BBC Radio Four’s Today program ran a piece on August 2 in response to an NHS report showing a startling 500% rise in prescriptions for antidepressants since the advent of SSRIs and a 9% rise last year. Close to 47m prescriptions were dispensed in the NHS in 2011 for anti-depressants and sleeping pills. There has been a rise year on year for the last two decades.
“Antidepressants work” and “antidepressants save lives”
In response to questioning on Today, Professor Clare Gerada, of the Royal College of General Practitioners, trotted out the standard lines “antidepressants work” and “antidepressants save lives”. Would we be worried if there was a rise in the use of statins or anti-cancer drugs?
The UK twittersphere exploded with tweeters taking sides. When challenged on the issue of antidepressants working Dr. Gerada insisted they do. There were predictable tweets from individuals who stated antidepressants saved my life – although as is often the case with such comments the person will often add that it was only on the fourth or fifth antidepressant that they were helped.
Claims that antidepressants work and save lives are not evidence based
Claims that antidepressants work and antidepressants save lives are not evidence based. There is no question that antidepressants do things and in this sense “work” (RxISK position paper on antidepressants). If the trials had undertaken to demonstrate SSRIs have an acute onset anxiolytic effect this could have been conclusively demonstrated. But the clinical trials that were done were undertaken to see if antidepressants “work” for depression and this has not been shown. They haven’t even been shown to “work” marginally better than placebo, as is often claimed.
What has been shown is that these drugs have “effects” on rating scales that regulators such as FDA can interpret as evidence they “might” work. This is quite different to demonstrating that the drugs get people back to work or save lives. It is indeed a moot point whether the law has been broken in the licensing of antidepressants in that the 1962 FDA statutes state that the agency will approve drugs that have been shown to be effective.
The rating scales moreover have been rating scales completed by doctors where some of the benefits may stem from sedative, anxiolytic or appetite enhancing side effects of antidepressants. On rating scales completed by patients, or scales less sensitive to the side effects of the medication, there is no evidence even for a rating scale benefit.
Pharmaceutical companies will sue
Pharmaceutical companies will quickly sue anyone who says things that the company believes it can prove in court are unsupported or injurious to the reputation of its product, as happened to Prescrire. (See also Welcome to Data Based Medicine). It is against this background that I am saying that antidepressants such as Cymbalta or Pristiq or Zoloft have not been shown in clinical trials to work.
Having made this point, I also have to say that I use antidepressants. They can have clear therapeutic effects. These effects are typically concealed by trials. If used judiciously I hope I can sometimes put such effects to good use. Whether on balance I do more good than harm is something neither I nor any other doctor can know, in the way we can know when we give an antibiotic for a life-threatening infection or a benzodiazepine for catatonia. Appealing to the literature won’t do it, as this is largely marketing copy and the better the marketing copy the more misleading it is likely to be.
More deaths on antidepressants
The second statement that antidepressants save lives has simply got no evidence base. In 2006, the FDA in the USA got all (or most) placebo controlled antidepressant trials from companies (FDA 2006). In 2004, the MHRA in the UK got all (or most) placebo controlled trials for some antidepressants from companies (MHRA 2004). There were large discrepancies between the two datasets. But a common finding was that there were more deaths in the antidepressant arm of these trials compared to the placebo arm.
So what is happening in the case of those who tweet that an “antidepressant saved me”? There are two options. One is that they are wrong. The other is that they are right but there are a slightly greater number of voices who might have tweeted an “antidepressant killed me”. All anyone hears though are the voices saying the pills saved me.
“Antidepressants saved my life” are like the wonderful stories of people whose lives were saved when their religious medal or medal for valor deflected the bullet away from their heart. We never get to hear the stories of those who die when the medal deflects the bullet the wrong way.
It’s the same with those who swear a statin or other medical drug saved them when trials show an excess of deaths on these also. The evidence base comes back to bite us in the case of treatment induced death – Pharmacosis – which has become at least the fourth leading cause of death. Some drug must be responsible for this, but everyone – psychiatrists, cardiologists, primary care doctors and others – look the other way and say “not me”.
Why are prescriptions rising so relentlessly
If antidepressants don’t work very well, why are prescriptions rising so relentlessly? A great part of the rise stems from the fact that an ever greater number of people are stuck on these drugs permanently. There is likely no more people being put on an antidepressant for the first time each year now than there was 10 or 15 years ago, but the total on treatment continues to build because of the people who cannot stop.
