Editor’s Note: Over the next several months, Mad in America will publish a serialized version of Peter Gøtzsche’s book, Mental Health Survival Kit and Withdrawal from Psychiatric Drugs. In this blog, he discusses the dangers of lithium, antiepileptic drugs, and ADHD pills. Each Monday, a new section of the book will be published, and all chapters will be archived here.
Lithium is a highly toxic metal used for bipolar disorder. Like most other psychiatric drugs, it sedates people and renders them inactive. Serum concentrations must be closely monitored because toxicity can occur at doses close to therapeutic concentrations.
In package inserts, patients and their families are warned that the patient must discontinue lithium therapy and contact the doctor if they experience diarrhoea, vomiting, tremor, mild ataxia (not explained even though few patients know that it means loss of control over bodily movements), drowsiness, or muscular weakness.
The risk of lithium toxicity is increased in patients with significant renal or cardiovascular disease, severe debilitation or dehydration, or sodium depletion, and for patients receiving medications that may affect kidney function, e.g. some antihypertensives, diuretics, and pain-relieving arthritis drugs. Very many drugs can change serum levels of lithium, which is therefore very difficult to use safely, and the list of serious harms is long and frightening.123
Psychiatrists praise this highly dangerous drug, saying it works and prevents suicide. However, the psychiatrists that reviewed lithium in 2013 concluded cautiously.124 There were six suicides in the trials, all on placebo, but the authors noted that the existence of just one or two moderately sized trials with neutral or negative results could materially change their finding. Selective reporting of deaths is always an issue, particularly with old trials, and most of the trials are old. Furthermore, patients were often titrated to the most appropriate dose before half of them were abruptly put on placebo.
A Swedish psychiatrist and I therefore did our own meta-analysis excluding the cold turkey trials. We found only four trials. There were three suicides in the placebo groups, and nine versus two deaths in favour of lithium, but because of the small numbers and unreliable data (about half of all deaths are missing in psychiatric drug trials),81 we did not draw any firm conclusions.125
Does lithium help? I am reluctant to use the four trials we found to answer that question. They had highly subjective outcomes, such as if the patients had relapsed or had improved by a certain amount, and the trials must have been poorly blinded because the side effects of lithium are very pronounced.
If we want to know what lithium does to people, we need large trials with something in the placebo that gives side effects so that it is more difficult to break the blinding, and there should be a long follow-up after the randomised phase is over where the patients are slowly tapered off lithium, so that we can see what the long-terms harms are. We already know that lithium can cause irreversible brain damage.123
This is not a drug I would recommend to anyone.
As already noted, antiepileptics double the risk of suicide.126 Psychiatrists use them a lot, but like most other drugs used in psychiatry, their main effect is to suppress emotional responsiveness by numbing and sedating people.56
Also like most other psychiatric drugs, they are used for virtually everything. I have seen so many patients entering the door of psychiatry with a variety of “starting diagnoses,” all ending up being prescribed a gruesome cocktail of drugs that included antiepileptics.
I am not surprised that psychiatrists think antiepileptics “work” for mania, because anything that knocks people down and incapacitates them seems to “work” for mania. But it is nothing else than a chemical straitjacket.
Antiepileptics not only sedate people, they can also have the opposite effect and make them manic.126 Depression pills can also make people manic,122 but this is not desirable, as it usually leads to a cascade of additional, dangerous drugs like neuroleptics and lithium that increase the risk of dying and make it very difficult for the patients to ever return to a normal life. Furthermore, the patients are now called bipolar even though they suffer from a drug harm.
Drugs for epilepsy have many other harmful effects, e.g. 1 in 14 patients on gabapentin develops ataxia, which, as just explained, is a lack of voluntary coordination of muscle movements.
Psychiatrists call these horrible drugs “mood stabilizers,” which is not what they do, and they have never clarified the precise meaning of this term.9 I Googled mood stabilizers and found the following: “Mood stabilizers are psychiatric medications that help control swings between depression and mania … commonly used to treat people with bipolar mood disorder and sometimes people with schizoaffective disorder and borderline personality disorder.”
Well, they are used for a lot else, and virtually every psychiatric “career” patient gets them. Just below that Google post, I could read that mood stabilizers not only include antiepileptics and lithium, but also asenapine, which is a neuroleptic. Thus, mood stabilizer seems to be a flexible plus term. They forgot to mention alcohol and cannabis, perhaps because they are not prescription drugs, and therefore have no commercial interest for the drug industry.
