More Thoughts on Psychiatric Medication

April 24th, 2011

I Should Have Mentioned Placebos!

Some years back a manager did not favour some of my writing similar to the essays on this site. That person essentially said, “I find it difficult to believe that people can get better from psychosis without medication.” Such is the influence of the medical paradigm. Fear was being expressed that patients may stop their antipsychotic medication and this was the only possible way they may get well.

    We live in a society where many people think the answer to problems will be medication.

I didn’t think to tell that manager that people recover from psychosis without antipsychotic medication, frequently. The evidence is in clinical trials – placebos are given to contrast the active medication being studied. Earlier I wrote (my essay, “Some Thoughts on Psychiatric Medication”) that in one meta-analysis of chlorpromazine (an antipsychotic medication that was used extensively for years,) in 11 of 55 clinical trials (17%) placebo was as effective as the drug. (Ref. Ch. 2, P.86. Errors of Logic in Biological Psychiatry, in Colin A. Ross and Alvin Pam, “Pseudo-Science in Biological Psychiatry: Blaming the Body.” (John Wiley & Sons Inc, NY. 1995)

Further on P.86 Ross & Pam cite another large study involving Chlorpromazine – the improvement of the drug over placebo was ‘one point’ on a 7 point rating scale – this means that on average the drug was more helpful, but certainly individual scores would have shown some clients improving markedly on placebos, while others did poorly.

It is obvious when one thinks about it, that many people improve without antipsychotic medication. People get better from all sorts of ailments when given placebos, even cancer (see footnote), so we should not regard psychosis as exceptional. A former colleague, who later worked as a drug representative in the psychiatric field, mentioned improvement seen by placebos has increased over the years – as a culture are we more believing of science and medicine, and hence the effect of placebos?

Change After ‘Long Term Treatment’

I have referred to Jay Haley (in my essay, There’s an Underlying Biological Illness.) In his early time as a therapist he learned the customary “talk therapy.” He was treating an adult woman for depression and over many months she improved. He pondered over the fact that during the period of therapy she entered into a relationship, she changed jobs, and there were other significant changes she made. Was she no longer depressed because of therapy, or because of the changes she instigated?

She may have made the changes because of the therapy and consequently became less depressed. Or maybe she would have made those changes regardless, and got herself better. Haley realised that with long term treatment, many things change in a person’s life and it is not possible to reliably attribute improvement to therapy. This spurred Haley towards his interest in short term methods – if change then results, therapy more likely was important.

This also applies to long term drug therapy. Large numbers of psychiatric clients are treated for years. Some are compelled by legal orders; some are detained to hospital numerous times, and coaxed by staff and/or families to comply with the prescribed medication. When in hospital staff are required to manage behaviour and influence patients to behave acceptably.

Both in hospital and when followed up by community appointments, a patient’s behaviour is modified. S/he learns that there are behaviours which will result in certain consequences or rewards. For instance in hospital, staff may take control of the patient’s cigarettes. If one ‘misbehaves’ it may be more difficult to get another cigarette. If one is combative to staff, one may be roughly treated or punished in some way to deter any repetition. If one is troublesome in the community, one may find oneself detained to hospital. If one finds hospital a negative experience, it will act as a deterrent. If one finds hospital a positive experience and one has too many admissions, staff will seek to deter admissions and manage unwanted behaviour in other ways.

There are many ways that patients’ behaviours are influenced over years of treatment. When some patients, who were previously difficult to manage, become easier to manage after months or years, we might assume that the medication has improved the situation. Almost certainly many other things have played a part…the parents or spouse may have changed their attitudes or expectations, the person may have made different friends, got onto a disability pension and no longer be pressured to work….etc.

    How do we know that the psychiatric drugs are effective, and it is not the other influences?

Mounting Evidence

A search on the net will quickly find an unending supply of studies and reports which question the validity of drug effectiveness claims, and the questionable behaviour of drug companies.

