in people for whom antidepressant drugs had failed (Br J Sports Med, 2001; 35: 1147) N Acupuncture. A recent Chinese study compared acupuncture head-to-head with Prozac. Acupuncture was found to be superior as it worked much faster, and the only side-effect was mild fatigue (J Tradit Chin Med, 2005; 25: 2436) N Thought Field Therapy (fingertapping on acupuncture points). TFT has been found to cut symptoms of emotional distress by 50 per cent (Traumatology, 1999; 5: 1, article 4) N Light therapy. Choose a light box with an output of at least 10,000 lux, and use it for 30 minutes between 7am and 9am. A recent clinical trial pitted light therapy against Prozac, and found that the drug worked no better (Am J Psychiatry, 2006; 163: 80512).
aged two to 19 tripled in just the 10 years from 1988 to 1998from 40 million prescriptions to 120 million after the introduction of fluoxetine (Pediatrics, 2002; 109: 7217). Equally surprisingly, very few SSRIs have actually been formally licensed for use by children, so all of this prescribing to them has been offlabel. This term is used to describe when doctors prescribe drugs that have been officially approved for one purpose to treat other, unauthorized conditions. In fact, few drugs are ever tested on children. The reasoning behind this practice is that children are simply little adults, so the hazard profile of a drug may safely be applied to them so long as the appropriate reductions in dosage have been made to accomodate their smaller size. But this is not necessarily true. For example, Ritalinthe infamous hyperactivity drugappears to act as a depressant in children, but is a stimulant when taken by adults. So we know that children can react totally differently from adults, particularly when mood-altering drugs are concerned. Indeed, in the case of SSRIs, it was largely childrens violently selfharming reactions to the drugs that alerted psychiatrists to the suicide problem in the first place. In 1991, Yale University doctors reported the case notes of six children, aged 10 to 17, who developed intense self-injurious ideation or behaviour while taking Prozac. For example, after three weeks on the drug, one 14-yearold girl, who had never been suicidal before, began cutting and otherwise injuring herself. She told hospital staff, Im just waiting for the opportunity to kill myself, and chanted, Kill, kill, kill; die, die die; pain, pain, pain (J Am
Acad Child Adolesc Psychiatry, 1991; 30: 17986).
Another study carried out 10 years later again found that SSRIs increased suicidal behaviour in children (J Am Acad Child Adolesc Psychiatry, 2001; 40: 13645). And yet, it wasnt until 2003 that the British Medicines and Healthcare Products Regulatory Agency (MHRA) finally recommended that SSRIs not be given to childrenand this only after being shamed into action by media reports of teen suicides caused

by Seroxat. Why did they take so long? According to Healy, there were two main reasons: a lack of statistical expertise on the part of the MHRA (and the FDA, too); and a mindset which overstates the benefits and underestimates the risk of drugs. As a result, both the British and the American regulatory bodies, he says, insist on such cast-iron statistical proof of harmful effects that they demand an all but unreachable threshold. The crowning irony of this official intransigence came in May of this year, when GlaxoSmithKline themselves sent a letter to doctors, warning them that paroxetine could cause a sixfold increase in the risk of suicidesa figure that neither the FDA nor the MHRA has so far acknowledged. Many people expect drug companies to be slow to concede that a drug causes hazards, commented Healy dryly, but we do not expect our regulators to be even slower. facturers. But those claims have since turned out to be highly optimistic. Study after study has shown that SSRIs are actually little better than the TCAs. Recently, researchers have pulled together 15 to 20 years worth of statistics, including previously suppressed data amassed by the drug companies themselves, as a sort of final overall verdict on the SSRI experience. These huge clinical meta-analyses have looked at SSRI use by a variety of patient groups. Here, for example, are direct quotes from what researchers have found in three different types of patients: N people with mild depression: . . . no differences between TCAs and SSRIs (Cochrane Database Syst Rev, 2000; 4: CD001130) N depression in general: There are no clinically significant differences in effectiveness between SSRIs and TCAs (Cochrane Database Syst Rev, 2000; 2: CD001851) N The elderly: . . . SSRIs and TCAs are of the same efficacy (Cochrane Database Syst Rev, 2006; 1: CD003491). So the truth is finally revealed: SSRIs have never worked any better than the drugs they were intended to replace. The anger in response to this revelation among the psychiatric profession is now palpable. Even normally conservative medical journals have spoken out against the drugs. An article in a major psychiatric journal recently concluded that drugcompany-sponsored research is no longer reliable: Caution is needed in interpreting drug company sponsored trials given the evidence of selective reporting and publication bias (Curr Opin Psychiatry, 2005; 18: 215). Similarly, another peer-reviewed journal revealed that, if the true data for these drugs had not been suppressed, it would have served as evidence that they dont work: We learned that pharmaceutical companies selectively released data that reflected positively on their products, and that combining suppressed and published data suggested that most of these medications had questionable efficacy (J Clin Psychol, 2006; 62: 23541). Any residual confidence in the SSRIs is now likely to be permanently eroded. However, most of the large pharmaceutical companies that produced the SSRIs will not receive any negative fallout on their share prices. After all, most of the SSRI patents have now expired (see box, page 16). So, it would seem that the drug giants have already made whatever money they can and can now do a runnera kind of smash-andgrab raid on the world of psychiatry. Nevertheless, their future share in this lucrative market may be damaged. Pharma-industry analysts warn that the world antidepressants market is in serious trouble, with revenues of only $7 billion a year 50 per cent down from their peak (The World Market for Antidepressants, 2006). They also predict that the world market will crash, mainly because there are not enough new antidepressants in the pipeline. That may indeed be so, but the market may also crash for at least three other reasons, too. The trust that may have existed between psychiatrists and their patients and the pharmaceutical companies is likely to be permanently tarnished. With this whole sorry episode, the biochemical model of depression and biochemical manipulation as a solutionis now in question. The result is that patients may be more willing to turn to the many safe, natural antidepressants that are available to them.
Tony Edwards
Major side-effects
Excess suicides are just the beginning. There are also major issues of sideeffects and efficacy. After 20 years of experience with SSRIs, it now turns out that these super-sophisticated drugs that were once hoped to be relatively free of side-effects are, in fact, potentially more dangerous than the crude tricyclic antidepressants (TCAs) of the 1950s they were meant to surpass (see box, page 15). But the SSRI scandal stretches even beyond that. The only reason SSRIs were allowed onto the market in the first place was that the drug companies claimed they were far superior to the existing TCAs. In the heady days of the 1980s, figures of 80 per cent effectiveness were confidently bandied aboutthis was three times better than with TCAs, said SSRI manu-
SSRIs: bad prescribing habits

ust when it seemed as if it couldnt get any worse for manufacturers of antidepressants like Prozac, new evidence reveals that they havent been correctly prescribed since their release on the market. Thousands of patients are being put at risk of life-threatening side-effects, including an increased risk of acts of self-harm such as suicide, because they are being given the drug beyond the point where it will do any good. New evidence shows that, if the drugs are going to have any benefit at all, it will happen within the first two weeks of taking the drug. Consequently, many patients are being put at risk of lethal side-effects because the drug companies and doctors are recommending that the drugs be taken for at least six weeks, if not longer. The conventional wisdom about the new antidepressants holds that it takes a little time for them to work. According to recent guidelines issued by Britains National Institute for Health and Clinical Excellence (NICE), . . . patients started on antidepressants should be informed about the delay in onset of effect. This was certainly the clinical and laboratory experience with the older tricyclic antidepressants. The drug companies and scientists believed that this early generation of drugs worked quickly until the research proved otherwise. Animal models showed that the drugs only worked once the animals (and, it was assumed, human patients) had developed an insensitivity in certain brain receptors. A review of all of the studies in the scientific literature also confirmed a delay in the time it took the drugs to start kicking in (Arch Gen Psychiatry, 1984; 41: 7826). In addition, many of the sophisticated theories concerning how selective serotonin reuptake inhibitors (SSRIs) worked all stressed this delay in onset. Then, when the SSRIs were first launched, psychiatrists and researchers simply assumed the same delay would occur. The assumption of a lengthy time between the start of treatment and any actual effect underpinned the prescribing habits of doctors for all
in that first week (Arch

2006; 63: 121723).
Gen Psychiatry,
the years the SSRIs have been on the market. However, after many years, the science has begun to challenge this basic assumption. A 2005 review of 76 double-blind, placebo-controlled studies of antidepressants discovered that nearly two-thirds of the improvement seen in patients took place within the first two weeks. Half of all patients who responded to the drug within a six-week period did so during the first fortnight (Am J Psychiatry, 2000; 157:14238). Then, a review of the major placebocontrolled studies of SSRIs cast even more light on the timing of therapeutic benefit. This meta-analysis showed that the greatest period of therapeutic response occurs within the first week and that benefit declines with every week thereafter. In fact, one-third of the full effect of treatment is apparent
This result jibes with the new neuroscience about the brain, which has found that the longer depressive thoughts remain unchanged in the brain, the more likely they are to become hardwired in and the less likely is the person to respond to conventional treatment. So worrying is this new finding that the US drugs watchdog, the Food and Drug Administration (FDA), has now issued a blanket mandate, instructing all manufacturers of SSRIs to update their black-box warnings. The new labelling must now include the warning that young adults aged from 18 to 24 taking these drugs may increase their risk of suicidal thinking and behaviour, even during initial treatmentthe first month or two. Manufacturers of all SSRIs are being given just 30 days to submit revised product labels and medication guides to the FDA for review. The new labelling follows quickly on the heels of the 2005 black-box warnings issued by the FDA, which warned of the increased risk of suicide among children and adolescents. At that point, the FDA asked that manufacturers include in the warning that all children and teenagers be closely observed and monitored while taking the drugs. Furthermore, SSRI drug companies were asked to develop medication guidesFDA-approved information packs for patients and their families to be handed out with each new prescription or refill. These guides were designed to be user-friendly and
Signs of SSRI-induced suicidal impulses

The following symptoms have all been reported by both adult and paediatric patients taking antidepressants. Although a causal link between these sideeffects and suicidal impulses has not yet been established, the FDA is concerned that they may be precursors to a drug-induced desire to kill oneself.
O O O O O O
Anxiety Agitation Panic attacks Insomnia Irritability Hostility
O O O O O
Aggressiveness Impulsivity Akathisia (psychomotor restlessness) Hypomania Mania.

easily comprehensible by non-medical people, and to improve monitoring of symptoms. However, after this latest bombshell, the FDA itself decided to examine whether adults also faced any similar risks. The agency began its own review of nearly 3000 antidepressant studies, which included more than 77,000 adults taking SSRIs. At the end of last year, the evidence was in. The studies showed that there were five additional suicides or suicidal impulses for every 1000 young adults studied. An earlier study showed that the drug causes 14 additional cases of suicidal impulses per 1000 in those under 18. The FDAs Psychopharmacologic Drugs Advisory Committee concluded that new labelling changes were necessary to inform healthcare professionals that young adults, as well as teenagers and children, also face suicide risk with these antidepressants. This new information about SSRIs calls for a drastic revision of the use of SSRIs. Patients should only be given these drugs for, at most, two weeks. Thereafter, doctors are needlessly exposing their patients to an increased risk of drug-induced self-inflicted death. The FDA is quick to add that the scientific data to date does not show an increased risk of suicide among those aged over 24. Indeed, it appears that adults over 65 taking antidepressants decrease their risk of suicidea benefit that will be highlighted in the new black-box warnings. One can only guess whether this last bit of received wisdom will also be undermined by evidence unearthed at a later date.
Lynne McTaggart
SSRIs: Its not addiction, its discontinuation syndrome

Call it what you will, but these drugs can still lead to dependence and withdrawal symptoms
ollywood celeb Lindsay Lohans admission to a Los Angeles court last month that shes addicted to antidepressants reopens a controversy that the drugs industry has tried to keep under wraps for 30 years. After the hearing, Lohans father Michael told journalists: These drugs are killing my daughter and killing millions of kids in America, and someone has to stop it. But, so far, no one has succeeded. Not even a US Senate hearing in 2007 could force an admission from SSRI makers that their drugs are addictive. The drugs industry has played a damage-limitation game ever since Eli Lillys first SSRI, Prozac (fluoxetine), was approved in 1977. It heralded a new family of drugs based on the idea that depressed people are low in sero-tonin, a brain chemical that acts on the nervous systema theory that has never been proven (see box, page 22).
docs/en/d/Js4896e/ 9.html). In other words, give the problem a different name, and it will throw everyone off the scent.
Whats in a name? The first indications that SSRIs were addictive appeared in 1992 for fluvox-amine (Br J Psychiatry, 1992; 160: 2834), and opened the floodgates to similar reports for paroxetine a year later and, for sertraline, in 1994. In a move to deflect concerns about the SRRIs addictive qualities, Eli Lilly coined the term discontinuation syndrome in 1996, a euphemism that started appearing on packaged inserts in 2001. The World Health Organization (WHO) was not impressed. SSRIs are an example of how a conceptual confusion over terminology can affect proper reporting, interpretation and communication of adverse drug reactions related to dependence (www.who.int/medicine-
The depressing reality Call it what you like, the reality remains the same: SSRIs are highly addictive. The independent Uppsala Monitoring Centre database lists three SSRIsfluoxetine, paroxetine and sertralineamong the 30 highestranking drugs for dependency (www. who.int/medicinedocs/en/d/Js4896e/9.html). Of these, paroxetine is cited as the most addictive of them all (http://news.bbc.co. uk/2/hi/health/1382551.stm). Claims of paroxetines addictive qualities have dogged its manufacturer GlaxoSmithKline (GSK) from the time of its launch in 1992. GSK has always maintained that its SSRI is not habitforming and that, at worst, around 2 per cent of patients might suffer from discontinuation syndrome. However, secret company papers from 1997 showed that 62 per cent of patients were addicted to the drug (Ann Neurol, 2008; 64: A79). The US drugs monitoring agency, the Food and Drug Administration (FDA), issued a warning about the drug in 2002 and, that same year, the International Federation of Pharmaceutical Manufacturers Association accused GSK of misleading the public and of breaching two codes of practice. Since 1992, around 5000 Americans have sued GSK for downplaying the drugs serious side-effects, while lawsuits citing similar issues have been issued in the UK. In 2004, GSK settled charges of consumer fraud by paying out $2.5 million. Legal discovery uncovered a deliberate and systematic suppression of unfavourable studies (Angell M. The Truth About the Drug Companies. Random House: London, 2005). Although drug companies maintain that discontinuation syndrome is mild
and short-lived, the packaged inserts admit that withdrawal reactions can be intolerable, with symptoms such as dizziness, electric-shock effects, sweating, nausea, insomnia, tremor, confusion, nightmares and vertigo (BMJ, 2005; 331: 824). Sexual dysfunction, such as loss of libido and impotence, is also common (J Sex Med, 2008; 5: 22733). But all this downplaying, aided and abetted by psychiatrists, keeps drug sales high, with global revenues in 2008 of $11 billion. Wyeths Effexor (venlaxafine) leads the field with a 36per-cent share of the total market and annual sales worth $3.93 billion (www.
wikinvest.com/concept/Antidepressant_Drug_ Market).
A major driver of salesat least in the USis direct-to-consumer (DTC) advertising. There, drug companies can advertise prescription drugs directly to the public. Also, as depression is often subjective, many people can be convinced that they have it. As a result, $120 million of the $900 million spend on DTC in 2005 was dedicated to antidepressants. In 2001 in the month after the 9/11 attack on the World Trade Center, GSK doubled its DTC advertising spend on paroxetine (CNS Drugs, 2009; 23: 10320). Depression was once a serious clinical condition suffered by a small

minority, but its now a lifestyle disease that many of us have from time to time, and SSRIs such as Prozac have become our chemical friends. Behind this is the assumption that the drugs are safe and non-addictive. Not so, says Dr David Healy, a leading expert on antidepressants. He believes that more than half of paroxetine users are physically dependent on the drug ( http://news.bbc.co.uk/2/hi/health/1382551. stm). Safety is also an issue. GSK paid out $6.4 million after a man murdered three members of his family before killing himself after taking paroxetine for just two days. In Australia, a judge ruled that sertraline had caused a man to murder his wife and then attempt his own suicide. Healy believes that one in 1000 people taking paroxetine could suffer from such suicidal thoughts.
Bryan Hubbard
The drugs dont work

If the theory of chemical imbalance is false, it follows that SSRIs wont ease depression, at least not beyond the placebo effect. In fact, an analysis of 74 SSRI studies bears this out. Researchers found that one-third of such studies were never published because the results were so poor. Around 94 per cent of the papers that were published had a positive result. Yet, when researchers from the US Food and Drug Administration (FDA) re-analyzed the findings, they found that the SSRI was effective in only half of the studies. These studies had been paid for by the manufacturer of the drug being tested (N Engl J Med, 2008; 358: 25260). Drug companies have an overly simplistic view of depression, which explains the overall ineffectiveness of SSRIs, say researchers from the Northwestern University Feinberg School of Medicine. Eva Redei, a professor of psychiatry at Northwestern, says that antidepressants are based on two false claims: that a stressful life causes depression; and that depression is caused by a chemical imbalance. Redei believes that depression is in some way associated with the development and functioning of neurons, and only when this is properly understood can an effective antidepressant be developed (Presentation at the 39th Annual Society For Neuroscience Conference, October 1721, 2009, Chicago, IL).
Drugs for children
Kiddie killers
Many of the mainstays of modern medicine can damage children
n 12 October 2007, three of the worlds leading drug companies voluntarily withdrew a clutch of cold and cough remedies for infants. This announcement was made immediately after a bombshell US Food and Drug Administration (FDA) report showed that everyday childrens medications had caused over 120 deaths over the last 37 years in the US alone. Most of the victims were infants under the age of two. In its defence, the drug industry partly blamed parents for not reading labels, thus inadvertently overdosing their children. At another extreme, parents have not only been blamed, but sent to jail because of drug side-effects (see box). These two extremes are merely the twin peaks of a huge iceberg. Doctors have been warning us for years that there are major problems concerning childrens medications in general, a situation that both the drugs industry and regulators have largely ignored.
and narcotics being the main offenders. Ironically, to combat the ADRs, 73 per cent of cases were treated with even more drugs, according to the hospital records (Drug Saf, 2004; 27: 81929). Earlier this year, pharmaceutical chemists at the University of British Columbia, in Canada, audited toxic reactions to drugs among their nations children. Their four-year survey revealed that 61 per cent of ADRs in children were serious, with as many as 41 (out of 1193) children actually dying as a result of drug side-effects. The main culprits were isotretinoin (an anti-acne preparation), paroxetine (an antidepressant), methylphenidate (Ritalin, the hyperactivity drug), amoxycillin (an antibiotic) and valproic acid (an anticonvulsant used in epilepsy)
Whos the criminal?

