![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 49. This is the beginning of the thread.
Posted by Squiggles on June 7, 2007, at 8:13:24
I'm now in a position where i have to
make a decision on how to cope with the
dillema of psychiatric non-compliance (not
my own, even though i do wish i did not have
to take drugs).Reading material such as Judi Chamberlin's article
http://www.power2u.org/articles/recovery/confessions.html
I understand very well that a person will not tolerate disabling drugs which make life less worth living. And certainly, being locked up in a hospital against your will is imprisonment. And in such cases the law will not and should not make the person take noxious drugs or be incarcerated.
Unfortunately, the fallout is that the person may harm himself or others, but perhaps that is the price to pay for psychiatric freedom.
It is with great unhappiness and anxiety that I come to this concession. My own life is in a state of anxiety and vigilance. The problem at the heart of the matter, in my opinion, is that psychiatric drugs are not yet perfected to make them pallatable. It may also be the wrong drug for the wrong dx. I *do not* believe like the Breggin group, that drugs are not necessary for mental illness.
I can only hope for the best, and wish that the state of affairs were otherwise. May serendipity be my guardian as it has in the past.
Squiggles
Posted by Phillipa on June 7, 2007, at 11:54:56
In reply to The right to non-compliance, posted by Squiggles on June 7, 2007, at 8:13:24
Scarey, sad and probably true. Love Phillipa
Posted by Quintal on June 7, 2007, at 13:32:21
In reply to The right to non-compliance, posted by Squiggles on June 7, 2007, at 8:13:24
Obviously this is very complicated, and in real life not something that can simply be reduced to black-and-white compliance vs. non-compliance. Often in these debates I notice you've tended to assume compliance always entails taking prescribed drugs and submitting to hospitalisation etc at the psychiatrist's discretion, and that non-compliance is a form of rebellion - refusing medication, dabbling in alternative or complementary medicine and engaging in talk therapy against the will of the psychiatrist or doctor. This is not necessarily the case.
Nobody has ever forced me (or so much as attempted to force me) to take medication against my will. Within a year of making my first appointment all of the medication trials were at my own suggestion, not the GP or psychiatrist, and on occasion they refused to make suggestions - they said I'd exhausted their expertise, particularly in the field of MAOIs. I complied with my psychiatrist's wish to try a course of talking therapy as an adjunct to medication. It's worth noting that the only time I felt ready to act on suicidal ideation was during the start-up phase of a medication trial of Effexor and Rivotril. The suicidal thoughts abated within days of stopping Effexor. So the idea that going medication free puts the 'patient' at greater risk of suicide and self-harm is far from universal (also the only time I engaged in cutting was when I was taking antidepressants and tranquillizers, and had no urges since quitting). Actually since he discharged me I guess it's the psychiatrist's recommendation that I no longer take prescribed medication?
So we're all different and luckily I'm one of those who seems to function better off medication when the crisis is over, and like Judi Chamberlin suggests I was one of those patients who was labelled as difficult and manipulative. I've often wondered why such a determined, intelligent, strong-willed and spirited person such as yourself seems so tormented by the non-compliance of other psychiatric patients?
A quote from Judi Chamberlin:
"Let us celebrate the spirit of non-compliance that is the self struggling to survivor. Let us celebrate the unbowed head, the heart that still dreams, the voice that refuses to be silent. I wish I could show you the picture that hangs on my office wall, which inspires me every day, a drawing by Tanya Temkin, a wonderful artist and psychiatric survivor activist. In a gloomy and barred room a group of women sit slumped in defeat, dresses in rags, while on the opposite wall their shadows, upright, with raised arms and wild hair and clenched fists, dance the triumphant dance of the spirit that will not die."
Q
Posted by linkadge on June 7, 2007, at 13:56:23
In reply to Re: The right to non-compliance » Squiggles, posted by Quintal on June 7, 2007, at 13:32:21
I feel that a human being has the right to take or not take these medications.
Nobody fully knows how a patient feels other than the patient.
Doctors are sometimes full of themselves and full of it in terms of their confidence in the efficacy of these drugs.
Sometimes a patient cannot fully explain exactly why they choose not to take meds.
To put into words the neural processes that are turned on or turned off by a certain med is not always possalble.
In addition, there is very little if any evidence that these medications actually do reduce the risk of suicide. Sometimes they increase suicidiality. The bottom line is believe the patient and not the theory.
Linkadge
Posted by Squiggles on June 7, 2007, at 14:15:18
In reply to Re: The right to non-compliance » Squiggles, posted by Quintal on June 7, 2007, at 13:32:21
This is not necessarily the case.
You're lucky, and depending on the temperament,
illness, education and circumstances, different
things can happen with non-compliance. It is
hard to predict. I think that statistics paint a grim picture.
