A psychiatrist thinks some patients are better off without antipsychotic drugs
washingtonpost.com
washingtonpost.com
And yes, that's a dilemma.
i had a psychotic break last year, really bad. i was put on intensive medications, which made it easier to fit into normal every day interaction, but also made me tired, depressed and, ultimately, more psychotic. all of the times i've experienced psychosis, it's been a defensive mechanism that my mind uses to explain why i'm feeling so shitty - so taking medicine that is exhausting, makes me gain weight and have trouble focusing just made the problem worse.
the meds stopped the immediately frighting and bizzare imagines my mind presented to me, but they didn't go away - they just changed into longer term, ultimately more frighting images that still scared me, but in a way that was more conducive to my behaving in a way that everybody else expected. i would believe i was trapped inside something like the matrix, where everything i did on the inside had intense consequences for people outside my reality; failing to wash my hands after using the restroom would cause millions to die far away. one of the 'rules' the psychosis imposed on me was that i could never talk about what i was struggling with because that would break the matrix and cause even worse problems.
it's pretty easy to see in retrospect that it was entirely metaphorical; the 'matrix' stands for the world of social convention, and small risks that add up over time (i.e. not washing hands or brushing teeth) were presented as catastrophic nightmares in order to make sure i focused on resolving them.
over the course of the past year i've slowly reduced the usage of these psychotropic medications - with approval from my psychiatrist - and with increased amounts of energy and happiness, i no longer have as much of the psychosis.
the issue i can see with all of this is that treatment for mental health issues requires love, patience and careful attention from a lot of people over a long time; if you ask me, our society does not want to give that to people for fear of being taken advantage by some unscrupulous people who would feign mental illness to get out of work.
i don't know what a solution would be, but i agree with you - these meds do more to help everybody else than the patients themselves.
I would not condemn anti-psychotic medication just because
1. we do not understand the brain and thus are not able to design more sophisticated methods to treat this terrible decease
2. many patients suffer from terrible side effects.
Thanks to some new generation anti-psychotic drugs (e.g. Risperidol, Abilify, etc) many a person who has the misfortune to suffer from psychosis can return to their daily live - and by this I mean that the person can do more then just 'function'. Of course, his ability to do so depends on the severity of psychosis and dosis of medication. I know a person who learned to live with his psychosis and has greatly improved his quality of life in the recent two years.. to such a degree that he may complete his (ambitious) studies and get a job. Medication was one of the key factors for his well being, other were a long series of psychologic treatments and support from his surrounding.
It also true that in societies where the access to anti-psychotic drugs is restricted (e.g. lack of a pharmaceutical industry) a completely different development of the person is observed, not necessarily in a negative way. However, the nature of psychosis is deeply connected with genetic (hard) and enviromental (soft) factors, such as family, society, experience as a child, etc - so no actual comparison can be made between those patient groups.
Right now, there is no solution to this phenomenon of brain disfunction, and research has a long way to go to understand the structural changes in the brain of psychotic persons during their beginning adolescence and possible treatment.
At the end, stigmatization of psychosis should be avoided, as should be any general magic recipe - every patient is a single case who deserves the best treatment and support from his family and friends.
Allow me to disagree.
We do not need to understand how the brain works in order to be able to find treatments for all the different mental deceases.
Its all trials and errors, hypothesis -> testing -> result, again and again and again until a final conclusion!
I have spend a lot of years researching the brain, the black box which everyone wants to understand but no-one has any clue about it and more specifically Alzheimer's disease (not in a pharmaceutical company but in academia).
From my experience, we don't need to understand how something works if we know what is the most likely outcome for a given input.
I was lucky enough to test different types of drugs, their long term and short term effects, how useful they are and of course what effects have in behaviour etc. From every single study I could put a piece of puzzle right there and be able to see a clearer picture of what's going on, make hypothesis, tests hypotheses, have controls, tests controls etc. I obviously have no clue how the brain works but for those things I checked I know:
Given an input -> Brain -> I get an particular output most likely*
From that (and of course many control studies), I could trust that this drugs will most likely give me the predicted output. And that's how research is done..Is not always correct but based on that, we managed to be where we are, to have drugs for diseases which in the past killed us and step by step we can move forward and it would be wrong to doubt how much improvement has been done so far by the research community.