N
ADRs in children In the last few years, a slew of medical reports has revealed the damaging effects of prescription drugs on children. Paediatricians across the globe have become aware that children are at particularly high risk of so-called adverse drug reactions (ADRs) from relatively common medications. Among the first whistleblowers were British researchers from Nottingham University who, six years ago, completed a major audit of the reasons given for childrens hospital admissions. They found that a staggering one in 50 hospital admissions was because of ADRs, and nearly 40 per cent of these were life-threatening reactions. As ADRs are often worse in children than in adults, they constitute a significant public health issue (Br J Clin Pharmacol, 2001; 52: 7783). Its a similar story in other countries, too. Three years ago, doctors did a sixyear audit of paediatric admissions in Ohio hospitals. Again, a significant percentage was found to be due to ADRs, with antibiotics, anticonvulsants
In November 1997, two-month-old Alan Yurko, born in a weakened state after a difficult pregnancy, suddenly stopped breathing. His father rushed the infant to a Florida hospital, where he died two days later. The hospital accused the father of causing shaken baby syndrome (SBS); he was subsequently convicted and sentenced to life imprisonment. Appeals court lawyers asked Dr Al-Bayati to investigate, who says, The hospital was at fault on two main counts: it failed to review the childs medical notes, which showed a history of infections, and to take account of the side-effects of the vaccines the baby had already received from the family physician. Furthermore, the child was given high doses of sodium bicarbonate and heparin by the hospital itself, and it was those drugs which caused the cardiac arrest and internal bleeding. I was able to establish that these symptoms, which are similar to those of SBS, did not develop until after the baby was admitted to hospital (Medical Veritas, 2004; 1: 20131). In August 2005, two-month-old Averial was rushed to hospital by her mother, and diagnosed as suffering from acute bronchopneumonia and respiratory distress syndrome. Blood analysis suggested major infection. Chest x-ray showed pneumonitis, and physical examination and body scans revealed no evidence of physical injury. The hospital gave her epinephrine (adrenaline), sodium bicarbonate, antibiotics and other drugs. It was only then that skull and rib fractures were seen on the scans. The baby died 11 days after admission. The post mortem found evidence of bleeding both inside and outside the skull which, taken with the rib fractures, was consistent with physical trauma. The girls 27-year-old father was accused of shaking his daughter to death and is currently awaiting trial. Dr Al-Bayati was called in. My investigation reveals that the infants bleeding, brain oedema and necrosis, and skull and rib fractures occurred after she had been brought to A&E. These injuries were caused by the original infection and the medications she received in hospital (Medical Veritas, 2007; 4: 145269).
Drugs for children

(Can J Clin Pharmacol, 2007; 14: e45e57). A considerably longer, 15-year survey found that, in Swedish children, the most frequent causes of adverse reactions were vaccines and antibiotics. Again, children died808 out of 5771as a direct result of medication (Pharmacoepidemiol Drug Saf, 2005; 14: 4939). This survey came hard on the heels of a more intensive Swedish study that tried to measure the reliability of drugreaction reporting in general. The researchers found that both doctors and the reporting system were particularly lax in recording serious drug side-effects. An intensive analysis of 1349 patient records from five Swedish hospitals revealed an underreporting rate of as much as 86 per cent. Of 107 patients whose symptoms had probably been caused by drugs, only 15 had ever been recorded as an ADR; the other 92 cases of drug toxicity had been totally ignoredand this in spite of the efficient, state-run Swedish medical system (Pharmacoepidemiol Drug Saf, 2004; 13: 4837). This suggests that the already substantial official rate of annual childhood ADRs is very likely far below the true figures. Indeed, last year, researchers from the Drug Safety Unit at Southampton University completed a huge survey of ADRs across 12 countries, and found that ADRs were underreported by an average of an incredible 94 per cent (Drug Saf, 2006; 29: 38596). This means that, to get a real picture of the situation, any official ADR statistics should be multiplied by 20. Yet, behind all these figures lies a stark and rather disturbing fact: most prescription drugs have never been tested to see if they are safe for children or, indeed, if they actually work for them. Less than 25 per cent of drugs can be advertised as safe and effective [for children], say the British Columbia pharmacologists. How can the authoritiesor doctors, for that matterallow children to be given drugs that lack safety or efficacy data for such patients? It appears that as long as a drug has been approved by the regulatory authorities for at least one medical condition, it can be used for any other medical purpose. Doctors have carte blanche to prescribe any approved drug for conditions for which it hasnt been
The main culprits

N
Decongestants O Anything with codeine, dextromethorphan, carbinoxamine, ephedrine, pseudoephedrine, phenylephrine or brompheniramine (CDC MMWR Surveill Summ, 2007; 56: 14) O Cough suppressants containing hydrocodone can lead to serious illness, injury, or death, says the FDA, which has issued a formal ban on most (over 200) of these products (www.fda.gov/bbs/topics/
O
NEWS/2007/NEW01713.html)
Withdrawn drugs: Dimetapp Decongestant Infant Drops, Robitussin Infant Cough DM Drops, Little Colds Decongestant Plus Cough, Pediacare Infant Drops Decongestant, Tylenol Concentrated Infant Drops Plus Cold and Cough, Triaminic Infant & Toddler Thin Strips Decongestant. Antihistamines O Anything with diphenhydramine, brompheniramine or chlorpheniramine (Nonprescription Drug Advisory Committee Meeting, 2007-4323b1-02-FDA 10-01-2007). Asthma drugs O Inhaled corticosteroids can stunt growth, and may cause osteoporosis (J Allergy Clin Immunol, 2003; 112 [3 Suppl]: S140). NSAIDs O Ibuprofen, aspirin and paracetamol (acetaminophen) are a significant cause of morbidity in children (Br J Clin Pharmacol, 2005; 59: 71823). Antibiotics O More than half of all antibiotics cause ADRs (Biomedica, 2007; 27: 6675) O These drugs are one of the leading causes of fatal ADRs in children (Arch Dis Child, 2002; 87: 4626) O Amoxycillin is one of the most common causes of ADRs (Can J Clin Pharmacol, 2007; 14: e4557). Behavioural drugs O Ritalin causes headache, insomnia, anorexia and tachycardia (Curr Opin Pediatr, 2002; 14: 21923). Vaccines O The most recent CDC report records 11.4 ADRs per 100,000 doses, primarily in children under six, and 14.2 per cent of all reports were seriousincluding life-threatening illness, hospitalization, permanent disability and death (MMWR Surveill Summ, 2003; 52: 124).
tested and for patients in whom it hasnt been studied. The drug industry uses two relatively innocuous terms to describe this situation: off-label and unlicensed. The former refers to the use of drugs for conditions not indicated in the products license, including dosage, type of medical condition and age of patient. Unlicensed refers to prescribing a drug for types of patients, such as children or the elderly, for whom it has not been authorized. Astonishingly, both uses are legal. In the UK and rest of Europe, they are permitted under the Medicines Act of 1968 and EU Pharmaceutical Directive 89/341/EEC. In the US, the Food and Drug Modernization Act of 1997 confirms the longstanding practice, even allowing drug makers to inform
doctors of potential off-label uses. Not surprisingly, some doctors are feeling increasingly uneasy about the impact this is having on children. There have been numerous studies to show that many of the medicines used in children are used off-label or are unlicensed for use in children, says Professor Ian Wong, of the School of Pharmacy, University of London. Some people may see these children as unknowing participants in informal and uncontrolled experiments (Drug Saf, 2003; 26: 52937). For decades, the pharmaceutical industry has argued that children should be excluded from experimental premarketing clinical trials to protect them from possible harm. However, another motive may well be financial. Clinical trials involving children are
both expensive and difficult to carry out and, yet, the market for childrens drugs is much smaller than that for adults. The end result is that children given even ordinary drugs like painkillers are likely to be exposed to substances with no objective evidence of safety or efficacy, or riskbenefit analysis. One Swedish survey of its doctors prescribing habits found that, on average, more than 40 per cent of the drugs prescribed to children were offlabel and that these were more likely to cause serious ADRs than approved drugs. In this case, anti-asthmatics were the most frequent category of problem drug, causing almost one in
every three ADRs (Pharmacoepidemiol Drug

Saf, 2004; 13: 14752).
The fact that GPs use drugs off-label is somewhat understandable, given that they are generally not in the vanguard of research. However, Italian researchers found that hospitals, rather than GPs, are the chief offenders. After a worldwide data search going back to 1985, they found that up to 80 per cent of hospital drug prescriptions for children were either off-label or unlicensed. The drugs most commonly used were paracetamol (acetaminophen), cisapride, chloral hydrate and salbutamol (Eur J Pediatr, 2005; 164: 5528). Small wonder, therefore, that children have been shown to be most
vulnerable to ADRs in hospital. In fact, according to the Nottingham University researchers, as many as one in 10 children suffers ADRs as a direct result of drug treatment received at the hands of hospital doctors (Br J Clin Pharmacol, 2001; 52: 7783). Voices in the wilderness None of this will come as a surprise to Dr Mohammed Al-Bayati, a toxicologist and pathologist, who fled Saddam Husseins Iraq 30 years ago and settled in California. When he arrived in the US, he was shocked to find an almost equally repressive regime in the guise of Western medicine. He was confronted with case after case of parents being
Non-drug treatments for childhood problems

Many children suffer adverse reactions when given drugs for problems that can be treated with safer alternatives. But, do consult a qualified practitioner before taking this route. INFECTIONS N Bacterial and fungal O Colloidal silver. Take care not to overdose: 100 mcg/day is safe for a child weighing 20 kg (Curr Probl Dermatol, 2006; 33: 1734) O Tea tree oil. As effective as standard antibiotics for skin infections, including MRSA (J Antimicrob Chemother, 2003; 51: 2416), although it may cause skin reactions. N Colds O Echinacea (Lancet Infect Dis, 2007; 7: 47380) and vitamin C (Cochrane Database Syst Rev, 2007; 3: CD000980) O Saltwater nose drops O Inhaling steam from water containing Friars Balsam, a 600-year-old herbal remedy. N Coughs O EPs 7630, a herbal medicine from geranium (Pelargonium sidoides) roots (Phytomedicine, 2007; 14 [Suppl 6]: 6973), made by Schwabe Pharmaceuticals, Karlsruhe, Germany; www.schwabepharma.com O CORSHE-E, an Ayurvedic herbal linctus (J Herb Pharmacother, 2004; 4: 112). A similar product is Olbas Cough Syrup. N Urinary and bladder O Cranberry or blueberry juice (N Engl J Med, 1991; 324: 1599). N Diarrhoea O Individualized homeopathic medicine (Pediatr Infect Dis J, 2003; 22: 22934). N Inner ear O Naturopathic herbal ear drops containing tea tree oil, garlic and other herbs (Cochrane Database Syst Rev, 2006; 3: CD005657) O Individualized homeopathic medicine (Pediatr Infect Dis J, 2001; 20: 17783) O Homeopathic Pulsatilla (J Am Inst Homeop, 1986; 79: 34).
N
Sore throat O Throat spray containing 15-per-cent sage (Salvia officinalis) extract (Eur J Med Res, 2006; 11: 206); a similar product is Echinacea Throat Spray, made by A. Vogel, Switzerland O Slippery elm, as a pre-drug therapy O Do nothing, rather than use drugs like penicillin (BMJ, 2003; 327: 13247). PAIN N Headache O Peppermint oil applied to the forehead and temples (Nervenarzt, 1996; 67: 67281) O Acupressure (Digital Dissertation Abstracts, 1990; DAI-B 50/ 12: 5890) O Self-hypnosis (Pediatrics, 1987; 79: 5937) O Check for food allergy (J Pediatr, 1989; 114: 518) O Feverfew may work (Lancet, 1988: ii: 18992), although a recent survey casts some doubt (Curr Opin Neurol, 2005; 18: 28992) O Homeopathy (although there are no clinical trials). N Toothache O Oil of cloves O Activated charcoal compress O Tincture of Plantago major (plantain) O Purple passion flower (Passiflora incarnata) for hypersensitive teeth O Prickly ash (Zanthoxylum americanum) bark tincture to numb teeth and gums. N Colic O See Q&A, page 19, for treatment alternatives. BAD BEHAVIOUR O Remove additives from the childs diet (Lancet, 2007; epub ahead of print; DOI:10.1016/S0140-6736(07)61306-3) O Check for food allergy in general (J Pediatr, 1989; 114: 518) O Pycnogenol, the extract from the bark of the French maritime pine tree (Eur Child Adolesc Psychiatry, 2006; 15: 32935) O Omega-3 and -6 supplements (Pediatrics, 2005; 115: 13606).
Drugs for children

prosecuted for killing their children, with some parents in jail and others even facing the death penalty. Looking at these cases, one thing stood out clearly to Al-Bayati: doctors, hospitals, prescription drugs and vaccinations were almost always involved in the childrens deaths. He soon found himself defending parents as an expert witness in the courts, sometimes the appeals courts (see box, page 23). To date, Dr Al-Bayati has successfully defended over 20 cases in the US and Canada. His success has relied on exhaustive detective work, forensically drilling down into fine medical detail. One of his latest cases was that of Patrick, a three-month-old baby boy. In November 2005, he became severely ill, and his parents took him to hospital. The hospital ran a battery of tests, and reported that the child had subdural and subretinal bleeding, seven rib fractures in various stages of healing, severe anaemia, thrombocytosis, low blood creatinine levels, hyperglycaemia, and elevated neutrophils and monocyte counts. The hospital doctors decided the child was suffering from shaken baby syndrome, and accused the parents of having violently abused their child. The parents lawyers called in Dr AlBayati, who soon saw the gaping holes in the indictment. The underlying problem was that Patrick had always been a sick childborn prematurely, and prone to vomiting and feeding problems, leaving him malnourished. Two weeks before the hospital emergency, the child had developed a severe cough, for which he was prescribed Tylenol. Five days later, the boy had gastrointestinal reflux, for which he was given Zantac, the antiulcer drug. The underlying culprit For Al-Bayati, that was the root of the problem. Patrick was treated with Tylenol, he says, which contains acetaminophen, at a dose of 200 mg a daya high dose for such a young childand one that could cause liver toxicity. The child was then treated with Zantac (ranitidine), despite the fact that ranitidine is known to potentiate the toxic effects of acetaminophen. Thus, liver poisoning partly explains the subdural and subretinal bleeding, which was exacerbated by the childs inherent vitamin K deficiency and anaemia. But what about the rib factures? How could they be explained? The child had a chronic cough, says AlBayati. The child was already deficient in protein and vitamin K, which would cause weakening of the bones, and so the childs ribs would be vulnerable to any violent coughing (Medical Veritas, 2006; 3: 101940). Twenty years ago, Dr Al-Bayati was a lone voice in the wilderness but, today, theres now a huge groundswell of concern within the medical profession itself. Its begun to realize that few drugs have ever been tested for use in childrenmainly because the official drug-approval process only requires evidence of safety and efficacy in adults. Many doctors are now clamouring for major reforms. The current situation regarding the licensing of medicines for children is a profoundly unsatisfactory state of affairs both for children and their doctors, says Professor Peter Hill, of the Great Ormond Street Hospital for Children (Arch Dis Child, 2005; 90: i178). The practice of giving children drugs meant for adults is being roundly condemned as unscientific guesswork. Says Professor Andrew Bush, of Londons National Heart and Lung Institute: . . . the differences between adults and children, and at different stages of childhood development, mandate strategies to improve this situation rather than continually relying on extrapolation from adult studies . . . Disease phenotypes may be completely different in children . . . wheeze in infants is not miniature adult asthma(Paediatr Drugs, 2006; 8: 2717). According to Professor Laura Cuzzolin, of the University of Verona, Italy, there is a need to take immediate action for a more rational use of drugs in paediatrics, to avoid exposing children and infants to unnecessary risks (Fundam Clin Pharmacol, 2003; 17: 12531). Regulatory authorities have finally begun to act. In 2001, the US Food and Drug Administration (FDA) asked the drug industry to provide specific paediatric safety and efficacy data for any drugs prescribed to children, in return for which the FDA offered six extra months of drug-patent exclusivity. Although the industry appeared to have embraced this enthusiastically, so far, virtually all the applications for extended patents have been for cardiovascular and other drugs that are rarely prescribed in the paediatric population, but for which an extra six months of exclusivity is very lucrative in adults, wryly observe Dutch paediatricians at the Erasmus University Medical Centre in Rotterdam (Eur Respir J, 2004; 23: 3103). Changes: too little too late Another major problem is that ADRs occur not just with prescription drugs, but with everyday over-the-counter (OTC) medicines, too, most marketed for relatively trivial conditions. On 1 October, the FDA issued a 356-page report on OTC decongestants (cough and cold medicines) which included the revelation that, between 1969 and 2006, 54 children died after taking these medicines, and 69 died after taking antihistamines. The report admits that, since ADRs are underreported, those figures are likely to be significant underestimates (Nonprescription Drug Advisory Committee Meeting, 20074323b1-02-FDA 10-01-2007).
As we go to press, the FDA is reviewing whether the roughly 800 decongestants on the market are either safe or effective for children. It has already banned one group of cough medicines. Running for cover, manufacturers have now voluntarily withdrawn another set marketed to infants (see box, page 24). In September, the Consumer Healthcare Products Association (CHPA), the OTC trade association in the US, relabelled childrens decongestants, advising against their use in the under-twosalmost certainly in response to a damning report seven months earlier from the US Centers for Disease Control and Prevention (CDC), which warned: Caregivers and clinicians should be aware of the risk for serious illness or fatal overdose from administration of cough and cold medications to children aged under 2 years (CDC MMWR Surveill Summ, 2007; 56: 14). But all this activity masks the underlying problem. With no safety or efficacy data, childrens medications as a whole are in chaos, and yet, authorities appear to be paralyzed. In Europe in 2002, the EU published Better Medicines for Children as a prelude to new regulations for childrens medications, but has gone
no further. In the US, the FDA is only shutting the proverbial stable door, and then only to address a tiny part of the problem. This climate of regulatory dithering is deeply frustrating to many paediatricians. WDDTY has collated a dossier of over 30 medical reports about childrens drugs written over the past decade. The pleas from doctors for
the authorities to act are almost anguishedundesirable situation, requires action and irrational are just a few of the comments. Doctors have rarely been so united against an industry they so often perceive as their lifes blood. Meanwhile, thousands of children are being injured by side-effects and, in some of them, fatally.
Tony Edwards
Drugs for children
Puffers get blown out

