Pharmageddon and Fertility

This post needs reading in conjunction with Has Healthcare Gone Mad and A Medical Triumph.

This image of declining British fertility from 1880 was repeated across the Western world and more recently the whole world.  The usual explanations are in terms of social and economic factors and are typically seen as a good thing. Progressives see women getting more control over the reproductive process, through the availability of contraception, more rights and openings for personal development.  Education is cited as playing a part.

Things get a little trickier around 1980 when fertility rates drop below 2.1 and the native population is no longer replacing itself. Will we have to turn to and tax immigrant workers to support an ageing population?  More generous maternity and child support arrangements and job guarantees have been put in place in France and elsewhere to staunch the hemorrhage. Without much success.

A less commonly heard viewpoint is that the fall in fertility coincides with physical factors like a rise in pollution and more recently endocrine disrupting chemicals.  Falling male sperm counts are pointed to as the canary in the coalmine for folk taking this point of view – social and economic factors seem less likely to cause this.

The important point to note from here is no-one knows what is causing the fertility changes since 1980.

The Has HealthCare Gone Mad post makes the point that up to 1 in 6 of British people are taking antidepressants, mostly serotonin reuptake inhibitors and these cause sexual dysfunction, loss of libido, lowered sperm counts, failed implantation, increased miscarriages, and voluntary terminations. It is at least plausible that these are contributing to the problem.

Britain’s fertility rate has dropped to 1.56 and might be a lot lower in the native population as immigrant and non-Judaeo-Christian faith communities are slower to turn to medicines than the natives.  Within the UK the place with the lowest fertility rate is Scotland – with figures of 1.31 in 2020 and 1.29 in 2019.

Scotland is also the nation with the highest consumption of antidepressants in the UK – one in four of the population are taking them.  Again consumption of antidepressants is more likely in the native population rather than newly arrived groups or among non-Western faith communities.

The UK, along with Portugal, Spain and Sweden rank among the highest consumers of SSRIs. The Portuguese fertility rate currently stands at 1.40.  Sweden is better at 1.66. Spain is the most striking.

Both Spanish and Italian fertility rates are causing concern. Estimates are that by 2050, both countries will have only three-quarters of the population they now have. It looks like the only way to keep the social structure in place is to allow millions (literally millions) of immigrants in but as things stand now both countries are concerned about the effect even current levels of immigration are having on their identity – culture etc. Accepting immigration on a much greater scale seems unimaginable.

At present, these questions are primarily Western European ones – Eastern fertility rates are better. Among Western countries, France has done better than others in holding fertility rates stable. Interestingly, following concerns about SSRIs given to French teenagers, a recent set of reports looked at possible impacts of SSRI antidepressants on sperm counts in rats.  This research going back two decades shows dramatic declines in sperm counts.

There is official huffery and puffery about sperm counts returning to normal but this looks like returns to normal once the rats stop the drugs whereas many humans can’t stop.  We also don’t know if the rat data means a return to normal after stopping several (rat) weeks after starting compared with several (rat) years after starting.  Nor do we know if boys going through puberty on these drugs return to normal.  Nor have the French authorities (HAS and ANSM) addressed the research indicating that rats on SSRIs while pregnant have asexual offspring.

The Spanish and Italian fertility figures are lower even than the 1.34 Japanese rate which is leading to much angst in Japan with projections that by 2040 over one third of the country will be over 80 years old and by mid-century it may have lost a third of its current population.

In January this year, the Prime Minister, Fumio Kishida, warned Japan is on the brink of not being able to function as a society because of its declining birth rate – but immigration is not acceptable nor even migrant workers.  However bad a horror, or at least nervousness, about mass immigration might seem, a turn to mass migrant workers almost feels like a return to slavery.  There is no chance of them becoming one of us, although down through human history people haven’t kept strictly to the sexual rules.

SSRIs came later to Japan – only taking off around 2000 after which their use has increased hugely.  But Japan had and still has an even heavier benzodiazepine consumption than the West and benzodiazepines can also impact fertility, by interfering with embryo implantation, by leading to low birth weight, pre-term births and possibly neonatal deaths. The profile of benzodiazepine effects is very SSRI like, especially with the later more potent benzos which have a profile that points to peripheral neuropathy effects consistent with SSRIs and thalidomide.

Throw in mood stabilizing anticonvulsants like gabapentinoids and valproate/Depakote and the idea these drugs are not contributing to fertility and related problems at least to some extent becomes ‘inconceivable’.

Pharmageddon

Over the Halloween weekend this year, staff in Walgreens and CVS pharmacies went on strike over conditions. Staff numbers have not expanded in line with a growing workload and pharmacists are concerned that the situation is becoming increasingly dangerous.

