
A psychiatrist thinks some patients are better off without antipsychotic drugs - gruseom
http://www.washingtonpost.com/national/health-science/a-psychiatrist-thinks-some-patients-are-better-off-without-antipsychotic-drugs/2013/12/06/547f5680-48aa-11e3-a196-3544a03c2351_story.html
======
stiff
My layman's impression is that the current generation of drugs for serious
psychiatric diseases does more to help family and society in general to live
with the patient, than to help the patient itself. Our understanding of the
brain is still very basic, so, even with the best intentions of the doctors,
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, "solving" the problem for everyone but the
patient. The dilemma described in the article is all the more difficult given
that suicide is so common in many of those diseases, and not administering
drugs (or using the wrong ones) might, on the other hand, cost the patient
their life.

~~~
ryanjshaw
While I'm sure you mean no harm, you are - quite simply - wrong. There are
plenty of people who live lives they would never be able to live without
medication, and without many of the harmful side-effects being discussed.

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.

~~~
stevoski
> Nobody tries to tell a cancer patient how to treat their cancer,

Oh I wish that was true. My gf had cancer and every crackpot we knew was
advising on nonsense causes and treatments.

~~~
ubercore
How many involved marijuana?

~~~
DerpDerpDerp
From the cancer.gov website, run by the National Cancer Institute, part of the
National Institutes of Health [0]:

6\. Have any preclinical (laboratory or animal) studies been conducted using
Cannabis or cannabinoids? Preclinical studies of cannabinoids have
investigated the following activities:

Antitumor activity

Studies in mice and rats have shown that cannabinoids may inhibit tumor growth
by causing cell death, blocking cell growth, and blocking the development of
blood vessels needed by tumors to grow. Laboratory and animal studies have
shown that cannabinoids may be able to kill cancer cells while protecting
normal cells. A study in mice showed that cannabinoids may protect against
inflammation of the colon and may have potential in reducing the risk of colon
cancer, and possibly in its treatment. A laboratory study of delta-9-THC in
hepatocellular carcinoma (liver cancer) cells showed that it damaged or killed
the cancer cells. The same study of delta-9-THC in mouse models of liver
cancer showed that it had antitumor effects. Delta-9-THC has been shown to
cause these effects by acting on molecules that may also be found in non-small
cell lung cancer cells and breast cancer cells. A laboratory study of
cannabidiol in estrogen receptor positive and estrogen receptor negative
breast cancer cells showed that it caused cancer cell death while having
little effect on normal breast cells. A laboratory study of cannabidiol in
human glioma cells showed that when given along with chemotherapy, cannabidiol
may make chemotherapy more effective and increase cancer cell death without
harming normal cells.

Stimulating appetite

Many animal studies have shown that delta-9-THC and other cannabinoids
stimulate appetite and can increase food intake.

Pain relief

Cannabinoid receptors (molecules that bind cannabinoids) have been studied in
the brain, spinal cord, and nerve endings throughout the body to understand
their roles in pain relief. Cannabinoids have been studied for anti-
inflammatory effects that may play a role in pain relief.

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/...](http://www.cancer.gov/cancertopics/pdq/cam/cannabis/patient/page2)

~~~
ubercore
Yeah, I didn't mean to imply they were making it up. I'm for medical marijuana
and marijuana research. It just seems that this gets inflated into "Did you
hear about [name of fringe researcher]? He cured [every disease] with just
marijuana!"

Sorry to make light of this.

------
brownbat
There is an inmate on death row who is not fit to face execution without
medication.

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.

~~~
dobbsbob
The Tuscon AZ spree shooter was forcibly given anti psych drugs so he would be
competent for trial. If not he would have been found insane seems odd to make
somebody sane so you can punish them for acts committed while barking mad

~~~
meowface
"Competent to stand trial" and "not guilty by reason of insanity" are two
entirely separate things. They are not mutually exclusive. Someone who is
competent to stand trial upon arrest, or weeks or months after arrest, could
still very well plead insanity and be found not guilty.

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.

------
andrewcooke
it's really hard being a doctor. i have recently been trying to work out what
is the best treatment with two doctors. both are decent, smart people who
understand the current literature and who care about me. yet they came to
quite different conclusions, and the arguments for either side are clear.
there's just too little known about many illnesses (in my case, it's not
mental, but ms) and you are left balancing risks and unknowns.

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...

~~~
tomfakes
Off the original topic, but I read something in the last week for MS treatment
that seems to cure it completely. This is done by taking the patient's own
bone marrow, and transplanting it back after killing off the existing bone
marrow.

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...](http://www.ottawacitizen.com/health/Ottawa+doctors+behind+breakthrough+multiple+sclerosis+study/8189161/story.html)

~~~
andrewcooke
yeah, there are lots of new things coming through. but also, these things
often are much riskier (or the risks are simply unknown because they are so
new and, with chronic illness, you may be taking the drug for years). i think
just this month something was approved (in the usa) that, for some people,
apparently "cures" ms with just a few injections over two years. one of the
options i face now (far down the list, thankfully) is only safe for 2 years -
after that you hope something else has come along...

[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]

------
bafjohnson
As someone who takes an antipsychotic (300mg of Quetiapine XR once daily for
bipolar) I can completely understand why these drugs don't suit everyone.

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.

------
DanBC
Some people might wonder what the problem with anti-psychotic meds is. "maybe
they have some side effects, but surely that's better than being mad?"

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.

