The Good, the Bad, and the Ugly: An Infographic on Bipolar Drugs

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This post helps make sense of the mountain of bipolar drug research. It distills into an infographic the pros and cons of five classes of bipolar drugs and gives observations on what it means for people who face choices on bipolar care.

Although this post wanders deeply into the statistical weeds, we avoid technical jargon. To maintain statistical rigor, we use technical definitions for important phrases below. [1]

(The infographic is kept fresh as research evolves. The latest version with footnotes is always here.)

A few key perspectives behind this infographic deserve attention:

How well do bipolar drugs work?

One sentence summarizes scores of bipolar drug studies:

Bipolar drugs work, but 75-85% of the time people don’t see substantial improvement attributable to them. [2]

Let me explain.

To test drugs, researchers take two groups of people with bipolar and give one a drug and the other sugar pills (placebo). After 1-2 months they count how many people in each group see substantial improvement (> 50% symptom reduction). If the tests reliably show more in the drug group, the drug works.

But we need to know much more if we are to make evidence-informed choices of care. We need to know the odds they’ll work. In fact, these odds (called attributable benefit) are vital, since they are the best way to understand the true value of drugs.

Consider lithium for mania. Many bipolar studies show us that we have a 31% chance of substantial mania relief in 1-2 months without using drugs. [3] For reasons we don’t fully understand, our natural healing ability — the placebo effect — works. If you want to boost your odds by 16%, you can take lithium. You will then have a 47% chance of substantial mania relief in 1-2 months (31% attributable to the placebo effect and 16% attributable to lithium). [4]

For bipolar depression, the placebo effect is even more powerful. 39% of people see substantial improvement in 1-2 months without drugs. [5] Taking an antipsychotic (lurasidone) boosts your odds to 59% (39% attributable to the placebo effect and 20% attributable to lurasidone). [6]

Surprisingly, our natural healing ability is twice as powerful as our best gold standard drugs — 1.9X for mania (31%/16%) and 1.95X for depression (39%/20%).

But there is no free lunch. The boost in odds of benefit comes with a boost in odds of harm. Data on harms is poorly quantified and numbers are highly variable, but here are rough odds of experiencing side effects from bipolar drugs: [7]

  • Lithium. Weight gain (75%), tremors (42%), sexual dysfunction (37%), chronic kidney disease (33%), hypothyroidism (14%).
  • Anticonvulsants. Elevated liver enzymes (11%), tremors (10%), rash (10%).
  • Antipsychotics. Weight gain (90%+), sexual dysfunction (66%), fatigue (35%), tremors (17%).
  • Benzodiazepines. Fatigue (50%), sexual dysfunction (33%), withdrawal syndrome (30%).
  • Antidepressants. Sexual dysfunction (58%), withdrawal difficulties (56%), fatigue (21%), weight gain (15%).

Bipolar drug therapy is a balancing act of benefits vs. harms. Odds of attributable benefit cluster in a 15-25% band, so 75%-85% don’t see substantial benefit. Stated differently, if five people take a bipolar drug, only one is likely to see substantial improvement due to it, but all five will have side effects. Experiencing this trade-off firsthand is a major reason why up to 60% of people with bipolar don’t take their medication as prescribed. [8]

Polypharmacy Risk

Most people with bipolar take 2-5 psychiatric drugs (polypharmacy), [9] a practice that boosts symptom relief somewhat, but at considerable additional risk.

Unfortunately, the sheer number of individual bipolar drugs makes drug combination testing “practically nonexistent.” [10] This creates an uncomfortable reality: although psychiatry seeks evidence-based care, it “ventures beyond the evidentiary base” [11] for all but the simplest bipolar prescribing. And straying from the evidence creates grim results: longer hospital stays, [12] increased suicide, [13] and a rise in drug-related illness.

Even if we are comfortable with this added risk, the benefits come with diminishing return. The benefit of multiple drugs is nearly always less than the sum of the parts, and in some cases add-on drugs provide no benefit at all (as we will see with antidepressants).

Antipsychotic polypharmacy — taking two or more antipsychotics at once — is considered one of the riskiest forms of polypharmacy. In fact, the American Psychiatric Association (APA) launched a campaign targeting antipsychotic over-use. The APA’s CEO and Medical Director cautioned, “…Physicians and patients together should be thinking carefully. Are the medications really needed and are there downsides and negative consequences for overuse?” [14]

This caution is well-placed: those on two or more antipsychotics for bipolar have almost triple the risk of requiring medical care, with no improvement in functioning. [15] And the greater the number of antipsychotics taken concurrently, the shorter the expected life span. [16] Despite this evidence, 10% of people with bipolar are on two or more antipsychotics.

