Some Final Notes Regarding the Book Anatomy of an Epidemic

Some final thoughts on the use of psychiatric medications.

--There is no doubt that many people need psychiatric medication.  Their depression, psychosis, or anxiety is so severe that it disables them.  And they need treatment--NOW.  People have to get back to work.  They have to pay the mortgage. Children may have misbehaved so badly due to ADHD that if they do not quickly change they will be expelled from school.  Parents may need to quickly calm their explosiveness so as to not emotionally injure their children.  Persons with a severe case of mental disorder may be so sabotaging their life that to wait for long term improvement with counseling or psychotherapy is not feasible, even if long term counseling or psychotherapy is the better treatment in the long run. 

--But troubling issues remain.  How do we know that psychiatric medications are safe and efficacious over the long run, when they are taken for years or decades?  I do not believe that there is data to support this.

--I wonder if all of the relevant research on this issue has been published.  Has any been withheld?  It is generally known that journals will generally not print studies which show that no significant experimental effects have occurred.  So if a long term study existed that did not show a beneficial effect of medication over placebo, would it be printed?  One important study, the Harrow study*, apparently was turned down by American psychiatric journals.  Was it because they considered it poor science?  Or because the results went against the grain of accepted psychiatric beliefs?

--Long term effects are hard to research.  It is hard to conduct a randomized study for more than a few months.  People don't want to abide by a tightly controlled treatment regimen.  People on medications during the acute phase of a study may, in the followup phase, want to start psychotherapy or may want to be on no treatment at all.  People who have been treated with psychotherapy may want to start medication.  And when people do change their treatment, it is not random.  They may get off of medications because the medications have made them feel better or made them feel worse.  All of this makes controlled comparisons over the long term very difficult indeed.  (Hopefully, some very bright researchers will find a way around these problems.)

--If science is providing better and better treatments, then why are rates of mental illness going up rather than down?  Why are rates of bipolar disorder going up?  The increase in the use of antidepressants and mood stabilizers has been suggested as one possible explanation of increasing chronicity.  But very long term trends are difficult to interpret.  There are concurrent, ongoing social changes which confound easy analysis.  There are changes in the public's use of street drugs, changes in the welfare system that reimburse people who are mentally ill, changed attitudes about reporting symptoms that make people more open about talking about their difficulties, changes in the diagnostic criteria, and changes in the social fabric and social support available to persons.  The increasing stresses of modern society also cannot be overlooked as the possible culprit causing a long term trend causing elevations in some psychiatric diagnoses.

--Is there a conspiracy to get people to take drugs that they don't need?  Hardly. Is there an economic system which rewards doctors and pharmaceutical companies for treating mental illness with psychotherapy?  Absolutely.  There is no way to get around the fact that a decreased use of psychiatric medications would severely impact the viability of both psychiatry and much of the pharmaceutical industry.  It is a merry round which it would be difficult for them to get off. 

--There is no doubt that there are clearly biological foundations for many mental disorders.  The research is voluminous.  I believe it is incontrovertible.  Many mental disorders have biological correlates.  Period.  But that does not necessarily mean that in all cases, these disorders will respond best to a biologically oriented treatment.  It is still theoretically possible that the body remains the best healer, or that psychotherapy is the best approach.  (Psychotherapy can be conceptualized as clearing away obstacles which would inhibit the body from healing itself.)

--Some psychologists and mental health professionals would argue that psychological avoidance is the source of many if not most mental health problems--avoidance of internal thoughts and feelings, and avoidance of dealing with problems.  Are we as a society encouraging avoidance by advocating the widespread use of medication?  And in so doing, are we thus actually making psychological problems worse?  Iatrogenesis is the causing of problems through medical treatment.  Is that occurring here with an over reliance on psychiatric drugs?  If there are natural healing forces in the brain, are the biological treatments we are using helping or hindering them?

--On the other hand, if everyone suddenly went off all psychiatric drugs, would there be enough counselors to deal with the number of patients?

--In the long run the scientific method will correct any current fallacies.  Science tends to correct itself.  However, in the short run, journal editorial decisions, and grant funding decisions at a federal level could impede some of data which is negative about pharmacotherapy from being collected or published.  Science eventually corrects itself, but it sometimes takes a long time.  As one author I once read put it, referring to Einstein and the quantum revolution in physics, old scientists don't change their minds, they just pass away. (I'm sorry I don't have the reference; it was in a biography of Einstein). 

