Sunday, December 10, 2006

Do Antipsychotic Drugs Control People?

"Antipsychotic drugs do not override personal choice, intentionality, or 'control' the people who receive them. On the contrary, abundant evidence suggests otherwise." So says research done by Yale University School of Medicine Psychiatry Working Paper Series. This is a fascinating paper written by Steven K. Erickson, J.D., LL.M., Ph.D. at Yale University and his colleagues that takes a look at the legal fallacies of antipsychotic drugs. Take a look.

40 Comments:

Blogger Evan M. Thomas said...

My father took antipsychotic drugs for most of his adult life. It turned into a cycle of on and off medication. It wasn't until close to his death that his doctors figured out why.

Once the medication got him back being relatively normal, he became self-aware of his psychotic nature and this lead him into a deep depression. Once in his depression he'd go off his meds.

11:36 AM, December 10, 2006  
Blogger Helen said...

evan m. thomas:

I have found this to be the case with patients, in fact, many with bipolar disorder go off their meds as it actually made them "too normal." I think it does not feel right to many who are mentally ill to feel normal.

11:47 AM, December 10, 2006  
Anonymous JustALayman said...

Reading this paper, it sounds to me like the psychiatrists and the lawyers are talking past each other. In particular, the authors seem to take umbrage at the use of terms like "artificial" and "synthetic" when used to describe the mental state of patients who are on antipsychotic medication. In context, though, those terms are correct.

Take the case of the schizphrenic individual who was sentenced to death. The court involuntarily administered antipsychotics, which had the effect of making him appear competent at trial in the eyes of the jury. To that extent, the sanity the jurors observed in the courtroom was artificial, in the sense that it was not a feature of the defendant's unmedicated behavior and abilities at the time the crime took place.

Imagine a case where a defendent claims he could not have committed a particular crime because his extremely arthritic hips would have made it ipossible for him to have chased down a victim. Before trial, the government involuntarily performs hip replacement surgery, so that at trial the jury sees the defendant walking in and out of the courtroom with no apparent difficulty. Would this make it harder for a jury to buy the defense case? Probably so. The defendent's ability to walk normally would be "artificial" and "synthetic" to the issue the court needed to assess.

11:54 AM, December 10, 2006  
Blogger intension said...

What about bipolars? I've read there's a link between bipolar and creativity. If drugs reduce mania, which seems to be when most bipolar work is done, then what are the impacts on society of drugging away creativity in bipolars? Would it have had an impact on society if Isaac Newton had not formulated his laws of motion?

Of course, bipolar disorder can be harmful, so there might be a cost/benefit analysis to weigh. I suggest however, instead of drugging bipolars, that we house them comfortably in environments that augment their creativity while keeping them safe.

Specifically male bipolars should be put in rooms with books, music, television, pencil, paper, a full refrigerator and access to unlimited sex. This would keep them calm and occuppied while allowing for maximum creativity.

(Can you guess my gender and mental disorder?) ;)

11:55 AM, December 10, 2006  
Blogger Helen said...

"Can you guess my gender and mental disorder?"

Oh no, it's not obvious at all.

12:00 PM, December 10, 2006  
Blogger Editor Theorist said...

This paper is tragically wrong, although as a young psychiatric trainee 20-some years ago I would have agreed that anti-psychotics/ neuroleptics were mind-saving.

The fact is that anti-psychotics do not cure, but supress symptoms by blunting emotions - in effect they induce a (more or less mild) version of Parkinson's disease.

Patients in under-developed countries which do not use antipsychotics actually have a better outcome than they do in the west. And the modern 'atypical' antipsychotics at least double death rates from metabolic and other causes, and have had-to be banned from use in the elderly by the FDA.

But the accumulated knowledge of several decades has made it clear that these drugs probably harm more people than they help. I have recently published on this:

http://www.hedweb.com/bgcharlton/neuroleptics.html

By any normal criterion it is frankly absurd to deny that anti-psychotics are mind-altering - one would only have to take a small dose of these drugs for oneself, or observe the behaviour of someone who did (for instance their blank 'Parkinsonian' facial expression and their demotivation), to know that they are mind-altering in an emotionally-blunting way. This effect was found - for example - by the discoverers of haloperidol (Paul Jannsen and colleagues) who could self-detect half a milligram of the drug in a blind trial (the recommended dose of this drug goes up to 10 or more milligrams).

For more see David Healy, The Creation of Psychopharmacology, Harvard Univesrity Press, 2002.

12:11 PM, December 10, 2006  
Blogger Michele said...

Risperdal has been approved for autistic children's meltdowns and rages. (the study was done on an extremely small group of autistic children) The fear of making a robot out of my child keeps me from going this route, and there are also so many frightening side-effects. I don't even really know what these drugs do to the brain, and whether it would kill some of the gifts that come along her diagnosis. I guess it is really the fear that the drug would control her, and somehow alter her that keeps me from using it. It's really much safer for us to try to stay out of environments that set off these rages.