..... I've often wondered why such a determined, intelligent, strong-willed and spirited person such as yourself seems so tormented by the non-compliance of other psychiatric patients?Thanks for the compliment. I'll tell you why:
because when my "counterfeit, or botched or old" lithium supply made me feel wonderful for the first few months, and then drove me to a psychotic state, in which only suicide seemed an escape, i realized that at 6months it could not have been withdrawal, but bipolar relapse. I reinstated and got stable, burning a few neurons in the course. That's why.
>
> A quote from Judi Chamberlin:
>
> "Let us celebrate the spirit of non-compliance that is the self struggling to survivor. Let us celebrate the unbowed head, the heart that still dreams, the voice that refuses to be silent. I wish I could show you the picture that hangs on my office wall, which inspires me every day, a drawing by Tanya Temkin, a wonderful artist and psychiatric survivor activist. In a gloomy and barred room a group of women sit slumped in defeat, dresses in rags, while on the opposite wall their shadows, upright, with raised arms and wild hair and clenched fists, dance the triumphant dance of the spirit that will not die."
>As I said, most of the drugs we have suck, and the diagnosis is probably wrong 80% of the time. We are not there yet. I suppose it is possible for some people to live with mental illness, but for it is hell.
S
Posted by Quintal on June 7, 2007, at 14:55:57
In reply to Re: The right to non-compliance » Quintal, posted by Squiggles on June 7, 2007, at 14:15:18
>This is not necessarily the case. You're lucky, and depending on............Absolutely.
>I think that statistics paint a grim picture.
I haven't looked at the statistics and as a rule I'm not inclined to accept them as infallible truth at face value. What agency was the source of those statistics, and what are their politics in this issue?
>I'll tell you why:
>because when my "counterfeit, or botched or old" lithium supply made me feel wonderful for the first few months, and then drove me to a psychotic state, in which only suicide seemed an escape, i realized that at >6months it could not have been withdrawal, but bipolar relapse. I reinstated and got stable, burning a few neurons in the course. That's why.What drugs exactly were you taking when you had this psychotic episode, and how did you discover that your lithium was "counterfeit, or botched or old"? Did you ever find out what it actually contained?
>As I said, most of the drugs we have suck, and the diagnosis is probably wrong 80% of the time. We are not there yet. I suppose it is possible for some people to live with mental illness, but for it is hell.
I'm not sure how often the diagnosis is 'wrong', but one thing that concerns me about modern American psychiatry is the huge rise in diagnosis (and liberal medication of) 'grey area' illnesses like soft bipolar, adult ADHD etc and the fashion for broadening diagnostic criteria almost to the point of pathologizing aspects of normal life. I think much of what is now being diagnosed as mental illness is more likely to be emotional disturbance or maladjustment, and the assumption that these 'illnesses' will require life long medication (to correct some biological deficit) is inappropriate and in some cases damaging. It's a growing concern that as a consequence many Americans are being overmedicated. Too much medication will cause chemical imbalances and make people unwell so the whole process can be counterproductive in these cases, unless of course you're the one making money from it.
Q
Posted by Squiggles on June 7, 2007, at 15:43:28
In reply to Re: The right to non-compliance » Squiggles, posted by Quintal on June 7, 2007, at 14:55:57
.......
> >I think that statistics paint a grim picture.
>
> I haven't looked at the statistics and as a rule I'm not inclined to accept them as infallible truth at face value. What agency was the source of those statistics, and what are their politics in this issue?Not infallible, especially since the discontinuation syndrome is another football in the pro and anti-psychiatry field. Here are some
i found (gad there are so many on this topic from so many sources):http://psychservices.psychiatryonline.org/cgi/content/full/55/8/886
http://pb.rcpsych.org/cgi/content/full/25/5/183#TBL1
>of course there are many more-- i hope you don't mind doing the search yourself;
> >I'll tell you why:
> >because when my "counterfeit, or botched or old" lithium supply made me feel wonderful for the first few months, and then drove me to a psychotic state, in which only suicide seemed an escape, i realized that at >6months it could not have been withdrawal, but bipolar relapse. I reinstated and got stable, burning a few neurons in the course. That's why.
>
> What drugs exactly were you taking when you had this psychotic episode, and how did you discover that your lithium was "counterfeit, or botched or old"? Did you ever find out what it actually contained?Synthroid, clonazepam and lithium. The lithium seemed weak from the beginning and was purchased from another pharmacy-- a different make. At that time there was a warning of bad lithium batches (below therapeutic level). I felt very light and had less side effects, but in progression the old bipolar symptoms came back. I called my dr. for my old perscription and upon reinstatement of that, i was lifted out of psychomotor agitation and suidicidal depression-- which btw, came suddenly, so i must have hit a therapeutic index point.