I am not suggesting you to trust anti-psychotic, just suggesting you that in my personal opinion, is wrong not trusting a drug (which you of course are well aware for advantages/ disadvantages) just because you don't know how brain works...Many other drugs which are for simple diseases actually affect your brain in many similar ways as anti-psychotics.
of course you are right: we do possess very advanced tools, starting from the actual design of drugs that target certain receptors selectively, medical trials, production and quality control. What I meant by "we do not understand the brain and thus are not able to design more sophisticated methods to treat this terrible decease" was the fact that most of the time, we are treating symptoms, for we are not sure what the actual causes are.
It is great what we can do, but (IMHO) pharmaconeurology still has a long way to go.
The actual process of choosing a drug for a patient is somewhat black voodoo magic: If A does not work/has bad side effects, B is prescibed, etc.
And of course, due to the nature of our organism, it is impossible (?) that a pharaceulogically active compound has just one system effect/side effect e.g "Aspirin".
--
On a side note: could you PM me in which field you are active as an entrepreneur? My email is in my account description.
Cheers!
That's exactly that—a layman's impression. Realistically this is very complex to evaluate. Personally, when I took my antipsychotic, I thought clearer. I stopped because there were physical side effects, but I still miss it.
As always, exercise caution when adopting new medication, and evaluate early and often whether it helps you address your needs.
However, I can't think of anything more harmful than denying patients medication that actually might help them. People have strong feelings about psychiatric drugs, and even more so when it's hard to quantifiably evaluate the beneficial effects. Add in that depression and anxiety have a practically infinite number of causes. The result is that it's very difficult to evaluate medications for a given patient without trying it, and there are a large number of failures before finding good medication.
It's incredibly frustrating seeing people who acknowledge they have no specialized knowledge in a field make sweeping statements about it, encouraging psuedo-scientific beliefs about psychiatry (which is, make no mistake about it, more of an 'art' than a science, but so was the beginning of many now-scientific fields). Nobody tries to tell a cancer patient how to treat their cancer, yet so many people feel obliged to opine about mental illness.
What this article is discussing is the (unquantified) subset of people who experience serious side-effects from anti-psychotics. The key takeaway from the article:
> “For some people, remaining on medication long-term might impede a full return to wellness,” Insel wrote. “For others, discontinuing medication can be disastrous.”
> The problem is that we do not know who is in which group.
> Some people can learn to talk themselves down from delusional thoughts. And some people might choose hearing voices over being 30 pounds overweight and tired all of the time. The point is that this is not a choice I should be making for my patients; it is a choice I need to make with them.
Of course, if somebody is having a psychotic break or mentally unstable, you can't even begin to have that conversation about their available options because they will be unable to focus or make rational choices. You pretty much need to start with the medication, then work from there to figure out which group they're in, and adapt their treatment accordingly (i.e. stick with meds or drop them but help them learn how to manage it).
I found the article to be a long-winded way of saying "psychiatrists ought to seriously consider dose reduction in their treatment regime", which is something that I doubt anybody would argue against. The devil is in the details (for some people, dose reductions can be incredibly dangerous), and the article does not delve into what a sensible strategy would look like.
Oh I wish that was true. My gf had cancer and every crackpot we knew was advising on nonsense causes and treatments.
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Antitumor activity
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Stimulating appetite
Many animal studies have shown that delta-9-THC and other cannabinoids stimulate appetite and can increase food intake.
Pain relief
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So it's not like the marijuana people are entirely making it up - cannabis definitely helps with pain relief and appetite (serious issues during cancer treatment), and may help with treating cancer directly.
[0] http://www.cancer.gov/cancertopics/pdq/cam/cannabis/patient/...
Sorry to make light of this.
This back-pedaling is where you begin to lose steam.
> Nobody tries to tell a cancer patient how to treat their cancer, yet so many people feel obliged to opine about mental illness.
Including the psychiatrists who admit to 'more art than science.'
>You pretty much need to start with the medication, then work from there to figure out which group they're in, and adapt their treatment accordingly (i.e. stick with meds or drop them but help them learn how to manage it).
Sounds essentially like just guessing.