I generally don't trust these studies. How do you quantify "personal choice" or "intentionality"? I usually ask other mothers in the same situation to share their advice about medications, diet, and therapies. Between us we find out what works and what doesn't. We love the children we study, so we have big vested interest in getting it right.

1:26 PM, December 10, 2006  
Blogger Seneca the Younger said...

Le tme recommend Peter Kramer's Against Depression for a long and thorough --- and I think convincing --- philosophical discussion of this issue.

Reduced to a sound bite, the argument is basically that we don't consider controlling diabetes as an "artificial" or "unnatural" thing. How can we suggest that not controlling a psychiatric patient's disease is somehow desirable, when it causes them real misery and tends to kill them young?

As a double-depressive who has had wonderful results with the meds, I think I'd even rephrase that "how dare we suggest...".

1:53 PM, December 10, 2006  
Blogger Helen said...

Seneca the younger,

I agree with you--I have often used that metaphor with patients. If they had diabetes, would they leave it untreated? I highly doubt it. I have also seen great results with medications with patients and I cannot understand why some people are so dead set against using them in mental illness. The suffering in mental illness can be tremendous and to leave it untreated or unmedicated is often to play Russian Roulette with one's live or the lives of their families. There is a recent news story about a mother who would not take her antidepressants as she was breast feeding her two year old; she jumped off a bridge with the two year old in tow. Think what would have happened if she had taken her medication, maybe she and her son would still be alive.

1:59 PM, December 10, 2006  
Anonymous Anonymous said...

I myself have take both Prozac and Paxil during different periods of depression. I was always deeply disturbed by the psychiatrists' use of the diabetes metaphor.

I can't speak to all mental disorders; only my own. Let me be clear on that. But sometimes, depression is warranted. Not everything can be bright and sunny.

When I took Paxil in particular, I found that it moderated my mood swings, but nothing felt good. Just gray. Maybe that is better than being severely depressed. And it made me gain quite a bit of weight, which didn't help matters.

I do think some people merit drug therapy. And who else could diagnose, but psychiatrists? Still, we have a big movement in this country to dope people at every turn. Kids too loud in class? Ritalin. Depressed after your divorce? Paxil. And so on.

2:13 PM, December 10, 2006  
Blogger Helen said...

Anonymous 2:13:

I think part of the problem is that sometimes drugs are used too much and other times, too little. The good practitioner knows how to diagnose a particular mental illness and what, if any, meds are needed. In the case of a situational depression, such as divorce, etc. no meds may be necessary, same with a kid too loud in class etc. However, if depression turns to suicidal thoughts and worse, antidepressants might be warranted. I see people who need medication who are not treated and those who do not need medication who are. Telling the difference and treating each case effectively is the key.

2:18 PM, December 10, 2006  
Anonymous Nom dePlume, Ph.D. said...

As both a consumer of psychotropic medications, and a frequent writer on the subject, I have to say that they are wonderful resources to have. I owe both my life, and my quality of life, to them. These medicines have restored me to myself, and I am very grateful.

Having said that, I must also add that, like all powerful medications, their inappropriate use can cause serious problems. In such cases, I would say blame not the medication, but the practitioner.

Sadly, sometimes even appropriate use can lead to serious problems. It is a sad truth that patients who take antipsychotic medication are at risk for diabetes and tardive dyskinesia.

Of all the psychotropics, I believe that antipsychotics are the most dangerous, and least satisfactory. We need better treatments, but the solution is not to throw out the good that we have, but to continue the research and development needed to find better. In the meantime, even our imperfect medications offer enormous benefits to many.

2:24 PM, December 10, 2006  
Anonymous Anonymous said...

Combining the legal criminal system and the medical psychiatric system rarely seems to work well for the individual subjected to the combination. Perhaps this is because the cases where it does work well don't get much attention.

I've been on anti-depressant drugs, off and on, for about half of my adult life. I think that they have probably saved my life, in preventing suicide, and this was a GoodThing. I think they've also turned me into a raving -- but non-violent -- monster, which was a BadThing. Bouncing from drug to drug as insurance plans changed their desired drug substitute lists while being treated for epilepsy and depression is not good. Moving from "generic" to "real" drugs doesn't always help. People, it seems, are more complicated than advertising and testing and have a larger range of responses than "better" and "worse".

What really helped, IMAO, was outgrowing the epilepsy and then being treated (at 55) with Strattera for ADD. I still wonder if I'm not borderline bi-polar, but I'll let the doctors worry about it.

