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.