Now let's look at your first statement.
>While I'm sure you mean no harm, you are - quite simply - wrong.
While I'm sure psychiatrists mean no harm, that doesn't mean they're right.
Even though I am a strong advocate of individual liberty, and I think that except in the most extreme cases people should have the right to choose their treatment, a cursory browsing of wikipedia suggests that there is strong evidence for the effectiveness of antipsyichotic medication.
As far as I know, almost all people taking medications for serious mental illness suffer serious side effects from them, that's just a fact. I am not trying to convince anyone to stop taking medication, some people might really be even worse off without them, I am just saying that it is a very difficult decision for a good doctor whether to put someone on psychiatric drugs or not, and whether to keep somebody on them. I speak from my personal observations of close family and friends who had mental health issues and were put on drugs, and from reading summaries of current research e.g.:
http://en.wikipedia.org/wiki/Antipsychotic
Antipsychotics are associated with a range of side effects. It is well-recognized that many people stop taking them (around two-thirds even in controlled drug trials) due in part to adverse effects.
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In people with schizophrenia less than half (41%) showed any therapeutic response to an atypical antipsychotic, compared to 24% on placebo, there is a decline in treatment response over time, and potentially a biases in the literature in favor of these medication.
...
If you have another opinion, I would love to hear where does it come from, do you have any kind of evidence that would counter what I said?
EVERY drug can cause side effects. and it seems that drugs meant for treating severe conditions, also have the most severe side effects. e.g. take a look at cancer medication. these meds are for a very serious condition, and simultaneously come with some of the worst side effects i know of. but the thing is, they can help. they can save lives. the same is true for psychiatric medication. psychiatric conditions often show drastic mortality rates (25%-50% of people diagnosed with bipolar disorder attempt suicide at least once, with of course many succeeding[1]). and there are plenty of other such disorders with very high mortality rates.
In people with schizophrenia less than half (41%) showed any therapeutic response to an atypical antipsychotic, compared to 24% on placebo..
numbers like these may seem low, but looked at alongside the mortality rates of many psychiatric disorders, these numbers can save A LOT of lives.
He isn't "quite simply wrong", by your own point. It could just as easily be the case that the severely mentally ill only couldn't live because of their interactions with "non-ill" people as it could be the case that severely mentally ill people would up and off themselves en masse by virtue of their 'illness' alone. The only life a severe schizophrenic can't live (for example) is one in a society which demands non-schizophrenic behavior, else death/shunning/exile/whatever. I here note that in order to determine that someone is mentally "ill", a defining criteria for diagnosis is being diagnosed by someone confirmed to be not ill.
The brain is something of a black box, and it is extraordinarily complex. We have a complex understanding of it - which isn't enough to understand it fully, but it's better than 'very basic'. The characterisation of our understanding as being so simple doesn't do either the brain or the researchers any justice at all, and makes us lean towards it 'being okay' to be helpless in the face of its complexity. It is, without a doubt, the most complex field in the human experience by far.
all the treatment often seems to do is to alleviate the most visible of the external symptoms, causing several new problems in the process, or simply making the patient apathetic
Some patients generally do okay with medication, others have transient episodes during which the medication helps throughout. Not every patient is on a rollercoaster to hell. If the argument "well, you can't save everyone, so don't try anything" really had any merit, there wouldn't be any Emergency Departments in hospitals.
The state has offered antipsychotics so that he can be put to death. His attorney and he have naturally refused the treatment.
His case was discussed by the authors of "Murder at the Supreme Court" on CSPAN, but I'm not sure offhand the name of the case or where it took place. I think they might have said he now gets a whole wing of Joliet to himself, not sure exactly.
So yes, at least one guy out there is better off without the drugs.
I don't know the specifics of this case, but given just those facts he could still very well be found to have been insane.
i am not sure what the answer is. i wonder if casting a much broader net, and collecting much more data, would help. maybe every patient should be tracked in some huge database that can then be trawled for correlations? but then the privacy (and insurance) implications are worrying - for me, it would not be such a hard choice, but others with more to lose would understandably object.
in some ways medicine has advanced hugely (for ~50% of sufferers, ms is no longer a big problem, which is awesome). yet there are sudden borders, and when you cross them, you are in the unknown...