Evidence on antidepressants

The largest-ever federally funded trial for bipolar depression reached a startling conclusion: antidepressants don’t work (don’t outperform placebo) when added to mood stabilizers (lithium or anticonvulsants). [17] And most people taking bipolar drugs are on mood stabilizers. [18] It also found that those on antidepressants were less likely to achieve durable recovery. [19]

Gold-standard meta-analyses and systematic reviews in 2001, 2008, 2011, 2012, 2013, 2014, and 2016 all reached variations of the same conclusion: antidepressants don’t work for bipolar. [20] One meta-analysis concluded: “evidence of efficacy does not support the short-term or long-term application of antidepressant therapy in patients with bipolar.” [21] Another warns that the research “suggests an unfavorable risk / benefit relationship for long-term antidepressant treatment in bipolar disorder.” [22]

This scientific reality collides with a prescribing reality: 30-81% of people treated for bipolar depression are taking antidepressants. [23] This disconnect is the largest controversy in bipolar care. To resolve it, a global expert task force of researchers and clinicians was convened in 2013. After considering all the studies, they found there was insufficient evidence to make any broad statements supporting antidepressants. [24]

Bottom line: antidepressant prescribing for bipolar is extremely common, but gold-standard studies and expert consensus offer scant support.

How does this happen?

First, bipolar prescribing guidelines — the rules that tell doctors what to prescribe in what situations — are inconsistent and some recommend antidepressants beyond the evidence. [25] Japanese guidelines conclude that bipolar is resistant to antidepressants. They don’t recommend them. Australia, New Zealand, and the U.K. updated their guidelines to reflect a more cautious view of antidepressants, not recommending them, but providing guidance should they be prescribed. Guidelines in Canada hold as a basic principle to discontinue antidepressants in many cases but consider them a possible second-line treatment. APA guidelines were last updated in 2005 and have not been changed to reflect global consensus opinion or recent research. They recommend first-line adjunctive antidepressant use and — remarkably — using two antidepressants at once. APA guidelines require urgent updates.

Second is the strong tendency to limit therapy to the five bipolar drugs. When initial drugs aren’t effective, antidepressants may appear “inevitable” [26] — a seemingly prudent leave-no-stone-unturned last resort. But limiting recovery options isn’t a good idea. Dr. Kenneth Duckworth, Medical Director of the National Alliance on Mental Illness emphasizes, “Psychiatric medications are rarely enough to promote recovery alone.… Use of non-medication strategies is crucial for most clinical situations…” [27]

Third is antidepressant withdrawal difficulties. It’s easy to get on antidepressants, but often hard to get off. 56% of people experience antidepressant withdrawal, 46% of these find it severe. [28] Many people can feel stuck — unable to extricate themselves from a potentially poor risk/benefit trade-off.

Although experts express no broad support for antidepressants, are there narrower bipolar situations where they are clear winners? Unlikely. Diligent research hasn’t found them.

Stand-alone antidepressants aren’t recommended nor FDA-approved since they can promote mania and switching. [29] Add-on antidepressants to mood stabilizers provide no benefit. [30] One antidepressant (fluoxetine) helps depression when combined with an antipsychotic (olanzapine), but the solution is almost as likely to harm as help. [31] Short-term use for bipolar II may provide value, but it can easily slide to long-term use because of antidepressant withdrawal difficulties. Long-term use may reduce the risk of new depression but it increases mood fluctuations [32] and the lifetime risk of polarity change and mixed episodes. [33]

Over 4 million people in the U.S. and U.K. are being prescribed antidepressants for bipolar when expert consensus and gold standard analysis confirm that the supporting evidence is weak and there is no corner of bipolar where antidepressants are shown to provide a compelling and reliable cost/benefit trade-off.

Nondrug options work

But there is good news. A paradigm shift is underway from conventional psychiatry to Integrative Mental Health, a discipline that includes the best of drug and nondrug therapies. Thankfully, options beyond the five bipolar drugs work. And we define work in the same way researchers do for drugs: they outperform placebo in randomized controlled trials.

Omega-3 fatty acids, [34] light therapy, [35] and folic acid (added to lithium), [36] can improve bipolar depression. Amino acid supplements appear to reduce mania. [37] Probiotics can reduce bipolar rehospitalization. [38] Cognitive Behavioral Therapy works on many levels, decreasing relapse rates, depression, and mania while improving psychosocial functioning. [39] One randomized controlled trial found that treating underlying inflammation — a common denominator in mental distress — with simple aspirin provided an attributable benefit for bipolar depression on par with psychiatric drugs [40].

These are not guaranteed solutions nor extensively tested. But neither are the multi-drug combinations commonly prescribed for bipolar.

