De-mystifying psychiatric drugs

1. De-mystifying psychiatric drugs Joanna Moncrieff, UCL, NELFT, CPN, Talk for Stuart Low Trust, London September 2013

5. Trends in antidepressant prescribing 1992-2010

6. Community antipsychotic prescriptions 1998-2010 (PCA)

7. Drugs used prior to 1950s barbiturates hysocine paraldehyde opium bromides benzedrine amphetamine

10. What causes bipolar disorder?Scientists don’t know for sure what causes bipolar disorder, though they believe it may be caused by chemical imbalances in the brain. Current medicines are designed to help correct these imbalances and have been shown to be effective at improving symptoms for many people. Pfizer, 2011

11. ‘antipsychotic medicines are believed to work by balancing the chemicals found naturally in the brain’ Eli Lilly, zyprexa.com, 2011

12. “People with depression may have an imbalance of the brain’s neurotransmitters” Eli Lilly, 2003 “Paxil CR helps balance your brain’s chemistry” PaxilCR.com, 2009

13. Pre 1950s: Sedatives Stimulants Post 1950s: Antipsychotics Antidepressants Anxiolytics Mood stabilisers Hypnotics Changes in Therapeutic Concepts

14. Models of drug action

15. No evidence that psychiatric drugs reverse underlying chemical imbalances or other biological abnormalities

16. Using drugs in a drug-centred manner Need to know full range of: • Mental effects • Physical effects • Short-term effects • Long-term effects • Withdrawal effects

17. and… • Are the effects a drug produces useful in an individuals particular situation? • Do they out-weight the negative effects? • Are there alternatives?

18. A drug centred approach: some drug-induced psychic effects • Euphoria • Sedation- different types • Emotional flattening • Relaxation • Stimulation • Psychedelic effects • Cognitive slowing and impairment • Reduced emotional sensitivity

19. Drug-induced effects of ‘antipsychotics’ Comments from ‘askapatient.com’ • Mental and physical stagnance • Emotionally empty, dead inside • A weird spacey empty feeling • Constant fog of lethargy and indifference (olanzapine)

20. The psychoactive effects of antipsychotics:Delay and Deniker 1952 • “the apparent indifference, or delay in response to external stimuli, the emotional and affective neutrality, the decrease in both initiative and preoccupation without alteration of conscious awareness or in intellectual faculties, constitute the psychic syndrome due to treatment”

21. From askapatient.com I’ve never been able to eat as much as I did when I was on Zyprexa. I gained 40lbs in no time and my mind was in a constant fog of lethargy and indifference. I didn’t care about anything. I just wanted to sit around and eat. (olanzapine)

22. From askapatient.com “decreased the intensity of inner voices” (risperidone) “stops my negative thoughts and feelings being amplified and overwhelming me” (risperidone) “hypersomnia (increased sleeping), calming of moods, general smoothing out of mania, calmness, less hallucinations” (olanzapine).

23. From askapatient.com “Although I felt very well, I felt as if I had absolutely nothing to talk about. I kept wondering about whatever [it] was that had been so interesting during most of my life that I had suddenly lost… But I was very much in contact with reality and for that I was thankful” (haloperidol)

24. Evidence on antipsychotic utility from randomised controlled trials • Short term symptom reduction or suppression • Long-term: may reduce relapses over 1-2 years. • But.. may impair social functioning in long-term and relapses may even out (Wunderink et al, 2013) • But….adverse effects

25. Adverse effects • Unpleasant • Impotence and reduced libido • Weight gain • Diabetes • Heart conduction defects • Tardive dyskinesia with mental impairment • Reduced brain volume • Mental impairment? • Death?

26. Treatment of bipolar disorder from a drug-centred perspective: classical manic depression • ‘Neurosuppressants’ (lithium, valproate, antipsychotics) reduce symptoms of mania • They may reduce the risk of recurrence of mania, but trials are flawed • No logical reason why they would reduce the occurrence of depression and may exacerbate it

27. Bipolar symptoms test

28. Treatment of emotional variation or intensity from a drug-centred perspective • ‘Neuro-suppressants’ (lithium, valproate, antipsychotics) will reduce activity • Increase sleep • Emotional indifference or disengagement • Some may reduce anxiety • No evidence that these effects are useful for these situations. They might be in some people, but risk benefit analysis is crucial

29. Antidepressants are not very different from placebo Meta-analyses show small differences on rating scales that are of doubtful clinical significance (Kirsch et al, 2002; NICE, 2004). Differences easily accounted for by psychoactive effects of antidepressants Many other possible biases: publication bias, selective reporting, unblinding

30. Do antidepressants improve the outcome of depression • Long-term outcomes for treated depression are poor – e.g STAR*D study in which only 3% recovered and remained well (Leventhall & Antonuccio, 2009; also Goldberg, 1998, Tuma, 2000; Kennedy, 2003) • People who take antidepressants do not do better than people who do not take them (Brugha et al, 1992; Ronalds, 1997)

31. Psychoactive effects of “antidepressants” Tricyclic antidepressants: • Profound sedation • Cognitive and motor impairment • EEG slowing • Dysphoria • Some have dopamine blocking activity at higher doses

32. Pychoactive effects of SSRIs and venlafaxine (Efexor): (askapatient.com) • “listlessness and lethargy” • “Total loss of libido” • “inability to care about anything” • “general numbness/mental blankness” • “sleepy all the time” • “Increased anxiety.., borderline panic, mild insomnia” • “sometimes suicidal” • “mood swings” • “irritability”

33. A drug-centred approach to treating depression • No evidence that any drug can specifically reverse or ameliorate depression or depressive feelings • Various psychoactive effects may suppress depressed feelings, or alter behaviour or emotions • Sedatives may be useful to help insomnia, anxiety and agitation • But…people may prefer alternative strategies!

34. The antidepressant will help normalise your serotonin levels The antidepressant will improve your depression The drug affects the way people think and feel (not just people with depression), but we are not sure how, because we haven’t bothered to study it properly. It may dampen down your emotions, and make you feel mildly drugged or groggy….. Patient information

35. Disease centred model- assumes benefit Drug centred model- assumes harm A new approach to use of drugs for mental health problems

36. Conclusions • Some drugs help some people in some situations • There is no evidence that they do this by reversing an underlying imbalance or disease • They are prescribed to many people with little or no evidence that there will be any benefit • Drugs produce altered physical and mental states • The harmful consequences of treatment often outweigh any positive effects

37. Antipsychotics and brains • Haloperidol vs olanzapine trial (Lieberman et al, 2005) • Macaque monkey study (Dorph-Petersen et al, 2007) • Long-term first episode follow up study (Ho et al, 2011)