Somehow, this has shown to be a cure, but the doctors that came up with it don't yet know why - the treatment is ahead of the knowledge in this case.
Edit: Here's the story I read: http://www.ottawacitizen.com/health/Ottawa+doctors+behind+br...
[didn't want to hijack the thread; posted initially because i think articles like this can lead to attacks on doctors, when often they are aware of the possibility that they are wrong, and are simply doing the best they can with limited data]
Now think about children, where there's strong social influences, and where they might not have had symptoms for very long, and where few meds are licenced for use and it's quite scary.
The sedating nature of them (at least the ones I have personal experience of) is huge.
The side effect I find most interesting is the often mooted suggestion of weight gain. It hit me very hard in the first six months but was more a matter of retraining my mind to ignore hunger pangs for endless sugar filled snacks at 11pm.
Anti-psychotic medication has a range of really unpleasant side effects. Weight gain is one. It's not just that the illness makes it hard to exercise and eat right, or that the meds are sedating. There's a weird mechanism on top of that which increases weight sometimes dramatically. This has all the other problems of weight (social stigma, ill health, cost, etc etc.)
Anti psychotics are not just prescribed for people with a psychotic illness either. Sometimes they're used for people with personality disorder (often against best current practice guidance) or similar.
See the example of the anti-epileptic drug, given a tweak and re-released as a mood stabiliser. This drug was later found to increase risk of PCOS. Thus, a bunch of women given a med against BCP guidance (because it probably wasn't that useful for them) had all the side effects of that med, and little benefit from it, and were then told that they were at higher risk of Poly Cystic Ovarian Syndrome. You don't have to hear too many stories from people on meds like that before you wonder just what this handful of drugs you've been given are.
In the past many people were sedated beyond the point of useful life, because we had asylums to keep these people warehoused for many years. Obviously that's bad. But now we (at least, the UK) don't really have decent enough community support, or better meds, and in-patient stays are rightfully kept for people who are a risk to themselves or others.
There is great work happening with FEP - first episode of psychosis. Early intervention can make a significant difference.
And we've stopped saying that psychosis is invented by the family of the relative too.
That said, they are nasty, nasty meds. And they are being used more frequently for pretty much anything. Abilify sells itself for treating depression. Seroquel for bipolar.
Downsides of them?
Can stunt you mentally, causing lack of concentration and motivation
Sedation
Potential for huge weight gain
Increased risk of diabetes
Reduced lifespan in general
Possible permanent movement disorder
Akathisa, or horrible anxiety is possible
and more.
She says it's hard to explain to people that for her, the side-effects are better than the alternative. People understand weight gain and don't like it. But they don't understand psychotic episodes.
This could be one incremental angle to push on, which could reduce the harm from over-prescription without requiring a radical overturning of approaches to mental health. There are a number of cases where drugs are prescribed despite any decent evidence that they actually improve outcomes in those cases, and those really should not be happening.
Part of it is that, at least in the US, there is an odd step function in drug approval. A drug has to be shown both safe and effective for treating some illness to be approved. In this approval process, things like placebo effects are controlled for, representative groups are sought, etc. If a drug isn't approved for any uses yet, it cannot be sold. But once it's approved as effective for any illness, it suddenly becomes legal to prescribe for anything at all, even "off-label" uses unrelated to the approved indications and regardless of any evidence of effectiveness for those alternative uses. Physicians tend to develop idiosyncratic ideas about how they think drugs work in these alternative cases, because they are not doing any of what's done in proper clinical trials, like controlling for placebo effects, or even really solid data collection.
I'm not sure if actually banning off-label prescriptions would be the right solution, but off-label prescription without convincing evidence-based support for the decision should be resorted to cautiously. There still seem to be too many psychiatrists who approach it as some kind of seat-of-the-pants endeavor, rather than following statistically validated best-practice guidelines.
It absolutely is not. There's no money in getting FDA approval for a lot of diseases and nobody's gonna bother even if the drug worked well. Lots of rare diseases have no funding.
I suffer from a rare disease that has no FDA approved treatments so my medicine is used off label.