But unlike drugs, nondrug options typically come with no or mild side effects and often support sustainable wellness. Additionally, some options address causative factors of bipolar distress, going well beyond the symptom management of bipolar drugs. For example, detailed blood tests help identify specific nutrient, gut-health, hormonal, and immune system issues that may be influential. This is important since 25% of people have identifiable physical issues that cause or exacerbate their mental distress. [41]

Psychiatrists, therapists, GPs, and other practitioners are advancing this paradigm shift. In fact, the APA sponsors a growing caucus of psychiatrists focused on Complementary and Integrative Medicine, and caucus leaders have recently published a book on evidence-based nondrug options. [42]

Final Thoughts

I leave you with these perspectives:

Drugs aren’t the savior nor the enemy. Blur your eyes and look at the infographic. An expanse of red will wash over your retinas. But there are also swaths of green. Yes, not a lot of big numbers on the green, but green. Many people confirm that drugs help them reside more often in a place of safety and stability from which they can build their recovery. Unfortunately, 75-85% of the time, people don’t see substantial improvement due to a bipolar drug they take. There is far more to healing than can be included in the chemistry of a pill.

Don’t wait for the paradigm shift. Most psychiatrists focus their practice on drug therapy, so you often need to expand your practitioner team to explore nondrug options. Fortunately, there is a vanguard of mental health practitioners that can help. Some are aligned with the emerging evidence of bio-individuality that informs individualized nutrient therapy, shown broadly effective in open label trials. Others see the correlation between bipolar and childhood trauma and are helping address sources of enduring pain. Others are aligned with expert consensus and are creating de-prescribing plans that slowly ween people off psychiatric drugs when needed. And professionals in peer support, mindfulness, mind-body disciplines, and more are providing valuable recovery support.

Nondrug options aren’t a panacea. Although there is growing gold-standard evidence that supports them, it’s much smaller than for drugs. Nondrug options may take longer to show benefit, they require greater personal commitment, most aren’t covered by insurance, and practitioners are scarce. They aren’t miracles. However, their ability to address causative factors of distress, support core wellness, and minimize exposure to the risks and side effects of bipolar drugs make them essential and a pragmatic source of hope.

Build a better plan with your practitioners. Carefully evaluate the evidence on your current bipolar drugs. Understand the odds and answer the APA’s question, “Are the medications really needed and are there downsides and negative consequences for overuse?” If you make adjustments, do so slowly under practitioner care. But — and this is my central point — don’t limit yourself to bipolar drugs. Explore evidence-based nondrug options. Avoid drug myopia. Trust your own experience. Your recovery may well depend on it.

Get started. Review the nondrug approaches most-promising for bipolar. Watch a short video of William Walsh, PhD on the methods and results of Nutrient Therapy for bipolar. Engage a practitioner trained in the diagnosis and treatment of the biomedical issues of mental health (see biomedical practitioner finder). Check out Safe Harbor’s Free Mental Health Strategies — 80 budget-minded nondrug mental health options. Practitioners can obtain Psychiatry Redefined training from Dr. James Greenblatt, one of the country’s leading integrative psychiatrists. Or consider the 27 broad evidence-based nondrug options that span all diagnoses. There is far more available than most people realize.

The only guarantee. Failing to look beyond drugs limits your paths to recovery.

So…

Pause for a moment. Trust yourself. You can do this, and you are worth the effort. Start small. Take one step at a time. Stay close to those who love and support you. Mistakes will be made, and that’s OK. Make the best choices you can as you walk the often-crooked path back home. Others have recovered. So can you.

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Epilog: This post leverages our growing library of Integrative Mental Health infographics and resources at Onward Mental Health. If you find them helpful, please use them. We welcome ideas on improvement and expansion. Many thanks to Stephanie Heit for her review and Dan Stradford, President of Safe Harbor, for providing the free mental health strategies. See disclaimer.

Footnotes

See the infographic footnotes and blog post footnotes. Both contain extensive commentary.

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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.

56 COMMENTS

    • Miranda, thanks for mentioning Functional Medicine! Yes, Functional Medicine practitioners leverage the pioneering work and concepts of Abram Hoffer and Carl Pfeiffer – a very common sense approach of running straightforward lab tests that might detect potential influencing factors to mental health. Dr. James Greenblatt is one of the leading practitioners that continues in that vein today.

      • Also, check out the Walsh Institute in IL, I believe he was also part of the Pfeiffer movement.

        The only thing is that these better approaches can be costly. I found a lab that tests for the Walsh protocol of $250, which i thought wasn’t too bad, considering. It is so hard to move forward in hope when trying to navigate a drug taper. We are down to 7.5 Zyprexa (can’t get out of bed until 3pm) and were just ok’d after two weeks of that, to go to 5mg to see if any quality of life improves. As you all know, seeing your loved one suffer is debilitating. Craig, I ordered your book on natural treatments, thank you.