The onetwo punch of steroids plus puffers for childhood asthma has just been knocked out by new findings
ong-acting beta-agonists (or LABAs), the standard-bearer of treatment for childhood asthma, have been found to be not only useless as a chaser drug, but also responsible for increasing the incidence of serious asthma attacks in children. So weighty is the evidence against the drugs in this categoryincluding Glaxos Advair and Serevent, AstraZenecas Symbicort and Novartis Foradilthat the US Food and Drug Administration (FDA) had an advisory meeting in mid-December during which FDA staff members recommended withdrawing approval for all of these drugs for children, and for Serevent and Foradil for adults, too. The last two contain only LABAs, while Advair and Symbicort combine them with an inhaled steroid. The FDAs move is a huge blow to drug makers, as LABAs with steroids have been the mainstay of asthma treatment for children with persistent or severe asthma that fails to respond to low- or medium-dose steroids. Indeed, some products such as Advair are fixed combinations of a LABA (salmeterol) and inhaled steroid (fluticasone). LABAs are also used against exercise-induced asthma and chronic obstructive pulmonary disease (COPD). The FDAs sudden interest in this class of drugs represents a particular blow to Glaxo, for which Advair is its number-one bestseller. LABAs are bronchodilators that relax the muscles around the airways in the lungs that, when tightened up, cause wheezing or bronchospasm. LABAs are said to relax constricted airways for 12 hours or longer, and so are often used for moderate-to-severe asthma and particularly to prevent nighttime episodes. Nevertheless, regulatory bodies have begun to realize that, although LABAs reduce the frequency of asthmatic episodes, they also have a rebound effect in that, when episodes do occur, they are more severe. A recent Cochrane Library overview
of seven reviews of LABAs as the primary or add-on therapyincluding four reviews of the therapy in childrenfound that inhaled ster-oids plus LABAs led to a significantly higher risk of adverse events vs steroids plus a placebo. Although the two-stage therapy improved the need for rescue medicine, nighttime awakenings and pulmonary function (as measured by the blow test), the researchers concluded, There is no clear benefit to LABA in preventing asthma exacerbations in children (EvidenceBased Child Health, 2008: 3: 90919; online: 10 December 2008).
The FDAs own meta-analysis of 110 trials, involving nearly 61,000 patients, found that, for every 1000 patients treated with LABAs, 2.8 had a more serious asthma attack. Those at greatest risk appeared to be children aged 411 years, with blacks and women also at higher risk than other users. The FDA has been tracking betaagonist problems since earlier this year, when the agency called for drug giants Glaxo, Novartis, AstraZeneca, Mylan and Sepracor to provide clinical-trial data demonstrating the safety of this class of drugs. The agency was first alerted in 2007 during a routine yearly review of adverse/safety data for drugs approv-ed for children. For Serevent alone, the agency uncovered nine adverse-event reports in children and five deaths over a 13-month period. The FDA had already set a black-box warning in 2006 for salmeterol and Advair on the basis of findings from the
Salmeterol Multicenter Asthma Research Trial (SMART), which examined the safety of adding salmeterol to a patients usual steroidbased asthma regime. Those taking the salmeterol suffered a significant increase in asthma-related deathfour times that of those taking a placebo. This works out to one additional death for every thousand patients. However, the study did not include any patients under age 12. In its advisory, the FDA warned that LABAs should not be used as a first-line treatment, or to relieve sudden wheezing or wheezing that is growing worse. One reason why it took so long for problems with LABAs to surface is that conventional meta-analyses focus on single comparisons between drugs rather than on a number of analyses of different drug regimens to rank their effectiveness. Indeed, a study using a networking meta-analytical technique attempted to do just that for the most commonly used inhaled drug regimens for reducing COPD attacks (BMC Med, 2009; 7: 2; doi:10.1186/1741-7015-7-2). It found that beta-agonists performed worse than all other regimes (long-acting anticholinergics, inhaled steroids and combination treatments) in patients with more serious forms of COPD, with the steroid/LABA combination only reducing exacerbations in those with milder disease.
Lynne McTaggart
Beware of these long-acting puffers

N N
Serevent Diskus, a disk-shaped inhaler that pumps out salmeterol Advair Diskus, which combines salmeterol with the inhaled steroid fluticasone, also delivered via a disk-shaped device N Foradil Aerolizer, a puffer containing the LABA formoterol N Symbicort, AstraZenecas combo drug, mixes formoterol and the inhaled steroid budesonide. To find alternatives to puffers that can help respiratory problems, consult The Asthma Manual, now available as an e-book (www.wddty.com) or at www.wddtyhealthshop.com/products.asp?recid=220.
The kiddie upper takes a tumble

f Ritalin is the Miss America of the ADHD drugs, then Dexedrine is the runner-up. When Ritalin doesnt work, doctors usually prescribe one of several amphetamines such as Dexedrine, Adderall or Dextrostat. Dexadrine used to be the recreational upper of choice for everyonefrom students cramming for an exam to overworked Hollywood starletsuntil it was vastly misused and discredited as a largely recreational drug that was known on the street as speed, another one of mothers little helpers. Then ADHD (attention-deficit/ hyperactivity syndrome) gave Dexedrine a new lease on life. ADHD is listed as its number-one indication for children between ages three and 16; the drug is routinely prescribed by family doctors if Ritalin (methylphenidate) doesnt do the trick. This cozy position is set to change with a recent requirement by the US Food and Drug Administration (FDA) that Ritalin and the Dexedrine-type drugs must now issue a warning on their labels, explaining that the drug can cause sudden death and serious cardiovascular adverse events. There have been reports of children with heart trouble dying suddenly while taking the drug. Dexedrine (dextroamphetamine sulphate) is an amphetamine that works by mimicking the effects of the hormone adrenaline (epinephrine), which triggers the bodys classic fightor-flight responses. The medical profession maintains that ADHD results from a genetically based abnormality in glucose levels and neurotransmitters in the brain. The prevailing view is that drugs like the amphetamines, which speed up bodily processes in adults, have a paradoxical effect on children, calming them down and somehow sorting out the biochemical imbalance. But this latest warning suggests that the two drugs act as stimulants in children as well as in adults, raising blood pressure which, in turn, leads to heart problems. The FDA still hasnt decided
whether the problems merit a blackbox warningthe agencys strongest classification of warning. The new boxed warning also points out that amphetamines have a high potential for abuse, that prolonged prescription may lead to drug dependence and must be avoided and that the drugs should be prescribed or dispensed sparingly. The FDAs decision, following the recommendations of two independent review panels, has shocked American doctors who, up until now, have handed out these drugs to all comers. The FDA estimates that one million adults and two million children refill a prescription for an ADHD drug every month. A national study among American children by New York Universitys Child Study Center discovered that about one in seven of the parents of schoolage children reported giving their children this type of daily psychoactive medication. The new label warnings alert parents that sudden death has resulted from this type of central-nervous-system stimulant treatment at ordinary dosages in both children and adolescents with structural cardiac abnormalities or other serious heart problems. These include cardiomyopathy (weakening of the heart muscle), abnormalities in heart rhythms and any other problems that predispose them to be vulnerable to stimulation of the central nervous system. Sudden death, stroke and heart attack have all been reported in adults
taking stimulant drugs at the regular prescribed dosage for ADHD. Although the FDA and medicine itself readily admits it doesnt understand how great a role is played by these drugs in causing these effects, it warns that any adult suffering from heart problems of any variety should not be taking stimulants. According to GlaxoSmithKline (GSK), stimulant drugs cause an increase in blood pressure of 24 mmHg and an increase in heart rate of three to six beats per minute. All patients taking stimulant medication are now to be monitored, according to the new warnings. Anyone suffering from hypertension, heart failure, a recent heart attack or ventricular arrhythmias is now being advised to avoid this class of drugs. As for children, the new warnings suggest that, before a patient of any age is given a stimulant-type drug, he should undergo a thorough physical exam to determine if they have cardiac disease. The same advice should apply to anyone developing chest pain or
Psycho-cocktails
When children dont immediately respond with one of the old standbys, todays doctors tend to prescribe a cocktail of psychoactive drugs. These back-up drugs can even include antidepressants such as desipramine (a tricyclic drug) or, inexplicably, high-blood-pressure drugs such as clonidine (an antiadrenergic). One American girl was given Ritalin for her ADHD, and Prozac to help manage her anxiety, hypersensitivity and fear of bugs. When her teacher complained that she was still disruptive in class, her doctor then handed her Dexedrine. Her mother then noticed that her daughter was pulling out her eyebrows and eyelashes and, at that point, said Enough is enough and discontinued the Dexedrine.
Drugs for children

other problems suggestive of heart problems while taking the drugs. But that isnt the only area of concern. The warning now states that new psychotic or manic symptoms, including hallucinations, delusional thinking or mania in children and adolescents, can also be caused by stimulants at the prescribed dosages. A meta-analysis of a number of short-term studies discovered that these kinds of symptoms occurred in one child out of 1000 (GSK prescribing information, 2006). As many children are having to take the drugs for years, the statistics could be far higher. Other worrisome side-effects listed in the new warnings include aggressive behaviour and hostility, and long-term suppression of growth. Studies of children aged between seven and 10, randomized to receive Ritalin or a
Not so calming: other side-effects

N N N N N
N N N N N N
Restlessness Insomnia Dyskinesis(involuntary movements such as spasm) Tourette syndrome Exacerbation of muscle and phonic tics (any possible sound or noise) Dysphoria (exaggerated feelings of depression and discontent) Euphoria (feelings of wellbeing and elation) Tremor Diarrhoea or constipation Anorexia/weight loss Impotence and changes in libido
placebo over three years, found that the treated children suffered a slowing of growth (2 cm less in height and 2.7 kg less in weight) over three years. Although this effect was temporary in the short-term, its not known if it becomes permanent in chronic users. Increasing susceptibility to seizures and blurred vision are other reported side-effects in the new warnings. GSK also notes: Long-term effects of amphetamines in paediatric patients have not been well established.
Lynne McTaggart
Antibiotics
Life after antibiotics

A new superbug could signal the end of antibioticsthe drugs that ended research on phage therapy, an approach that harnesses the power of viruses to kill deadly bacteria
he test results from the hospitals laboratory were worse than the doctors had even dared to fear. They signalled the end-days of a war that had raged for more than 60 years between antibioticsarguably the most successful group of drugs ever developed, and which have made much of modern medicine possibleand the bugs. Specialists at the hospital in London knew from the results they were
getting that the bugs had finally won. They were looking at a doomsday scenario of a world without antibiotics, said Professor John Conly, a specialist in infectious diseases, months later. We are essentially back to an era with no antibiotics (Bull World Health Organ, 2010; 88: 8056). The tests revealed that a gene already known to doctors in Indiahad made its way to the West. NDM-1 (New Delhi metallo-beta-lactamase) is the ultimate superbug. It transforms any
bug into a superbug that is resistant to every antibiotic, including the lastresort carbapenems. In August of last year (2010), when the discovery was made, 50 patients in hospitals in London and Nottingham had been infected with NDM-1, most of whom were health tourists who had gone to India for cosmetic surgery. Since then, NDM has been discovered in New Delhis public water. Researchers have found 11 new species of bacteria carrying the NDM-1 gene,
Alternatives to antibiotics
Phage therapy is not the only alternative to antibiotics. Many others have been used for centuries in traditional medicine, although proof of their efficacy often rests on anecdotal stories and case studies. Good research is limited because funding usually comes from drug companies, which have no commercial interest in discovering non-drug approaches. N Echinacea. Up until the late 1930s and the advent of antibiotics, Echinacea, a North American herbaceous flowering plant of the daisy family, was a popular herbal remedy for treating infections. In recent years, its primary use has been side-tracked by interest in its supposed abilities to fight the common cold, although some researchers are still interested in Echinaceas antibacterial qualities. Using the commercially available product Echinaforce, researchers at the University of British Columbia in Vancouver discovered that it could combat upper respiratory infections, often the result of a viral complication. Echinacea purpurea also has an antiinflammatory effect, they discovered (Phytomedicine, 2010; 17: 5638). Echinacea works in a similar way to antibiotics by attacking the bugs cell wall, researchers at Carleton University in Ottawa have found (Med Mycol, 2010; 48: 94958). N Essential oils. Used as aromatherapy, essential oils have successfully combatted a host of bacteria, such as staphylococci, streptococci and Proteus species. Within three hours, 90 per cent of the bugs were killed in one test that used clove, lavender, lemon, marjoram, mint, niaouli, pine, rosemary and thyme oils (Chir Dent Fr, 1976; 46: 53). N Goldenseal. This herb is a broad-spectrum natural antibiotic that is especially effective when used together with Echinacea. On its own, it has proved to be a successful antidote against some of the more familiar bugs, such as Chlamydia, E. coli, Salmonella and Helicobactor pylori (Antibiotics, 1976; 3: 57788; Phytother Res, 2003; 17: 21721). Honey. Manuka honey can clean chronically infected wounds and might help to reverse bacterial resistance to antibiotics. Honey interferes with the growth of three types of bacteria: Pseudomonas aeruginosa, streptococci and MRSA, researchers from the University of Wales have discovered (Presented at the Society for General Microbiology Spring Conference, held in Harrogate, England, April 13, 2011). Garlic. Crushed garlic has been a recognized natural antibiotic for many centuries, and was recommended by Hippocrates as a disinfectant. Even garlic juice can slow the growth of up to 20 types of bacteria. Yet, despite its age-old use, good research to prove its effectiveness is virtually non-existent. Tea tree oil. This essential oil, made from the leaves of Melaleuca alternifolia, has been used topically on the skin to fight MRSA and other skin infections, such as acne, athletes foot, nail fungus, wounds and infections. In laboratory tests, the oil killed the deadly MRSA bacteria, although funds have never allowed a full clinical study to be undertaken (Am J Infect Control, 2004; 32: 4028). Cranberry. These berriestaken as a juice, an extract, capsule or tabletare most often used against urinary tract infections (UTIs). They have also been tested against H. pylori infection, which can cause peptic ulcers. Although they are a proven UTI preventative, the evidence that they can also fight the infection is still inconclusive (Cochrane Database Syst Rev, 2008; 1: CD001321). Others. Other natural antibiotics that have plenty of anecdotal evidence, but precious little scientific support, include St Johns wort, colostrum, selasih, liver herbs, wild oregano, grapefruit seed extract, colloidal silver and liquorice root.
Antibiotics
some of which can cause cholera and dysentery, in the citys water supply. Professor Tim Walsh, the lead researcher from Cardiff Universitys School of Medicine, fears that public water throughout India, Pakistan and Bangladesh could be contaminated with the super-bug. Westerners who had not been in Indian hospitals have already been infected, he added (Lancet Infect Dis, 2011; 11: 35562). Ironically, the NDM superbug may be the creation of the pharmaceutical industry. Researchers have discovered that Indias waterways are polluted by pharmaceuticals, including antibiotics. Many pharmaceuticals are processed in India, where manufacturers can take advantage of lax environmental controls to deposit their waste into the nearest river. Researchers from the University of Gothenburg in Sweden, who made the discovery, fear that the manufacture of pharmaceuticals could paradoxically spark a global epidemic of infectious diseases (PLoS ONE, 2011; 6: e17038) NDM is the inevitable end-point of an injudicious use of antibiotics that, since the mid-1940s, have been inappropriately prescribed, used on crops, fed to live-stock, and washed away into our water-ways and back into the public systems. The phage is set The discovery of antibiotics was accidental. While he was studying influenza at Londons St Marys Hospital Medical School in 1928, biologist Alexander Fleming noticed on his return from a holiday that mould had grown on a set of culture dishes being used to develop the staphylococci germ. The mould had created a bacteria-free circle around itself. Fleming experimented further and named the active substance penicillin. However, it took another 17 years before penicillin went into mass production. Despite its slow progress, Flemings accidental discovery halted research into an equally promising antibacterial approach that was happening at the same time. Phage therapy harnesses the natural power of a type of virus called bacteriophages (which literally translates to bacteria-eaters) to kill bacteria.
Probiotics and the good bacteria