>
> I'm not sure how often the diagnosis is 'wrong', but one thing that concerns me about modern American psychiatry is the huge rise in diagnosis (and liberal medication of) 'grey area' illnesses like soft bipolar, adult ADHD etc and the fashion for broadening diagnostic criteria almost to the point of pathologizing aspects of normal life. I think much of what is now being diagnosed as mental illness is more likely to be emotional disturbance or maladjustment, and the assumption that these 'illnesses' will require life long medication (to correct some biological deficit) is inappropriate and in some cases damaging. It's a growing concern that as a consequence many Americans are being overmedicated. Too much medication will cause chemical imbalances and make people unwell so the whole process can be counterproductive in these cases, unless of course you're the one making money from it.
>Yes, i have discussed this too, and there are a lots of consipracy theories about the drug companies wanting to make more money etc. On the other hand, when you look at the state the world is in, perhaps pathologizing the present human condition is not such a hyperbole.
Squiggles
Posted by linkadge on June 7, 2007, at 16:21:23
In reply to Re: The right to non-compliance » Quintal, posted by Squiggles on June 7, 2007, at 14:15:18
Just a question.
How do you know that the lithium was botched? Isn't it possable that it was a perfectly normal amount of lithium and that you just had a breakthrough episode?
Or is there a concrete reason that you know.
Linkadge
Posted by linkadge on June 7, 2007, at 16:26:45
In reply to Re: The right to non-compliance » Quintal, posted by Squiggles on June 7, 2007, at 15:43:28
I wouldn't call them conspiracy theories as there is plenty of evidence that the drug companies will, time and time again, put the prospect of income before the wellbeing of customers. There are plenty of instances where the drug comapnies will think short-sightedly
As another topic, Tracy Johnson, a girl with no history of depression commited suicide when having to go through the hell of duloxetine withdrawl. Lots of people admit to feeling worse upon withdrawl of meds than they ever did prior to starting the medications.So. People go off their meds, and perhaps the reactions are due to withdrawl? Of course the doctors take it as evidence that they should resume treatment.
Linkadge
Posted by Squiggles on June 7, 2007, at 16:35:42
In reply to Re: The right to non-compliance » Squiggles, posted by linkadge on June 7, 2007, at 16:21:23
> Just a question.
>
> How do you know that the lithium was botched? Isn't it possable that it was a perfectly normal amount of lithium and that you just had a breakthrough episode?
>
> Or is there a concrete reason that you know.
>
>
> LinkadgeI know because i opened the cap and it was a smaller amount, because it tasted chalky, had a different reaction with water; also it was a different company (won't mention it here) and at the time there was a Health Canada Warning about 300 caps of lithium being weak. I also know because my dr. complied with my report and the switch to the higher, older brand (after the 6th month when psychosis set in) brought me to stabilization.
I think there is little doubt, though i did consider the thyroid butting in at the same dose, and the possibility that reinstating a stronger (my old brand) dose jolted me. But you have to reinvent the length of thyroid effect, and explain how the psychosis set in before the reinstatement of the old, stronger dose i used to take.
One more thing-- my friend has crashed into depression after discontinuation, time varied.
And there were a couple of times i got off lithium and crashed.If you can come up with other theories that wont't fit the fascist psychopharmoclogy picture,
let me know.Squiggles
Posted by Squiggles on June 7, 2007, at 16:42:32
In reply to Re: The right to non-compliance, posted by linkadge on June 7, 2007, at 16:26:45
>
> As another topic, Tracy Johnson, a girl with no history of depression commited suicide when having to go through the hell of duloxetine withdrawl. Lots of people admit to feeling worse upon withdrawl of meds than they ever did prior to starting the medications.
...........Yes, it could be withdrawal. Tracy's death was so sad. I was very disturbed to read about it.
I'm not sure that withdrawal can be so sudden though, for suicide. I think it takes a week or so? Nor do i think that lithium after 6 months was withdrawal, but it's likely that it was below therapeutic level at that point. The symptoms were almost identical for what I was given it for in the first time. To stretch things, for your explanation, you would have to match those withdrawal symptoms after 6 months with the suspect withdrawal symptoms of Valium taken sporadically and not very often.I can't say for sure I know what was going on pharmacologically. One things seems sure though, and from a clinical point of view, relevant to one's health-- discontination is risky.
As for the greedy pharm companies- all corporations are greedy- that's why we have the FDA.
Squiggles
Posted by Quintal on June 7, 2007, at 18:16:20
In reply to Re: The right to non-compliance » Quintal, posted by Squiggles on June 7, 2007, at 15:43:28
The examples you gave appear to have studied the rate of relapse among hospitalised Schizophrenics and those with severe bipolar disorder, which is a different population entirely to people being treated as outpatients for depression. I've never opposed the notion that medication and hospitalisation is often necessary for people who suffer from psychotic disorders. Those people are more vulnerable and the decision to withdraw from medication is much harder to balance. But surely there should be no question that people who present themselves voluntarily to doctors in the hope of treating emotional pain or anxiety (which is most of the people here) have an equal right to walk away and reject any treatment which is ineffective or makes their suffering worse if they so choose?