Freudian slip
A year ago in the New York Review of Books Marcia Angell wrote a two-part review of recent books including Bob Whitaker’s Mad in America, Irving Kirsch’s The Emperor’s New Drugs, and Daniel Carlat’s Unhinged that, based largely on the issue of do antidepressants work and save lives, asked the question are Americans in the middle of a raging epidemic of mental illness.
A year later organized psychiatry is still fuming. The latest response is from John Krystal, the President of the American College of Neuropsychopharmacology. After the usual arguments which amount to the claim that the evidence is not what it appears to be, that only we guardians of the flame can interpret it, and that the media should stop alarming people, he comes to an extraordinary conclusion:
“By stigmatizing a field progressing toward a scientific foundation and by disparaging treatments that show signs of efficacy, Dr. Angell’s facile criticism of psychiatry could do harm.”
This is astonishing on a few levels? Herbalism and a range of other fields could be characterized as progressing toward a scientific foundation with treatments that show signs of efficacy. Put a sufficiently large number of people in a trial and choose your measures carefully and even snake oil will show efficacy. Dr. Krystal seems to have consigned psychiatry to a lower level in the pecking order than physiotherapy and other paramedical disciplines. Many in other branches of medicine will likely smile wryly.
If psychiatry is only progressing toward a scientific foundation and its treatments only show signs of efficacy, the harm lies in the fact it has sold itself as a fully scientific discipline with treatments that work and save lives. If this isn’t the case, people need to be told.
Our Olympic games are beyond successful, the wonderful triumphs and years of training for our youngsters and our Prime Minister, David Cameron, is opening up a medical research centre for GSK, in the shortly defunct ARENA. He is quoted, this week, as saying this is for PRECISION MEDICINE.
Wouldn’t it be something for the ARENA to be devoted to youngsters, deprived and non-deprived, to get an introduction to sport and attainable goals.
But, no, this wonderful ARENA is to be given up to the likes of GSK who drug babies, children, teenagers and adults, denying them any chance of a fulfilled and wholesome life.
David Cameron is blind to 3 bn for fraud, corruption and death from drugs by our UK success story, GSK.
Is anyone going to tell DC that GSK have killed more than they have saved?
The babies, the children, the teenagers, the adults – doped and duped. The doping centre would be a fine thing, were it not for the duping.
THE ARENA NEEDS TO BE FOR OUR CHILDREN, NOT DRUG INVENTORS, SPOILING AND DEFILING OUR LIVES, BY INVENTING MANIFESTATIONS OF MENTAL ILLNESS, WHICH THEN LEADS TO BILLIONS, FOR CURING US.
This hypocracy of medicalised myth has to be stopped before any more suicides/atrocities/murders/baby defects occur.
David, I would urge you not to give out medication which you know, can occasionally urge the patient to suicidality. You have been lucky thus far, but it only takes one and I know that to my cost. For you to give this medication, knowing what you do is what I find incredibly baffling.
David, I just wonder how you equate what you prescribe with what you have seen and promote.
The prescriber is part of the circle of death, surely.
Annie
SSRIs are not the only type of antidepressant. Many of the ones that have been around for over 80 or so years are very effective and act very quickly in patients who really are seriously, clinically depressed. Psychiatrists today, and not only those recently trained, have forgotten about them and have bought into the PR of Big Pharma. I believe that, without the SSRIs, most would have no idea of what to do. I’ve also come to the conclusion that few psychiatrists, GPs, paediatricians would know a depressed patient if he asked for a gun to shoot himself. They seem to confuse grief, sadness, anxiety, fatigue, sleeplessness and the depressive aspects of physical illnesses such as mononucleosis and lupus with real, clinical depression. Of course, if all you use is a rating scale as a substitute for actual diagnosis, then a majority who get the same score will be identified as depressed when they are not. It’s very much like the mental acuity scales that are widely used to “diagnose” cognitive impairment. All they can tell is that there is something wrong but never what that something actually is.