The human gut contains hundreds of different types of bacteria. Most of them are good probiotics; they maintain the ecological balance that keeps us healthy and wards off the bad bacteria. However, when the bad bacteria gain the upper hand, we take a broad-spectrum antibiotic that kills the good along with the bad. When that happens, the guts natural eco-system is disturbed, the defence system is impaired, and we are more likely to become a host for bad bacteria and especially Clostridium difficile. Probiotics are the best way to restore our natural barriers after a course of antibiotics, researchers at the University of Paris-Sud in France have found. In one study of 53 infants, 26 tested positive for C. difficile bacteria. Those who did not have the bug had high levels of Bifidobacterium longum, a species of the good probiotic bacteria (J Clin Microbiol, 2010; 49: 85865).
Just as with Fleming and antibiotics, bacteriophages were discovered by accident. In fact, two meneach working independently discovered them at around the same time. One of them, George Eliava, head of the Central Bacteriology Laboratory in the Georgian capital of Tbilisi, collected specimens of water from the citys Mtkvari river to study cholera bacteria. He left the slide under a microscope for three days and, when he next looked, the bacteria had gone. There had been something else in the water that was choleras natural enemy, he surmised, and that something was bacterio-phages, as they had been dubbed earlier by French-Canadian scientist Flix dHerelle. The two men collaborated and, from 1923, worked together at a new institute in Tbilisi, which was later renamed in Eliavas honour. Within a few years, the scientists at the institute had created an armamentarium of more than a dozen phages that could treat a range of bacterial infections. Bacteriophages became part of conventional medicine in the new USSR. In the US, drugs giant Eli Lilly took a keen interest in the therapy, and started its commercial development. However, the early results were not convincing, and research and production stopped once the first antibiotics were produced. However, in the USSR, phage therapy continued, and bacteriophages were regularly used to treat the wounds of Russian soldiers fighting in the Second World War. The therapy
successfully countered dysentery and gangrene. Even after the war, Russian scientists persisted with the therapy, although the restrictions of the Cold War prevented any research findings from reaching the West. Phage one Bacteriophages have many advantages over antibiotics. They are in limitless supply, they attack only a specific bacterial species and do not have the same debilitating effects on the overall immune system that antibiotics can have. The one major disadvantage of the therapy is that there is only one bacteriophage for each bug, so there has to be one Escherichia coli bacteriophage to nullify the E. coli bug. This presents two problems for the doctor: he may not be able to treat the patient immediately, as he first has to be sure of what is causing the infection and, second, there is no such thing as a broad-spectrum bacteriophageone that will kill a wide range of bugsas there is in antibiotics. However, the greatest advan-tage of bacteriophages is their natural ability to adapt as quickly as their preythe bacteriawhereas an antibiotic represents a frozen moment of millions of years of evolution while the bacteria continue to adapt, eventually creating an antibiotic-resistant superbug. As a result, there is no such thing as a superbug that can beat its bacteriophageor, at least, not for longas the phage will adapt in order to continue having the upper hand.
The age of the superbug Superbugs began to appear within a few years of the start of penicillins mass production. By 1947, four years after penicillin was launched, researchers discovered the existence of a form of Staphylococcus aureus that was resistant to methicillin, then the most popular antibiotic in use. Today, these bacteria are better known by the initials MRSA (methicillin-resistant Staphylococcus aureus), and they join a host of other antibiotic-resistant superbugs that have become familiar names, including E. coli, Clostridium difficile and Salmonella. Each year, antibiotic-resistant bugs, such as MRSA, kill around 100,000 patients in hospitals in America alone (Clin Infect Dis, 2011; 52 [suppl 5]; doi: 10.1093/cid/cirl154). MRAB (multidrugresistant Acinetobacter baumannii) is another common cause of infection in hospitals. In one study of 164 infected patients, 37 died, and 72 per cent of the MRAB samples were resistant to multiple drugs (BMC Infect Dis, 2010; 10: 196). In Sweden, the staphylococcal skin bacteria S. epidermidis are widespread in hospitals. They have the capacity to adapt to hospital environments, accord-ing to a doctoral research paper by Micael Widerstrm at Umea University, Sweden (submitted in September, 2010). Another superbug, known as KPC pneumoniae carba(Klebsiella penemase), has been making its way across the US since its discovery on the East Coast in 1999, and there have also been outbreaks in Israel. According to a report from the Rush University Medical Center in Chicago, IL, in October 2010, KPC causes pneumonia and urinary tract infections. The rise of the superbug has been caused by the widespread misuse of antibiotics. Today, there are more than 150 different antimicrobial compounds, and most of them are being prescribed inappro-priately. One study estimates that 80 per cent of antibiotic prescriptions are written for ailments that the drugs cannot treat, such as viral infections (J Antimicrob Chemother, 2007; 60 [suppl 1]: i3i90). Finlands health authority was one of the first to act when, 20 years ago, it issued new guidelines to
Antibiotics down on the farm

Even if we dont take antibiotics, we are still exposed to them whenever we eat meatespecially poultry. But theres an alternative for poultry breeders that American scientists have been testing. A dietary yeast extract appears to be every bit as good as an antibiotic for decreasing pathogens in organic turkey production, say researchers working for the US Department of Agricultures Agricultural Research Service (ARS). The yeast extract works by boosting the immune system and so providing a natural defence against the bacteria that cause illness in the birds (Poult Sci, 2010; 89: 44756). In a separate study, researchers from the University of Delaware say there is growing evidence for several alternatives to antibiotics that poultry breeders could use. These include bacteriocinsnatural agents that are lethal to bacteriaas well as antimicrobial peptidesa natural defence against some pathogensand bacteriophages (see main story) (Poult Sci, 2003; 82: 6407).
stop indiscriminate antibiotic use. It had discovered that group A streptococci, a virulent infection, was becoming resistant to erythromycin, which is used as an alternative for people who are allergic to penicillin. After the policy change, the level of strepto-coccal bugs fell from 16.5 per cent in 1992 to 8.6 per cent in 1996 (N Engl J Med, 1997; 337: 4416). The UKs National Institute for Health and Clinical Excellence (NICE) issued its own edict in 2008 in an attempt to reduce the 38 million prescriptions written for antibiotics every year in Great Britain. Eating and drinking antibiotics In fact, even when we arent taking antibiotic drugs, were absorbing them through the environment and the food we eat. Researchers have discovered that nearly half of the meat and poultry sold in stores is contaminated by antibiotic-resistant staph infections. The bugs, which can cause lifethreatening diseases such as pneumonia and sepsis, are the result of intensive-farming methods. The research team bought 136 meat samples from 26 stores in five US cities; of these samples, 47 per cent were contaminated with S. aureus bacteria. Although the bacteria are usually killed in the cooking process, the researchers fear that some of the bugs may be left on kitchen surfaces during preparation (Clin Infect Dis, 2011; 52: 122730). This is not a new development. In 1996, researchers
discovered that mincemeat sold in German shops was contaminated with vancomycin-resistant enterococci (Lancet, 1996; 347: 1047). Our waterways have also become a breeding ground for superbugs, and they may already have entered our drinking water, one research team fears. They took water samples from rivers, lakes and wells throughout North America, Europe and East Asia, and discovered significant traces of pharmaceutical drugs, including antibiotics. Industrial plants wash the waste from the manufacture of pharmaceuticals into waterways, and patients often flush prescription drugs down the toilet. They are also used on farms for crop-growing to control disease and these, too, can be washed into the nearest river. The researchers found three classes of antibiotics in the water they analyzed that can create superbugs. Once in the waterways, they can make their way into the public supply and the water we drink, wash and cook with, says lead researcher Sbastien Sauv, from the University of Montreal (Environ Health Perspect, 2009; 117: 67584). Turning the phage Despite the rise of the superbug, research into phage therapy began to dwindle in the USSR and, by the mid1970s, the Eliava Institute had virtually closed its doors. Without electricity, even the phage samples being stored in the refrigerators would have been lost
Antibiotics
had the researchers not taken them home. In 1993, the electricity was switched off for good, and the Institute was closed. Today, phage therapy is active only in Georgia and, to a lesser extent, in Poland. However, in the West, it was beginning to dawn on the researchers who were studying the rise of superbugs that antibiotics carry the signature of their own eventual ineffectiveness. They started to take a fresh look at phage therapy. In 1994, researchers used phages to help improve the success of skin grafts in laboratory mice by reducing Pseudomonas the underlying aeruginosa infection (Burns, 1994; 20: 20911). Phages for killing Listeria, the foodpoisoning bacteria, have started to be used tentatively in the West (Lancet, 2000; 356: 1418). A clinical trial of phage therapy for otitis, a bacteria-caused middle-ear infection, has been underway at Londons Royal National Throat, Nose and Ear Hospital (Clin Otolaryngol, 2009; 34: 34957), while a research team at the University of Minnesota in Minneapolis tested a cocktail of phages against various antibiotic-resistant bugs such as MRSA and E. coli in venous leg ulcers (J Wound Care, 2009; 18: 2378, 2403). Animals first Acceptance of phage therapy may be slow in the West, but it appears to be happening faster for agricultural and livestock purposes. In 2006, the European Union banned the use of antibiotics for non-medical purposes in animals and livestock, while several manufacturers have been phasing out growth-promoting antibiotics. A number of companies are currently working on the commercial mass production of phages for livestock. One, Intralytix, has been granted a US license to develop a phage to combat Listeria monocytogenes in poultry. The licence, granted in 2006, is for a product called ListShield (www.intralytix.com/Intral_
Diseases caused by antibiotics

Antibiotics dont only help to create the superbugs. They can also cause asthma, leave us open to serious bacterial attack, cause birth defects and send us to the hospital emergency room with hypotension (abnormally low blood pressure). N Asthma. Babies who are given antibiotics are 50 per cent more likely to develop asthma when they are small children. In a study of around 1400 children with asthma, around one-third had been given antibiotics by the time they were six years old. The antibiotics interfere with the good bacteria in the gut, which prevents the immune system from maturing, say researchers from the Norwegian University of Science and Technology (Am J Epidemiol, 2010; 173: 3108). N Birth defects. Antibioticsand the sulphonamides and nitrofurantoins in particularcan cause birth defects if taken when a woman is pregnant. Although defects were also seen in women who had taken penicillin, the risk was less evident (Arch Pediatr Adolesc Med, 2009; 163: 97885). N Immunity. Our natural immunity can be impaired for up to two years after taking antibiotics, leaving us more open to serious infection. A study by the Swedish Institute for Infectious Disease Control revealed that the impact of antibiotics is far greater than the common belief that impairment lasts for only a month or so (Microbiology, 2010; 156: 321623). N Hypotension. Antibiotics can cause life-threatening shock and hypotension (too-low blood pressure) if they are taken with common blood-pressure medications. The macrolide antibioticswhich include erythromycin, clarithromycin and azithromycincan increase the risk of sudden hypotension sixfold if taken with a calcium-channel blocker drug (CMAJ, 2011; doi: 10.1503/cmaj.100702).
News_PR062308.htm).
Intralytixwhich recruited several researchers from the old Eliava Instituteis hoping that the use of ListShield will demonstrate the safety of phage therapy and will eventually herald in a way of combatting killer bugs in the way that Nature intended. The new age of the phage Antibiotics have been medicines greatest success story, and have doubtlessly saved millions of lives. They have been the doctors most powerful ally, and have granted him miraculous healing powersand, as a result, have been absurdly overprescribed over the years. While the antibiotic has been a moment of millions of years of evolution frozen into a chemical formula, its preythe bughas continued to adapt in order to survive. The superbug is just thata bug that
has adapted in order to outwit the antibiotic. Understanding this, antibiotics should have been treated as a precious resource and used sparingly. Instead, we have killed the goose that laid the golden egg. Fortunately, there is another goose that can come to our rescueMother Nature herself. Bacteriophages are Natures own answer to bugs, and there is one bacteriophage for every bug. They are found in limitless supplyjust put a bucket into any river and you will fish out trillions of themand they adapt along with the bug. Whats needed is just for the West to realize that the end-days of antibiotics are with us now, and to work with the Russians on the research they carried out right up until the 1970s, and begin funding the age of the bacteriophage.
Bryan Hubbard
Antibiotics: definitely not kids stuff

Routinely given as preventative drugs to mothers-to-be and infants, antibiotics are far more dangerous than we could have previously imagined, as new research suggests.
ntibiotics are routinely given to pregnant women and young children. In the US, 30 million prescriptions are written each year for childhood ear infections alone, and there are more than 60 different antibiotics that can now be given to infants. However, while these drugs have saved lives, they are also known to be among the most dangerous groups of drugs around. One study found that antibiotics can cause long-term health problems in children whose mothers took these drugs during pregnancy. Antibiotics are regularly given in pregnancy to reduce the possibility of premature labour and to guard against infection. Yet, this routine procedure has genuine health risks for the unborn child. Researchers at the University of Leicester in the UK found that the antibiotic erythromycin dramatically increased the risk of having a child who would develop visual or hearing impairment, or even cerebral palsy, by the age of seven. The team tracked 4221 women who had taken either erythromycin or amoxicillintwo commonly used antibioticsor a placebo while pregnant. Of these, 658 children whose mothers had taken an antibiotic had some kind of functional impairment. Their health problems included seizures, ADHD (attention-deficit/ hyperactivity disorder), respiratory conditions such as asthma, diabetes and bowel disorders. In general, the children of mothers who had taken the drugs were nearly twice as likely to develop cerebral palsy vs those whose mothers took a placebo. These children were also much more likely to have problems in learning to walk, other learning difficulties and poor eyesight by the age of seven compared with those whose mothers had taken a placebo. Worst of all, the researchers found that the drugs had not been any more
effective than a placebo in preventing infection, not even in cases of a ruptured membrane. This suggests, say the researchers, that only those women who are very likely to develop infection due to membrane rupture or to suffer other injuries that could lead to infection should be given antibiotics in future. Certainly, their routine use should be stopped (Lancet, 2008; Sep 18; Epub ahead of print). Nevertheless, and despite these findings, the Royal College of Obstetricians and Gynaecologists, which sets the best practice guidelines in the UK, says it will not be altering its current recommendations. In 2001, the RCOG changed its guidelines for the management of preterm membrane rupture to exclude coamoxiclav (amoxicillin and clavulanic acid) from the treatment protocol. Drugs for newborns Antibiotics are just as dangerous for newborns. One study has established that children who are given an antibiotic in their first 12 months of life are twice as likely to develop asthma by the time they are seven. The risk is highest among children who have undergone four courses of antibiotics and have taken broadspectrum drugs for general just-incase healthcare. Researchers in Canada made the discovery when they reviewed the medical histories of 13,116 children. Those who were prescribed antibiotics for anything other than a respiratory problem, thereby excluding those who had a preexisting condition that might have led to asthma, were twice as likely to develop asthma as those given a placebo (Chest, 2007; 131: 17539). But the dangers of antibiotic use in children have been known for years. A study published as far back as 12 years ago found that children in Nigeria were losing their hearing
because of indiscriminate antibiotic use. It was reckoned that two-thirds of cases of deafness in children were being caused by the overprescribing of antibiotics such as streptomycin and gentamicin (BMJ, 1996; 313: 648). The lessons to be learned seem clear, says Alison Russell, of Warwick Medical School in the UK. Contrary to the popular opinion that antibiotics dont do any harm so we might as well give them, antibiotics are not risk-free. Adverse events are common Dr Russells opinion has been supported by the fact that antibiotics are responsible for 20 per cent of all drug-related visits to Accident & Emergency departments. It appears that, over a two-year period, 142,000 Americans reacted so badly to an antibiotic that they had to be admitted to hospital. Indeed, antibiotics were as dangerous as drugs such as warfarin, insulin and digoxin, all of which have a known track record for causing serious adverse reactions. Nearly 80 per cent of the antibiotic patients who received hospital care did so because of allergic reactions, whereas the rest of the patients suffered from severe diarrhoea, headache or dizziness. Also, around 6 per cent had to stay in hospital for at least one night (Clin Infect Dis, 2008; 47: 73543). Yet, despite these dangers, doctors continue to give so many antibiotics to children that there are now considerable rates of antibiotic resistance, researchers at Oxford University have found. In 119 children with acute respiratory tract infection, 71 were given amoxicillin, a moderate-spectrum penicillin. After just two weeks, the number of these treated children carrying antibioticresistant bacteria had doubled compared with those only taking a placebo (BMJ, 2007; 335: 429).
Bryan Hubbard
Medicine and the elderly: age shall not weary thembut drugs might
For the elderly, the cure is very likely worse than the disease
oets may exhort us not to grow old, but they could have added the rider that, when we do, stay away from the doctor for as long as possible. Growing evidence suggests that aggressive interventions by doctors are accelerating the decline in the general health and mental capacities of the elderly, and may even be a direct contributor to their death. The over-65s take one-third of all pharmaceuticals that are prescribed by doctors every year, despite the fact that they represent just 13 per cent of the total population. On average, an elderly person is taking around six drugs at any given time (Johnston CB.
UCSF Division of Geriatrics Primary Care Lecture Series May 2001. Geriatric Assessment in a Time Dependent Practice: Practical Approaches for Primary Care Practitioners).
Polypharmacywhen more than one drug is prescribed at a timeis an even bigger problem in hospitals and care homes, where the average patient is given at least seven different drugs every day. In addition, powerful dementia drugs are being prescribed for most patients as a chemical cosh to keep them quiet, evidently mainly for the convenience of the medical staff. An official UK government review has revealed that the drugs are being inappropriately prescribed in around 80 per cent of cases. In the UK alone, this works out to around 150,000 people who are being given anti-psychotic drugs just to keep them pacified. Worse, the drugs are directly responsible for about 1800 deaths every year (http://news.bbc.co.uk/2/ hi/8356423.stm). This may perhaps explain why 11 per cent of elderly patients, admitted to hospital for other medical conditions, will suffer a heart attack
while they are there. In addition, they are also twice as likely as a younger patient to die within 30 days from such an attack. Researchers made the discovery when they examined the health records of 7054 patients who were admitted to hospital as part of the US Veterans Health Administration between 2003 and 2004. Of those patients, 792or 11.2 per centsuffered a heart attack while under hospital care (Arch Intern Med, 2006; 166: 14106). Tick-box medicine Most patients are over 65 and, yet, they rarely see a doctor who specializes in geriatric medicine. This might be because, in almost every country except the UK, there is a serious shortage of geriatricians. In Canada, for example, there are fewer than 200 qualified geriatricians serving the entire country. In an attempt to attract more medical graduates into geriatric medicine, Dr Laura Diachum, at the University of Western Ontario, has gone as far as to describe the speciality as totally sexy (J Am Geriatr Soc, 2006; 54: 145362). As a result of the lack of geriatric specialists, an elderly patient is
invariably seen by a general practitioner, whose almost instinctive tendency will be to start reaching for the prescription pad. Sadly, as discovered by a doctoral thesis defended by Sandra Pennbrant, at the Sahlgrenska Academy in Sweden, elderly patients tend to become passive when faced by the doctor and feel intimidated by the practitioners power and, so, fail to participate in the consultation by almost never challenging the decision to start taking a drug or even asking any questions (http://gupea.ub.gu.se/dspace/ handle/2077/21198). Doctors routinely hand out prescription drugs simply because the patient is old, not because he or she needs them, says Michael Oliver, an emeritus professor of cardiology at Edinburgh University. This tick-box medicine, as he calls it, means that elderly people are not only taking drugs they dont need, but they are also being exposed to side-effects that can seriously endanger their health. Nowadays, few elderly people are allowed to enjoy being healthy, he says (BMJ, 2009; 338: b873). One example of this so-called tickbox medicine is bringing down levels of blood cholesterol, especially in the
elderly. But this is, in fact, a failure to understand the changing metabolism of older patients, who appear to need higher levels of cholesterol for their general wellbeing and, especially, to support mental acuity. One study that involved 3572 men, aged 7193 years, discovered that those who had the lowest cholesterol levelsfrom 2.09 to 4.32 mmol/L (80.0 to 167.0 mg/dL)were up to 40 per cent more likely to die than those whose cholesterol levels were higher. Indeed, this study, which monitored the health of the partici-pants for 20 years, questioned whether there was any scientific justification for lowering cholesterol to very low concentrations (below 4.65 mmol/L [179.8 mg/dL]) in elderly people (Lancet, 2001; 358: 3515). Not only may higher cholesterol levels be health-giving in the elderly, but the cholesterol-lowering drugs themselves may also be doing more harm than good, according to a study
from the Yale University School of Medicine. There, the researchers found that, while there was a marginal benefit from the drugs in reducing heart fatalities, they also found that the patients were dying of other causes as a result of taking the drugs (JAMA, 1994; 272: 133540). Worse, most general practitioners are unaware of the dangers of the drugs they are prescribing to their elderly patients, despite the frequent drug alerts and warnings they are sent by drug-monitoring agencies. In fact, researchers have discovered that around one in five elderly patients is being given drugs that are dangerous, and could be the cause of debilitating side-effects. In a study of 760,000 elderly people taking a prescription drug, it was revealed that 21 per cent were taking one or more drugs that were on the Beers list, a compilation of all the prescription drugs that geriatric patients, in particular, should avoid (Arch Intern Med, 2004; 164: 16215).
In another study, researchers found that 20 drugs had been identified as being too dangerous for use by the elderly and, yet, most of these patients (79.6 per cent) were being prescribed one of these drugs and 20.4 per cent were taking two or more, including the beta-blocker propranolol, the antihypertensive agents methyldopa and reserpine, the painkiller dextropropoxyphene and the anticoagulant dipyridamole (JAMA, 1994; 272: 2926). Many elderly people regularly take a common NSAID (non-steroidal antiinflammatory drug) such as aspirin and ibuprofen to help ease their aches and pains. Yet, according to a survey of 4099 people aged 70 years and over, these drugs increase the risk of kidney dysfunction. Those who took an NSAID at least once a day had the highest levels of blood urea nitrogen and serum creatinine, both of which are markers of kidney problems (J Am Geriatr Soc, 1999; 47: 50711). Prescribed drugs may also be
Living a long and healthy life

