
The Most Popular Drug in America Is an Antipsychotic - samclemens
http://www.alternet.org/most-popular-drug-america-antipsychotic-and-no-one-really-knows-how-it-works
======
phren0logy
I'm an MD who specializes in Psychiatry. Although much of this article is
somewhere between a little and a lot inaccurate, the basic premise that an
absurdly expensive antipsychotic is the most popular drug is alarming. It is a
useful and effective medication with a clear role for a relatively small
subset of the population. Why it is being prescribed so widely is a question
worth asking.

~~~
hga
If you read the article carefully, and/or click through, you'll find it's only
#1 in dollar sales, it's still on patent until April or so.

I wouldn't be surprised if Ativan/lorazepam is still #1 in terms of
prescriptions.

~~~
refurb
On a per prescription basis acetaminophen plus hydrocodone is the top selling
drug.

~~~
andyzweb
I tried my google-fu at this. what is your source?

~~~
dmix
Here, most units sold:

[http://www.drugs.com/stats/top100/units](http://www.drugs.com/stats/top100/units)

acetaminophen/hydrocodone is #2

budesonide is #1 which is used to treat asthma (in puffers I believe).

I spent some time scraping medication information and learned that pharmacies
in the US mine massive amounts of data about pharmaceutical purchases and
there are a few billion dollar companies that collect/sell this data. Customer
information is "anonymized" of course at the pharmacy level. You can find the
sales of the top 100 drugs drugs pretty easily online, but there are thousands
of drugs and the data-mining companies charge you to see sales of the smaller
ones (from my experience).

~~~
refurb
You are correct! Budesonide is available as a generic inhalable steroid for
asthma.

As for Rx data, IMS is king. They pay pharmacies, wholesalers, etc to report
all of their sales. It's used heavily by pharma companies. I've seen some of
the data and it goes all the way down to individual Rxs by doctor. Incredible
stuff.

~~~
pinaceae
down to the HCP is only allowed in the US. most markets protect HCPs from
pressure by the industry, you can only get clustered Rx data there.

------
JumpCrisscross
A few months ago I succumbed to a particularly drawn-out case of the hiccups.
Two nights in, sleepless from constant hiccuping, I made it to the ER. The
cause was heartburn, triggered by an earlier night of celebratory drinking,
irritating my esophagus. The irritation was close enough to my diaphragm to
stimulate it.

One dose of thorazine, given by the ER doctor, and the hiccoughs subsided.
Thorazine dampens the vagus nerve. This was the intended effect. Less intended
was my complete lack of motivation to do anything outside the confines of my
apartment for the rest of the weekend. (I also took great interest in my
neighbourhood parks, for once.)

~~~
derefr
Fascinating... and makes me wonder whether anyone has experienced hiccups as a
side-effect of amphetamines or other dopamine agonists.

~~~
girvo
Yes, I have. Also, nictotine oral sprays are known to cause them as well,
quite consistently.

------
mrbrowning
I used to work in a pharmacological research lab, and while I'm frequently
discomfited by the misalignment between commercial incentives and social good
in the pharmacology industry, this statement isn't quite fair:

> Everyone has heard of "mission creep." In the pharmaceutical world, approval
> creep means getting the FDA to approve a drug for one thing and pushing a
> lot of other drug approvals through on the coattails of the first one.

This is more accurately referred to as "drug repurposing," and it's hardly the
unalloyed evil that it's characterized as here. It's true that drug companies
love to repurpose existing FDA-approved drugs, both because it saves them
money and because it typically permits them to patent the compound again in a
new context, but there are nonetheless real benefits to the public at large
when a drug whose side effects are comparatively well-characterized over the
long term is put into service to treat a different malady.

~~~
jdietrich
The real problem isn't drug repurposing, but off-label promotion. If you want
to take a drug through FDA approval for another set of indications, that's
fine and dandy. What isn't cool is actively promoting the use of a drug
without market approval - having reps drop subtle hints, funding third-party
publication, paying doctors to speak at conferences about their off-label
prescribing and so on.

Eli Lilly, Pfizer and AstraZeneca have collectively paid out more than $2.5bn
in settlements over the off-label promotion of atypical antipsychotics. The
drugs that they unlawfully promoted are now being used widely for the
treatment of a variety of conditions for which there is little evidence of
efficacy. Lilly were marketing Zyprexa for the treatment of dementia, in spite
of having extensive unpublished research showing that it was ineffective.

Atypical antipsychotics are being used by far too many psychiatrists as a
catch-all where other lines of treatment have failed - OCD, autism, PTSD,
ADHD, anorexia, substance abuse, you name it. In most cases the evidence of
efficacy is slim-to-none. That's not medicine, it's quackery. Frankly, I'd be
happier if they were prescribing placebo; Nobody has ever died from the side
effects of sugar pills.

~~~
silencio
But turning an off-label use into an on-label one to promote it has its own
nasty consequences, even if the drug is proven to work for the new indication
(or whatever).