Taking a subtherapeutic dose of a drug is totally different to taking no drug at all. Looking at the cases where psychiatric patients have suddenly become suicidal or committed murders for example, have most often happened either at the beginning of treatment before the onset of therapeutic effect, during withdrawal, or after a sudden dose increase, not several months or years after quitting the drugs completely. But obviously if lithium helps you of course it makes perfect sense to keep on taking whatever dose keeps you stable.
Regarding drug companies, conspiracy theories and the present state of the human condition, I'm tempted to quote the old adages "There's nothing new under the sun" and "There's nowt as queer as folk". I was quite impressed by my psychiatrist's view after pressing him on the subject "Yes, we know that drug companies not only hide information from us - they also lie". It's not only patients that are angry at the corruption of Big Pharma and the regulatory bodies.
Q
Posted by Quintal on June 7, 2007, at 18:30:21
In reply to Shades of Grey? » Squiggles, posted by Quintal on June 7, 2007, at 18:16:20
THE ROLE OF THE PHARMACEUTICAL COMPANIES
IN THE TREATMENT OF MENTAL ILL HEALTHMental Health North East (MHNE) AGM and Conference,
Bowburn Community Centre, DurhamProfessor C Heather Ashton, DM, FRCP
May 18, 2007The Ashton Manual · Professor Ashton's Main Page
Thank you for inviting me to speak today to Mental Health North East. I congratulate everyone involved in setting up this charity which I am sure will be a help to many in promoting services for mental ill health in this region.
I have been asked to talk about the role of pharmaceutical companies in the treatment of mental health. There is indeed an extraordinary entanglement between drug companies and the medical profession. On the one hand the drug industry develops new drugs and promotes drug use in order to make money. On the other hand the medical profession prescribes these drugs in order to help people. One might think that there would be a healthy symbiotic relationship between these two organisations. But sadly there is emerging evidence that this is not the case and that the relationship is especially unhealthy in the case of drugs used for mental ill health. This situation stems from faults on both sides, and also from government policy.
In the 1950s a whole host of psychotropic drugs - drugs that affect the mind - entered the medical scene. These included major tranquillisers such as chlorpromazine (Largactil), since developed into a range of antipsychotic drugs; antidepressants, tricyclics and monoamine oxidase inhibitors, now joined by the SSRIs such as Prozac; and so-called minor tranquillisers, the benzodiazepines, Valium and Librium, now including a number of Z-drug hypnotics such as zopiclone and others.
These early discoveries were very exciting at the time, as they seemed to promise a cure for all mental illnesses. Schizophrenics taking antipsychotics could be let out of hospital to live, apparently safely, in the community. Patients with depression could, allegedly, be freed from suicidal thoughts and from the perceived threat of electroconvulsive therapy (ECT). And the minor or major anxieties of life could be universally replaced with tranquillity and peaceful sleep induced by benzodiazepines. One eminent neurologist, Sir Henry Miller, even wrote that from now on all mental illness could be cured by a handful of pills and there would be no need for psychiatrists.
At the same time it was believed, by a sort of backwards logic, that the cause of mental illness would be revealed by these drugs. Antipsychotics were found to block brain receptors for the neurotransmitter dopamine; therefore schizophrenia must be due to an excess of dopamine. Antidepressants were shown to increase the activity of the neurotransmitter serotonin; therefore depression must be due to a lack of serotonin. Benzodiazepines increased the activity of the neurotransmitter GABA, so anxiety must be due to lack of GABA.
These naïve and simple hopes turned out to be false. 50 years later we still do not know the cause of schizophrenia or depression or even how the drugs work. The prognosis of these illnesses has changed little. And anxiety is as common as ever. It has become clear that the drugs do not cure any mental illness. They do control some symptoms but have little effect on the underlying processes. And, of course, the drugs carry their own disadvantages. But these same drugs have made billions of dollars for drug companies.
Following the new drug discoveries, there was a search in the pharmaceutical industry for new drugs acting on dopamine, serotonin or GABA. Once the basic work had been done, drug companies did not have to foot the cost of developing new drugs. It was much cheaper to manufacture "me too" drugs with similar actions. As a result, the world ended up with over 20 different but similar compounds in each class of antipsychotics, antidepressants and sedative/hypnotics. "You have to go where the market is", remarked one scientist working for a drug company.
And there was a change in the way drug companies were run. A pharmacologist working for Sanofi Pharmaceuticals said: "In the beginning, the pharmaceutical industry was run by chemists ... This was not so bad. [But] now most of them are run by people with MBAs, or things like that, people who could be the chief executive of Renault, Volvo or anything. They don't know about drugs." But clearly, they do know where the market is.
Another quote from the same pharmacologist: "When you find a drug that is really active on one receptor .... The problem comes when you present it to the financial analyst. You say 'I have a new drug, a very interesting antagonist of '[receptor X]' 'Good', says the financial analyst, what is the market?....' So you have to decide for what indication the drug should be developed, at what dosage, what will be the price of the drug and so on. This is totally stupid, but it's what you have to do." So it is the drug company chemist or pharmacologist who decides for what indication the drug will be developed. If the indication is not there, it must be created - in other words a disease suitable for the drug must be invented.