Aside from avoiding drugs and medicine, there are three keys to a healthy life into old age: diet; exercise; and an active social life.
N
Diet. Vitamin Efound in nuts, seeds, and corn and olive oilis arguably the single most important nutrient in determining whether or not we will live a long and healthy life. In a study of 698 men and women, aged over 65 and living in Tuscany, Italy, those who had low levels of the vitamin in their circulation suffered a decline in their physical capacity over a three-year period compared with those who had higher levels of the vitamin. This was also the only vitamin that had a direct impact on the physical wellbeing of the study participants. Their levels of folate, vitamin D, iron and B vitamins apparently made no difference to the physical decline. The researchers believe that vitamin E, which is an antioxidant, prevents damage to DNA, muscles and neurons (JAMA, 2008; 299: 30815). The Mediterranean diet, primarily consisting of fresh fruit, vegetables and olive oil, has been proven in countless studies to help maintain health into older age. One study, involving 1393 participants, discovered that the diet protects against cognitive decline as we age. Those who stayed close to the diet nearly halved their chances of developing mild cognitive impairment compared with those who ate low amounts of fruits and vegetables (Arch Neurol, 2009; 65: 21625). N Exercise. Even moderate exercise, such as a brisk walk every day, can help to keep you healthy into older age, and even elderly patients who already have conditions
such as heart disease and arthritis can see improvement. In heart patients aged 50 years and over, moderate exercise that leaves you a little out of breath increased life expectancy by 3.7 years in men and 3.5 years in women (Arch Intern Med, 2005; 165: 235560). Older people with osteoarthritis of the knee also noticed improvements in their knee pain and mobility after 18 months of brisk walking for 40 minutes, three times a week (JAMA, 1997; 277: 2531). Overall, older people who take regular exercise have stronger hearts, better circulation, stronger bones, better balance, less pain, better sleep quality, sharper minds and a lower risk of developing most cancers (Am Fam Physician, 2002; 65: 41926). N Social networks. An active social life, including volunteer work, attending sports and social events, and visiting friends and relatives, is as important as exercise for helping older people to maintain good health. In a US study of 906 retired people, it was found that physical decline was up to a third more rapid in those who were socially inactive, even when they took regular exercise (Arch Intern Med, 2009; 169: 113946). Curiosity and maintaining an interest in the world also play important roles in determining how longand how wellwe live. One study of 1118 men, with an average age of 70 years, found that having this attitude in life was the single most important factor in determining longevity. In ancillary analyses in 1035 older women (mean age: 69 years), curiosity appeared to be equally important in women as well (Psychol Aging, 1996; 11: 44953).
Staying sharp
Mental decline isnt an unavoidable consequence of ageing. Theres lots we can do to stay sharp right up to the end. People who exercise at least once a week, dont smoke and maintain an active social life are more likely to retain their cognitive abilities throughout their 70s and 80s, according to a study of 2500 participants aged 7079. However, an eight-year follow-up showed major cognitive decline in 16 per cent of this population, whereas 53 per cent displayed normal, age-related decline. Yet, the research team saw a unique profile of activity and social engagement that appeared to have protective effects in around 30 per cent of participants who displayed no cognitive decline whatsoever. A good education, not smoking and a good level of literacy were found to be important factors, and those who carried out volunteer work and were not living on their own also appeared to be less likely to suffer from cognitive decline (Neurology, 2009; 72: 202935). Maintaining an interest in intellectual pursuits, such as reading and doing crossword puzzles, can also help to ward off dementiaand the more you do, the better. The study participants who engaged in 11 intellectual activities a week, such as reading every day and doing the crosswords four times a week, delayed the onset of dementia by 1.29 years compared with those who read or did the crosswords
responsible for dry eyes and dry mouth, assumed to be a natural consequence of growing old. However, common painkillers such as aspirin could be responsible, according to a study of 2481 patients aged 6584 years. Antidepressants and antipsychotics may also be the cause of similar side-effects (Arch Intern Med, 1999; 159: 135963). Whats more, doctors are more than ready to prescribe off-labelhanding out drugs for health problems for which they have been neither tested nor licensed to treat. The problem has become so prevalent, and dangerous, that Americas drugs watchdog, the Food and Drug Administration (FDA), has warned doctors to stop using atypical antipsychotic drugs to treat general behavioural problems in elderly patients. Indeed, agents such as olanzapine, aripiprazole, risperidone and quetiapine are so dangerous that they double the risk of deathand they are supposed to be prescribed only to those with schizophrenia (www.fda.gov/cder/drug/ advisory/antipsychotics.htm). The four giants In 1965, when geriatric medicine was still in its infancy, Bernard Isaacs, a professor of geriatric medicine at Birmingham University in the UK, said the elderly were faced with four giants that would determine their health: immobility; instability; incontinence; and impaired intellect (Isaacs B. An
Introduction to Geriatrics. London: Ballire, Tindall
and Cassell, 1965). Every health concern in the elderly could be traced back to one of those four conditions, he said. However, neither Isaacs nor the other pioneers of geriatric medicine could have foreseen that, in many older patients, these giants would be caused by the very medicines that were supposed to help them, and not by the ageing process itself. N Immobility and instability. Around 30 per cent of all over-65s fall each year, and this proportion rises to half of all those in hospital or in nursing care, where multiple drugs are an essential part of their daily regimen. Also, 25 per cent of these patients die within six months of falling. While there may be a number of reasons why an elderly person falls, prescription drugs are among the biggest causes, responsible for around 18 per cent of all cases (Johnston CB. UCSF Division of Geriatrics Primary Care Lecture Series May 2001. Geriatric Assessment in a Time Dependent Practice: Practical Approaches for Primary Care Practitioners).
Tranquillizers and sedatives, such as benzodiazepine, can increase the risk of a fall in an elderly patient by nearly threefold. Flurazepam and triazolam (both of which are benzodiazepines) are the most dangerous, according to Canadian researchers, and the elderly patient was most likely to suffer a fall within the first two weeks of starting such drug
therapy (Age Ageing, 1996; 25: 2738). In a separate small US study a year later, the geriatric researchers in Durham, NC, found that benzodiazepines acted directly on the central nervous system, and affect neuromuscular processing and balance control, thereby causing falls, disorientation and slower responses in the elderly (J Am Geriatr Soc, 1997; 45: 43540). Powerful antidepressants of the class known as SSRIs (selective serotonin-reuptake inhibitors) as well as the older tricyclic drugs, can also significantly increase the risk of falls in the elderly (N Engl J Med, 1998; 339: 87582). As a consequence, elderly people taking an SSRI are 2.4 times more likely to suffer hip fractures compared with those not taking these drugs, researchers from the University of Toronto, Ontario, have found. However, the earlier types of antidepressant are not much safer for elderly patients. In this study, which involved 8239 patients, aged 66 years and over, who had been treated in hospital for hip fractures, it was found that those taking a tricyclic antidepressant such as desipramine or nortriptyline were 2.2 times more likely to suffer from hip fractures as a result of falls (Lancet, 1998; 351: 13037). Insulin can also cause falls, and is among the three drugs that are also most likely to cause an adverse reaction in the elderly; the other two are warfarin, a blood thinner, and digoxin, a heart drug. The three drugs alone accounted for 59,108 of the 177,504 cases of adverse drug reactions reported by US emergency services in 20042005. Insulin can cause sudden hypoglycaemia (low blood sugar), which may result in a seizures or unconsciousness (Ann Intern Med, 2007; 147: 75565). In fact, most prescription and over-the-counter drugs appear to increase the risk of falling. In a metaanalysis of studies published from 1996 to 2007, involving more than 79,000 participants, aged over 60, who were taking some sort of pharmaceutical, it was found that many drugs significantly raised the risk of falls. The biggest culprits included sedatives, SSRIs, antihypertensives, diuretics, beta-blockers,
and even NSAID painkillers such as aspirin and ibuprofen. Elderly people may be more sensitive to drugs effects and less effective at metabolizing medications, leading to adverse events which, in turn, lead to falls, said researcher Carlo Marra, at the University of British Columbia in Vancouver, Canada (Arch Intern Med, 2009; 169: 195260). Incontinence. This is often viewed as an unfortunate consequence of ageing, but this is not so. The US Agency for Health Care Policy and Research reports that eight out of 10 cases of incontinence can b either resolved or greatly improved by medical interventions (Agency for
Health Care Policy and Research. Overview: Urinary Incontinence in Adults, Clinical Practice Guideline Update. Rockville, MD. March 1996; www.ahrq.gov/clinic/uiovervw. htm).
The one exception is agerelated prostate enlargement, which can cause urinary incontinence. In fact, incontinence can arise for many reasons and in people of all ages, although one in 10 of those aged over 65, and three in 10 aged over 80, have some loss of bladder control, and half of all elderly patients in nursing homes have incontinence. Many prescription drugs cause temporary incontinence and, as the elderly take onethird of all drugs prescribed, its not unreasonable to conclude that they are a primary cause of the condition in the over-65s. Anticholinergic agents, which block the passage of neural impulses, include drugs such as antihistamines, antidepressants, opiates, antispasmodics and Parkinsons drugs, and can all lead to incontinence (Cochrane Database Syst Rev, 2006; 4: CD003781), as can heart drugs such as the calcium-channel blockers. Diuretics, or water pills, increase the bodys loss of fluid by promoting the production of urine and, as a result, can frequently cause acute incontinence. They are among the most regularly prescribed drugs
among the elderlyand often unnecessarily so, as one study has identified (BMJ, 1994; 308: 5113). Alpha-adrenergic blockers, which include drugs for hypertension (high blood pressure) such as doxazosin (Cardura), prazosin (Minipress) and terazosin (Hytrin), can also cause incontinence (Drug Saf, 1994; 11: 1220), as can the angiotensin-converting enzyme (ACE) inhibitors such as benazepril (Merck Manuals; www.merck. com/mmhe/sec11/ch147/ch147a.html). Impaired intellect. Around 22 per cent of those aged 71 years and over have some degree of cognitive impairment, which is often seen as a forerunner of dementia and Alzheimers disease (Ann Intern Med, 2008; 148: 42734). However, researchers at the Mayo Clinic reckon that this figure could be lower, with only 12 per cent of individuals aged between 70 and 89 years displaying such symptoms, according to a study funded by the National Institute on Aging (www.mayoclinic.org/news2006-rst/ 3306.html). The Mayo researchers define cognitive impairment as having problems with remembering words, or placing things in time and space, or finding it more difficult to make decisions, or suffering from shortterm memory loss. The problem doubles in those aged between 80 and 89, and it also appears to affect more people who have received only basic levels of education. However, although ageing is a genuine factor in cognitive decline, pharmaceuticals also play a role in accelerating the problem. Scientists from the University of Florida have demonstrated that any drug that has anticholinergic (nerve-blocking) qualities can speed cognitive decline in the elderly patient. Although this includes drugs known to have anticholinergic actions, such as those used to treat an overactive bladder, many other drugs have similar effects, but have not been listed as such in the literature (Presentation at the American Academy of
Neurology 60th Annual Meeting, Chicago, IL, Abstract S51.001, 17 April 2008).
Indeed, it appears that almost every commonly prescribed or overthe-counter drug can produce symptoms that resemble dementia in the elderly. A pair of researchers from the Medical University of South Carolina have reported that many drugs cause side-effects that include confusion and memory loss, two signs of cognitive impairment. In addition, the problem can be magnified when the patient is taking more than one drug at the same time (J R Soc Med, 2000; 93: 45762). Polypharmacy Its evident that the dangers to the elderly of taking any one drug are bad enough, but its almost impossible to measure the negative impact of taking many drugs at the same time, as most elderly patients are doing. Even young Hollywood celebrities, such as Heath Ledger and Brittany Murphy, may have died as a result of taking several pharmaceuticals at the same time. As Dr Bruce Goldberger, a professor of toxicology at the University of Floridas College of Medicine, said of the latters death, Mixing a number of these drugs could have resulted in her death. Every drug is tested for its safety and efficacy on its own, but no one is testing the lethal cocktails that can result from taking several powerful chemical compounds in combination. Nevertheless, what is clear, as pharmacologists at the University of Wales College of Medicine, Cardiff, have pointed out, is that drugsand especially polypharmacymay be responsible for many of the common health problems seen among the elderly, such as confusion, weakness, incontinence, depression and falls, all of which have been blamed on growing old (Drugs Aging, 1998; 12: 48594). Without drugs and medicine, perhaps getting older wouldnt be such an unhealthy rite of passage.
Bryan Hubbard
The damaged brain: how drugs cause dementia