--People sometimes talk about drugs as being a crutch. They sometimes talk about psychotherapy in the same way.  But I believe that misses the important point.  Crutches are good things.  Or at least I would think so if I broke my leg.  But a crutch is a temporary thing.  It allows healing by taking the stress off of the body.  All medical treatments, whether they are pharmacotherapy or psychotherapy need to encourage the body in its own natural healing.  And if they cannot encourage natural bodily (or brain) healing, they at least need to permit it to occur.  (This may seem to contradict my point about the use of psychiatric medications being a way of avoiding dealing with problems.  There is considerable complexity in this issue.  I believe that in an ideal situation, the psychiatric drugs would be used for a short period of time alongside a psychotherapy plan of helping the person to psychologically deal with issues.)

--Psychiatric research is not necessarily objective.  In one research program in which I participated, the results of a study indicated a slight advantage of the antidepressant condition over psychotherapy, at least in the short run (the acute phase of the study; in the followup phase, the cognitive therapy did better than the medication.)  A nationally known psychiatrist was highly bothered that the benefit of the medication was not found to be stronger.  He insisted that a new more powerful statistical technique be used to look for differences between the different treatments (essentially pharmacotherapy versus psychotherapy).  Now, you need to understand that we already had TOP statisticians on the project.  But with the use of the new statistic, the effect of the medication condition was a little stronger.  This was an example of statistics being used in the service of ideology.  It is not for me to say whether the statistic was valid or not.  I assume that it was.  However, if there had not been such ideological devotion to the medication condition being superior by this one influential psychiatrist, there would never have been such an impetus to look around for another statistic and to perform a reanalysis.

*M. Harrow, "Factors Involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medication."  The Journal of Nervous and Mental Disease, 195 (2007): 406-414.  The study seemed to show that psychotic individuals who went off of their medications did better than individuals who stayed on them.  The data is open to various interpretations; but it is surprising that it did not receive more prominent journal coverage.  In general, it is surprising that it has not been talked about more widely.

Anatomy of an Epidemic--the Explosion of Psychiatric Drug Use in America

I'm reading a new book, Anatomy of an Epidemic.  And I find it both interesting and disturbing.

The book takes a look at the abuses of psychiatric drugs which has increasingly arisen in our culture.

Now, I am not generally one to bash such drugs.  My own background is of a psychologist trained in medical settings, where psychiatric drugs were used routinely and responsibly to help people.  I have also worked in clinical research trials where medication was being compared with psychotherapy, and I have seen the data showing that in the short run, medicines work about as well as psychotherapy, and sometimes better.  The settings I have worked in have usually, but not always, involved collegial relationships between the MD and non-MD professionals, so that patients could receive the best of both types of treatment.

Another reason I have been comfortable with patients receiving medications is that I am aware of the empirical literature on their effectiveness.  My graduate school training taught me methodological theory and how to analyze outcome studies, to know what was a good outcome research study and what was not.  I generally have kept abreast of research on outcomes of both medication in general and psychotherapy.

But after years of being in private practice and away from more intensive contact with research findings, I feel that perhaps I have been caught napping.  This book has been a rude awakening.  The author has done his homework extremely well, and he is getting invitations from prestigious groups in the U.S. and abroad to come present his point of view.  He has ferreted out numerous studies and facts to back his statements.  Everything he says is based on either a research study or on the opinions of biologically oriented psychiatrists and psychologists.

What is it that he points out?

• When outcome studies have been published, the positive aspects of outcomes have been touted, and the negative aspects, such as side effects or negative effects after drug withdrawal, have been downplayed almost to the point of being hidden.
• Outcome studies have often focused on the 12 to 16 week initial treatment period.  This has always seemed to me to be logical.  Most psychiatric drug effects would become visible and obvious during that time period.  But in the very long run, some medications, such as lithium and neuroleptics (antipsychotics), may be having negative outcomes on cognitive functioning.  (See my blog on dementia and bipolar disorder; I did not mention there the possibility that medication itself might be the cause of cognitive decline.)
• The 12 to 16 week studies generally do not spend much time or space talking about drastic withdrawal effects from some medications.  Some antidepressants and some anti-anxiety medications are very hard to stop taking once they have been started.
• Some medications stop working.  The NIMH sponsored study of stimulant medication for ADHD found a clear "winner" in medication for the first acute study period, but no clear advantage to medication over the long run.
• Some studies which did not find efficacy for medication have never been reported.  Studies with results inconsistent with the prevailing viewpoints of biological psychiatry may be relegated to less well read journals and refused for publication by the top of the line journals.
• Pharmaceutical companies have often used psychiatric researchers as consultants. This compromises their objectivity by paying them salaries.