        • Melanie, thanks for your feedback. You are absolutely right. Walsh worked directly with Pfeiffer. Walsh has what is likely the largest database of blood samples of people with diagnosis and has an effective protocol that reduces symptoms in open label trials for 75% of people so that drug dosages can be reduced. His book, Nutrient Power, outlines his ideas. Yes, I wish the blood/hair tests were less expensive since they are vital to inform nutrient therapy. SSRI withdrawal can be very difficult – I admire your efforts to move forward with it. Good luck.

          • Craig,
            I just received your book, it’s so thorough and helpful, thank you for all of your efforts in presenting things in a very user-friendly manner and with sound research citations. Question: I understand and agree re no “one size fits all” on the nutrient approach. Do I understand correctly though, the EMPowerplus seems one supplement that is tested and “safe” to take as is, for Bipolar? I will be working with our doctor and also True Hope staff, but it seemed like one approach that does not need metabolic panel testing, and can just be started, correct? We are tapering off just Zyprexa, (thankfully)and she has not been on it long, more thankfully. Thank you again for this empowerment.

          • I’d like to make one clarification in this post. Attributable benefit is an excellent metric since it defines the true value of the drug. In the same way, attributable harm is the preferred metric to use in measuring side effects. Attributable harm is the harm of the drug over placebo. For example, if 30% of people get headaches when using a drug, and 5% of people get headaches taking placebo, the attributable harm from the drug is 25%. Most studies give only the frequency of harm (30% figure in this case). For this reason, harms are often somewhat overstated in studies, by the amount of harm people naturally encounter without drugs. Unfortunately, attributable harm is rarely tracked in studies. Practically, the harms in the placebo group are usually quite low, so the overstatement of harms is usually not large.

    • Hi Cat, Thanks for the kind words. I find that there is so much complex detail in mental health research that we need some way to distill it to things that are a lot easier to understand – something to separate the wheat from the chaff. People need that clarity. I would love to see this kind of information in every dialog about care options. Unfortunately, the downsides are rarely discussed in detail, and there is little appreciation for the reality that the lion’s share of benefit from every psychiatric drug is our body’s natural healing ability (placebo effect).

      • My favorite is the prescribing cascade cause that’s what happens. Make one for strictly psych drugs it goes like this https://www.youtube.com/watch?v=2UnJ4H8JLmM

        I wouldn’t even take part in this if I was an anomaly and other people were getting better. Been around alcohol and addiction recovery, dual diagnosis for years. People always coming in with their big ziplock bags of pill bottles that did nothing but pave the way to treatment.

        The big thing now is Gabapentin. In 2010 everyone was getting Zoloft and Abilify. It is getting better though even though our one counselor keeps perpetuating the serotonin myth.

        I think the best tool for recovery/stability is getting into fitness. They need to emphasize that more. Alot more. Insurance companies should pay for gym memberships.

        IMO the stupidest thing they do to recovering alcoholics and addicts is put them on bipolar drugs to “stabilize” them. We like to fly high, hard enough getting used to doing the world sober and they add pills to make you tired flat zombie on top of it. One of the top complaints new in recovery “nothing is fun sober” so why flatten them further ? What I nightmare that was when I went along with that. You want to party just to feel something. And I did.

        And most of the time bipolar is a crock, bipolar II certainly is.

        • Cat, thanks for mentioning the fitness angle. Although there is a concern for it encouraging mania, it’s clearly beneficial for depression and one way to combat the weight gain and diabetes risk accelerated by psychiatric drugs – especially if olanzapine is used. Walking outdoors in nature is a particularly good way to slow down the mind while getting the heart pumping – but whatever works for someone. I think you’re right on target with getting insurance coverage for preventive/restorative approaches like fitness and yoga, which not only can promote sustainable wellness, but decrease total cost in the long run… Good luck, Cat.

        • As someone diagnosed “Bipolar 2” whose mood swings started from an SSRI reaction and stopped 24 years later when I finished going off I strongly agree. From R. Whitaker’s writings and comments here and elsewhere I wonder how many cases of “Bipolar” were iatrogenic snafus the shrinks refuse to own up to.

          • I think some research should be done on the percentage of adults diagnosed as “bipolar.” Because I think most “bipolar” is misdiagnoses of the common ADRs and withdrawal effects of the antidepressants and ADHD drugs, just like Whitaker found with the “childhood bipolar epidemic.” At least I’m one more who had the common symptoms of antidepressant discontinuation syndrome misdiagnosed as “bipolar.”