I have often encountered patients who are on the antiepileptic lamotrigine. Only two positive trials were published for this drug, while seven large, negative trials were not.127 Two positive trials are all it takes for FDA approval and the agency regards the others as failed trials, even though we see a failed drug. You need to have a vivid fantasy to imagine what goes on at drug agencies, and the length to which they are willing to go to accommodate the interests of the drug industry.51 The bottom-line is that drug regulation doesn’t work. If it did, our prescription drugs would not be the third leading cause of death,128-138 and our psychiatric drugs would not have come close to record.4
The amount of fraud in the clinical trials in this area is massive.4 You should not believe anything you read. Unless you have epilepsy, forget about these drugs and, if you are on them, find help getting off them, as quickly as you can.
Pills for the social construct called ADHD
I have never heard about a psychiatric drug that is mainly used short term. All of them, even benzodiazepines, are used for years in most patients, and drugs for the social construct called ADHD are no exception.
These drugs are stimulants and work like amphetamine; in fact, some of them are amphetamine. The way the WHO describes them is interesting.139 Under the heading “Management of substance abuse: amphetamine-type stimulants,” they say:
“Amphetamine-type stimulants (ATS) refer to a group of drugs whose principal members include amphetamine and methamphetamine. However, a range of other substances also fall into this group, such as methcathinone, fenetylline [sic], ephedrine, pseudoephedrine, methylphenidate and MDMA or ‘Ecstasy’—an amphetamine-type derivative with hallucinogenic properties. The use of ATS is a global and growing phenomenon and in recent years, there has been a pronounced increase in the production and use of ATS worldwide. Over the past decade, abuse of amphetamine-type stimulants (ATS) has infiltrated its way into the mainstream culture in certain countries. Younger people in particular seem to possess a skewed sense of safety about the substances believing rather erroneously that the substances are safe and benign … the present situation warrants immediate attention.”
Crystal meth is the common name for crystal methamphetamine, a strong and highly addictive drug. In 2017, about 0.6 % of the US population reported using methamphetamine in the past year.140 The usage of stimulants on prescription was 0.8% of the Danish population, also in 2017.
Why then, does the WHO not mention with one word that the increasing use of stimulants on prescription is also a huge problem? Why this double standard?
There were 10,333 drug overdose deaths in USA in 2017 involving stimulants,140 compared to only 1,378 in 2007.
Meth is regarded as particularly dangerous. We don’t know how many people are killed by stimulants on prescription, but we do know that children on these drugs have suddenly dropped dead in the classroom.
We also know that stimulants increase the risk of violence,129 which is not surprising, given their pharmacological effects. But psychiatrists say the opposite. I have heard them argue many times, even at a hearing in the Danish Parliament, that Ritalin (methylphenidate) protects against crime, delinquency and substance abuse. This is not true—if anything, they do the contrary.142
As with other psychiatric drugs, the long-term effects are harmful.4 This was demonstrated in the large US MTA trial that randomised 579 children and reported results after 3, 6, 8 and 16 years.142-146 After 16 years, those who consistently took their pills were 5 cm shorter than those who took very little, and there were many other harms.146 We can only speculate which permanent effects these drugs might have on the children’s developing brains.
The short-term effect is that the drugs may cause children to sit still in class, but that effect disappears quite quickly. Short-term harms include tics, twitches, and other behaviours consistent with obsessive compulsive symptoms, all of which can become quite common.9,147 Stimulants reduce overall spontaneous mental and behavioural activity, including social interest, which leads to apathy or indifference, and many children—more than half in some studies—develop depression and compulsive, meaningless behaviours.56,148
Animal studies have confirmed this,148 and we have documented other harms, e.g. that the drugs impair reproduction even after the animals were taken off them.149
At school, the compulsive behaviour is often misinterpreted as an improvement even though the child may just obsessively copy everything shown on the board without learning anything. Some children develop mania or other psychoses,56,150 and the harms of the drugs are often mistaken for a worsening of the social construct called a “disease,” which leads to additional diagnoses, e.g. depression, obsessive compulsive disorder or bipolar—and additional drugs, leading to chronicity.148
Trials of ADHD drugs are biased to an exceptional degree, even by psychiatric standards, and therefore most systematic reviews of the trials are also highly biased. A Cochrane review of methylphenidate for adults was so bad that the criticism we and others raised led to its withdrawal from the Cochrane Library.151 Two Cochrane reviews performed by my former employees, who paid sufficient attention to the flaws, found that every single trial ever performed was at high risk of bias.152,153
We also found that the reporting of harms is extremely unreliable.153 In the British drug agency’s review, “psychosis/ mania” was reported to occur in 3% of patients treated with methylphenidate and in 1% of those on placebo. The 3% estimate is 30 times higher than the 0.1% risk of “new psychotic or manic symptoms” that the FDA’s Prescribing Information warns about.