Seems Dr Krystal has a lot to protect according to the declaration of conflicts of interest cited in Mickey’s comment on his own blog (from Stan’s earlier comment). http://1boringoldman.com/index.php/2012/08/05/poltergeists-make-up-the-principal-type-of-spontaneous-material-manifestation/
Let’s tell people: Your children are being screened and weeded out from pre-school to become lab rats for psychiatrist’s who currently have no clue as to how the brain regulates or effects mental states, mood and behavior. Lacking in knowledge about the normal developing brain, these psychiatrists prescribe toxic drugs that change the brain quantitatively and qualitatively , or rather, impair and or damage the normal functioning of neurotransmitter pathways. Signs and symptoms of adverse drug reactions are *diagnosed970 ngslick* as either new brain disorders, or more severe symptoms of the original diagnosis. Academic medical center leaders, federal regulatory agencies and frontline mental health professionals in collusion with public school teachers are gung ho about this experiment. It is obscenely profitable. So PEOPLE– good luck! You’re on your own!
They work on the real clinically depressed. Is that the answer I am looking for?
Why is that, Irene.
Placebo or do they really change the chemical imbalance in really clinically depressed persons.
If I attempt a hanging, blades and an overdose after eight weeks off Seroxat and, boy, have I tried to get my head around it, and all these people, and all professional psychiatrists and gps, are telling me that I have problems when the problem was the ill-advised drug, then I have serious problems taking that in.
What was missed here was that I know, and they do not know, and my knowing and their not knowing, gives me the edge on anything remotely accusatory about my character. I may be small fry in the current scheme of things, but I know a drug induced near loss of life like no other, because I am still here.
Nothing can remotely touch on that.
The nonsense that they all talked when I was picked over, spat out and left to my own devices. Yes, you are on your own after all that.
Or are you?
Annie – we don’t know what is wrong in depression and so cannot say antidepressants correct it. In more severely ill cases you can show a better improvement on rating scale scores than for less severely depressed patients. But this is not the same thing as demonstrating the drugs work. At the end of the day though it does support a clinical judgement in severely ill people that the pills have likely made the difference when a doctor sees an almost mute or stuporous patient get out of bed and start to interact. When a doctor sees what they think is an improvement in a less severely ill person they are more likely to be seeing a placebo effect.
So who or what is responsible for the suicide of a beautiful, loving 20yr old daughter?
Was it herself and her “depression”?
Was it both her and my belief that our GP could “do no harm”
Was it medication from the age of 17 to 20?
Was 3 years too long?
Was it absolutely no conferral with me her mother, so I was absolutely no help and totally unaware that there were even dangerous side effects to the medication?
Was it the assurance by our GP that this particular medication was completely safe?
Was it ill an advised withdrawl method – 20mg cipramil one day 10mg the next for a month, then 10mg every other day, followed by 10mg every 3rd day, 4th day etc. She had only completed this procedure about 2/3 weeks before returning to GP and being given a new prescription for 20mg. Again I was assured it was safe – as she had been on it before. She and I were also informed that she had clinical depression and could be like this for the rest of her life. Next day my daughter took 1 of her 20mg tabs. She was by herself at home. I found her hanging when I returned from work.
So was restarting medication to blame?
Was it the life sentence of “clinical depression”
Was it the drug company who withheld important information from our GP?
Could the drug company have mistakenly overestimated the effectiveness of their product?
Was the medication missold as a cure for something unproven?
Is it a “one size fits all” problem?
Is profit somehow involved?
If I misread road conditions and ended up killing someone I would be held responsible.
Why is my daughter’s death so different – a statistic where only she is guilty?
Chris, I am so sorry, for the loss of your child. We will all be shocked and horrified that you have had to face this tragedy not knowing whether it was the drug or this awful phrase ‘clinical depression.’
I really don’t know what this means. Luckily for me I was never given this strange label.
But, you bringing this to David’s attention will, I hope, bring some comfort, because every time this comes up, a lot of creadance and justification is available from David’s blog.
You must be gutted and I know exactly how you feel and so do thousands of others, but I know that won’t bring your daughter back; take comfort that this was not your fault in any way whatsoever.
We will all do our best to get some sort of respite for you, because as we all say, this Russian Roulette is getting a bit out of hand now.
Great article David,
As a former long term SSRI user, it frustrates me when I head those kinds of statements , “Anti-depressants work” and “Anti-depressants Save lives”. Of course they ‘work’, alcohol also works, as does cocaine and nicotine. A lot of things ‘work’, but that doesn’t mean that the are good for us… Do anti-depressants ‘save lives’? , perhaps in some cases patients believe that they do, but I know from experience, that they can very much ‘destroy lives’ also. But, as you pointed out, what way do they work?, how do they work?