            Craig, I agree, great infographics. But I’d recommend you add to the problems with the antipsychotics for “bipolar,” anticholinergic toxidrome. Since I’m guessing most “bipolar” is actually misdiagnoses of the ADRs of the antidepressants, which is then wrongly treated with the antipsychotics, resulting in anticholinergic toxidrome poisoning.

            Especially since this is no longer a misdiagnosis, according to the DSM5. Although, I guess such a change to the DSM is evidence that the primary goal of the mainstream psychiatric industry is to harm their patients for profit, rather than help them.

          • Not necessarily harm them. Just turn them into helpless drug addicts good for nothing but Consuming psych drugs till they die 30 years prematurely.

            Most shrinks aren’t Snidely Whiplash types, but they just prefer their prestigious, cushy jobs to acknowledging, “Hey these drugs–the only thing I can actually do is prescribe them–are harming patients. Making many crazier than they ever were to start with. Causing all of them horrible, scary health problems, brain shrinkage, and nerve damage. Diminished quality AND quantity of life. Why am I even here?”

            (All bets are off for the high ranking creepers on the Inner Circle. You know. The “well informed” ones.)

            Once you let yourself ask this question you’re faced with the ugly task of leaving the field for training in a different specialty where lawsuits can occur or talk therapy that pays 1/4 or less what filling out a dozen prescriptions for 4 patients in one hour would. Your pesky conscience may turn you into a whistle blower. If their’s one thing psychiatry hates more than those it “helps” it’s a conscience.

            Yet Psychiatry says it’s guarding society from sociopaths and psychopaths. Ha ha.

          • Someone Else, good catch. Yes anticholinergic toxicity from antipsychotics can lead to the very symptoms they are trying to address (hallucinations). I’ll see if I can dig up any quantifiable detail on that and include it in the next update to the infographic. Thanks!

        • Hi Melanie, thanks for the support, I hope you find the book helpful. In terms of what nutrients are most effective for bipolar, I can’t give medical advice, but I can tell you that there hasn’t been extensive independent testing for EmpowerPlus that I’ve seen. I believe their website has a number listed, but a review of those a few months ago seems to reflect that more testing is needed.

          The problem with taking supplements without testing is that you’re never quite sure if you’re taking what is needed. Not sure if you saw it, but at the end of the post is a link to a practitioner finder. Especially those Walsh-trained, would be good practitioners to consider. Dr. James Greenblatt is well-versed in Nutrient therapy (Boston). Dr. Albert Mensah (Chicago area) is one of the more prominent Walsh-trained practitioners. http://www.DHAlab.com has a combination of testing + consultation with Dr. Mensah. I’m not sure, but perhaps testing and consultation can be done remotely (blood draws can be done where you live and the practitioner can have samples frozen/shipped to DHA). Working with your current doctor and insurance company you could figure out what portions of the testing might be covered.

          Good luck, Melanie

  1. Almost forgot my favorite part about ‘dual diagnosis’ its pretty well known that more then 80% of people that come in for drinking or addiction relaps so they fill them up with psychiatric drugs to drink and use on top of when they relapse and get even more erratic then they were before.

    Here is your Zolft Abilify Gabapentin… Don’t drink with this. Ya sure. Half of them drink at the airport on the way home.

    • This makes zero sense to me how the do this, too.

      This is how I believe the Rehab doctors helped kill my best friend, and how some these “accidental” deaths are happening. Putting a newly recovering person on psychiatric drugs that aren’t supposed to be mixed..the person is new to recovery and relapses..now they are hooked on a psych med that isn’t supposed to be mixed with illicit drugs/ alcohol…but they are off the wagon and do mix..recipe for disaster. Then it gets blamed on accidental OD or suicide. It’s maddening :/

  2. I totally disagree the principle of having a “balanced” point of view on psychiatric drugs. These drugs already benefit from an apologetic publicity from the pharmaceutical industry and the psychiatric staff: to really balance the discussion, only the critic must be put forward: the glorification, we already have ad nauseam.

    On the other hand, the arguments in favor of drugs are extremely doubtful. You did well to present your sources, it makes a difference with the practices of the psychiatric vulgarization.

    Here I will take just one example: you say that lithium could probably reduce the risk of suicide by 14%. However, the study cited (Song J et al, 2017) simply shows that the rate of suicidal events is lower during periods of lithium consumption than during periods of non-consumption, in people who regularly take lithium and subjected to massive psychiatric polytoxicomania (see Table 1 of the original study).

    This is not a proof that lithium reduces the risk of suicidal events. This could be due to withdrawal syndrome, and more so to the consumption of antidepressants that were taken by 70.8% of subjects on lithium. Since lithium reduces mania, while antidepressants increase it, the combination of lithium withdrawal and the use of antidepressants increases the risk of mania, and therefore could increase the risk of suicide events.