From a site by John H. Grohol http://psychcentral.com/ referring to studies using antidepressants with people diagnosed with bipolar disorder:

“The most surprising finding, though, was that the placebo outperformed the antidepressants in the study in helping to relieve depressive symptoms.

27% percent of patients getting a placebo held off depression for at least 8 weeks during the 26-week study while antidepressants only worked in 23.5 percent of patients.”

Reference
http://psychcentral.com/blog/archives/2007/12/21/mental-health-year-in-review-2007/

From a site www.clinpsyc.com there is a blog entry about Zoloft, a leading antidepressant medication, and used for Post Traumatic Stress Disorder:

“Convenient Honesty and Zoloft (1. Ref Below)Recently, a study (2. Ref below) was published which cast doubt on the efficacy of sertraline (Zoloft) for PTSD, finding that the drug was no better than a placebo.

‘The kicker is that the patent has expired for Zoloft, which is why the data are now flowing more freely. I’ll make the case here that data were buried until they would no longer hurt sales to any meaningful extent, at which point data were published, at least partially as a public relations move to show just how “honest” the companies are with sharing both positive and negative results with the psychiatric community.

“The Research: The latest study, (Reference 2) which appears in the May 2007 Journal of Clinical Psychiatry, showed no benefit for drug over a 12-week period. Placebo tended to outperform Zoloft on the majority of outcome measures, though the differences were of a small and statistically insignificant degree. Patients were significantly more likely to drop out of treatment on Zoloft. It was unclear if there were any serious adverse events (e.g., suicide attempts, notable aggression, etc.) because the article did not mention them at all. Patients started this study between May 1994 and September 1996. The original draft of the study was received by the journal in March 2006. Nearly 10 years passed between study completion and writing up the data for publication.

“Two prior studies found positive results for Zoloft and were published quickly, while these negative results languished until the Zoloft patent had expired. One earlier positive study did not list the dates during which the study occurred, but it seems clear that it was rushed to publication much quicker than the negative study. Another positive study was conducted between May 1996 and June 1997 and was published in 2000. It’s quite obvious why the positive studies were rushed to press and the negative study languished, is it not?”

Reference
http://clinpsyc.blogspot.com/2007/05/convenient-honesty-and-zoloft.html

Also from www.clinpsyc.com there is a blog entry about another common antidepressant, Paroxetine, and its use with children:

“Dr. Graham Emslie, who has participated in a number of psychiatric drug trials for children, appeared in a brief interview clip on an Austin TV station’s investigation into SSRI use among children. Emslie was contracted by GlaxoSmithKline as an investigator in a study examining the effects of paroxetine (Paxil) on child/adolescent depression. As such, he was aware that data showed that Paxil was no more effective than a placebo, but (and here’s the killer quote):

“I couldn’t talk about it because it was proprietary.

“In other words, Emslie had an agreement with GSK that he would not share their trial data without GSK’s permission, even when it showed that Paxil was no more effective than a placebo and related to poorer safety outcomes than placebo.”

Reference
http://clinpsyc.blogspot.com/2007/01/one-quote-says-it-all.html

Conclusion

Are we using psychiatric medication too much? Are staff confident that they have other skills to offer, if clients do not want medication? If not, what is being done to raise the skill level, so that consumers have choices when seeking help for their concerns?

(The End.)

References

1. http://clinpsyc.blogspot.com/2007/05/convenient-honesty-and-zoloft.html

2. Randomized, double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department of Veterans Affairs setting http://www.ncbi.nlm.nih.gov/pubmed/17503980?dopt=Abstract

Footnote

[For those interested to read a powerful article about the politics of cancer treatment, and many references pointing to alternatives to chemotherapy being worthy of consideration, see “DoCS – STEALING OUR CHILDREN FOR MEDICINE? One Australian Family’s Nightmare Loss Of Health Freedom,” by Eve Hillary. http://www.evehillary.org/docs.stealing.children.revised.1.htm


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