Perhaps the most alarming current trend in psychiatry, documented by Domino and Schwartz (2008), is the rise in prescriptions for the class of drug called “atypical antipsychotics”, which include seroquel/quetiapine, abilify/aripiprazole, clozaril/clozapine, geodon/ziprasidone, invega/paliperidone, risperdal/risperidone, zyprexa/olanzapine. Initially, these drugs were introduced for the treatment of psychosis. They were touted as being superior to earlier antipsychotics because the belief was that they would not induce the very uncomfortable Parkinson’s type motor symptoms associated with the older typical antipsychotics, and the long term motor problems called tardive dyskinesia. Unfortunately, the large government-funded CATIE study found that movement disorders are associated with the atypicals as well, although perhaps to a lesser extent than the older anti-psychotics.
In psychiatry, the pattern is always the same. An initial treatment is found either to be ineffective or associated with serious side effects. Then a new drug is introduced which is supposed to be more effective or avoid the problems of the earlier treatment. Presently, the new class of drug for anxiety, sleep disorders, Major Depression, and Bipolar Disorder appears to be atypical antipsychotics (documented by Comer, Mojtabai, and Olfson, 2011, Crystal, Olfson, Huang, Pincus, Gerhard, 2009, and Fullerton et al.,2011). Atypicals are even being given to children for a wide range of problems. DosReis et al. (2011) examined the use of atypical antipsychotics in foster children. Among the children receiving antipsychotic medications, 53% had a diagnosis of ADHD, 34% had a diagnosis of depression, 21% had a diagnosis of bipolar, while only 5% had a diagnosis of schizophrenia. Apparently, psychiatrists are using atypical antipsychotics as general panaceas.
In moving from the older drug to a newer drug, psychiatrists are well intentioned. Everyone knows that antidepressants don’t work very well and some (see Irving Kirsch) argue that they don’t work period. Antidepressants can induce mania, so they are contraindicated for anyone with Bipolar Disorder. Lithium, a medication for Bipolar, destroys kidneys. Anti-epileptics are also used for Bipolar, but they have a warning from the government for inducing suicidal ideation. Thus, one can see why psychiatrists were searching for a better option for treating major depression or Bipolar Disorder. With regard to anxiety and insomnia, drugs of the valium class, prescribed for sleep and anxiety, are fairly rapidly addicting. If people discontinue use of valium-type-drugs abruptly, they risk life threatening seizures. Thus, the older drugs for Major Depression, Bipolar Disorder, Anxiety Disorder, and insomnia are bad news. The motivation for something better is understandable. But, the new panacea, the atypicals, is effectively jumping from one bad remedy to an even worse one.
In February 2011, Ho, Andreasen, Ziebell, Pierson, and Magnotta documented the brain volume reduction among their patients taking drugs that block dopamine, which includes the older antipsychotics and the newer atypicals. To prove causation, subjects have to be randomly assigned to a particular treatment or a control group. Fulfilling that requirement can be difficult with human subjects. So for proof of the causal connection, Ho et al., cited animal studies which observed the necessary random assignment. Researchers randomly assigned monkeys, none of whom were suffering from psychosis, to receive or not receive anti-dopamine drugs for two years. The animal researchers found that the antipsychotics do result in brain volume shrinkage. These results are consistent with what is known about brain health generally. Dopamine is a trigger for the release of growth factors in brain. If you block the dopamine message with a drug that sits on the receptor, there will be less release of growth factors, and poorer brain health.
Of course, brain volume reduction is only the latest, most awesome problem with the atypical antipsychotic drugs. From the outset, it has been known that the atypicals are associated with significant weight gain, diabetes, and high levels of fat in the blood. Moreover, atypicals are associated with QT wave prolongation (capable of inducing a heart attack). So if you take seroquel for sleep, you might be sleeping for longer than intended.
When drugs are approved by the FDA, they are evaluated for damage to major organ systems. Unfortunately, the drugs given to change mood and behavior are not evaluated for damage to structures in the brain. Perhaps tests of changes in cognitive capacity should be added to the check-list for evaluating pharmaceuticals. If a drug, taken over years, is shown to impair ability to learn in an animal, then the psychiatrists won’t be able to blame cognitive deterioration, widely acknowledged in the journals regarding patients with schizophrenia and bipolar, on the underlying condition of the patient. If impairments in ability to reason and process information are clearly acknowledged as side effects, then patients can evaluate whether the small possibility to escaping distress by taking the drug is worth the risk of long term brain damage.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.