One of the many examples of this process was the development in the 1970s of Xanax (alprazolam), a very potent benzodiazepine, for panic disorder. The marketing of this drug involved a clear strategy to take advantage of the medical profession's current confusion about the classification of anxiety disorders and to create a perception that the drug (Xanax) had special and unique properties that would capture a market share of benzodiazepines that would displace diazepam (Valium) from the top position. There was in fact nothing unique in this regard about Xanax. All the benzodiazepines including Valium were good for panic attacks.
Xanax was marketed by Upjohn with approval of the FDA (US Food & Drug Administration) in doses of up to 6mg (equivalent to 120mg of Valium). There was no animal model of panic disorder so it was decided to try it out in a rather cavalier fashion on a small group of patients who had panic attacks. "It was dark; it was fall in Boston" recalled Dr. Sheehan, a doctor carrying out the first trial. "I particularly remember two sisters who were so phobic of medication that they asked if they might take it in my unit so that I could rescue them if anything bad happened... So they took two alprazolam tablets in the waiting room, waited for 30 minutes and then felt ok and decided to take the subway home. I was still in my office when I got a phone call. It was the two sisters; one of them had got a phenomenal effect, was sedated and ataxic and had to be helped off the train to get home. The second sister said "This is incredible, she's cured'". (She couldn't walk straight, but she was not panicking.)
"Another patient in this group, a dynamic executive type, phoned the next day and said to Dr. Sheehan: 'Doc, I am lying here on the couch in my office'. "Oh my god, that's terrible", he replied. 'No Doc this is not terrible at all', he said, 'I haven't felt this good in 10 years, you have no idea what a relief this is. I feel so calm, I just don't feel any anxiety, it's really wonderful'.
Then a further group of these patients in the study said 'Doc, this is amazing - there are so many panic patients out there in the world ... the company that makes this is going to make a fortune ... You should buy stock in this company - you won't have another opportunity like this."
History does not relate what happened to these patients if they continued to take Xanax long-term. But there is no doubt that Upjohn had a field day. Xanax duly overtook Valium as the most widely prescribed benzodiazepine. Xanax was dropped from the NHS limited list in 1985 (because of adverse effects), but it is still widely prescribed in 4-6mg doses in the US and I get calls every week from people having long-term problems with this potent drug.
Meanwhile alongside the development of Xanax, the confused psychiatrists were working on a new classification of anxiety disorders. Panic disorder (invented by the makers of Xanax) became a new separate anxiety state in the new Diagnostic and Statistical Manual (DSM III) published by the American Psychiatric Association in which, incidentally, 60-100% of the panel members had financial ties to the drug companies and today anxiety is still split into separate categories which include panic disorder, agoraphobia, social phobia, other specific phobias and generalised anxiety disorder. But of course people with generalised anxiety get panics and develop agoraphobia and people with panics have generalised anxiety and other phobias. The inference of the new classification was that these separate disorders respond to different drugs (opening a market opportunity for the drug companies), but in fact they merge together and they all respond to the same drugs including all the benzodiazepines and also to all the antidepressants including the old ones and the SSRIs like Prozac. If they all respond to the same drugs and the symptoms are common to all types, they clearly cannot be separate entities.
But of course you don't have to have anxiety to be prescribed a benzodiazepine. They have been prescribed for sports injuries, muscle spasms, premenstrual tension, exam nerves, depression, general malaise and much else. Because they make some people feel good at first, like the ladies on Xanax, these prescriptions tend to be continued long-term. I am sure everyone here knows how the long-term patients themselves - not the doctors or the drug companies - discovered that if you take benzodiazepines long-term you become dependent on them or, in common parlance, addicted.
How the dependence potential of the benzodiazepines was overlooked by doctors when it was clear that they could replace their predecessors such as the barbiturates is a matter for amazement and casts shame on the medical profession which claims to be scientifically based. Cross tolerance between different drugs, for instance between barbiturates and alcohol, was well understood at the time and clearly implied that if one drug could replace another it must have common characteristics and usually a common mode of action. But the similarity between benzodiazepines and barbiturates was ignored and doctors were urged to prescribe benzodiazepines. They complied with such zeal that benzodiazepines became for a time the most commonly prescribed drugs in the world. They were greatly helped by Hoffman-La Roche who attacked barbiturates in order to sell their first benzodiazepines Librium and Valium.
The backlash came when the patients themselves complained that the drugs were addictive, mainly because they got withdrawal symptoms if they tried to stop. Eventually, in the early 1980s controlled trials of such patients in the UK demonstrated beyond doubt that withdrawal symptoms from regular therapeutic doses of benzodiazepines were real and that they indicated physical dependence on the drugs. Finally, the medical profession accepted officially, on the grounds that they produced a withdrawal syndrome, that benzodiazepines were dependence-producing, i.e. addictive.