    By the way, “At least one suicide-related event during follow-up”

    Lithium: 10.1%
    Valproate: 13.1%
    Never Treated With Lithium or Valproate: 7.8%

    This is statistically significant. From this study, I could possibly conclude that lithium and valproate increase the risk of suicidal events, and that the increase in suicidal events in the lithium group at discontinuation was due to withdrawal syndrome and to the consumption of antidepressants.

    But that would be a hasty conclusion, because all subjects massively consumed all kinds of drugs: the difference in the rate of suicidal events could be due to these drugs or their withdrawal, or to a subtle and complex combination of all this bazaar.

    Moreover, the 8-year actual suicide rates in the lithium (1.1%), Valproate (1.2%) and Never Treated With Lithium or Valproate (1.2%) groups are about the same, and the difference is not statistically significant.

    In any case, this study does not prove that lithium decreases the suicidal risk.

  3. Craig this is just brilliant and genius. I really wish this had been out when I started working in the MH system.
    This is also great for those that I know who have chosen to take chemicals. I would tell them read this read that but this is clarity for visual learning.
    And Cat – I so appreciate your 12 step viewpoint. The old timers were anti – drug and yes they were right.
    The big Pharma folks created moral injury to us all.

    • CatNight, Thanks for the the kind words. We each can add something to the equation here. I’m a detailed guy who can figure out all the nuance and present in an understandable form. We have many on this site who are passionate about their lived experience and courageously proclaim it. We have others who fearlessly take on established psychiatric wisdom with a full-throated howl… It takes a village. Your comments are part of that symphony.

  4. Sylvain, thanks for the feedback. Good stiuff. My effort here is to advocate informed choice about drugs and to try to provide information to support that choice. I attempted to show, by highlighting a lot of negative information on drugs, that the cost/benefit equation is much worse than most people realize.

    But you touch on a meaty topic that I’ve struggled with, and you have obviously thought about it. We agree on the overwhelming abundance of pro-drug information. To someone who does their homework, pro-drug arguments are weak and lob-sided. But the question is, how do we respond to that biased view? Are we best served countering a lob-sided view by building a lob-sided argument of our own? I think the stronger argument is one that embraces full transparency. The evidence is on our side. Just as we can rip down a pro-drug biased argument with ample negative data, if we play the same game and refuse to acknowledge any benefit in drugs, I think we weaken our own argument. We’re too easy to dismiss.

    And the reason I acknowledge value in drugs is an important conversation I had a year ago that really stuck with me. I presented similar material to a group of peer support specialists and emphasized the many downsides of drugs. At the break a woman came up to me and told me, “Craig, you can give me all the negative research in the world on antipsychotics, but that doesn’t matter to me. The only reason I am able to do my job is because of the antipsychotics I take. Be sure you never take your argument to the degree of saying drugs are bad in every situation, because I’m living proof that they’re not”.

    I think two perspectives are needed. The “only the critic should be put forward” can win the hearts of many. There is much negative data to stoke that fire. It can help shake the foundation of things to promote change.

    But that argument doesn’t work well with the rationalist who wants a full picture. They need an argument that appeals to their head, not their heart. There are many people who see pro-psychiatry as biased and anti-psychiatry as biased. They want some reasonably transparent portrayal of the facts in all their muddled gray. That’s one perspective that I have attempted to offer. And I think we have a strong argument. We will win by capturing both the head and the heart and offering both perspectives.

    Dr. Joanna Moncrieff does a good job of explaining why the evidence on lithium and suicide is weak. That’s one reason I used the word “suggest” in that context. Although RCTs to clearly test it may never be run, there is considerable circumstantial evidence that supports the word “suggestive” (but not “conclusive”).

    Thanks for the stimulating thoughts.

    • In my case the cocktail prevented me from working. 90% of “med compliant” people can’t maintain gainful employment. As far as the woman you cited Craig, it may be the placebo effect. If she suddenly quit her neuroleptic she probably would suffer withdrawals. And as a peer support specialist being “naughty” would definitely lead to her getting fired. Not just that her “meds” are working but she needs to toe the line.

      • Rachel, good observation. Yes, there might well have been placebo effect with the woman I mentioned, or perhaps even withdrawal effects masquerading as relapsing symptoms. For me the biggest trump card is self-determination and trusting an individual to interpret and direct their own experience. For that reason, I didn’t hammer on drugs any further in that conversation. I left our dialogue with a bit of optimism – she had a very strong sense of self-determination and hope which are among the most powerful tools of recovery. She apparently had come a very long way clawing back from a difficult experience. That human capacity can help her potentially revisit her use of antipsychotics in the future.