Personally, I think it’s quite subjective. In the sense that, when an individual is depressed or anxious, all they want is for those intolerable feelings to be alleviated. Therefore, there is a hell of a lot of ‘hope’ and ‘faith’ involved when a patient is prescribed an anti-depressant. They want to believe that the drug works and the doctor tells them that the drug works, so before they even know the effect, there is presumption that the effect will help alleviate their negative feelings. I believe Peter Breggin calls this the ‘spellbinding’ effect…
The problem is: these drugs anesthetize rather than cure. So, do they work? Yes, they work by anesthetizing feelings, emotions and thoughts, even physically they dope you up. They make you sleepy, unresponsive, generally lacking in the ability to care whether you are depressed or not… the anesthetic for the mind is quite seductive, quite a comfortable place to dwell…Not exactly bliss but not far off a ‘nothingness’… much better than depression or anxiety surely? Yes, and no… or maybe just for a short while…
Because, all the while, the longer you are on them, as the SSRI works on fiddling with dopamine and serotonin receptors in the brain, giving you that illusion that everything is fine in dopey land, the rest of your body doesn’t really like having this foreign chemical ingested every day, your organs aren’t too keen on this chemical invasion…
So after a few months, or perhaps a year- in dopey land, your stomach begins to get irritated from the chemicals, you’re rushing to the loo quite often, and sometimes you don’t make it… You’re having very strange dreams, some of them so vivid and real that you jump out of your skin with fright… as dopey land begins to merge with sleepy land and all that serotonin and dopamine soup starts to overload and spill into other parts of your brain…. Your muscles begin to jerk and spasm, you get strange twitches and rashes… and your liver just simply cannot handle this foreign chemical… life becomes a little bit like a cross between ‘shameless’ and ‘twin peaks’…
Your body tries to reject the SSRI… sometimes at the most embarrassing moments… like when you’re in work, and suddenly you break out in a sweat all over your body, or when you’re on a date, and suddenly it’s like you’ve been caught in a down-pour, so you rush to the bathroom and try to dry yourself under a hand-dryer… ignoring the weird looks of the people who happen to see a grown man trying to stand-full body under a hand dryer… ignoring the fact that you are dependent on a chemical to function, or at least to imagine you are functioning…
I am not, nor was I ever anti-SSRI, but.. I am anti-long-term SSRI use… I believe these drugs can perhaps ‘help’ some people in the very short term… people that are crippled by anxiety or depression maybe need a little anesthetic for their mind, maybe dopey-land is a better place for them to be than gloomy-land but if they don’t deal with the underlying root causes of what got them there in the first place, then the SSRI’s will be pretty pointless…
Anyhow, I’m rambling…
Good night..
TM, rambling or not, you are pretty spot on with your description of what it’s like to be on an ssri.
R, said recently, she felt that after coming off the ssri even after seven years was like coming out of a coma. That was spot on too, because, every so often I get amazing clarity which lasts for a while, but then disappears again and this after ten years off Seroxat.
It’s only when you get the clarity you realise that something vital has been missing for a very, very long time.
Long term damage needs to be investigated.
It is hoped, beyond hope, that this isn’t a permanent problem because living with brain/neurotransmitter/nervous system damage isn’t a thought to be welcomed from ssris.
The other important thing here is the memory loss. I was so shocked and traumatised that all my delightful memories were wiped out and thank god I have the photos, that life was enjoyable and emotions were present at that time before Seroxat entered my life.
Trying to keep a handle on what is normal and what are drug effects is the most difficult thing that can ever be overcome.
A mental challenge; not helped, assisted, or even acknowledged, makes is so, so hard.
This one of the most hellish and mind-bending states of mind that could ever be overcome.
Let’s give ourselves a bit of credit for working through this mental torturous journey where an ssri has led us and maybe, just maybe, find a big enough voice to put the likes of GSK and others in the spotlight where chemicals messing with the mind are outlawed because they basically screw with our minds.
“But a common finding was that there were more deaths in the antidepressant arm of these trials compared to the placebo arm.”