There are huge dangers in people being on the ten or more drugs many are now on, if they are prescribed correctly, but even more dangers if owing to the pressure of a workload, the pharmacist gets some of those medicines wrong. Between cramped conditions, poor pay, having to give vaccines in addition to dispense a tsunami of prescriptions, pharmacists figure they, and we, are facing Pharmageddon.  Pharmageddon became the brand name for their actions – with US friends drawing it to my attention.

In most recent lectures, I have mentioned our growing polypharmacy and attributed a stalling and now falling life expectancy in part to this. As with many of these things the US leads the way and the outcome is striking.

A recent paper by Jacob Bor and colleagues features this graph, showing US Mortality Rates (the red line) were better than the Western average (the broken black line) through to the mid-1980s.  The graph from 1930 to 1980 is even more striking – no one in their right mind would have wanted to live anywhere but in the US. After the mid-1980s US figures began worsening slowly – like the sand initially seeming to flow slowly through an hourglass – but they are now dramatically worse than the average of other developed countries.

The mid-1980s coincided with a turn to treating risk factors, rather than just diseases, a turn to giving us problems that suited companies, rather than the traditional medical use of company products to help us live the lives we wanted to life. A shift to treating us for multiple risk factors inevitably leads to polypharmacy, a word that appeared on our radars around 2000. It was billed as a problem for older adults, not something the rest of us had to worry about. But polypharmacy has now reached down into the teenage years and is even happening in utero – with women taking an increasing number of medicines in pregnancy and up to 7 vaccines while pregnant.

All sorts of social and economic factors are thrown into the mix to explain these data, from poverty to Covid (Covid is also a favorite explanation as to why women have been less likely to get pregnant), and these may play a part but it seems unbelievably unlikely that polypharmacy is not also playing a significant part.

It’s white, university educated, liberal-leaning, white women, some of them bioethicists, who are leading the way in consuming drugs during pregnancy and their life expectancies are falling also.

We have no problem in figuring that drugs like alcohol and nicotine and street drugs might be killing us. We think its obvious that if you are taking several of them you are more likely to die early than if you are just on one of them  But we are pretty resistant to the idea that our on-prescription sacraments could be having similar effects, and that taking ten or more of them might similarly lead to a premature death. We cannot conceive of the fact that nicotine for instance is likely to be at least as effective as many SSRIs for the conditions SSRIs are given for – and provided it is not smoked it looks like it may also be safer for many, perhaps even most, people.

Its worth making a point here. Street drugs and prescription drugs are chemicals.  What makes one of these chemicals into a medicine is the information that comes with them.  The information that comes with prescription drugs is effectively fraudulent. Lots of folk on the street, testing these things for themselves likely keep each other nearly as safe as our doctors are capable of keeping us.

Substance Abuse

It is a sign of a sophisticated mind, F Scott Fitzgerald said, to be able to hold two contradictory things in mind at the same time and still function.

There is a comfort and simplicity to viewing things in terms of Black and White. Nowhere is this more obvious than when it comes to drugs – street and even dinner table drugs bad, prescriptions drugs good even sacramental – this means they can only benefit and cannot harm. We like to view our problems in terms of social and economic factors, but at the same are much more likely to turn to biological interventions like vaccines or drugs to solve them rather than embrace political or social action.

On October 16, the Canadian Medical Association Journal published a Guideline for the Clinical Management of High Risk Drinking and Alcohol Use Disorder.

On October 16, the British NHS published a Draft Guideline for Alcohol Treatment.

These documents come from different planets.  The Canadians introduce the idea that SSRIs can cause alcohol use disorder and clinicians should be alert to the possibility that this might be happening in the person in front of them, and clinicians should also not use SSRIs to treat alcohol use disorder. This very simple move, based on the latest evidence, stands a chance of eliminating a number of problem alcohol cases, in particular perhaps among the Desperate Housewife class.

In a vastly longer draft document, the Brits don’t mention SSRIs.  They figure one of the important reasons that we have alcohol problems is that its use is stigmatized making it difficult to seek treatment.  Muslims stigmatise its use and have very low rates of alcoholism.

People with alcohol problems can feel shame but not an extraordinary amount. In AA meetings folk are quick to berate anyone who says (correctly) they think their problem is linked to the SSRI they are on. Someone like this, bewildered at an abrupt onset of alcohol use, who has crashed a car and maybe killed someone is much more likely to feel shame and stigma than a lifestyle alcohol use problem.  The draft has not a mention of the need to avoid stigmatising the person for getting it right. The promoted option is a course of CBT, that will likely uncover the trauma that has led to the recent onset alcohol use – even though CBT should not be uncovering trauma.

The divide between the Canadian and British Guidelines – see Medical Triumph for more details – illustrates something that we need to grapple with in the realm of fertility, sexual function, and life expectancy also.  The stakes in terms of fertility and life expectancy could not be higher.

 

Japan, Finland and Canada