        • If she did go drug free it would probably end her position as a peer specialist and might get her involuntarily committed. So–if she chooses to leave–she will probably not announce it in that kind of setting.

          Surprised they allowed you to make this presentation. But the low-key method you used helped. Congratulations on using the term “drugs.” They aren’t medicines the way insulin, thyroxin, or antibiotics are. The first two are to be taken long term but replace real deficiencies in the body. Antibiotics are only prescribed short term.

          Zoloft replaces nothing, kills nothing known to be harmful, yet is prescribed for a lifetime. It’s destroying my 12 year old nephew’s brain. 🙁

          For me, just going off my drugs wasn’t enough. Had to leave the “mental health” setting. Being told how sick, helpless, hopeless, and dependent you are–day after day–year after year–can be depressing.

          • Rachel, congrats on finding your way out of the woods. Many haven’t. The whole message that “this is a lifetime problem that is only managed by drugs” is incredibly disempowering.

            Yes, my approach to get the message across is lower key. What I’ve found is that there are many people within mental health that see the poor outcomes they’re producing and want to find a better way. They feel constrained – not wanting to step too far outside of psychiatric orthodoxy lest they get ostracized from their career choice. A lower-keyed approach has allowed me bring the message to NAMI, the Psychiatric Rehabilitation Association and others, considered fairly mainstream psychiatry.

            I think we need a combination of approaches to advance a new mental health paradigm: the frontal assault of MIA and others, a lower key “expand the options of recovery” approach, a heavily research-based approach, a strongly emotional approach, and more. Different people respond to different approaches. The more we can push with a variety of approaches, with a variety of audiences, the better.

          • I agree with you on this point. I think we have to meet people where they are at. Many people who post here today with very radical views acknowledge that they were once taken in by the system. Change starts with education. It’s not enough, but it is a start.

          • “Congratulations on using the term “drugs.” They aren’t medicines the way insulin, thyroxin, or antibiotics are.”

            What’s there to congratulate? All medicines are drugs. Drugs are not intrinsically good or evil, they’re just a category of substances. Alcohol, aspirin, quetiapine (okay, yeah, that one is much closer to being evil haha), cannabis, insulin, antibiotics, alprazolam, heroin, caffeine, and countless others. All are drugs. Some have therapeutic value, and can thus be used as medicine (in specific contexts and dosages, of course). Even then, most substances than can be used as medicines at a certain dosage can also be used as poisons at higher dosages.

  5. My problem with these drug studies and when claims are made that there is a “reduction in symptoms” (whatever that might mean) is how do they account for the myriad of factors that could have contributed to doing or feeling better in addition to ingesting the drug. It is as if we are seen as an inert recipients of “treatment” and that nothing else goes on for us or in our lives while we just wait for the drugs to do their magic

    • Gerard, you see the problem clearly. Over the last few months, I’ve looked at over 100 bipolar studies in a fair amount of detail. There is a lot of messiness in all of them. Large drop-out rates. A lot of information isn’t tracked. The tools used to measure symptoms vary. Some studies aren’t placebo controlled. There is acknowledged bias going on – to the extent that meta-analyses attempt to assess the degree of bias… The saving grace is that if the studies are large enough and placebo controlled, at least we hope the things we can’t account for will be somewhat evenly distributed between the placebo group and the treatment group.

      Then the biggest confounding factor is this: although the studies can give us odds, at one level it doesn’t really matter too much what happened to 500 people in Timbuktu who took the drug 5 years ago, we never know the results until we try something. With that said, the odds are really important since they tell us that 4 out of 5 people won’t get substantial improvement from the drugs they take…

      That one reality is the only thing I would need as incentive to vigorously investigate reasonable nondrug approaches…

      • Actually, I think the biggest confounding factor is the fact that no one can objectively decide who “has bipolar” and who does not. So whatever groupings you create, they are likely highly heterogeneous and not really comparable to each other.

        The best we get from these studies is “the drugs do something. Some people think it’s good. Other people don’t. They also do bad things. We don’t know who will get the bad things. So essentially, we’re guessing. Try it out and see if you like it or not.”

        • And how can they determine numbers of stuff that might have been so but isn’t?

          Great science fiction. But don’t confuse the figures pulled out of thin air with science.

          If people read these statistics and know the “chemical imbalance” myth is BS I guess that’s informed consent. If they want to try anyhow they must be desperate and at least they have all the facts.

          Like most survivors here I was lied to.

          A positive and more accurate word for these drugs is “emotional pain killers.”