Forcing someone to be drugged so that they can "participate" in a trial -- or execution -- makes a mockery of both justice and the idea of "show trial".

htom ("p" tag is not allowed?!)

3:10 PM, December 10, 2006  
Anonymous triticale said...

"Can you guess my gender and mental disorder?"

I could see where a female who was a nymphomaniac might suggest providing manic males with axcess to unlimited sex.

3:42 PM, December 10, 2006  
Anonymous Anonymous said...

At age 56, I finally took enough Paxil to realize that most of the traits about myself that I wished to change were due to mental illness, and not any deficiencies in my personality or desires. Since being on Paxil, my experiences have been mostly of a positive kind. I do have some sleep trouble and some trouble losing weight, but they are entirely outweighed by the positives, including lack of panic attacks, no O/C disorder, overcoming phobias and social phobia.

At least from my experience, the study is dead right.

6:49 PM, December 10, 2006  
Anonymous Venomous Kate said...

There is a distinction between anti-psychotic medications and anti-depressants. My understanding is that the article specifically addresses anti-psychotic medications, which are the phenothiazines or butyrophenones. Anti-psychotics are used to treat disorders such as schizophrenia and other disorders which involve acute loss of contact with reality. Depression, on the other hand, is a dysfunction which allows a person to remain in contact with reality, although that reality may seem overwhelming or fraught with danger/disappointment.

Anyway, just thought I'd throw that into the mix. I hope Dr. Helen, who's infinitely more qualified than I, will correct me. As a patient who's recently been prescribed Cymbalta, I wanted to offer this up for the sole purpose of sharing that anti-depressants aren't used to "control people" and their perceptions of reality (to paraphrase Norman O. Brown) so much as to mediate peoples' reactions to their reality, the receipt of which a true psychosis would prevent them from receiving.

8:09 PM, December 10, 2006  
Blogger Graham Strouse said...

Tell me what the accepted definition of a disease is under the conditions imposed by non-psychiatric medical authorities.

After that, please tell me the criteria required for a mental disorder to be registered in the Diagnostic Statistical Manual.

Now tell me what the medical & psychological professions proscribe against members who violate conflict-of-interest while work for Big Pharma.

There may be a quiz.

8:12 PM, December 10, 2006  
Blogger Helen said...

Venomous Kate:

Yes, there is a distinction between antipsychotic and antidepressant meds. Basically, antipsychotics are those meds used to treat those who suffer from psychosis--delusions or hallucinations. Around 1990, newer antipsychotic medications have been used in this country. These include Clozaril, Risperdal, Zyprexa, Seroquel, and Geodon. These meds are referred to as atypical because they have lower risks of side effects such as tardive dyskinesia which are abnormal movements. In addition to psychotic symptoms, these drugs can be used for rage attacks, mixed-irritable moods, and very rapidly cycling moods such as what we see in those with bipolar disorder. Antidepressants can treat depression, anxiety, and panic disorders. It should be noted that one can have a depressive disorder with psychotic features or a bipolar disorder with psychotic features that can also be treated with antipsychotic meds--even though the person does not have schizophrenia etc.

8:31 PM, December 10, 2006  
Anonymous Vicki Small said...

I have no experience to offer, except as a close-up observer in the distant past. My father was, for periods of time, psychotic; the rest of the time, he was a mess and undiagnosed. Except when he was hospitalized, I don't think he ever took medications. This was back in the '40s and '50s, so I don't know what was available.

My first husband finally had to start taking antidepressants, and I know that he still takes them, some 30 years later. They helped, but no, they were no substitute for personal choice. I hope he has also learned better coping skills than he had while we were married.

Years later, I was acquainted at work with a wonderful man who was bipolar. Gentle, kind, possessing a dry sense of humor, and highly intelligent, when he was on his med's and they were working. Otherwise--about this time of year, twice while I knew him--he was acutely psychotic. Writing instruments and paper? My Lord, numerous times, he brought in cartons filled with paper on which he had covered every space with his ranting, hallucinatory, suicidal, sexual ideation. Without medications, I expect he would have killed himself, years earlier, possibly taking someone with him. It was so sad to see him so far from what I believe was his real self. Thank God for the medications that were available.

10:47 PM, December 10, 2006  
Anonymous Anonymous said...

No psychotropic medication is going to help someone that was falsely or fraudulently diagnosed.

Medication should be voluntary. Forced involuntary medication is a crime, tort, and violation of human rights.

12:25 AM, December 11, 2006  
Blogger jw said...

I wonder about some of the things the authors say ...

I take seroquel for off-label use. Without meds I do not sleep enough, no where near enough. After a few weeks of almost no sleep I become so anxious and just plain weird that I effectively cannot do anything. Seroquel and carbamazepine taken together allow sleep. Why? No idea ...