Not to be outdone, the drug companies rapidly produced a series of drugs that were not chemically benzodiazepines but produced the same effects. These were the Z-drugs zopiclone, zolpidem, zaleplon and now eszopiclone (Lunesta). They were marketed as sleeping pills but in fact have similar properties to benzodiazepines. They lead to dependence and, like benzodiazepines, cause a withdrawal syndrome. Yet 4-6 million of these are at present prescribed in the UK each year.
With the declining popularity of the benzodiazepines came a renewed interest in antidepressant drugs which led eventually to the SSRIs (selective serotonin reuptake inhibitors) - that we have today. It started as a deliberate tactic to displace benzodiazepines from the market. Drug companies sponsored large international symposia attended by 100s, sometimes 1000s, of physicians where speakers warned of the harm benzodiazepines were doing because of dependence and suggested that serotonergic drugs would work not only for depression but were also good anti-panic drugs and good in generalised anxiety, social phobia and even in post-traumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD).
Thus Prozac came on the scene and was so successful that five different drug companies vied to corner some of the market with "me-too" SSRIs that are cheaper to make. Calculations showed that if a drug company could get just 20% of the Prozac market it could make 400-500 million dollars a year with very little investment in research and development. The outcome of this is that we now have 5 other SSRIs in addition to Prozac including paroxetine, sertraline and others.
But there is a sting in the tail of this story too. After a while it became apparent from patients' experiences that SSRIs, like benzodiazepines, produced a withdrawal reaction when they were stopped. This is another example of the surprising ignorance on the part of the physicians. It was already known that the older antidepressants, tricyclics and MAOIs, produced a withdrawal syndrome which had been well described in 1984. Yet the doctors appeared to be taken by surprise by SSRI withdrawal effects.
As mentioned before, the benzodiazepines had been accepted as being dependence-producing, or addictive, on the basis of their withdrawal effects. Now there were clear withdrawal effects from SSRIs. In a scramble to prove that SSRIs were not addictive, psychiatrists actually changed the definition of drug dependence. Criteria for substance dependence were altered in the 1994 DSM IV by the American Psychiatric Association. In this edition, withdrawal effects alone were not enough. A patient now also had to have evidence of tolerance, dose escalation, continued use despite efforts to stop and other characteristics to qualify for dependence. And the withdrawal syndrome was replaced by the patronising euphemism "discontinuation reaction". As if a patient would think there was some subtle difference between "discontinuation" and "withdrawal".
I can't help feeling there is something Orwellian in these manipulations like the slogan in George Orwell's Animal Farm which started as "4 legs good; 2 legs bad" but when pigs started walking on their hind legs like men, the slogan was changed to "2 legs good; 4 legs bad". Or the addition to another slogan "All animals (or withdrawal effects) are equal - but some animals (e.g. pigs or discontinuation effects) are more equal than others".
So it seems that Big Pharma is slowly strangling the medical profession, like ivy growing up a tree, and forcing medical complicity with drug company aims, resulting in new definitions of dependence and even new classes of mental illness. How has the industry obtained this insidious stranglehold on the profession?
One method is to sponsor drug trials which are published in high impact medical journals. These trials are very carefully designed. They appear to be properly controlled trials but the new drug is often compared to a drug or treatment known to be inferior, or against a non-equivalent dose of a competitor drug. Then only the favourable results are published. Negative results are suppressed, such as those recently showing the suicidal tendency with SSRIs. Positive results from the same trial are published in multiple journals, giving them added weight. Drug companies will often purchase thousands of reprints of an article, giving the journal a profit margin of 70%. According to Richard Smith, editor of the British Medical Journal for 25 years, an editor may face a "stark conflict of interest: publish a trial that will bring in $100,000 of profit, or fire an editor to meet the end-of-year budget."
A second method is to woo doctors by funding conferences for academics at attractive resorts, upgrading their seats to business class on the plane, paying honoraria for talks, handing out free gifts and paying for expensive dinners. In 2005 Roche Products spent more than 71,000 Australian dollars on lavish dinners for 330 doctors at one symposium in Sydney. Doctors say that they are not influenced by such blandishments, but you can be sure that the companies would not go to such expense if it were not shown to be productive.
And then there are the drug reps who visit doctors in their offices. In the US drug firms employ around 100,000 reps at a cost of $5 billion/year. The tactics pay off - successful rep campaigns bring in more than $10 for every $1 spent.
The fourth method is by advertisement. There is abundant evidence that advertisement works. The more heavily advertised a drug the greater the sales, and the greater the number of prescriptions, compared to similar but less advertised drugs. More worryingly, the apparent incidence of the illness at which the drugs are aimed also increases. According to Professor David Healey, the effective incidence of depression, OCD, social phobia and PTSD has increased one thousand-fold worldwide since 1980. And now there is direct-to-consumer advertising, at least in America, which has increased the demand of patients to their doctors, who are often compliant with patients' wishes. Furthermore, prescription drugs can be obtained on the internet and some herbal products surreptitiously include prescription drugs.