        • Steve, good point. And further, since nearly all classes of psychiatric drugs can be given for almost any diagnosis, the meaningfulness of an accurate diagnosis is diminished. We give antipsychotics for bipolar depression, major depression, and PTSD even when the individual doesn’t have psychotic symptoms. Benzodiazepines are prescribed across all diagnoses. In the presence of all this uncertainty, and drug solutions that provide attributable benefit to only a small percentage of people, experimenting with options that have a lot fewer downsides than psychiatric drugs seems like the prudent path…

  6. This info graphic should be handed to all patients and their families if they are “diagnosed” with so-called “bipolar disorder”.
    ADHD drugs and anti-depressants trigger symptoms of “bipolar” in many people.
    Poisoning ppl bc of ignorance and $.

  7. Thank you so much for this article, and for your extremely helpful website. You’ve really captured the complexities of the issue, and presented it in a way that’s organized, and understandable.

    Regarding psychiatric drugs and the medical/ disease model, I just wanted to comment on that. Psychiatry and drug companies have been so successful, I believe, because they’ve nailed how the art of advertising works- take a complex issue (your web of causation illustration), over simplify it (you have a chemical imbalance) and offer and a simple solution (these drugs). Their advertising works.

    And when you are dealing with people who are struggling, or who have a friend or family member who is, from what I’ve seen going on out there, they don’t really want to hear it about how mental illness doesn’t exist, or about the evils of psychiatry. They want a solution.

    All of the truth telling and exposes in world, and much as I do see the value in that, aren’t necessarily going to help a person in the moment, in crisis, when there is no solution in its place, and people don’t know where else to turn to or what to do.

    Thank you for your very thorough explanations, and for offering solutions. Very helpful!

    • Leonora, you hit the nail on the head. People aren’t given suitable accurate and distilled information. That’s why education is so vital – people need to understand they have many more options than just drugs, and they need to know the full extent of the risks, limitations, and odds of success of drugs. When that information is laid out fully, it paints a very different picture from what most prescribers tell their patients.

      My belief is that the quickest and most assured way to change the paradigm to integrative mental health is to get people educated so they change their demand for psychiatric services. In a market economy that is what makes a difference. Instead of choosing conventional mental health care, I would love to see people flood the practices of integrative practitioners so that those practices thrive and grow. Each individual has the ability to make that choice today if they have the information (regrettably, however, cost and practitioner availability remain big issues)… If we had a very informed public, this shift in demand would build the bandwidth of integrative practitioners and shrink the demand for conventional mental health services.

      You are exactly right when you say people just want a solution. As a result, when people are told, “the only real solution is drugs” they’ll go that way. The true situation is much more complex than that as you point out: many interacting potential causes that require careful and detailed evaluation that goes way beyond symptoms.

    • Krista, thanks for the kind words. We each bring our unique skills to this important effort. I read your first MIA post with interest (welcome aboard!). Your words, “you’re not broken”, are so important, and brought me back to a cathartic poem that crashed from me many years ago… The ending of it is…

      At times through shallow eyes I see my loved-one as irreparably broken.

      But then I look deeper.
      There I see my loved-one whole and intact, worthy and good, sharing in my desire for wellness.
      There I see a hope in a therapy not yet tried, in a kind word not yet spoken, in an hour not yet arrived.
      There I see a beauty, not broken, not diminished, not missing, but shrouded in a scrim of pain.

      We can work together to pierce this scrim if and only if we recognize the stunning value of what lies beneath it.

      I choose to look deeper.
      I choose to help my loved-one and others similarly struggling.
      I choose to help, not to compensate for their weakness, but to supplement their strengths.
      I choose to help, not to conform them to my ideas of recovery, but to liberate them to the greatest vision of wellness they can attain.
      I choose to help, not because I must, but because I can.

      I choose to look deeper because I choose to recognize the human treasure trove at stake.
      I ask, “What do you choose?”

      — The full poem is on my website. I’ve learned a lot from the courageous people, like yourself, who have reached to the core of their being and found that which is not broken, and sunk their fingers into it with such vigor that it is never very far away.

  8. Mr. Wagner, “…the courageous people, like yourself, who have reached to the core of their being and found that which is not broken, and sunk their fingers into it with such vigor that it never very far away”…..
    Gosh, I need to lie down a moment.
    While I feel confident that you meant this as a compliment somehow, I can only request you not characterize me in any way, other than MY words and behaviors. The “broken” remark, edited by MIA for brevity, is just not that ‘deep’, Mr. Wagner.

    If you WOULD like a ‘deeper’ view of who I am, wait for Part 2 of “Full Moral Status”…in the meantime: Dr. David Healey’s RxISK.org 2018 July-August, 4-part “A Unicorn: Changing a Diagnosis”.

    I am not a branding or marketing expert; I AM a veteran of the psychiatric industry, the “belly of the beast”, and well-researched to the “core of my being” in facts, history, and selling techniques steeped in glossy, empty rhetoric.