~~~
_delirium
> (often against best current practice guidance)

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.

~~~
aestra
>I'm not sure if actually banning off-label prescriptions would be the right
solution.

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.

------
bane
This is such a complicated problem, probably like many people here, I have
family members with various psychiatric issues. One person who was incredibly
informative to me was a dear late uncle who suffered from severe Paranoid-
Schizophrenia. Over the years he ended up with a small case of maybe a dozen
medicines he had to carefully administer to himself so he could keep in
tangential touch with reality. The side effect was that many of the medicines
caused him to sleep through most of the day and night. I have an inkling that
some of his perpetual drowsiness was a way for the psychiatrist to also help
alleviate the difficulties of the family with managing him and may have had
nothing to do with supplying effective antipsychotics.

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.

------
do_re
"Those who remained on the drug were less likely to return to work or develop
meaningful relationships."

------
lettergram
I have had a friend on antipsychotics, she basically told me that the side
effects match the disease. She has since stopped taking the drugs and has
focused pretty much entirely on simply "ignoring" her disease. For the most
part she seems alright, she is a loner and doesn't leave the house much, but
has and is working so she seems alright...

Further, one interesting story is that of John Nash [1], he essentially just
lives with his disease and managed to suppress it almost entirely.

[1]
[http://en.wikipedia.org/wiki/John_Forbes_Nash,_Jr](http://en.wikipedia.org/wiki/John_Forbes_Nash,_Jr).

------
tokenadult
What does he propose to do to demonstrate that some new way of treatment has
greater safety and effectiveness than the way he desires to replace?

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.

~~~
wissler
"What does he propose to do to demonstrate that some new way of treatment has
greater safety and effectiveness than the way he desires to replace?"

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.

~~~
DanBC
This is a bizarre post.

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.

~~~
wissler
It's really bizarre, and telling, that in this culture you're not permitted to
suggest that mental health problems can be caused -- and therefore, remedied
-- by personal choices.

It's not only bizarre, it's perverse and sick. No wonder mental issues are
running rampant.

------
bayesianhorse
The current system of drug development is broken. The pharmaceutic industry
did a great job in the past, and reduced a lot of suffering. But currently
drug development takes too long and has become too expensive to make bigger
strides again.

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...

~~~
javert
There are almost always alternative ways forward when an existing market
structure stops working. For instance, maybe drug development needs to be more
bazaar and less cathedral? More open source, more distributed, less
decentralized?

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).

~~~
bayesianhorse
That is sort of the knee-jerk reaction I'd expect from the startup world. It
has been tried. For that matter the "healing technology" community has
departed somewhat from small-molecules into using more technology or
biologicals.

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.

~~~
javert
Thanks.

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).

------
zw123456
This is some really great discussion here about this issue. I am very glad to
see it, I wish the main stream press would pick up on this issue, I think
there needs to be more study of the side effects of psychotherapeutic drugs,
they do so much good for so many but I am think more research is needed. If it
does turn out to be that these drugs are causing people to have violent
episodes we need to learn why.

------
drdoppler
[http://pastebin.ca/2498765](http://pastebin.ca/2498765)

------
etanazir
In the past, people were 'possessed by demons' and a priest was brought in to
help. Now, psychiatry is the institutionalized national religion.

------
joeldidit
I think someone did this to me (probably to get revenge). There is no history
of mental illness in my family, and I showed no signs at all, then I randomly
start getting harassed with the same thoughts and the same bad memories over
and over again, and I randomly lose all higher cognitive functions stopping my
career and my life dead in their tracks. And this all happened right around
when I quit a job due to harassment of much the same form. And to top it off,
I, at the same time, also lose my ability to get and maintain an erection, and
my ability to ejaculate (now nothing comes out). Who are you kidding? And then
I realize that supplements, medication, etc (especially ones that previously
worked) now have no effect on me whatsoever.

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.

------
simonsickboy
REVOULUTIONARY THINKINING! Seriously, thank God we see some thoughts of this
ilk actually voiced in mainstream media. Not on like...FOX or anything, but
still. The trouble is reaching the sheeple, not the people who already "know"
for the most part. But this is where it starts.

~~~
bayesianhorse
Writing in caps does not make me extremely confident that you understood the
medical issue discussed in the article. At least not beyond "stop using
antipsychotics", which isn't actually the message at all...

------
kiep
slowpokes.. "Insanity - a perfectly rational adjustment to an insane world."
R. D. Laing

------
marincounty
Psychiatry is still an Art. I don't blame MD's. I blame the drug companies who
fudged the studies; there is no excuse to pick on society's most vulnerable.

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.

------
vacri
Balancing potential benefits from antipsychotics against problematic side-
effects is news to exactly zero people in the mental health field. Not
everyone gets better when put on antipsychotics, but this doesn't mean a given
individual has no hope.

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.

~~~
gruseom
You make it sound as if the author's stance is trivial, but I have the
impression that it's controversial and that she has taken a professional risk
in publishing it.

------
squirejons
the real story behind this is how americans and american social and political
policy is being manipulated by corporations.

We swim in a sea of propaganda. We need to wake up to that fact.