A combination of drug company promotions and doctors' overprescribing has led to some tragic results, such as prescribed drugs entering the illicit drug scene. Nowadays most illicit drug abusers also take, and may inject, benzodiazepines - which can result in limb amputations, HIV infections and hepatitis C - among other complications.
It seems clear that money, not science, is driving pharmacology. Yet the drug companies are the only ones with the funds to conduct large drug trials and to develop new drugs which can, and have, saved many lives; and doctors persist in the belief that a drug will be found that is the answer to each mental illness. There appear to be failures in the whole system under which we have insidiously come to operate. What can be done about it?
One measure we could take is to separate the pharmaceutical industry from health care policies. In 2005 the House of Commons Health Committee issued a definitive report entitled "The Influence of the Pharmaceutical Industry". The conclusions were damning. The report states: "The Department of Health has for too long assumed that the interests of health and the [pharmaceutical] industry are one". In practice the industry affects every level of health care provision from the licensing of new drugs, to the promotion of drugs to prescriber and patient groups, to the prescription of new medicines and the compilation of clinical guidelines.
The crux of the problem is that the Department of Health sponsors both the drug industry and public health matters. The Health Committee wisely recommended (among other things) that the sponsorship of the drug industry should pass to the Department of Trade and Industry while the Department of Health should concentrate solely on public health.
This seemed like a sensible and hopeful development but the government rejected this recommendation. So the same Department, indeed the same Minister, responsible for negotiating drug prices for the NHS is also responsible for ensuring that Health Service spending on drugs is sufficient to keep the UK drug industry profitable. Sadly, patients' welfare will remain vulnerable while government health policies and practice are dominated by the will of Big Pharma.
However, the medical profession should take much responsibility for allowing the present situation to arise. They have been too easily persuaded by the drug industry and have been guilty of decades of thoughtless prescribing. Therefore we need to increase our efforts to train medical personnel better in more careful prescribing and also in the management of withdrawal in patients dependent on benzodiazepines or SSRIs. We should perhaps train more clinical psychologists and counsellors to improve non-drug or psychological therapies, particularly for anxiety disorders and depression, and to improve social adjustment in schizophrenia.
Secondly, we also need to train doctors and nurses and drug company personnel to listen to patients more. Listening to patients seems to be a lost art. In the present system, GPs do not have enough time with 10-20 minute appointments (at which the patient is allowed to voice only one complaint) and doctors are more influenced by results from high-powered investigations and drug advertisements than by what patients say. Many are overworked by the need to keep up with government targets.
Nurses are too few and there are more hospital administrators than there are nurses and more managers than there are physicians or surgeons. There is little communication between all these different supposed health care workers. Where are the "joined up" policies the government is always recommending? There is a need for projects like this one to foster better communications between the different people involved in mental health care.
In addition, perhaps we should turn our attention beyond the idea of drugs as cures for mental illness and look more in our research towards causes and prevention. These days it is very hard to get a grant in universities, either from independent bodies like the MRC or from drug companies, for research which explores new and original ideas and does not have an immediate application or clearly lead to a defined or lucrative outcome. Yet it is basic research that leads to scientific breakthroughs. There have been no breakthroughs in mental health for 50 years.
Finally, the public, that is all of us, should keep up the pressure on the authorities and should publicise what we see and hear every day from patients and health care workers. I don't think that the powers that be who set government targets about hospital turnover, waiting lists, NHS spending and who have appointed so many administrators, have any idea what goes on in the lives of individuals who, through failures of the whole present system, are driven outside the system to seek advice from voluntary organisations. I am sure that this organisation has the potential to improve mental health care in many spheres.
http://www.benzo.org.uk/ashdurham.htm
Q
Posted by linkadge on June 7, 2007, at 19:13:23
In reply to Re: The right to non-compliance » linkadge, posted by Squiggles on June 7, 2007, at 16:35:42
Not to dismiss your case, but both me and my mother got that same batch you are talking about in canada.
Everbody reacts differently, but we didn't notice any difference.
Linkadge
Posted by linkadge on June 7, 2007, at 19:20:25
In reply to Re: The right to non-compliance » linkadge, posted by Squiggles on June 7, 2007, at 16:42:32
>I'm not sure that withdrawal can be so sudden >though, for suicide.
Withdrawl from antidperessants can happen after the first dose! Lilly probably took her down from like 200mg to 0 in a day or two.
>I can't say for sure I know what was going on >pharmacologically. One things seems sure though, >and from a clinical point of view, relevant to >one's health-- discontination is risky.But people can make their own decisions. This isn't THX-1138. If people don't want to be on drugs, and they want to off themselves, so what? Its their life.
If life on the drugs was honestly better, then they'd stay on the drugs, thats my take. People usually come off the drugs because they're not working, or that they feel better off them.