Something that's very interesting to me growing up was my uncle's intense awareness of that names, purposes, dosage and side effects of dozens of different medicines he had taken over the decades. When I'm sick with something, the doctor gives me some pills, I barely remember what they are, I half-forget to take them but eventually I get through the course and usually feel better. My uncle, who on a good day could hold a partially connected conversation for a few minutes without veering off into his personal psychosis, knew the cornucopia of drugs he was taking at any one time cold. There's an intensity to the kind of treatment he was receiving on a daily basis that I hope I never have to encounter for any particular disease in my life.
Would he have been better off without antipsychotics? Definitely not. He once overslept through the time he was to take a dose of something during a family get together and tried to attack my sister thinking she was the source of the blood and insects that were coming out of the walls and insisting that my long dead Grandfather would rise from the grave a la Jesus Christ and bring about the salvation of the Earth with his disciples, my Uncles. I heard other similar accounts from my relatives over the years before he finally died.
I also know a friend with less severe psychiatric issues, who spent most of her growing up years in and out of psychiatric hospitals and welfare. She used to have "episodes" every year or so and go completely loony, and often try and kill herself in various ways and end up under supervised care for a bit - on various antipsychotics for a while. At some point, she got married, had a couple kids and somewhere along the way just stopped taking the drugs. The "episodes" completely stopped. She had some very high stress issues in her marriage and still has yet to have an "episode". Is this related? I have no idea, but it seems to be working for her and she's living a better life, relatively speaking, than when she was under professional care.
Further, one interesting story is that of John Nash [1], he essentially just lives with his disease and managed to suppress it almost entirely.
For historical perspective, the author of the opinion piece kindly submitted here has been practicing medicine for about as long as I have been an adult. At the beginning of his practice, the Freudian paradigm of "treatment" was just beginning its long decline into the ash heap of history, after decades of not working for patients. The current use of antipsychotic drugs to treat schizophrenia is imperfect, to be sure, but it is much better than what came before.
> Half remained on drugs continuously; the others stopped taking drugs when they became well but restarted them if symptoms emerged. After seven years, the researchers found that those who were not continuously on drugs had a much greater likelihood of getting a job and resuming their regular life activities than those who remained on medications. Remember that people who stop drugs have a higher rate of relapse? It turns out that over the seven years, those who remained on the drugs relapsed as often as the others.
His point is that they are evidently not safe.
There's good old fashioned self-discipline available for most people. I mean, just because you're having mental issues doesn't necessarily mean you can't step outside yourself and understand and assert self control.
How exactly does someone who is having auditory or visual hallucinations exert self-discipline?
I'd certainly agree that some people know the voices they hear are hallucinations, and that some of those people live happily with those voices and don't need meds. Is that what you're trying to say?
Because it sounds like you're saying "pull yourself together", or "try harder" or similar.
Someone who has a severely broken leg needs to have a cast and needs to do the physiotherapy, and both of those need some self discipline. But after that discipline isn't going to make the bone knit faster.
Many people with "mental issues" can't just think themselves better.
To a large degree and for many people, mental health issues are something the individual can deal with on his own. To the extent that one can he should be urged to do so, not be put on drugs which we simply do not know all the unintended consequences of.
I know that is an unpopular sentiment in our culture but it's the truth.
To be more specific: often it's bad ideas and habits that lead to most mental health problems. E.g. if you sit around all day watching TV that's not good for your mental health. Everyone can choose to not do that, on their own, without drugs.
It's not only bizarre, it's perverse and sick. No wonder mental issues are running rampant.
is this sarcasm?
Edit: I'm afraid the "historical perspective" you supply is not very historical. The decline of Freudianism began long before the 1980s, and pharmaceutical psychiatry has a much longer history than you imply. The antipsychotics that Steingard writes about were discovered about 60 years ago—something you might have learned from the fifth paragraph of her article. It is highly unlikely that she was trained as a Freudian; she says she spent 20 years routinely prescribing antipsychotics.
Thanks to the participants here who openly disagreed with me and prompted me to read the article a second time when I didn't have an appointment rushing me out the door.
A lot of the criticism the industry receives is a direct consequence of "paying billions to perhaps earn billions". This kind of risk structure necessitates big companies that can stomach several billion-dollar failures while still turning a profit...