New evidence shows that all forms of dementia may largely be caused by most of the drugs we take as we get older
e may be living longer and better than ever but, by the time we reach our golden years, the chances of us having any awareness of it are rapidly fading. Dementia of all varieties, including Alzheimers disease, is now epidemic, approaching an incidence similar to that of the major killers: for instance, seven million Americans aged over 65 are currently diagnosed with dementia compared with 10 million of all ages with cancer. Furthermore, the incidence rates of dementia are sharply on the increase. Predictions suggest that the disorder will increase fourfold among the elderly within the next 40 years, and escalate across all age groups. Nevertheless, the raw statistics fail to reveal the most insidious aspect of the diseasenamely, that the chances that any one of us will suffer from dementia sharply increases with every decade. According to one team of researchers, who tracked the incidence of the disorder over time, after the age of 60, your risk of developing dementia doubles every five years. This means that, by the time you reach your mid-80s, you face a one-in-four risk of having dementia and, by the time you reach 90, the odds increase to one chance in three (Alzheimer Dis Assoc Dis, 2003; 17: 637). One reason for the prevalence is simply due to the ambiguous nature of the term. Virtually every form of cognitive decline is now classified as dementia, including memory loss, and impairment in planning, judgment, reasoning and ordinary thought processes. However, modern medicine must take the greatest blame for the mental decline seen among the
elderly. Even though they represent only one-seventh of the population, the over-65s take one-third of all prescription drugsand usually a cocktail of them. The average senior is taking six drugs at a time, many of which affect the brain. Evidence is emerging that a large coterie of drugs given for other conditions, such as high cholesterol, depression, inflammation, insomnia, anxiety, heart disease and arthritis in short, most of the drugs given to us as we grow oldercan all bring on dementia. Many of these drugs cause actual damage to the structure of the brain, including shrinking brain volume and destroying the crucial fatty structures of brain cells, thus leading to the abnormal accumulation of tissue in vital brain structures. Given the fact that some 90 per cent of Americans from their mid-50s onwards are taking at least one drug regularly and nearly one-third are taking five or more drugs, it may well beas American psychiatrist Grace E. Jackson claims in her brilliant and damning self-published studythat dementia is, in many cases, a druginduced disease (Jackson GE. DrugInduced Dementia. AuthorHouse, 2009). Of the 36 million Americans who now take statins, for instance, an estimated 162,000 people could be severely cognitively impaired because of these drugs in the US alone. The chicken or egg dilemma Although used as an all-purpose catch phrase, dementia could be defined as any condition in which there is an observable abnormality involving neurons or glial cells. On the basis of such a description, it could be said that there are four types of true dementia: N Lewy body dementia, in which
patients have movement disorders much like those seen in Parkinsons disease, with abnormal deposits of Lewy body proteins, named after the German neurologist who first observed them, throughout the neurons of the brain; N vascular dementia, where the brains blood supply has become cut off or interrupted, usually as a result of large or small strokes, causing the death of neurons; N frontotemporal dementia, usually diagnosed in patients aged under 65, where the frontal or temporal lobes (including the hippocampus) of the brain shrink; and N Alzheimers disease. According to Jackson, Alzheimers victims all share three specific abnormalities: N senile plaques, abnormal clumps of amyloid and other sorts of proteins that form outside of cells in the gray matter of the brain; N neurofibrillary tangles, abnormal, twisted bundles of fibres within brain neurons mostly made up of tau proteins that impair the formation of tubulin, a protein necessary for healthy connective nerve tissue, the result of which is that messages in the brain arent transmitted properly; and N granulovacuolar degeneration (GVD), where neurons in the brain have abnormal holes (vacuoles),
each of which contains a small, dense protein. The problem is that researchers cannot agree on whether these characteristic findings are the cause or the effect of an abnormal process in the body. The evidence from studies of the effects of aluminium and mercury on the brain suggest that they are the result of toxicity rather than being a true cause of dementia. In test-tube studies using human brain cells, for instance, minute doses of mercury produced changes identical to those seen in Alzheimers disease (J Neurochem, 2000; 74: 2316). In other, animal studies, professor of medical biochemistry Boyd Haley and colleagues at the University of Kentucky fed rats aluminium, but observed no changes in tubulin levels, whereas mercury-fed rats displayed diminished tubulin levels similar to those seen in typical Alzheimers patients. Furthermore, some researchers suggest that the vacuoles seen in GVD are filled with toxic materials, such as aluminium, which the neuron has fenced in to keep the rest of the brain safe (Am J Pathol, 1999; 155: 116372). Research at the University of Pittsburgh has discovered that a fatbinding agent known as apolipoprotein D (or apoD in medico-speak) is present in the brain plaques seen in patients with Alzheimers disease. However, apoD is also found in other kinds of pathology, and many animal and human studies have shown that antipsychotic drugs induce the production of apoD. Furthermore, scientists have found this type of lipoprotein in fat and brain cells following injury, which suggests that it plays a role in cell renewal and repair. Nevertheless, the evidence in general suggests that toxicitya form of insult to the brainrather than natural cellular degeneration is the cause of dementia. Antidepressants There is no doubt that certain drugs cause damage to the structure of the brain, thereby impairing its function. Among the chief offenders are antidepressants, which appear to target the white matter of the brain.
Why the brain needs fats

Although medicine used to believe that the master conductor of brain activity was the neurons, or nerve cells, that create and release neurotransmitters and electrical signals, this view has been revised by a more holistic view of the brain. This concept appreciates that the brain works in its entirety through a web of activity between neurons and four varieties of glial cells. Glial cells, which surround the neurons, keep them in place, provide them with nutrients, and destroy and mop up pathogens. They also insulate one neuron from another and modulate the transmission of signals. One major function of glial cells is to form myelinthe insulating sheath that covers every tentacle of a nerve cellwhich is largely made up of lipid (fatty) tissue. Yeon-Kyun Shin, a professor of biophysics at Iowa State University, recently went on record to say that high cholesterol is vital for good brain function, and a lack of cholesterol impairs the brains thinking ability and memory. If you deprive the brain of cholesterol, then you directly affect the machinery that triggers the release of neurotransmitters. Neurotransmitters affect the data-processing and memory functions; in other words, how smart you are and how well you remember things, he said (Proc Natl Acad Sci USA, 2009; 106: 51416).
The white matter is the part of the brain that contains bundles of nerve fibres covered with myelin, a white fatty substance that forms an insulating sheath around each fibre. It is through these neural bundles that messages are passed between different areas of gray matter, which is made up of unmyelinated nerve cells, within the nervous system. This means that the white matter is rather like a telephone network, responsible for the rapid transmission of nerve impulses and cell-to-cell communication. One natural aspect of ageing is losing neural connections. Each of us begins adulthood with some 176,000 km of white matter, but we all should expect to lose around 10 per cent of these connections with every decade of life. However, antidepressants clearly hasten this process. In 2008, a US study carried out by Duke University Medical Center in Durham, NC, published the results of the 10-year study, which examined the magnetic resonance imaging (MRI) scans of more than 1800 patients performed over two periods of timefirst, from 1991 to 1994, and then, from 1997 to 1999. The authors compared the findings for the 163 patients who had begun taking antidepressants between the first and second scans
with those for patients who were not using any such drugs. They found similar incidences between the two groups of virtually every condition looked atdiabetes, stroke, heart attacks, hypertension save one. Those taking the antidepressant drugs experienced more bright spots in the white matter on MRI. This sort of appearance on a scan is thought to indicate damage to blood vessels, impaired blood flow, demyelination (degeneration of the myelin sheath of nerve cells), disintegration of the bloodbrain barrier and even damage to the nerve cells in the gray matter of the brain (Stroke, 2008; 39: 85762). Indeed, those taking the drugs suffered a 36-per-cent incidence of white-matter damage compared with 27 per cent in those who had been drug-free over the decade. In addition, all types of antidepressants be they old or newhastened the decline. Whats more, although the worst offenders were the old-style tricyclic antidepressants, adverse effects were observed with all of the newer types of drugs that inhibit the uptake of serotonin. Overall, 60 per cent of the patients who used either type of antidepressants showed increased damage to white matter that was above the norm. Antidepressants also appear to
shrink the hippocampus, part of the limbic system of the brain that is involved in long-term memory, spatial navigation, learning and mood. There is solid scientific evidence that patients who are chronic users of antidepressants, particularly SSRIs (selective serotonin reuptake inhibitors) such as Prozac (fluoxetine), have smaller hippocampal structures compared with controls. In one fascinating study, the hippocampi of long-time depressed patients who were taking long-term medication were compared with those of two other patient groups: those whod just been diagnosed with the illness and had not yet begun taking any drugs; and a group of non-depressed controls. There was no difference in brain size between the just-diagnosed depressed patients and the controls, whereas the long-time medicated showed a hippocampus that was 12 per cent smaller, on average, than those of the others (Proc Natl Acad Sci USA, 2003; 100: 138792). The importance of this study is that it demonstrates that its the drugs themselves, and not the depression on its own, that causes the brain to shrink. Autopsies of cavaders have also revealed brain damage in those whod been long-term users of antidepressants. In one Dutch study, of patients whod been taking antidepressants, 73 per cent showed evidence of brain cell death (apoptosis) compared with 33 per cent in patients using long-term steroids and 6 per cent of their matched controls (Am J Pathol, 2001; 158: 45368). In addition, epidemiological studies have also shown a greater incidence of dementia among populations using antidepressants. Researchers in Copenhagen carried out a sweeping study, involving nearly a third of the entire Danish population, focused on patients aged over 40 whod taken antidepressants, even if just one single time. The risk of developing dementia was two to five times higher in those whod used antidepressants compared with nonusers (J Affect Disord, 2009: 117: 249). However, Jackson believes that
The role of coenzyme Q10

It is well known that patients taking statins lose coenzyme Q10 (CoQ10) in a dose-related manner. The drugs block production of both cholesterol and CoQ10 by inhibiting the enzyme precursor of not only cholesterol, but also that of CoQ10. CoQ10 participates in chemical reactions, particularly those that involve cellular energy production, and helps to make cell membranes more resistant to oxygen damage. It is found abundantly in the heart mostly because of the huge energy requirements of cardiac cells. In fact, studies have shown that a deficiency of CoQ10 is linked with heart failure and impaired heart function. Of 15 published studies in the literature, nine have confirmed that statins can significantly lower CoQ10 levels (Arzneim Forsch, 1999; 49: 3249). Critics of statins believe that the widespread use of these drugs has caused an increase in statin cardiomyopathy, where the heart loses its ability to pump blood or heart rhythm is disturbed, leading to irregular heartbeats. Drug manufacturers tacitly acknowledge this effect by offering several drug formulations that combine a statin with CoQ10. But a less well-known problem with blocking CoQ10 is that it interferes with cognitive performance, resulting in memory loss and muddled thinking. In an elderly person, this sort of side-effect is almost invariably passed off as age-related dementia, requiring yet another coterie of wonder drugs. Other researchers have been discovering that statins also inhibit and cause mutations in mitrochondria cells, the energy power packs of the body. Scientists now suspect that an array of neurodegenerative diseases are due to mutated or altered mitochondria.
this population study may have underestimated the risk, as one-fifth of those using antidepressants died during the study follow-up period. Statins Statins, those miracle cholesterollowering drugs, also appear to lead to progressive cognitive decline. This is particularly ironic, as medicine has been under the illusion that cutting down on cholesterol in the elderly is desirable particularly for the brain (see box, page 41) and, consequently, that statins can keep Alzheimers at bay. It is true that statins can cross the bloodbrain barrier and alter cholesterol metabolism in the brain, but this has no bearing on Alzheimers disease. Earlier this year, Harvard University researchers, in conjunction with a number of other centres in the US, Germany and Spain, gave statins for 12 weeks to patients with mild Alzheimers disease or mild memory loss. During the course of this study, they found a modest but significant inhibition of brain cholesterol
biosynthesis. Nevertheless, although the drugs lowered cholesterol in the brain, this had no alleviating effects on Alzheimers disease whatsoever (Alzheimer Dis Assoc Disord, 2010 May 13 doi: 10.1097/WAD.0b013e3181d61fea). In fact, the lack of effectiveness of statins as a treatment for Alzheimers disease was finally established last year, when two reviewers independently analyzed two largescale randomized controlled trials, involving a total of 26,340 patients as part of the HPS 2002 and PROSPER 2002 studies, and reached an agreement after discussing their results. Their conclusion was that statins given late in life to individuals at risk of vascular disease have no effect in preventing either Alzheimers disease or dementia (Cochrane Database Syst Rev, 2009; 2: CD003160). Indeed, far from helping memory and cognitive function, statins can cause sudden and complete memory loss. This evidence emerged when flight surgeon Duane Graveline suffered global amnesia when taking atorvastatin (Lipitor) for the first time.
When his family doctor Jay S. Cohen took up his case with Pfizer, the drugs manufacturer, he was sent clinical evidence gathered before the drugs release showing that there were 4.5 cases of severe cognitive disturbance out of every 100 patients given the drug. This included cases of impaired, worsening or general lapses of memory, general forgetfulness and short-term memory loss. Pfizers own studies had also discovered instances in which patients had difficulty concentrating, or suffered abnormally slow or difficulty in thinking, slowed or decreased mental activity, impaired intellect or judgment and even irrational thinking. Graveline and Cohen then conducted an online literature search of MedWatch, the US Food and Drug Association (FDA) database of reported drug side-effects, for reports of severe cognitive impairment or serious amnesia associated with Lipitor. They found 662 such reports, including 399 cases of amnesia and 236 cases of memory impairment. The investigating pair also found that, over time, the complaints had become more frequent (Townsend Lett Docs, 2009; 311: 6470). MedWatch, which is thought to be notified of only 2.5 to 5 per cent of all drug side-effects, therefore suffers from vast underreporting, so the true incidence of memory problems from statins is probably closer to 66,000 or more. In fact, Graveline and Cohen believe that virtually every patient taking the drug suffers from cognitive damage in one form or another that may be too mild to be initially detected. This is perhaps because all statins lower levels of coenzyme Q10, known to be vital for brain function (see box, page 42). Graveline and Cohens detective work has also been vindicated by a meta-analysis carried out by Duke University in Durham, NC, which uncovered 60 patients with memory loss attributable to statins. Half the patients had noticed cognitive decline within just two months of starting the drugs; of these, more than half found that their memory improved as soon as they stopped
Other drugs to avoid

Besides the agents already mentioned (see main story), there is mounting evidence that you should also avoid the following types of drugs. N Stimulants, such as methylphenidate (Ritalin). A vast number of animal studies show that all amphetamines cause parts of the brain to shrink, trigger degeneration of dopamine cells in the brain and reduce the survival of neurons in the hippocampus, among many other effects (Jackson GE. Drug-Induced Dementia. AuthorHouse, 2009). N Beta-blockers, calcium-channel blockers and ACE inhibitors, and other drugs that aggressively lower blood pressure. These antihypertensives can lower blood flow to the brain and produce all the hallmarks of Alzheimers disease (Drugs Aging, 1999; 15: 1528). N Antiarrhythmic drugs, given to correct abnormal heart rhythms, can also cause dementia. N Anticholinergic drugs, a giant category that includes drugs for gastrointestinal problems such as diverticulitis and ulcerative colitis, respiratory ailments such as asthma and genitourinary disorders such as cystitis or prostatitis, are associated with cognitive decline in the elderly (Presentation at the American Academy of Neurology 60th Anniversary Annual Meeting in Chicago, IL, 17 April 2008). N Opioids, many of which can cause delirium (Drugs Aging, 1993; 3: 34957; Postgrad Med J, 2004; 80: 38893). N Non-steroidal anti-inflammatory drugs (NSAIDs). Initially thought to offer protection against Alzheimers, different types of these common painkillers can cause a variety of cognitive changes, ranging from delirium (indomethacin and sulindac) to disturbances in memory and concentration (naproxen and ibuprofen) (Drugs Aging, 1999; 15: 1528). N Levodopa . This antiparkinsonian medication causes cognitive symptoms in up to 60 per cent of users (Clin Geriatr Med, 1998; 14: 10127).
taking the drugs. Furthermore, all of the four patients who started taking the drugs again suffered a recurrence of their memory problems. As a further nail in the coffin, not one single experimental study could find any evidence to support any benefit with statins in delaying cognitive decline (Pharmacotherapy, 2003; 23: 87180). Antipsychotic agents Another major culprit causing dementia is that broad class of drugs called antipsychotics. The first socalled neuroleptic medications were developed in the 1950s to relieve patients suffering from hallucinations, paranoid schizophrenia and other psychoses. Unfortunately, these drugs brought with them unwanted extrapyramidal (brain motor system) side-effects such as tardive dyskinesia, characterized by muscle stiffness, tics, tremors and other awkward movements. The arrival of clozapine (Clozaril)
introduced the next generation of neurolepticswhich also includes olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal)that were dubbed atypical antipsychotics to distinguish them from their older and supposedly more dangerous cousins. These drugs are supposed to suppress the psychotic and antisocial aspects of schizophrenia without all the antipyramidal effects (World J Biol Psychiatry, 2000; 1: 20414). However, this newer generation of drugs comes with its own laundry list of dangerous, even life-threatening, side-effects, including serious mental deterioration. There is no doubt that the socalled antipsychotic drugs can cause or speed up the development of dementia (J Neurol Neurosurg Psychiatry, 2007; 78: 2339). This is ironic because these drugs are often given to sedate or calm patients with dementia, whereas it appears that they are also speeding up and worsening the
process of cognitive decline. Nevertheless, the most compelling evidence comes from autopsy studies that have compared patients using antipsychotic drugs with those who did not. In one study by the Wolfson Centre for Age-Related Diseases at Kings College London, those whod been given neuroleptics had a 30-per-cent greater density of amyloid plaques and 65- to 367-per-cent more neurofibrillary tangles than those who were free of neuroleptic drugs (Int J Geriatr Psychiatry, 2005; 20: 8725). Moreover, in a similar US study, 102 patients with schizophrenia showed evidence on autopsy of brain deterioration that was suggestive of Alzheimers or some other form of dementia. The signs were present in 74 per cent of those whod been given antipsychotic drugs, but in only 36 per cent of those whod died prior to the advent of these drugs (Alzheimer Dis Assoc Disord, 1994; 8: 21127). In other words, taking antipsychotics more than doubled the patients chances of developing dementia. The worst combination of all is taking an antipsychotic together with an antidepressant, which appears to quadruple the speed at which the disease develops (J Neurol Neurosurg Psychiatry, 2007; 78: 2339). Whats more, Alzheimers patients who are given an antipsychotica common practice, usually to sedate themhave double the usual risk of death. In a major study involving various centres across the UKthe first independent study of its kind not paid for by a drug companyless than half the patients (46 per cent) taking an antipsychotic were still alive at the two-year follow-up. After three years, only 30 per cent of those taking antipsychotics were alive compared with 59 per cent taking a placebo (Lancet Neurol, 2009; 8: 1517; doi: 10.1016/S1474-4422(08)70295-3). In another UK study that was focused on care facilities in the North East of England, the Londonbased researchers compared the efficacy of the antipsychotic quetiapine, the cholinesterase inhibitor rivastigmine and a placebo in calming institutionalized patients with dementia. Neither of the patients in the active-treatment groups were any calmer than those who were simply taking sugar pills, although there was one significant difference with quetiapineit was associated with significantly greater cognitive decline (BMJ, 2005; 330: 874). Antipsychotics also appear to shrink the volume of the frontal lobes of the brain by 0.2 per cent per year, according to a University of Iowa study (Arch Gen Psychiatry, 2003; 60: 58594). Other studies have shown size reductions in a variety of areas of the brain with both older (haloperidol) and newer (olanzapine) antipsychotic medications (Arch Gen Psychiatry, 2003; 60: 58594). What is coming to light is a clear association between antipsychotic drugs and cognitive decline. In a painstaking English survey, every case of dementia recorded on a dementia register during 19931994 was examined. Researchers studied the patients diagnoses and treatments from their various medical carers and interviewed their next of kin, then matched these patients to a similar group of elderly people living in Southeast London. Of the patients on the register, 13 per cent had a past history of psychiatric treatment, and the use of psychiatric drugs was three to four times higher among those whod gone on to develop dementia (Age Ageing, 1998; 27: 1818). Benzodiazepines In addition to the major antipsychotic drugs, benzodiazepine tranquillizers and sleeping pills are also responsible for cognitive decline. One Argentinian study noted evidence that sleeping pills, which are often handed out without a prescription in that country, led to severe memory and cognitive impairment, and delirium (Vertex, 2001; 12: 2725). Newer studies now show that this effect has to do with an effect on gangliosides in the brain. These molecules, which contain fat and sugar, are present to a large extent in brain lipids and on the surface of every neuron. They are essential for regulating cell growth, maintaining the integrity of the material contained within cells, and responding to foreign invasion by toxins and bacteria. Without these gangliosides, we lose myelin and entire neurons, and may even die. A series of studies by the Institute for Medical Research in Belgrade, Yugoslavia, has demonstrated that, at least in ratsso it may not apply to humanschronic doses of Valium (diazepam) led to the loss of 46 per cent of gangliosides in the cerebellum within six months. After a short period of total drug withdrawal, the rat brain still had not fully recovered (Physiol Res, 1999; 48: 1438). When the researchers repeated the study in 2002, focusing especially on the effects of the drug on various regions of the brain, they found significant reductions of gangliosides in the hippocampus, cerebral cortex and cerebellum, as well as increases of simple gangliosides in other areas (Neurol Sci, 2002; 23: 6974). These findings are consistent with those of many human neurological diseases, including Alzheimers. Indeed, in a 1993 British study, researchers took computed tomography (CT) brain scans of long-term benzodiazepine users and compared them with those of drug-free controls. The scans revealed that the drug users had a reduction of brain tissue in their frontal and occipital lobes, as well as in the left caudate nucleusareas that are crucial for cognitive function (Psychiatry Res, 1993; 48: 13544). At present, in the US alone, six million patients are being treated for dementia at a cost of $90 billion, or one-third of all Medicare bills. This means that 1 per cent of the entire gross domestic product of the US is being spent on a mostly iatrogenic (doctor-induced) condition. Medicine has reached the point where it is chasing its own tail, attempting to mop up with yet more drugs and treatments a vast and costly problem that it has itself caused in the first place. Evidence is mounting that one of the major toxic insults to the brain is the mercury from amalgam fillings, but this effect may be eclipsed by the dangers we face from the modern medical response to ageing. Keeping bright and alert in old age requires a few simple practices:
regular exercise; eating an antioxidant-rich wholefood diet along with good fats; minimizing toxic exposure to heavy metals; engaging in regular brain workouts (crossword puzzles or reading); and staying
connected through a social network. However, now there is one more simple homily to add to the list: avoid as many prescription drugs as you can.
Lynne McTaggart
Anticholinergic drugs: the stupid pills