If I was to off myself, I don't think drugs would make a difference. Infact the times that I came closest was when I was on these drugs. Lithium is one of the only drugs that has any proven antisuicide effect, the case for other drugs is highly equivocol.
>As for the greedy pharm companies- all >corporations are greedy- that's why we have the >FDA.
Yeah, well I don't think much of them either.
Linkadge
Posted by linkadge on June 7, 2007, at 19:22:35
In reply to Re: The right to non-compliance » linkadge, posted by Squiggles on June 7, 2007, at 16:42:32
The case for these drugs is so weak! Perhaps they'd have better luck forcing people to take placebos, both from the standpoint of efficacy and tollerability.
Linkadge
Posted by Squiggles on June 7, 2007, at 19:26:09
In reply to Shades of Grey? » Squiggles, posted by Quintal on June 7, 2007, at 18:16:20
Agreed -- though generalizations apply to
all cases, and that may be a mistake.Squiggles
Posted by linkadge on June 7, 2007, at 19:27:20
In reply to Shades of Grey? » Squiggles, posted by Quintal on June 7, 2007, at 18:16:20
I think that even people with psychotic disorders diserve the right to make their own decisions about medications.
Where would we be if people like John Nash were forced to take medications?
In addition, the rates of remission for things like Schizophrenia are higher in some less developed countries where medications are scarcely prescribed.
I think fewer drugs would probably lead to more recoveries. In a lot of cases, medications hinder recovery.
Linkadge
Posted by Squiggles on June 7, 2007, at 19:30:28
In reply to Re: Shades of Grey?, posted by linkadge on June 7, 2007, at 19:27:20
You may think this outrageous, but after
reading his bio, i just got the feeling that
John Nash never had any psychiatric disorder,
except perhaps being in the Asperger's spectrum
early on. I think he made it up to pursue his
passion.Squiggles
Posted by Bob on June 7, 2007, at 19:30:48
In reply to Re: The right to non-compliance, posted by linkadge on June 7, 2007, at 19:20:25
> >I can't say for sure I know what was going on >pharmacologically. One things seems sure though, >and from a clinical point of view, relevant to >one's health-- discontination is risky.
>
> LinkadgeI second every word of what Linkadge says there. He's making some awfully good points. Indeed, if these drugs were so tolerable and effective, they truly would be making feel better, and there wouldn't be a constant insidious drive to get off of them. I too never came closer to suicide than when discontinuing a drug. Unfortunately, it seems I need to continue with the miserable compromise of a life on psychotropics.
Posted by linkadge on June 7, 2007, at 19:42:37
In reply to The Role of Pharmaceutical Companies............., posted by Quintal on June 7, 2007, at 18:30:21
Posted by linkadge on June 7, 2007, at 19:44:49
In reply to Re: Shades of Grey? » linkadge, posted by Squiggles on June 7, 2007, at 19:30:28
I read the book. I don't see how Nash could have made something like that up.
Didn't he undergoe ETC?? I don't think Nash would risk his brain in such a way if there wasn't something there.
Just because somebody gets better without drugs doesn't mean their illness wasn't genuine.
Linkadge
Posted by Squiggles on June 7, 2007, at 21:04:17
In reply to Re: Shades of Grey? » Squiggles, posted by linkadge on June 7, 2007, at 19:44:49
> I read the book. I don't see how Nash could have made something like that up.
Not necessarily malingering but crashing;
>
> Didn't he undergoe ETC?? I don't think Nash would risk his brain in such a way if there wasn't something there.
>
NO! His wife ordered the drs. not to mess
with his "beautiful mind". He went to live
with her after he tired of the hospital, as you may recall in the book.
> Just because somebody gets better without drugs doesn't mean their illness wasn't genuine.True, but whatever it was, it was transient.
I doubt that is the case with clinical depression
and manic-depression.Squiggles
Posted by linkadge on June 8, 2007, at 6:42:33
In reply to Re: Shades of Grey? » linkadge, posted by Squiggles on June 7, 2007, at 21:04:17
>True, but whatever it was, it was transient.
>I doubt that is the case with clinical depression
>and manic-depression.A single episode of clinical depression rarely lasts longer than 8 months. Nash was out of it for longer than that.
And like I said in previous posts, the recovery rate for shizophrenia is higher in some less developed countries where antipsychotics are not used.
So there is not a doubt in my mind that this may not have been shizophrenia or some other serious mental illness that improved over time.
Linkadge
Posted by linkadge on June 8, 2007, at 6:45:17
In reply to Re: Shades of Grey?, posted by linkadge on June 8, 2007, at 6:42:33
According to:
http://www.namiscc.org/newsletters/February02/JohnNashDrugFreeRecovery.htm
But as Sylvia Nasar notes in her biography of Nash, on which the movie is loosely based, this brilliant mathematician stopped taking antipsychotic drugs in 1970 and slowly recovered over two decades.
So he did take them for a point, and he didn't recover over night.
Linkadge
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