Of course, existing laws probably make it illegal in the US to work in this area at all if you aren't one of the hand-picked big names (i.e. cathedrals).
It doesn't solve the problems all that much though. For one thing, clinical trials still are expensive and can't usually be scaled down, partly for regulatory issues but also because it's sort of frowned upon to take wild risks with the health of humans (or animals for that matter).
On the other hand the failure rate still persists. If a dozen startups invest several millions each befor failing a few years down the road, the capital still has to come from somewhere, and the experience and institutional knowledge of pharmaceutical industry can't easily be transferred to these small startups anyway.
Maybe one way forward would be more medium-sized companies instead of a few larger ones. (But as an outsider, maybe I'm mischaracterizing the situation.)
As for expensive clinical trials---I bet nobody has tried crowdfunding them. Surely that would be illegal, but I think crowdfunding has the potential, today, to be what the joint stock company was at the dawn of global trade (e.g. the Virginia Company and the like).
I, against my will, and then out of desperation have tried many many anti-psychotics, and nothing makes this torture go away. And yet all I hear from these people is that I should stay on the medication, that it takes time to find the right combo that works, that this is all in my head, and that I should accept that the shit happening is just a part of who I am.
Everyday more excuses, more runaround, and more bullshit. And now I just sit around watching my life rot away due to all this torture/harassment, and the only thing medication seems to bring are more side-effects (some of these drugs cause depression, suicidal thoughts, etc (the very fucking problems that are to be avoided and the very reason people get put on medication) in addition to the "usual" weight gain, diabetes, tremors, twitches, sleepiness, zombification, restlessness, loss of higher cognitive function, etc). This is the biggest bag of bullshit I have ever seen. And then they try to use the medication working for one or a few people to justify forcing everyone else to go through this hell.
The hell only begins with the torture. The medication steps in and makes it worse, then the idiots forcing the medication onto me and everyone around me step in to drive the final nail into the coffin. I'm surrounded by a group of people who fully intend on seeing me driven mad and who seem willing to die trying to make me just another run-of-the-mill human being. But it's not that, it's that "they are here for me, and want to see me do my best." Oh please. Any talent or potential of mine must be destroyed, and everyday there's another excuse.
Take the medication, take the medication, take the medication, take the medication, take the medication, take the medication. All I hear chanted, all day long.
They don't care that the medication doesn't work, they don't care that it doesn't help me, they don't care that there are side-effects, they just care that I keep taking it, and that I sit and waste my life away, and that I blindly and continuously do as I'm told. That is their obsession, getting me to do as I'm told. And they care about nothing else. And sometimes it's almost like they get off on saying that what's happening to me is who I am, and that no one is doing this to me but me. I'm am absolutely shocked that psychiatrists say this garbage to their patients. Why would you want the patient to accept this torturous existence, then just sit there in it? Why waste their time, and waste/end their life with medication that is as ineffective as it is side-effect ridden? I'm always left speechless.
By the way, people always approach the side-effects of these medications as though they present themselves while the medication works to relieve symptoms of the illness, but this is stupid. In most cases, the medication prescribed does nothing to help with the symptoms, and instead just brings side-effects which makes life even more unbearable. And then there is the stupidity, depression, and suicidal thoughts that come as a result of some medications, but "it's not the medication, it's the illness."
What a joke.
I myself had to drop out of graduate school because of a horrid case of anxiety. The daily anxiety stayed with me for years. It's hard to remain cheerful when the person you thought you were suddenly disappears. I don't have Schizophrenia--which I'm grateful. The only advise I can give is that, at least in my case, time did help my disorder.
To any Psychiatrist out there; If your patient is stable. There's no need to drag them into endless office visits, especially if they don't have insurance. A prescription lasts one year. Don't become part of your patients problem. If you don't have a better business model--that's life. Yes--your patients know the game.
Antipsychotics, like any medication, need to be monitored and modified as time goes on. Not working? Change course. Building up an immunity? Perhaps increase dose, perhaps change drug. Side effects worse than the ailment? Perhaps try alternate therapies (or use them in conjunction), perhaps assign another drug to control the side effects.
We swim in a sea of propaganda. We need to wake up to that fact.