David, I could not find this statement, or data supporting it in either the FDA or the MHRA docs. From page 21 of the FDA doc:
“Table 10 shows estimates of suicidality risk (ideation, preparatory acts, attempts and completed suicide) associated with assignment to antidepressant drug treatment compared to placebo observed from the entire dataset. All of the estimates show a slightly lower risk with antidepressant drug treatment that is not statistically significant. ”
The table provides a point estimate of relative risk = 0.85 for pts on AD compared to those treated with placebo. Subgroup analysis found elevated risk among those under 25 years of age, with a likely protective effect in older patients. This was summarized in the study conclusions:
“Regardless of the exact mechanism, the observations contained in this review support the idea that antidepressant drugs can have two separate effects, one that promotes suicidality or suicidal behavior and one that prevents it. A simpler explanation that denies a preventative effect and assumes only a promoting effect does not explain the protective effect seen in older subjects. The
relative susceptibility to these two effects varies with age. In older subjects the preventative effect tends to predominate while in younger subjects the opposite is true.”
The MHRA study draws a less positive conclusion, but not one that supports the blanket statements that are found in your post. For adults:
“From the available clinical trial data, both published and unpublished, a modest
increase in the risk of suicidal thoughts and self-harm for SSRIs compared with
placebo cannot be ruled out.”
For Children:
” The balance of risks and benefits for the treatment of depressive illness in under-18s is judged to be unfavourable for paroxetine (Seroxat), venlafaxine (Efexor), sertraline (Lustral), citalopram (Cipramil), escitalopram (Cipralex) and mirtazapine (Zispin). .. Overall, the balance of risks and benefits for fluoxetine in the treatment of depressive illness in under-18s is judged to be favourable.”
Its good to hear alternate points of view, but I think you have significantly mis-stated the content of these documents, especially that from FDA.
John
The statement had to with deaths. Ideation is something of a red herring that may have been introduced to conceal the problem. See my article from the Canadian Journal of Psychiatry.
There is an error in this – the FDA data should show 8 (not 11) suicides in 58,261 patients on antidepressants versus 2 suicides in 32,685 patients on placebo. The MHRA data shows 17 suicides in 32,267 patients on antidepressants versus 4 suicides in 19,955 patients on placebo. I have checked with FDA re other deaths and there was no compensatory increase in non-suicide deaths on placebo, so the statement more deaths on antidepressants holds.
FDA also appear to be operating on an odd database. Two years later Pfizer produced figures quite at odds with what they gave to FDA that raised the number of suicides on antidepressants further – this is in an earlier post Where were the adults.
But also FDA have excluded all withdrawal linked suicides. These suicides may account for the higher rate of suicides in the MHRA data.
There is also a higher rate of suicidal acts in both datasets.
I have simply stated what the data in both reports shows. For a number of reasons the regulators may wish to put a different spin on the data
John
We will have to disagree then. In my opinion, regulators introduced ideation because this is poorly ascertained in trials and they could know that it was likely to swamp the signal from acts. Its the acts, including suicide, that have been statistically significant and led to the warning. But these acts show not that these drugs cause suicidal acts but that they cause more suicidal acts than they prevent.
There a number of ways to game the data and hide the problem and I think many of these ways have been employed. One of these appears to be the red herring of age. The relative risk in 18-25 year olds is the same as in 45-64 year olds. Something odd happens in FDA’s elderly data that they have refused to share with the rest of us. The Pfizer dataset suggests the elderly are at more risk than any other age group.
In real life a fourth option is that I am being treated by a doctor and its likely this doctor does not accept the risks and because neither I nor my family are warned properly lives are lost that should not be lost.
Thank you for posting my comment and for your thoughtful response.
Your point about suicides vs suicidal ideation is a fair one, though I suspect both agencies may have been reaching for a broader variable that would increase the statistical power of their study. For example, I get p = 0.12 for the MHRA data you quoted and p = 0.48 for the FDA numbers. (I’d be interested to know how many of these deaths were among patients under age 25, for which the risk is widely acknowledged, and in the US at least, included on the product labeling.)
So, bearing in mind the potential of people to exaggerate the benefits of a product that they feel has helped them, I would add a third possiblity to your statement
‘So what is happening in the case of those who tweet that an “antidepressant saved me”? There are two options. One is that they are wrong. The other is that they are right but there are a slightly greater number of voices who might have tweeted an “antidepressant killed me”.’
