Dr Peter Gøtzsche will make the case that the harms of drugs are underestimated and the benefits oversold in a series of lectures next month in Australia. Here, Dr Gøtzsche, Dr Jon Jureidini and Dr Peter Parry give a preview.
The version of psychiatry that many professionals, politicians and laypeople would like to be true is that mental illnesses are specific brain disorders with specific drug treatments, to which they are very responsive if identified early.
In reality, the way we categorise mental illnesses is arbitrary, and the diagnostic criteria are overinclusive.
Furthermore, the focus on drugs means that the biopsychosocial model for understanding mental disorders has too often been reduced to a bio model.
Whilst psychiatric drugs can be helpful, the dream of a quick fix by targeted drugs has become a nightmare where we often do more harm than good in the way we use drugs, e.g. against depression, schizophrenia and ADHD.
The focus on drugs, combined with insufficient focus on what caused the patient’s problems and how to cope with them in the future, is dangerous for patients. Even though psychotherapy and other non-drug treatments are often advocated, the most common response to making a diagnosis is to prescribe a drug.
In an era of marketing-based medicine, drugs are often used in a way that is at odds with good practice and the scientific evidence, e.g. it is common to use several drugs at the same time, not only of different types but also from the same drug class. Side effects and withdrawal effects can be misinterpreted as disease symptoms, leading to even more drugs, higher doses and more harm, although a tapering off would have been beneficial for the patient.
Psychiatrists are not adept at noticing the harms done by medications, partly because vigilance in asking patients is difficult to maintain. Even when psychiatrists do ask their patients in surveys, they may sometimes ignore what they are told and believe that the patients are mistaken and need psychoeducation.
That a medication can be harmful doesn’t necessarily mean it is bad medicine; think of cancer drugs, for example. But the problem with psychiatric drugs is that the harms have been underestimated and the benefits overestimated.
This has happened at least partly because of the hold the pharmaceutical industry has over leading psychiatrists. Career advancement is contingent on research publications, networking opportunities and conference profile. The pharmaceutical industry opens the doors for early career opportunities in a way that nobody else can.
Psychiatrists have been slow to recognise the price they pay for this self-serving industry “generosity” and often remain genuinely puzzled that their patients and independent researchers see evidence of bias, both in their trials and in the way they practice.
A major problem with almost all placebo controlled trials of psychiatric drugs is that they are flawed by design. In particular there is a lack of effective blinding. The drugs have conspicuous side effects, and many patients and their doctors will therefore know if the blinded drug contains an active substance or placebo.
Many years ago, adequately blinded experiments were performed with tricyclic antidepressants. The placebo contained atropine, which causes dryness in the mouth and other side effects similar to those seen with antidepressants. A Cochrane review of these trials did not find any meaningful effect of the drugs. Clinicians, however, are being misled by their clinical experience, which is mainly the spontaneous remission of the depression.
The overuse of psychiatric drugs leads to many deaths. Based on drug sales and a meta-analysis, it has been estimated that just one antipsychotic drug, olanzapine, has caused 200,000 deaths worldwide.
The common use of antidepressants in the elderly is also lethal. A carefully controlled cohort study where the patients were their own control showed that antidepressants led to falls. These falls may lead to hip fractures, and a quarter of patients with hip fractures die. For every 28 elderly people treated for one year with a selective serotonin reuptake inhibitor (SSRI), there was one additional death, compared with no treatment. This is an extremely high death rate for any drug.
What should we do better?
First, psychiatrists need to become better educated in psychotherapy and should not earn less if they prefer psychotherapy to drugs, which they unfortunately do today.
Second, we should use far fewer drugs than we currently do, as prolonged drug treatment can maintain the problems they were supposed to alleviate and can cause even worse diseases. For example, both antidepressants and ADHD drugs can precipitate bipolar disorder, and it is likely that all psychiatric drugs can cause chronic brain impairment.
Finally, psychiatrists should stop accepting money and other favours from the drug industry, as this is harmful for their patients.
It is not possible to serve two masters. Doctors should be patient advocates, not industry apologists.
This blog appeared first on Croakey.com.
Details of the lectures are here.