A giant class of drugs has been implicated in the development of dementia and loss of physical functionality
nticholinergic drugs, widely prescribed to the elderly for everything from incontinence to ulcers, can hasten an older persons decline. Recent studies carried out in the US found that nursing-home patients taking dementia and incontinence drugs at the same time had a 50-percent faster rate of physical decline compared with those taking only dementia drugs. Anticholinergics work by blocking impulses in the parasympathetic nervous system, responsible for the involuntary actions of smooth muscle in many parts of the body. They also prevent the neurotransmitter acetylcholine from binding with its receptors in nerve cells. Three types of these drugs are used for problems such as ulcers, bladder spasm, heart arrhythmias, motion sickness, Parkinsons and control of blood pressure, and as muscle relaxants or pre-anaesthetics. Perhaps the best-known examples of this drug family are Zantac (ranitidine) and nifedipine (Adalat, Procardia). In this latest study, researchers examined 3536 nursing-home residents, aged 65 and older, who were taking a bladder anticholinergic (oxybutynin or tolterodine) for incontinence. They then carried out repeated analyses to assess the effects of the two drugs on cognitive function, and also examined any changes in daily activities. Around 10 per cent of the residents were taking both drugs. They found that the combination of drugs most affected those whod started out with higher levels of functioning in activities such as personal hygiene, dressing, bed mobility, eating and toileting. Among these residents, those given both drugs suffered a 50-per-cent greater decline in functionality compared with those given only cholinesterase inhibitors [for Alzheimers (AD)]. Those given both drugs dropped 1.62 points per quarter on the scale for daily living function, while those given the single drug for AD declined 1.08 points. Those starting out with lower functionality had no further decline with both drugs compared with single therapy (J Am Geriatric Soc, 2008; 56: 84753). However, the research-ers concluded that the tests they used were not sensitive enough to determine whether taking both drugs together increased mental decline. Nevertheless, according to the studys lead author, Kaycee Sink, the decline was analogous to a nursinghome resident who initially required only limited assistance suddenly becoming completely dependent on others to help him perform his daily routine. The researchers believe that the results may be due to an oppositional effect between the two sorts of drugs. Dementia drugs such as donepezil (Aricept) and galantamine (Raza-dyne) increase acetylcholine, whereas the anticholinergics do just the opposite. The team concluded that such pharmacological opposites would cancel out the effectiveness of either or both drugs. However, even on their own, anticholinergics may lead to functional decline. Older adults taking these
drugs on their own for incontinence, high blood pressure or allergies are likely to suffer from impaired physical function. This was shown in a study of 3000 seniors, 40 per cent of whom were taking anticholinergics. Patients whod started out needing only limited assistance in a physical activity were entirely dependent on assistance one year later. These findings were presented at the American Geriatrics Society meeting in Washington, DC, in May of this year. According to the researchers, these effects were seen even in older adults who had normal memory and cognitive abilities. The effect is essentially that of a three- to four-year increase in age, said Sink. So someone who is 75 in our study and taking at least one moderately anticholinergic medication is at a similar functional level to a 78 to 79 year old. Earlier studies suggested that drugs for incontinence may be associated with cognitive decline. The most worrying aspect of these studies is the sheer number of elderly people whose decline is being hastened by polypharmacy. Dementia and incontinence represent two of the most common conditions for which drugs are dispensed in nursing homes. According to Sink, nearly a third of all patients taking anticholinergics also take a drug for incontinence. In this instance, Alzheimers may not be all in the patients head. With this class of drugs, a patient may be trading incontinence for incapacity.
Lynne McTaggart
Dementia or side-effects?
N N N N N N N N N N
Loss of coordination Disorientation Agitation Confusion Short-term memory loss Inability to concentrate or maintain a train of thought Illogical thinking Incoherent speech Muscle jerks Visual and auditory hallucinations.
Diabetes: epidemic by prescription

Dr Lisa Landymore-Lim, a British chemist specializing in immunology and biomedical chemistry, became curious about the explosion of childhood illnesses such as asthma and diabetes, and carried out a pilot study of drug-prescribing among juvenile diabetics. In 1994, WDDTY published her initial findings. Here is her evidence for suggesting a link between the excessive use of antibiotics and diabetes.
ases of chemicals and drugs causing temporary and permanent insulin-dependent dia-betes (IDD) are well documented in the medical lit-erature (Pharmacol Rev, 1970; 2: 485518; J Rheumatol, 1987; 14: 7325). Unfortunately, such cases dont usually come to the attention of physicians, and most patients are completely unaware of these potential hazards. Two of the best-known chemicals capable of damaging pancreatic beta cellsresponsible for the production of insulinare the antibiotic streptozocin (Zanosar, also used in chemotherapy) and the chemical alloxan. These drugs are routinely used in animal experiments to study diabetes. Vacor, a rat poison, has also been reported to cause the disease. There is a structural similarity between the chemicals streptozocin, alloxan and Vacor: in each, there is at least one oxygen atom joined by two bonds to a carbon atom (C=O), forming a carbonyl group, which is flanked on each side by a nitrogen (N) atom. This is of interest because carbonyl groups and nitrogen atoms can be considered reactive species due to their excess of negative charge. This means that they are electron-rich and, thus, have an affinity for positively charged species such as zinc ions (Zn2+). Thus, they behave like magnets, attracting oppositely charged species. Insulin is stored in the pancreas together with zinc. In fact, the pancreas has the highest concentration of zinc in the body, making it potentially a major target for chemical attack. In addition, double-bonded oxygen groups are also potential sources for the formation of free radicals, those
destructive agents that have been implicated in the onset of cancer. Other chemicals known to be capable of producing diabetes in humans include the drugs dapsone, used in the treatment of leprosy, and pentamidine isethionate, an antiprotozoal agent used to treat pneumonia in AIDS patients. However, dapsone and pentamidine bear little structural resemblance to streptozocin and alloxan, except that dapsone does contain electronegatively charged oxygen atoms that are doublebonded to sulphur (instead of carbon). Both drugs also have electronegative terminal amino (NH2) groups attached to, or in close proximity of, a benzene ring. Nevertheless, comparison of daps-
one and pentamidine with the drugs frusemide and chlorthiazide, diuretics reportedly associated with the onset of diabetes, also reveals structural similarities. In frusemide, once again we see the electronegative sulphonyl (S=O) group and a terminal amino (NH2) group, whereas chlorthiazide has two SO2 groups and a terminal NH2.
Dispensing habits in the UK

Region East Anglia Wessex Northern Mersey Oxford Yorkshire North Western Trent South Western West Midlands SE Thames SW Thames NE Thames NW Thames
aof
Rates per 100,000 of incidencea 17.7b 17.1c 15.8c 15.8c 15.2c 14.9c 14.6c 13.5c 13.4c 13.3c 13.1d 12.4d 11.8d 8.0d
diabetes in children under 15 years of age; bhigh; dmedium; dlow NB: This shows more than a twofold variation in incidence between the North West Thames region and East Anglia. What could account for such variation between area health authorities that are situated in close proximity? Could it be that dispensing practices are a factor in the onset of diabetes?
NIDD: low-grade poisoning?

Non-insulin-dependent diabetes (NIDD), where the diabetic symptoms are not severe enough to warrant the use of insulin, is, in the present authors opinion, simply subclinical insulin-dependent diabetes. Many patients who are not treated with insulin have abnormally high blood-glucose levels and often eventually require insulin. One reason why insulin-dependent diabetes (IDD) and NIDD have been considered two separate and distinct disorders is that NIDD is most commonly detected in mature adults and islet-cell antibodies are not found in such patients. However, if chemicals are capable of causing diabetes and with exposure taking place over many years, antibody levels in NIDD may be low as the onset of the disease is likely to be much more gradual. The idea that IDD and NIDD are essentially the same disorder (apart from differences in the degree of insulin-producing impairment) is supported by the following findings: N Some 50 per cent of newly diagnosed IDD children do not have detectable islet-cell antibodies N Some 8 per cent of non-diabetics have been found to have islet-cell antibodies N Many NIDD patients eventually require insulin therapy N NIDD has been found to be as common as IDD in a study of school children in Japan.
Indian J Exp Biol, 1982; 20: 934).
Such groups are not commonly found in drugs. In the American Hospital Formulary Service Drug Information database, which lists some 1000 drugs, less than 5 per cent have either an amino group or a carbon atom bound to a benzene ring. Sulphonyl groups, however, are commonly found in thiazide diuretics and sulphonamide drugs. Alarmingly, in Australia, diuretics like hydrochlorthiazide (identical to chlorthiazide except for an additional hydrogen atom) are given to young women to treat premenstrual water retention. Indeed, diuretics are among the top most frequently prescribed drugs in the West. If drugs such as thiazides are causing diabetes, then it comes as no surprise that the incidence of diabetes is increasing in adults. There have also been reports that some antihypertensives (drugs prescribed to control high blood pressure) may also cause diabetes. One of these is the calcium channel-blocker nifedipine. Again, although the overall structure of this drug is not like any of the other drugs previously mentioned, it does contain several electronegative double-bonded oxygen groups, including an NO2 group bound to a benzene ring such as is found in Vacor rat poison. So, indeed, it is evident that nifedipine shares some structural
similarity with chemicals known to cause diabetes. To summarize, the chemicals and drugs currently known or suspected to be associated with a risk of diabetes appear to have a primary amine (NH2), a carbonyl (C=O) group close to a nitrogen or an oxygen atom, and S02 or NO2 groups. Primary amines and oxygen atoms bound to carbon, sulphur or nitrogenall considered reactive species due to their negatively charged centreswill bind to zinc under the right conditions by a process known as chelation, a form of tight chemical attachment. The pancreas, being a rich source of zinc, could therefore be a potential target for attack by zinc-seeking chemicals. Indeed, it has been suggested that chemicals that can cause diabetes may do so by interacting with zinc in the insulin-secreting beta cells of the pancreas (Mol Pharmacol, 1985; 27: 36674). This suggestion is supported by the fact that diabetes arising from chemical exposure is accompanied by a loss of detectable zinc from the pancreatic beta cells (Arch Exp Pathol Pharmakol, 1952; 216: 45772), and that zinc injected into animals before exposure to a diabetes-causing chemical will protect the animals against developing the disease (Anat Record, 1951; 109: 377;
It has also been reported that penicillin interacts with zinc (J Pharm Pharmacol, 1966; 18: 72938). So, it is conceivable that a chemical such as penicillin circulating in the bloodstream could be attracted to the beta cells of the pancreas, which contain zinc. This could result in the displacement of insulin bound to zinc and chelation of penicillin to zinc, thereby changing the acidity within the cells as new, different bonds are formed. This, in turn, could cause the insulinzinc aggregates to dissolve, leading to a marked increase in osmotic pressure and cellular rupture. It is then possible that such chemical changes within the pancreatic beta cells might activate the bodys immune-defence system, resulting in the formation of antibodies directed against the beta cells in an attempt to bind and destroy them, as they are now seen as being foreign to the body. This may account, at least in part, for the presence of islet-cell antibodies in the blood of many newly diagnosed diabetics. And if this is so, the agent that caused the diabetes would be the chemical that led to rupture of the pancreas cells, but not to the production of antibodies, as the cells of the pancreas have already been damaged. This is an important distinction as, after the discovery of islet-cell antibodies, the current scientific thinking as to the origin of diabetes has centred on its being an autoimmune disorder, causing the body, for some unknown reason, to manufacture antibodies directed against pancreatic beta cells, damaging their ability to produce insulin. This scenario implies that it is the patients constitution (immune function) that is at fault. However, if chemicals and drugs can cause diabetes, there is every likelihood that both IDD and NIDD which in many Western countries today has reached epidemic proportionsare predominantly the result of chemical exposure by way of prescription drugs. Possible zincdrug interaction If its true that drugs, or the chemical byproducts formed in the body following their ingestion, have an affinity
for zinc, then when they enter the bloodstream and pass through the pancreas, they will bind to the zinc in the islet cells of the pancreas. This could displace someif not allof the six insulin molecules that are temporarily bound to zinc in the pancreas. Such an interaction could change the acidity of the cells, causing them to burst as the osmotic pressure within them becomes too great. The result would be irreversible damage to the cells that, in turn, could result in activation of the immune system as it detects a deformed cell, which it would regard as foreign (abnormal in form). This would trigger the formation of antibodies, proteins that are directed against such foreign (non-self) agents within the body, and explain why many newly diagnosed diabetics have isletcell antibodies in their blood. However, if this were the case, these islet-cell antibodies would simply be formed as a result of preexisting damage to the pancreas, but would not be the agents responsible for the destruction of the insulin-producing capacity of the pancreasas is currently thought. If chemicals such as drugs or their byproducts are not responsible for eliciting an immune response that results in the formation of antibodies, the unanswered question then remains: what is it that triggers the immune system to produce these antibodies? On the other hand, if some chemicals are indeed capable of destroying the ability of pancreatic beta cells to secrete insulin, as is known to occur in those who have ingested the rat poison Vacor, then it is conceivable that the damage may be gradual, with just a portion of the pancreas being destroyed with each chemical attack. Also, it would appear to be logical to suppose that children who are exposed as fetuses and newborns to such an agent might become diabetic at a younger age than those exposed to the same agent as babies or children, and may require only one exposure to cause damage if it occurred in utero or soon after birth. For example, if a fetus of 25 weeks has half of its insulin-producing cells
Drugs causing diabetes