We also encountered discrepancies within the regulatory documents. In the British drug agency’s Public Assessment Report, the rate of aggression for those on methylphenidate was reported to occur in 1.2% on page 61 and in 11.9% on page 63, based on the same population and follow-up time.153
We furthermore observed huge differences across trials that could not be explained by trial design or patient populations, e.g. decreased libido on methylphenidate was experienced by 11% in one trial versus only 1% in a pooled analysis of three other trials. As quality of life was measured in 11 trials but only reported in 5, where a tiny effect was found,153 it is reasonable to assume that quality of life worsens on ADHD drugs, which is also what the kids experience. They don’t like the drugs.
Doing the right thing in psychiatry is rarely possible. An Irish child psychiatrist told me he was suspended because he didn’t put his children on psychiatric drugs, including ADHD drugs.
Instead of changing our children’s brains, we should change their environment. We should also change the psychiatrists’ brains so they no longer want to drug children with speed on prescription; perhaps “psychoeducation” would help?
ADHD medications are prescribed much more to children of parents with low-skilled jobs, compared with children of more educated parents.154 These drugs are used as a form of social control, just as neuroleptics are.
A British documentary was very revealing about what is needed. It showed highly disturbing children, which were so difficult to deal with that even critical psychiatrists might conclude that ADHD drugs were necessary. “We cannot have children hanging around in the curtains,” a child psychiatrist told me at a hearing in Parliament about the drugging of children.
However, the families got help from psychologists and it turned out that the children were disturbed, which was why they were disturbing. One mother who always reprimanded her “impossible” daughter was taught to praise her instead, and somewhat later, she had developed into a very nice child that was no longer hostile towards her mother.
Sexual abuse of children is frighteningly common and hugely damaging. You can easily find references on the Internet to the fact that about one in ten children have been sexually abused before their 18th birthday. If a child behaves badly, is provocative and defiant, this can easily lead to a diagnosis of ADHD or borderline personality disorder, although it is a reaction to a horrible situation of ongoing sexual abuse that the child doesn’t dare talk about to anyone.
One of my colleagues, child psychiatrist Sami Timimi, often asks parents who want him to drug their child for ADHD:54 “Imagine this drug working perfectly; what changes are you hoping will result from this?” That question may surprise parents, but it is important to say no more until one of them breaks the silence and starts talking about what changes they imagine will happen. That helps Timimi understand the parents’ specific areas of concern.
Is it, for example, behaviour at home, peer relationships, academic performance at school, a lack of a sense of danger? Timimi might then respond that no drug in the world can alter these things in their child. Drugs don’t make decisions, have dreams and ambitions, or perform actions.
By discovering the specifics of what the parents want to see change, Timimi can divert their interest from drugs to more targeted measures such as developing parental management skills for children who are more “intense” than most. He helps them understand the anxieties and stress their children may be feeling, or he supports them getting more structured interventions in schools.
He also reminds parents that one thing is certain about children: they change as they grow older, and often the problems labelled as ADHD (particularly the hyperactivity and impulsivity) tend to diminish and go away as the child matures during adolescence.
Since ADHD is just a label and not a brain disease, we would expect more of those children born in December to get an ADHD diagnosis and be in drug treatment than those born in January in the same class, as they have had 11 fewer months to develop their brains. A Canadian study of one million school children confirmed this.155 The prevalence of children in treatment increased pretty much linearly from January to December, and 50% more of those born in December were in drug treatment.
The ADHD diagnosis should not be a prerequisite for getting extra help or money for schools, which it is now. It drives the prevalence of this diagnosis upwards all the time, and the use of AHDH drugs, too, which was 3.4 times higher in Denmark in 2017 than in 2007, an increase of 240%.
Some countries have experienced a spiralling increase in the use of psychiatric drugs in children that is directly attributable to school partnerships with hospitals. In one Canadian province, the hospitals aggressively lobbied special services personnel and high school guidance counsellors, who in turn referred any child under stress to the psychiatric department within the children’s hospital. The school board hired a school psychiatrist who consulted with staff on school refusal situations and behavioural issues and recommended depression pills or ADHD drugs.
Schools and hospitals have become dangerous places for children and adolescents. How sad this is. Schools should stimulate children, not pacify them with speed on prescription.
- Don’t ever accept that your child be treated with speed on prescription.
- Don’t ever accept this yourself, but resist becoming a faceless number in the new market for adults.
- Approach children with patience and empathy, which allows them to grow up and mature without drugs.
- Work on changing the mechanisms that label more and more children with a psychiatric disorder; they must be able to get the help they need without getting a diagnosis first.
To read the footnotes for this chapter and others, click here.
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.