What I do know is that there is for me and the people who know me, there is no difference in my waking behavior or actions. I see no effect, other than I do sleep, not much, but enough to get by. Mind you, some of the long term side effects are very scarey and that is a worry.

So, to me, the statements about the drugs changing behavior seem quite strange. I've seen the effect these drugs have on psyotics and they are amazing. Yet, at least for Seroquel, there seems little or no change in my behavior, thinking or actions.

I cannot balance the two concepts ...

4:30 AM, December 11, 2006  
Anonymous bugs said...

People who whine about antipsychotic drugs - and psychiatric drugs in general - shouldn't talk until they've lived with one of the conditions the drugs were designed to treat.

10:59 AM, December 11, 2006  
Anonymous Anonymous said...

People who whine about antipsychotic drugs - and psychiatric drugs in general - shouldn't talk until they've lived with one of the conditions the drugs were designed to treat.

It's funny, bugs. The people you mention actually have better outcomes when they live in a less affluent country that can't afford all the fancy brain candy.

And no, you don't have to "walk in the shoes" of a mentally ill person to realize its assault when a falsely or fraudulently diagnosed person is pointlessly pumped full of these dangerous medications of dubious effectiveness.

2:02 AM, December 12, 2006  
Anonymous ten thousand screaming edgar allen poes said...

"Yes, there is a distinction between antipsychotic and antidepressant meds."

Generally, yes. However, it is not generally recognized that the tricyclic antidepressants do seem to have weak antipsychotic effects, with amoxapine being strong enough to carry a tardive dyskinesia warning. Their weight gain side effect is also suspiciously neuroleptic in nature.

"People who whine about antipsychotic drugs - and psychiatric drugs in general - shouldn't talk until they've lived with one of the conditions the drugs were designed to treat."

Or taken the drugs off-label for a neurological condition not normally considered "crazy". I highly recommend Topamax if you want to experience having your mind taken away from you.

2:34 AM, December 12, 2006  
Blogger a psychiatrist who learned from veterans said...

Thanks Helen. This paper is a nice review, which has items actually to teach clinicians. May it be useful for its court audience and, in general, I think it reduces, but does not eliminate, suspicion to have these papers openly available. Logically, I thought it might have been of interest to include in the discussion the McNaughton rule, which might also put courts in a better light. In this first case in which the (English) judge failed to convict, for reason of insanity, the evidence was that Mr. McNaughton believed that the Scottish ambassador was conspiring to kill him. In fact, the ambassador had no knowledge of him; however the court ruled that McNaughton's action would have been self defense were his delusion correct; so the murder charge was inappropriate. 'Nature' is more mind altering than psychiatric drugs.

9:42 PM, December 12, 2006  
Anonymous Anonymous said...

Great topic. I'm quite interested in this, as I have a diagnosis of bipolai II and have taken Lithium, which was great except when I weighed 185 (I'm a 5'10" woman) and now take trileptal. Both have had profound stabilizing effcts on my mood, in an entirely positive way. I never had any psychosis (hence the bipolar II), but the insomnia that came with the manic phases was wearing me out, and the depressive phases could sometimes be debilitating.

However, I do sometimes wonder whether I really "need" to be taking the drugs. I seem to need the meds to keep me productive at work and calm at home, to help in not alienating myself from my co-workers in a job where effective communication is essential, and keep me from blowing up at my toddler or screaming at my spouse. However, if I cut out the major source of stress in my life, namely my job, maybe I'd be fine.

In other words, sometimes I wonder if I am using Trileptal as a professional performance enhancement drug.

10:01 PM, December 12, 2006  
Blogger Scot said...

I'm dually diagnosed, in that I am both a mental health professional and bipolar. I take a lot of depakote in maintenance mode to keep the mania at bay, and very small doses of Zyprexa when I get psychotic or severly depressed.

The question of whether they change my personality is a sticky one. My personality is bipolar. I think you almost have to be bipolar to really understand that. Zyprexa makes me feel boring and bland, but there are times that is a good thing; like it makes me sleep when I'd go days without sleep otherwise.

I'd rather be bipolar than boring 95% of the time, because I wouldn't want to live if I couldn't be creative and passionate. I'ts just who I am. But, I'll take boring over halucinations and raging suicidal depression. Just my .02 cents.

Scot

2:06 AM, December 16, 2006  
Blogger Stephany said...

.."People who whine about antipsychotic drugs - and psychiatric drugs in general - shouldn't talk until they've lived with one of the conditions the drugs were designed to treat."

I agree. I've seen antipsychotics destroy a family member/ and I've used Seroquel for insomnia. I had horrific withdrawals; and am better off w/out antipsychotics; speaking from a bipolar point of view, and as a mother of a complex dx young adult.

11:19 PM, May 07, 2007  
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12:07 AM, June 08, 2009  

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