One drug that appears to have the potential to cause diabetes is the barbiturate phenobarbitone, due to its similarity in structure to the chemical alloxan. Phenobarbitone and other barbiturates used in human medicine also bear some resemblance to alloxan. Chemical modifications of alloxan have also been shown to cause diabetes in some animal models. So, all of these chemicals, which share structural similarities, can cause diabetes in animals. Nevertheless, Lisa Landymore-Lim is unaware of any investigations into their potential diabetogenic effects in humans. The following drugs could be considered the major potential culprits in causing diabetes: N Antibiotics Penicillins (such as amoxycillin) Cephalosporins (structurally similar to penicillin) Erythromycin N Tranquillizers Barbiturates (structurally similar to alloxan) Benzodiazepines N Other drugs Syntocinon (synthetic hormone, used to induce labour, containing ergometrine) Ergometrine (used to stop postpartum bleeding) Paracetamol (analgesic).
already destroyed during its development, it would be unlikely to present any of the clinical symptoms currently associated with diabetes. However, after birth, the child may be expected to run out of its insulin-producing capability at an earlier age than a baby that is exposed to the same amount of toxic chemical, but after birth. In the latter child, a smaller proportion of the pancreas would be affected as its exposure was later in its development. Damaged pancreatic cells, unlike liver cells, are not replaced as they lack any significant capacity for regrowth. So, as the body weight of both these infants increases after birth, the one with the lower level of insulinproducing capability would be expected to exhibit signs of diabetes sooner, at an earlier age. The drug penicillaminewhich is also one of the breakdown products of penicillinis an effective chelator of metal ions, including zinc, and is used in medicine as chelation therapy for the reduction of toxic levels of zinc salts. Also, although erythromycin was reported some 25 years ago as not binding to zinc, it is now known that it can be made to react in vitro [in the lab] in a one-to-one ratio (Brocades
Pharma [now known as Yamanouchi Europe], a
personal communication).
The probability of binding (chelation) between zinc and organic compoundsthat is, compounds containing carbon, nitrogen and oxygenis high. Such binding usually occurs between the negative-ionrich centres of either the oxygen or nitrogen groups of the chemical and the positively charged zinc (Zn2+) ion. In the case of insulinzinc complexes found naturally in the pancreas, the binding is reversible, as it enables insulin to be stored until required. Whatever the route of destruction of the pancreas ability to secrete insulin, it is worthwhile noting that some of the drugs that diabetic children are exposed to during fetal development are structurally similar to each other. For example, in the survey of diabetic children that I carried out, one child was exposed to Asacol (mesalamine) and another to paracetamol. The structure of Asacol is similar to paraaminophenol, a highly toxic chemical formed in the body in tiny quantities following paracetamol (acetaminophen) breakdown. Whats more, Asacol and penicillamine both have an amine (NH2) and a carboxyl (COOH) group. A drug connection would also
account for another mysterious feature of diabetes: that only the beta cells of the pancreas are destroyed. The alpha and delta cells of the pancreas, also located in the islets of Langerhans where the beta cells are, are not damaged in diabetes. It is only the zinc-containing beta cells that are damaged. This selective destruction may well be caused by chemicals with an affinity for zinc. UK dispensing practices When considering diabetic children in the same family, rather than heredity, the cause may be the family doctor. If the familys physician commonly prescribes antibiotics to babies and children, and if one accepts that antibiotics may be implicated in the onset of diabetes, then it would not be surprising to find more than one diabetic child in the same family. The table shown in the box on page 47 shows the geographical variation in the incidence of diabetes in England among the under-15-year-old age group. East Anglia, a predominantly rural area, has the highest incidence, whereas the four Thames regions, areas of higher population density and pollution, have the lowest. The incidence in East Anglia is more than double that of the North West Thames region. This pattern of a rural area having a higher incidence of diabetes than an urban region is also seen in Scotland. In the UK, doctors are allowed to dispense their own drugs for patients who are living more than a mile away from the closest pharmacy. Consequently, although few GPs in builtup areas dispense their own drugs, in rural areas, the proportion of dispensing practices can be rather high. In one study comparing children living in the Cambridgeshire and Wessex Areas, the health authorities data showed that a high proportion of diabetic children lived in the countryside and not in the towns, despite the presumably higher population density of children in the latter. In other words, if all children were at equal risk of diabetes irrespective of where they lived, the expectation would be to find more diabetic children in the urban areas. Furthermore, it appears that some of the dispensing practices in the countryside were considerably more affluentdespite being supported by fewer GPscompared with those in the outer-London areas. Indeed, some surgeries had recently been purposebuilt, and at considerable cost. It was also noticeable that in some of these practices, antibiotics were apparently being liberally prescribed to babies and children. The small areas looked at were located in area health authorities with a high incidence of diabetes. This raises the question of whether the proportion of dispensing doctors might be related to the incidence of diabetes in children. If drugs such as antibiotics were implicated in any way with the onset of diabetes, and if dispensing doctors prescribed them more liberally perhaps as a result of financial incentives, then it might be reasonable to expect to find a higher incidence of diabetes in country vs city children. The North Western and Mersey regions, which both have a medium incidence of diabetes and yet a low number of dispensing doctors, are both, incidentally, regions with the highest number of prescriptions (excluding those dispensed by prescribing doctors) per person in England for 1981 and for 1990. They are also the regions with the greatest increase in the number of prescriptions per person in England between 1981 and 1990an average increase of 25 per centcompared with around 8.7 per cent for the four Thames regions over the same time period. In addition, the NW Thames area [the Thames region with the lowest incidence of diabetes in under-15s during 1988] was also the region with the lowest number of prescriptions per person in 1981 and in 19905.6 and 5.9, respectively. By way of comparison, the SE Thames area (the Thames region with the highest incidence of diabetes) was the Thames region with the highest number of prescriptions per person for 1981 and 1990 (6.3 and 7.0, respectively). Although these data do not include prescriptions issued by dispensing doctors, the percentage of dispensing doctors in both of these Thames regions is approximately the same. However, the SW Thames region, which has a low percentage of dispensing doctors (6 per cent), but ranked second highest for incidence of diabetes of the four Thames regions (see box, page 47), was reported in 1985 to have the highest rate of induced births in England (23.9 per cent), compared with an average of 17.2 per cent for the other Thames regions (Francome C. Changing Childbirth:
Interventions in Labour in England and Wales. London: Maternity Alliance, 1989).
Since dispensing doctors are more liberal in handing out drugs, then it might be expected that an area with a high proportion of dispensing doctors would also have a high incidence of diseasewhich is indeed the case here. Furthermore, regions with a higher number of prescriptions per person also had a higher incidence of diabetes. The idea that drugs can cause diabetes is not new. What is novel is the suggestion that there are drugs in common use that may be partly responsible for the epidemics currently seen in many industrialized countries today.
Lisa Landymore-Lim Dr Landymore-Lim is a chemist who specializes in immunology.
HRT: the latest cancer risk

Just when it looks as if it couldnt get any worse for HRT, a new study shows that it causes lung cancer
nyone with shares in hormone replacement therapy (HRT) is in the doldrums. HRT was touted as the modern-day equivalent of the fountain of youthuntil 2002, when the US Womens Health Initiative (WHI) study, one of the largest-ever studies of these drugs, discovered that women taking HRT were more likely to have breast cancer, ovarian cancer, stroke and heart disease. And now, new evidence from the WHI data shows that the use of HRT during the menopause increases lung cancer by 60 per cent after five years. Dr Rowan Chlebowski, a medical oncologist at Harbor-UCLA Medical Center in Los Angeles, CA, analyzed the WHI statistics, and found a link between prolonged HRT use and nonsmall cell (NSC) lung cancer. Although most of the adverse publicity after the WHI study focused on the breast cancer risk, this is the first time that a link between HRT and lung cancer has been identified. It also happens that NSC lung cancer is the leading cause of death in women. The most vulnerable women were smokers using HRT, who accounted for slightly more than half of all cases of NSC lung cancer. In the WHI study, the researchers found one extra death from this for every 100 women using Prempro, Wyeths combination oestrogenprogestin HRT drug.
140 extra cases during the eight-year follow-up, accounting for 5 per cent of all cases of the cancer. The risk of having the disease were the same regardless of how long the drug was taken, which formulation was used, how much oestrogen was included in the mix and what sort of delivery method was chosen. As ovarian cancer is difficult to detect and is often fatal, such a risk should not be brushed aside, the Copenhagen researchers noted. HRT to blame Up to now, medicine has tended to blame a familial predispositionthat is, a family history of breast cancer and the presence of certain predisposing geneson many inci-dences of breast cancer, particularly in women using HRT. Nevertheless, the latest trawl through the WHI data shows that HRT shoulders much of the blame. Epidemiologists from the Univer-sity of Rochester Medical Center, in New York, followed-up the more than 16,000 postmenopausal women given either HRT or a placebo during the five-year WHI study, which was abruptly abandoned when the health risks emerged. When they evaluated the 349 women whod developed breast cancer, they could find no link with a family history. The researchers concluded that a family history and hormones have independent and non-interacting effectsin other words, the cases of cancer were most likely entirely caused
by HRT (Epidemiology,
2009; 15 May: doi:
10.1097/EDE. 0b013e3181a71279).
Ovarian cancer risk This announcement, made at the annual meeting of the American Society of Clinical Oncology in May, coincided with the release of the findings from a large-scale, long-term Danish study showing that women who take HRT increase their risk of ovarian cancer by 38 per cent (JAMA, 2009; 302: 298305). The study, which included more than 900,000 women aged 5079, found that the current use of hor-mones accounted for a 38-per-cent greater chance of ovarian cancer. This translates to one extra case every year for every 8300 women using HRT, or
Fewer cases after the facts Following the disclosures of the WHI trial, breast cancer rates fell by 13 per cent among more affluent women in California, but only by 7 per cent in rural areas. When researchers from the Northern California Cancer Center investigated the discrepancy, they found that women in the more rural areas had not heard about the link between HRT and cancer, and so had continued taking the drugswhich would again tend to point the finger at HRT (BMC Med, 2009; in press). After the WHI results were reported, Wyeths products took a hammering, and their use declined by 50 per cent. Nevertheless, sales of the oestrogen-only drug Premarin and various cream formulations still constitute a business totalling up to one billion dollars per year. Last month, the US Food and Drug Administration added a final nail in the HRT coffin with a boxed warning for Prometrium, a progesterone drug, warning of the WHIs results showing increased risks of heart attack, stroke, invasive breast cancer, blood clots and deep vein thrombosis, and a greater risk of dementia, among those taking combined oestrogens and progestogens of any variety.
Lynne McTaggart
The current risks of HRT

According to the US Womens Health Initiative study, hormone therapy increases your chances of developing the following diseases by these percentages: N Coronary heart disease-related events, 29 per cent N Stroke, 41 per cent N Deep vein thrombosis, 200 per cent N Blood clot in lungs, more than 200 per cent N Invasive breast cancer, 24 per cent N All cancers among previous users, 86 per cent N Ovarian cancer, 38 per cent N Lung cancer, 60 per cent.
The big cure-all unmasked

The great all-purpose preventative for cholesterol has been found to cause prostate cancer
tatins, the gold standard of cholesterol treatment, have become the liver tonic of the modern age. Doctors hand them out for everything from osteoporosis to senile dementia, as early studies suggest that they may have preventative effects. When early laboratory evidence showed that statins induce apoptosis (cell death) and reduce prostate cancer cell growth and spreading (Cancer Epidemiol Biomarkers Prev, 2008; 17: 8894 ), medicine concluded that statins were a potent cancer preven-tative (J Natl Cancer Inst, 2006; 98: 181925) . Early studies bolstered this view, offering preliminar y evidence that longterm statin use could prevent cancers of the breast, prostate, blood and colon. Studies of populations with prostate cancer found links between statins and the prevention of more advanced forms of the disease ( Curr Opin Urol, 2008; 18: 3339). Doctors were particularly enthusiastic when a case-control study found a cancer risk reduction of 20 per cent with statins (J Clin Oncol, 2004; 22: 238894). Now, that reputationthat statins are a powerful cancer preventativehas been sullied with the latest findings that statins may actually cause prostate cancer in overweight men. Researchers at the Fred Hutch-inson Cancer Research Center in Seattle, WA, discovered the link while studying more than 1000 cases of prostate cancer, diagnosed between 20022005, compared with a similar number of age-matched controls. Although there was no risk of developing the disease in normalweight statin users, including those who had taken the drugs for more than 10 years, overweight men those with a body mass
index of more than 30 kg/m2 increased their risk by 1.5 times over overweight non-users. Also, the risk increased to 1.8 times with statin use for five or more years (Am J Epidemiol, 2008; 168: 25060). But the Seattle evidence is only the latest to challenge the myth of cancer prevention. A University of Athens review of 19 epidemiological studies found no evidence of a protective effect with statins and even suggested that the earlier evidence of lowered risk was just coincidental (Int J Cancer, 2008; 123: 899904). More detailed analyses found a lower incidence of advanced cancer, but no reduction in the risk of overall prostate cancer ( Curr Opin Urol, 2008; 18: 3339 ). An even larger meta-analysis of 35 randomized controlled trials showed a link between the drug and developing cancer, depending on the patients age: the older the man, the more likely he was to develop cancer (J Clin Oncol, 2006; 24: 480817). Another meta-analysis of pravastatin in elderly patients confirmed an association between the drug and an increased risk of cancer with increasing age (CMAJ, 2007; 176: 64954). As for other forms of cancer, the Department of Pharmacology team at the University of Athens School of Medicine has systematically examined and combined all the
evidence of statin use and cancer incidence. Their review of 14 studies found no evidence to support claims that statin use can protect against malignancies of the blood, such as leukaemia (Br J Clin Pharmacol, 2007; 64: 25562 ). They also found no evidence that statins can significantly reduce the risk of colorectal cancer, although they concluded that there might be some effect with higher doses (J Clin Oncol, 2007; 25: 34628 ). The same methodology also found no evidence that statins can reduce the risk of either pancreatic or breast cancers (Am J Gastroenterol, 2008; 103: 264651; J Clin Oncol, 2005; 23: 860612). Yet another research team, from the Department of Epidemiology and Survellance Research at the Ameri-can Cancer Society, found that neither short- or long-term (five years or more) use of the drug prevented colorectal cancer (J Natl Cancer Inst, 2006; 98: 6972 ). Similarly, a Boston University study of more than 3600 patients in Massachusetts could also find no protective effect other than a lower
Take as little as possible

If you must take a statin drug, take the smallest dose possible. New evidence shows that even the minimum daily dose of 20 mg/day causes potentially fatal muscle pain and weaknessand may even lead to complete breakdown of muscle tissue (N Engl J Med, 2008; 359: 78999). Higher doses or taking the drug with other drugs had a magnifying effect, causing a far higher incidence of myopathy than the official figures claim. The latest evidence shows that as much as 1.6 per cent of patients develop muscle weaknessthats 128,000 patients in the US alone.
risk of stage IV (advanced, metastasizing) cancer among statin users, an association that the authors believe requires confirmation (J Natl Cancer Inst, 2007; 99: 3240). The final blow was dealt by a University of Connecticut School of Pharmacy meta-analyses of nearly
90,000 participants involved in all studies claiming a protective effect against all cancers. Again, the data indicate that no type of cancer is affected by statin use (JAMA, 2006; 295: 7480). Aside from the damning evidence against its role as a cancer preventative, the latest evidence
also shows that statins dont prevent fractures or type 2 diabetes either ( Pharmacoepidemiol Drug Saf, 2007; 16: 62740 ; Curr Med Res Opin, 2008; 24: 135962). This kicks away several platforms on which the drugs reputation as a preventative treatment has been based.
Lynne McTaggart

Dangerous Drugs

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What Big Pharma doesnt want you to know

Part one: Dangerous drugs

Drugs for depression

Drugs for children

31 Life after antibiotics 35 Antibiotics: definitely not kids stuff

OTC drugs: medicines dark side

2 WDDTY Dangerous drugs

Think twice about these OTC drugs

WDDTY Dangerous drugs 3

4 WDDTY Dangerous drugs

The history of OTC drugs

WDDTY Dangerous drugs 5

6 WDDTY Dangerous drugs

The story of aspirin

WDDTY Dangerous drugs 7

Is it truly a heart helper?

8 WDDTY Dangerous drugs

WDDTY Dangerous drugs 9

10 WDDTY Dangerous drugs

Drugs for depression

The great depression myth

Whats the idea? Its generally accepted by doctors

WDDTY Dangerous drugs 11

Drugs for depression

What can cause depression?

12 WDDTY Dangerous drugs

Treating depression without drugs

WDDTY Dangerous drugs 13

Drugs for depression

14 WDDTY Dangerous drugs

The great Prozac conspiracy

Safety and side-effects

WDDTY Dangerous drugs 15

Drugs for depression

16 WDDTY Dangerous drugs

WDDTY Dangerous drugs 17

Drugs for depression

18 WDDTY Dangerous drugs

SSRIs: bad prescribing habits

in that first week (Arch

Signs of SSRI-induced suicidal impulses

Anxiety Agitation Panic attacks Insomnia Irritability Hostility

Aggressiveness Impulsivity Akathisia (psychomotor restlessness) Hypomania Mania.

WDDTY Dangerous drugs 19

Drugs for depression

20 WDDTY Dangerous drugs

SSRIs: Its not addiction, its discontinuation syndrome

WDDTY Dangerous drugs 21

Drugs for depression

The drugs dont work

22 WDDTY Dangerous drugs

Drugs for children

Whos the criminal?

WDDTY Dangerous drugs 23

Drugs for children

The main culprits

24 WDDTY Dangerous drugs

every three ADRs (Pharmacoepidemiol Drug

Non-drug treatments for childhood problems

WDDTY Dangerous drugs 25

Drugs for children

26 WDDTY Dangerous drugs

WDDTY Dangerous drugs 27

Drugs for children