Dreams of a Quick Fix, Gone Awry

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.

A final point is that the risk of suicide is underestimated in the randomised trials. Out of character violence against self or others can happen at any age.

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.

Conflicts of interest: none.

* * * * *

Previous articlePeter Parry, MD – Short Bio
Next article“We Need Publicly Funded Research Centers”
Jon Jureidini, MD
Healthy Skepticism: Jon Jureidini, a child psychiatrist in Australia, writes on the quality use of medicines, misleading drug promotion, suicide, medical education and child abuse.
Peter Gøtzsche, MD
Deadly Psychiatry and Organised Denial: Professor Peter C. Gøtzsche, MD, co-founded the Cochrane Collaboration. He has published more than 70 papers in the top five general medical journals, and six books, most recently, Death of a whistleblower and Cochrane’s moral collapse (UK link). He is currently crowdfunding to launch the new Institute for Scientific Freedom with the goal of preserving honesty and integrity in science.
Peter Parry, MD
Dr. Peter Parry is a child & adolescent psychiatrist, clinical director of mental health services at the Lady Cilento Children’s Hospital in Brisbane and a senior lecturer at University of Queensland and visiting senior lecturer at Flinders University. He has published on issues relating to psychiatric nosology and the deficits and problems associated with the bio-medical model compared with the more accurate biopsychosocial model in child and adolescent mental health practice.

28 COMMENTS

  1. Neurosis, delusions and hallucinations come from the brain. Drugging the brain does stop the problem. In the long run though, a person needs to use their brain. their cognitive abilities to look after themselve, so the neurosis and delusions have to be confronted with reason , love and science instead of being swept under the (d)rug. The rug can only hide so much dirt underneath.

    Outcomes from from the bible “You will know them by their fruits. Every good tree bears good fruit, but the bad tree bears bad fruit.”

  2. Thank you for speaking the truth, doctors. I wish there were more doctors who were as ethical as you, and the fact there are not does not imply good things about our current society.

    “In a time of universal deceit, telling the truth is a revolutionary act.” George Orwell

    “No one can serve two masters. Either you will hate the one and love the other, or you will be devoted to the one and despise the other….” Matthew 6:24

    True wisdom is found in the Holy Bible, not a “bible” of stigmatizations. “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 over inclusive.”

    “Do to others as you would have them do to you.” Luke 6:31 Perhaps this slice of wisdom should be passed on to the psychiatric community?

    Thank you for your courage, doctors.

    • Let me add to one of those statements,

      “No one can serve two masters. Either you will hate the one and love the other, or you will be devoted to the one and despise the other….” Matthew 6:24 “Doctors should be patient advocates, not industry apologists.” This biblical wisdom does give insight into why the doctors are treating their patients as if they despise them.

      • Very well expressed Someone Else
        You’ve got to despise someone to call them names and steal off them.

        (I have experienced the tricyclics myself in the 1980’s. They made no difference to me when I went on them, and no difference when I came off them and had no side effects when I was on them. So in my case they were no good and no harm).

  3. I agree with all of your points here… I think one point, that psychiatrists should not earn less for using psychotherapy rather than just prescribing drugs to people sums up one of the big underlying problems with this picture.

    As a society, we have given doctors of medicine much power and control and this is mixed in with Big Pharma and the underlying capitalism that fuels inequality. I am concerned that 99.9% of psychiatrists will not voluntarily give up their power or their money. Thus, psychiatrists, who often are not trained psychotherapists anyway, will not choose to offer this treatment, since it takes more time for less money. This whole picture seems so sad to me…and such a huge crime for the people who receive these mental health “services.” I know that there are some psychiatrists out there, many on this site, that do not fall into this category…and they are trying to do something much different. Perhaps, similar to what Sandra Steingard MD has said, psychiatry should actually have a smaller role in treatment since medications should also have a much smaller role …

  4. Thank you for the brilliant post Doctors.

    The idea behind a diagnosis of “Schizophrenia” is that medication is the only option, but this isn’t true.

    Practical Psychotherapy can work for “schizophrenia” in the same way that it can work for anxiety or anything else. For example: When the time spent on any preoccupation is reduced it’s importance also reduces – this can be reality checked.

    “Mental illnesses” are not real illnesses like cancer or diabetes, this is wishful thinking (and its obstructive). It’s also possible to make full recovery with decent help.