I am worried about the possibility that some psychiatric drugs may be causing cognitive decline and deterioration in the long run.  I recall one particular patient, Barbara.  After starting my first job at the University of Oklahoma Health Sciences Center, I "inherited" this patient from a long time psychiatrist and researcher.  She received medication from a psychiatric resident, and she was in group counseling with me.  She was part of a long term maintenance group of bipolar patients.

Barbara had been somewhat of a child prodigy in piano.  She had been quite brilliant.  But she also had a very dysfunctional family and almost surely had inherited the bipolar gene set.  By the time I had started treating her she was 50 years old.  She spoke slowly, deliberately, and emphatically, making her appear to be of borderline intelligence.  There was a childlike, regressed manner to her speech.  I did not test her IQ, but I believe that if I had, it would have probably been around 80.  Why had this woman declined so precipitously?  I asked senior colleagues, and they did not know.  The thinking at the time was that she must have had some form of undiagnosed schizophrenia.  It was known that schizophrenia had a long term course which could result in severe deterioration.  But the problem was that there was absolutely no evidence that she had schizophrenia.  Her symptoms were controlled with Lithium, a medication for bipolar disorder.  I lost track of Barbara after I left OUHSC, and then later I heard that she had died.  I believe that it was due to complications of her severe smoking habit.  I am left wondering if her fall from brilliant child pianist to a fairly simple minded existence was due to her medication.  I suppose I will never know, but it is certainly a possibility.  No other explanation made any sesne then or now.

The issues raised in this book will put some patients into a dilemma.  Their trusted mental health professionals say one thing, that the medications are safe and efficacious, and this book implies something else.  Is the glass half empty or half full?  It also puts me into somewhat of a dilemma since I work very closely with psychiatrists.  I respect them, their knowledge, and their experience.  I respect their caring for their patients. 

But let's say that the premise of the book is true and that there are significant negative effects of psychiatric medications in the long run.  Let's go further and say that the positive effects from psychiatric medications decline for many patients in the long run, after a year or so.  The research literature is still relatively strong in showing that these medications work in the short run (although the negative outcome literature may have been unreported).  Let's say that I am the treating psychiatrist for a man with severe depression and anxiety.  He is functioning poorly on the job, and he may lose it if he does not do better.  Doesn't he need to improve as quickly as possible to keep his job?  Imagine how my patients would feel if I said to them the following: "Just hold on without the medications.  Using psychotherapy you will eventually do just as well and even better than with medication; but in the short run, you are not likely to improve as rapidly."

The outcome picture is more complicated if a person is on medication and receiving psychotherapy at the same time.  They would receive the best of both worlds.  But there might also be some withdrawal effects coming off of the medication.  I certainly encountered that with one college professor I treated.  He was convinced that his Xanax was a major culprit in causing him further problems.  I doubted it at the time, but now I believe that he knew himself and his body fairly well and that he was correct.  In that situation, coming off of the Xanax meant that we had to extend the psychotherapy to help him through the process of getting off the medication.

Not everyone has a negative reaction to medications.  Not everyone has difficulty coming off of them.  There are obvious ethical problems here.  A person may lose their job if not rapidly treated.  A person may be in needless pain due to severe depression and anxiety.  (It is probably not overly dramatic to refer to moderate and severe anxiety as a form of torture.)  A person with severe depression or anxiety might commit suicide without the relief available from medication.  Rapid treatment is often necessary to prevent a person from doing things which are irreversible--not just commiting suicide but also making mistakes on the job or severe mistakes in parenting.  If a person loses their job, their marriage, or their children, then the long term job of the psychotherapist becomes all that more difficult.

Patients need to be made aware of the positive and the negative outcomes from medication.  This is true of psychiatric and non-psychiatric drugs.  For my own practice, I am left in somewhat of a dilemma.  Here are the resolutions I have made to myself.

1.  To do more research on the negative outcomes of psychiatric drugs.
2.  To tighten up my criteria for when I do and when I do not recommend medication evaluation.  (I do not perform psychological testing and then recommend medication.  I come up with a diagnosis and then recommend a medication evaluation for some patients.  There is a difference.)  Similarly, I will be more conservative in making those diagnoses which most often lead to medication (ADHD, bipolar disorder, psychosis).
3.  To emphasize to patients that the medications may not be a long term treatment.  I will encourage them to talk with their treating MD about just how long they would be on the medication and when it might be feasible to start coming off of it.

I will be writing more in future columns about this.  There is a great deal at stake here for all involved.