Consider Lucentis vs Avastin. Ophthalmologists were using Avastin off-label
for wet AMD. Genentech was making a huge multifaceted effort to discourage
off-label use because they had sunk a bunch of effort/$ into the order-of-
magnitude-more-expensive Lucentis for not much of an improvement. Similar
situation and different ending with Lumigan (glaucoma/ocular hypertension
eyedrops) vs Latisse (eyelash enhancer), where Latisse's patent (afaik) was
thrown out because Allergan was trying to patent a known major side effect of
Lumigan.

I'm not a fan of misleading promotions of off-label uses either, but I wish
there was a middle ground still banning that that didn't also involve more
patents and protection.

------
spiritplumber
It was a shock for me to have worked in the US for a few years, and slowly
realize that I was in the distinct minority in my circle of friends in not
taking any medications consistently (I'm in my thirties). Made me think of
Brave New World.

~~~
mercer
I'm Dutch, but I grew up with many Americans around me. It always shocked to
see the huge amount of pill-bottles in the bathrooms of my American friends,
and how much part of daily life these things were.

Anti-bacterial wipes for everything, pills at the smallest sign of illness
(even just the sniffles), copious use of sleeping aids, and so on.

In my upbringing (which was kind of 'typically' Dutch), we took medication as
a last resort. Even painkillers were not something you took unless your
headache was unusually bad.

I have no doubt that this is also changing in Holland, especially when it
comes to prescription drugs for psychological issues, but in general it seems
a bit healthier to me to allow the body to take care of itself when it can,
rather than stuffing it with foreign bodies that often have all kinds of
adverse side-effects.

This state of affairs often makes me think about how malleable societies
really are, for both good and bad, and how much variation there is even within
'Western-European' nations.

------
joesmo
"The standardized United States Product Insert says Abilify's method of action
is "unknown" but it likely "balances" brain's neurotransmitters."

The whole neurotransmitter imbalance hypothesis is itself not proven for
Abilify or any other anti-depression drug (like SSRIs). At best, it is a guess
since there is no way to measure levels of neurotransmitters in live subjects.
At worst it is a lie. Regardless, the method of action is irrelevant if
medicines work, but considering the efficacy of such drugs (not very good) and
their frequency of prescription (very high) it's not surprising that the
medical industry would work so hard to push an unproven theory as fact simply
to sell more drugs.

~~~
ajarmst
Not only is it not proven for <insert drug here>, it's not even a useful
hypothesis in the scientific sense. No one has ever proposed a useful model of
the "chemical balance" that is hypothesized to be "imbalanced", so the whole
theory is a non-sequitur. It is proposed because the more accurate explanation
of "this is a powerful drug that introduces long-term changes to the structure
of your brain. A few cherry-picked studies funded by pharmaceutical companies
seem to show that there might be some short term amelioration of your
symptoms. We have no idea how it works, but that's not surprising, as we have
no idea why you have your disorder, or what it is other than a particular
constellation of symptoms. We won't find out in the near future, because
there's really no money being invested in finding out the ultimate causes for
mental illness or in studying the long term effects of these treatments."
doesn't get you invited to the really nice pharma-sponsored conferences.

------
ladzoppelin
The title is misleading. Abilify is being prescribed for people who are
already on SSRI's for depression because the combination helps accelerate
recovery and not because these people need traditional anti-psychotic
medicine. With this headline you give people a reason to be hesitant before
asking for help.

~~~
slazaro
Nevermind the fact that alcohol and coffee are way more popular drugs.

------
djur
The insinuation of headlines like this is that antipsychotics are inherently
hardcore drugs for people with severe, possibly dangerous mental illness. This
delegitimizes depression by suggesting it is not or cannot be a serious mental
illness; furthermore, it stigmatizes people who suffer from psychosis by
suggesting that their symptom is beyond the pale of what a normal person might
suffer.

That is: Antipsychotics are for people who experience psychosis, and people
who experience psychosis are crazy lunatics, so it's absurd that so many
normal people are being prescribed antipsychotics.

~~~
001sky
This point is sort of irrelevant to the article.

Read this, perhaps instead.

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518694/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518694/)

The issue is not that they are portrayed as too "hardcore", but rather in
general things like depression are over-simplified and dumbed down to stoke
consumer demand for narcotic remedies.

(Trivializing the subject is not a good thing.)

------
ef4
I have heard that people in post-acute care (think nursing homes) frequently
end up taking Seroquel because it appears on their hospital discharge
paperwork, despite never having any diagnosis of psychosis.

It turns out that certain hospital physicians find it a convenient sleep aide
for use in the hospital, and the prescription unintentionally follows the
patient, sometimes for months or years.

(Source: I sell software to long-term care facilities and their pharmacists.)

~~~
hga
I have _really_ bad insomnia, due to genetic anxiety and depression
(apparently "of a bipolar nature", but only a drug can make me manic), and
without a low dose of Seroquel before bed I'd only be getting ~4 hours of
sleep a night (and my anxiety would be much worse). It's been pretty much a
life saver.

Seroquel is ... interesting in that it hits a histamine receptor harder than
anything else; for someone like me, who also suffers from bad allergies, this
duel side effect is particularly advantageous.

As far as I know, all atypical anti-psychotics have been black boxed (major
league warning) for treating the elderly with dementia, the side effects in
them are worse than the benefit.