That third possibility (in my opinion, a certainty) is that the sample size in both the FDA and MHRA datasets is too small to support any conclusions about the relative suicide rate among patients treated with antidepressants relative to similar patients not so treated.
The doctor does not even want to know the evolution of our quests.
If I spend ten years doing my research and reading everything there is about anti-depressants and coming to reasonable and obvious conclusions, why is it that the average gp/psychiatrist does not do this?
Did they do all their studying qualifying for their jobs and then decide that it was far too difficult to take on board that their prescription pads were actually the causation of immense harm and wrongdoing.
Sometimes, words fail me that as ‘the patient’ I was the one doing the research and these people are not worth even discussing any problems with.
Never again, will I even think about discussing anything remotely private or personal and allow these people to advise me, with copious amounts of drugs, because they are so ignorant and will remain so all their lives.
They live in a bubble and don’t deserve their place in society as doers of good if they can’t even spend five minutes researching the drugs they are prescribing.
The average gp/psychiatrist has no idea that court cases are going on, that their drugs are woefully lacking credibility and that they are the causing extreme harm to us.
A simple example happened to me this week. I have high blood pressure, probably due to my horrific withdrawal from Seroxat. Not one to ever visit a doctor, after all that, I had to, and I said I didn’t want to take any pills with side effects.
The new German doctor said, ‘there is not a drug out there without side effects’.
I told him that I had chronic fatigue and tinnitus.
He gave me Amlopidine. The common side effects are sleepiness, tiredness, dizziness, palpitations, difficulty sleeping, mood changes, ringing in the ears, shaking, weakness, etc. etc. etc.
This guy had not read the leaflet, and so my fatigue is worse, my tinnitus is worse just to get my blood pressure down.
You cannot win, it seems.
With regard to your criticism of symptom rating scales as clinical trial endpoints, what are your thoughts on what would be a feasible, clinically meaningful endpoint?
John – we have a few options. One is to demonstrate an anxiolytic effect to SSRIs for instance. Using rating scales we could show dramatic and rapid onset effects v placebo. The use of these drugs would then be down to clinical discretion but would leave all of us with the problem that we have to data proving the drugs work reliably in particular syndromes. But lets say we have a get back to work criterion and in short terms trials the drugs did manage to beat placebo, we then have a snag which is given over the longer run do we really have evidence that the drugs have produced the kind of benefit an antibiotic does? When it comes to giving a tricyclic antidepressants in melancholia (dexamethasone non-suppression cases), I feel more confident that the drug is likely to have produced the apparent improvement I’m seeing. There are also a number of trials in which TCAs beat SSRIs but none the other way around and SSRIs are ineffective in dexamethasone non-suppression cases. So with SSRIs I am confident when patients say they have a chill out effect on this pill, which they can say whether or not the pill has helped, that the pill is causing it. When a patient with a depressive syndrome improves I am less confident we can attribute that to the pill, especially if the patient cannot also describe a beneficial anxiolytic effect. But I think we have little option but to accept that we cannot demonstrate a convincing basis for what we are doing, that we may be doing more hamr than good with SSRIs and as such should limit the use of these drugs to cases where the patient stands to benefit and is fully informed of all the hazards
I guess it kind of depends on what one is trying to accomplish. We’ve taken a cluster of 100% subjective symptoms and called it a disease. If the disease is defined by the subjective symptoms, and the subjective symptoms are the main thing the patient seeks relief from, wouldn’t objective endpoints such as “returning to work” be less relevant than the patient’s self assessment of symptom relief?
To a certain extent, I’m starting to see Thomas Szasz’s point here. Maybe the medical model is a tough fit and all we can do is respect the internal experience of the patient.
Realizing that you probably consider the entire crew too corrupt to be worth dealing with, I think you should show up for NCDEU next year. Your perspective is an interesting one and it would shake the place up a bit.
John – the medical model works quite well with melancholia. We even have a decent biological marker for it. It doesn’t work for distress and unhappiness. I definitely don’t think the entire crew are too corrupt to deal with – its not possible to make changes without bringing people along with the argument. My concern is that medics in helping companies hype efficacy and deny hazards are committing professional suicide – see earlier posts – in our own self-interest we need to make it clear that these medications need skill to administer.
Thank you David, I think I understand your point of view a little better now.