  5. Why are there still people making the argument that psychotropic drugs can sometimes be helpful? I’m glad that there are doctors who are willing to speak out against drugs and psychiatric coercion, but can someone please help me to understand why there is any question whatsoever about whether or not psychiatry and psychotropic drugs should be completely annihilated? This just does not make sense. Why is there so much tip-toeing around the truth? Again, I am grateful that there are doctors who are willing to speak out against these terrible, and euphemistically called “treatments,” but why concede any ground to such evil and oppressive forces?

    • The psychotropics didn’t work for me (in any therapeutic manner).

      What I notice is that it’s the antidepressants that are the drugs mostly associated with “dramatic” acts of violence. But in the UK like the rest of Europe and America more than 10% of the adult population are on SSRIs, and these people are not the so called “mentally ill”, anyway.

      • What I mean by above is that the “dramatic violence” as depicted in the media would seem to point in the direction of normal people on psychoactive medication rather than in the direction of “serious mental illness”.

        Ordinary doctors have been prescribing these drugs for years so they are in a sense unconsiously tied in with the disaster.

    • Some of the medicines help me. One of my problems is that I’ve built a world around me that no longer exists. The meds disrupt me from thinking about that kind of stuff. It’s been wired into my brain.

      Why can’t we talk about it? It’s something that disturbs other people, especially the people who did it to me that have moved on. They don’t need to suffer either. We went through bad times, and I got sick from it.

      The medicines have created a disturbance in the flawed thought process long enough for me to think about it. They’ve broken down the architecture that was messed up.

      Now I have to adapt and work on being self-sufficient and med free.

      I don’t think they should be used in the long term. I might get stuck with them a wee bit.

  6. A big problem with drugs, the worst one, is the forceful push to focus everything on compliance. That just about ruins the availability of services for anyone who would like some help with a noticeable problem with cognition or any type of irresistible and incapacitating mental state. I have never seen anyone in practice go at the drug option like it was an option, and talk about how to cope with the process of adjusting to symptoms. Obviously until you are doing your best with what your exact dysfunctions are or usually are, you can’t settle on the category of diagnosis and t-r-y the drug. The selection should certainly be to your liking and not based on patronizing insistence. There always is a distinction to be drawn between between what your problem is, bio-, psycho-, or social, and How You Handle It. The mainstream doctors are much worse in preparing you to handle drugs than street dealers.

        • Witch, what you’re focusing on here, here’s what gets me about it.

          If someone in a hospital had ever tried to get inside my head, it would have been many magnitudes better in there. Almost invariably, the real thing that happened was that they would report what was going on in my head without asking me or looking one fraction of a second, the tiniest bit skeptically, at possibilities beyond the worthless label.

          Absolutely unexceptionably, I met no one who validated re-thinking a diagnosis or re-structuring it to include actual effects on the personality of trauma and abuse, in and of themselves, except that that also served to justify the existing treatment plan and make compliance even more important. With all these people, as best I could tell, the only right new diagnosis was (and most likely always is and just will be) a worse one.

          • travailler-vous, as you say:

            “Absolutely unexceptionably, I met no one who validated re-thinking a diagnosis or re-structuring it to include actual effects on the personality of trauma and abuse, in and of themselves, except that that also served to justify the existing treatment plan and make compliance even more important. With all these people, as best I could tell, the only right new diagnosis was (and most likely always is and just will be) a worse one.”

            Yes, I managed to collect all the hardest diagnoses they have on offer in the span of 2-3 years. It started with bipolar, then psychosis schizophrenia, then in when I left this public health care unit, the diagnosis said I had major depression with psychotic symptoms. I had paranoid thinking, my thinking was illogical, inconsistent and strange, based on what they wrote in their papers. They wrote all the worst diagnosis and observations about me in their papers one could imagine. Yet, during that time I actually quit all my psychiatric drugs and returned to a full time job, etc. If I had eaten their drugs and accepted their diagnosis, I would be an unemployed “schizophrenic”.

            I met two other psychiatrists after the first diagnosis of schizophrenia. It’s very hard to formulate an argument against the first diagnosis, if that diagnosis is “schizophrenia” with “paranoid thinking”. Anyway, concerning diagnosis, I got the worst of them in a short period, and now I don’t eat any drugs, I’m in a demanding full-time job, and I’m doing relatively fine. If any of those diagnosis is actually “true” in my case, I can go around telling people these diagnoses not that bad actually.