~~~
derefr
> apparently "of a bipolar nature", but only a drug can make me manic

Insomnia is, in my experience, symptom of _low_ dopamine. You need to exert
executive function to intentionally drop trains of thought that are keeping
you awake—without enough dopamine to do so, you end up increasingly exhausted
but unable to sleep. Vyvanse is the best thing that ever happened to my sleep
schedule.

~~~
hga
There are several kinds of insomnia. In my case, getting to sleep is seldom a
problem (and when it is, it's indeed often if not most often that kind of
"thinking too much"), waking up too early is the big one. So, besides this
being a generic disorder (my uncle the engineer followed the same path as I at
the same times in our lives, but he's frankly bipolar with anxiety being of
less significance), the effects of Seroquel on dopamine are not much if
anything of an issue for me. Then again I'm taking a low dose of it (50-100 mg
in one dose before bed, therapeutic dose of it for its formal indications
don't go below 300 mg/day).

One thing to emphasize from our disparate experiences is that in this arena
there aren't "one size fits all" solutions. There are common symptoms which
respond to common solutions, sometimes after a search for a particular drug
that works with acceptable side effects, then there are people like me where
doctors and myself struggle for years to find a set of drugs that provide the
best solution (for now) that control but by no means cure my symptoms (like my
uncle, this eventually disabled me).

Getting back to the original basis of this discussion, I'm absolutely sure
that Amblify when used as an adjunct for current generation antidepressants
works from some people with refractory depression, which I can attest is no
fun at all, since mine is only partially alleviated, and I have friends who
spent years before they found at minimum partial solutions for their more
standard unipolar depression. Is it seriously over-prescribed? Who knows? In
my experience, there are enough people out there with refractory depression
that it might well not be. And I'd certainly try it before e.g. electroshock
therapy, which is one of the alternatives if you're desperate enough.

As a side note, I learned cognitive psychology in the '80s (now cognitive
behavioral psychology, [http://www.amazon.com/Feeling-Good-New-Mood-
Therapy/dp/03808...](http://www.amazon.com/Feeling-Good-New-Mood-
Therapy/dp/0380810336/) is the classic and highly recommended layman's
introduction), and it's _tremendously_ useful, and in retrospect ended any
benefits from talking therapy, but it's pretty clear that like the 3
particular antidepressants I've tried from two generations of them, only a
partial solution for me.

------
ekianjo
I always find it interesting that these kind of articles points the fingers at
Big Pharma and completely forget that there's a key element needed for
prescription: Doctors. So, why not blame doctors as well, at least as much as
Big Pharma? They share a huge part of responsibility in the situation.

------
meepmorp
> [Thorazine] was an antipsychotic given to mentally ill people, often in
> institutions, that was so sedating, it gave rise to the term "Thorazine
> shuffle."

I think the term "Thorazine shuffle," refers to the characteristic locked-knee
shuffling gait that develops because Thorazine frequently causes tardive
dyskinesia as a side effect.

Edit: ignore this, see below; though, the drug does induce discomfort and
restlessness in the limbs that prompts patients to pace around.

~~~
rosser
It's _tardive_ dyskinesia, and the term is typically used to denote the facial
tics that are a sometimes _permanent_ side effect of older antipsychotics. The
"shuffle" is a separate effect, and calling it that is often regarded as
pejorative.

~~~
kaffeemitsahne
If you're not mad already a proper dose of Haldol will make you look (and
feel) it.

------
amelius
Does anybody know of natural drugs against depression?

So far I have only found lavender oil, sardines and chocolate to work.

~~~
intopieces
Saint John's Wort in conjunction with therapy is one that comes to mind. All
antidepressants should be combined with active, regular therapy. Often the
cause of depression is not chemical imbalance, but an actual issue in the
person's life.

~~~
jsmeaton
> Often the cause of depression is not chemical imbalance, but an actual issue
> in the person's life.

Not trying to be contrary, but do you have a source?

~~~
oldspiceman
I met a Swedish nurse who worked in a ward where they treated young people
who'd had mental breakdowns. She said the most common cause was a tough life
situation. In the short term they would prescribe drugs, but ultimately their
treatment was focused on changing that persons life to remove the negativity
which spurned the breakdown. Whether it be encouraging them to get a new job
or move out of their current living/ relationship situation.

~~~
unclebucknasty
OTOH, plenty of people go through tough life situations without suffering
mental breakdowns.

I think it's more complicated than a simple either-or proposition.

------
steven2012
20 years ago, I dated a pharmacist and she said that two of the most
prescribed drugs that she dispensed was ritalin and Prozac. It shocked me back
then, so hearing that anti-psychotics are amongst the highest these days is no
surprise, unfortunately.