            Or whatever. When I see the next doctor or psychiatrist who has read these papers and diagnoses about me, the show will start again. Maybe I need to formulate some arguments to shut them down, or get some doctor to insert more favourable comments about me in their databases.

          • “With all these people, as best I could tell, the only right new diagnosis was (and most likely always is and just will be) a worse one.”

            And I reached the bottom of the worst diagnoses in less than a year. According to their diagnoses and descriptions, I guess I’m basically so bad a case that I can’t possibly go worse. Hah, they no longer have any ammo against me.

  7. I couldn’t help but thinking, when reading this, that once again, psychiatry gets it all wrong. Maybe its the training, the way systems of the body are broken down and examined for disfunction. With the eye to putting things back together once again in the right order.

    What always strikes me about analytical thinking, is the thought that feelings are just other ideas. And that cognition, reasoning, thinking different thoughts can change how people feel.

    First their must be a realization that feelings are not intellectual processes in the sense that working a math problem is. Changing the way problems are solved may help with reasoning, but emotions don’t respond that way.

    Approaching emotional issues, by subtilely shifting to the intellect, is of itself, dismissive of a patients concerns.

    Emotional issues are not about faulty reasoning, many, many, patients have advanced skills in Math and Physics, and can reason just fine.

    There is more missing from psychiatry than just a knowledge about talk therapy. Whats missing is caring, empathy, and love.

    But fundamentally, it is very difficult if not impossible, to learn about talk therapy in an intellectual way, that’s just another attempt to intellectualize things.

    You have to be in therapy, you have to spend many long years plumbing your own emotional depths, a process that never really ends. Otherwise you will be unable to feel, and to be smart enough about your own feelings, your own process to help others.

  8. One can only wonder what wholesale transformation must occur to allow all those who currently look to medications as treatment have other choices. I wonder. Where will skilled mental health providers of all stripes come from? How can we ensure that these providers are the ones who can help make a difference in the lives of those they assist? How will we make certain that all will have access to the help they need when they need it? When will a broad system of services and supports necessary to foster recovery & wellness exist?

    I’ve long known that the numerous medications I’ve taken for depression don’t work. (Not surprising to anyone who follows MIA.) Consequently, it has been recommended to that I consider ECT as other therapeutic modalities of any significance are not available to me. For many of us a system which allows for actual choices other then the “choice of medication” or ECT in the case of depression will come too late. The pity for all is that a system that broadly affords a “focus on what caused the patient’s problems and how to cope with them in the future” is some time away. What will happen till then when so many need this focus now?

    • Joe, I think there are solutions but unfortunately not within psychiatry.

      Solutions can be found outside of psychiatry in the broader community, in independent self help groups, spiritual fellowships and what a person can access or afford by way of psychotherapy.

      It just depends on what a persons choice is. I did find suitable help myself in the community.

      • I’m glad you were able to find the supports you needed in the community. I have not been so fortunate despite having tried both self-help groups and psychotherapy over many years.

        The choices I referred to are all outside psychiatry. I should have made this clearer.

  9. Sometimes factual discussions of human experience in general seem to really help, although you have to shape your own attitude of such basic informationin order to create the therapeutic edge for yourself. But just relying on literature specific to the case of one or another form of distress, implicating psychiatric perspectives (like 100% of psychology unless explicitly stated otherwise), gets eventually far too narrow to motivate natural desired changes.

    Some very interesting ideas are discussed in this video series, for instance–

    http://www.voicesfromoxford.org/news/buddhism-and-science-video-list/337

    I started watching it because I knew that the talks and discussion converged on the idea of self in modern neuroscience, and in turn on the convergence between some interpretations of self in Buddhism and in a robust scientific understanding of experiencing. That means a nice healthy distance from psychobabble all the way around. There’s also a great brief drumming sequence upfront that sets the tone for the series, and it’s very relaxing and centering. Obviously, I should make a point of finding more such things for myself… but I’m just saying, this one’s particularly informative and broad-minded. Although the presentations can become pretty abstract, the theme of the inquiry is right up our alley as survivors.