Critical Psychiatry Textbook, Chapter 7: Psychosis (Part Two)

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Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Critical Psychiatry Textbook. In this blog, he discusses the evidence that psychosis pills substantially increase mortality. Each Monday, a new section of the book is published, and all chapters are archived here.

Psychosis pills increase mortality substantially

The psychiatrists presented many arguments as to why it is important to use psychosis pills, but all of them were unsustainable. One of them was that patients with schizophrenia live 15-20 years less than other citizens,18:288 and among the causes were mentioned suicide, accidents, cardiovascular diseases, metabolic syndrome, lifestyle, undertreatment of somatic diseases and drug harms.16:628 Treatment with psychosis pills was not mentioned.17:308

One book noted that mortality is increased if the psychosis appears early in life,19:239 but it didn’t occur to the authors that the longer the duration of the psychosis, the longer the treatment with psychosis pills, and therefore also a higher mortality because the pills increase mortality.

Two textbooks raised the highly implausible claim that psychosis pills reduce mortality from psychotic disorders.16:222,18:101,18:236 They don’t; they increase mortality substantially.

Photo of a human skull sitting on a pile of pills against a black backgroundIt is not possible to use the placebo-controlled trials in schizophrenia to estimate the effect of psychosis pills on mortality because the drug withdrawal design increases mortality in the placebo group. The suicide rate in these unethical trials was 2-5 times higher than the norm.1:269,161 One in every 145 patients who entered the trials for risperidone, olanzapine, quetiapine, and sertindole died, but none of these deaths were mentioned in the scientific literature, and the FDA didn’t require them to be mentioned.

When I decided to find out how deadly psychosis pills are, I focused on patients with dementia, assuming that few of them would be in treatment before randomisation. A meta-analysis of placebo-controlled trials with 5,000 patients showed that after only 10 weeks, 3.5% had died while receiving olanzapine, risperidone, quetiapine, or aripiprazole, and 2.3% had died on placebo.162 Thus, for every 100 people treated for 10 weeks, one patient was killed with a psychosis pill. This is an extremely high death rate for any drug.

Since half of the suicides and other deaths are missing, on average, in published psychiatric drug trials,125 I looked up the corresponding FDA data based on the same drugs and trials. As expected, some deaths had been omitted from the publications, and the death rates were now 4.5% versus 2.6%, which means that psychosis pills kill two patients in a hundred in just ten weeks,163 or double as many as the published trial reports indicate.

I also found a Finnish study of 70,718 community-dwellers newly diagnosed with Alzheimer’s disease, which reported that psychosis pills kill 4-5 more people out of every hundred per year compared to patients who are not treated.164 If the patients received more than one drug, the risk of death was increased by 57%. As this was not a randomised trial, the results are not fully reliable, but they are plausible given the data from the randomised trials. Thus, the pills might kill 4 times as many patients as the published reports indicate, or even more, if we extend the observation period beyond one year.

One textbook noted that psychosis pills may increase mortality in patients with Alzheimer’s disease.18:49 This downplayed the problem. These pills not only may increase mortality, they do increase mortality, and to a substantial degree, which the textbook said nothing about.

This phenomenon is seen everywhere, in textbooks, scientific articles, on websites, in lectures and in interviews in the media. There is a huge asymmetry in the way psychiatrists describe benefits and harms. There are rarely any reservations when the benefits of drugs are commented upon and their effects are much exaggerated, which I shall exemplify throughout this book.

Another textbook was even worse. It noted that meta-analyses on large patient materials suggested a small excess mortality of patients with dementia treated with psychosis pills compared to placebo, but that it was uncertain what caused this excess mortality.17:243

This comes close to fraud. There was no reference, but the meta-analyses not only suggested but proved the excess mortality; it was not small but huge; and the FDA has explained what causes it: Most of the deaths in the demented patients were either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia).163

The important question then is: Can we extrapolate these results to young people with schizophrenia?

We have no other choice. In evidence-based healthcare, we base our decisions on the best available evidence. This means the most reliable evidence, which are the data presented just above, two deaths per hundred people treated for ten weeks. Thus, absent other reliable evidence, we will need to assume that psychosis pills are also highly lethal for young people.

Young people on psychosis pills also often die from cardiovascular causes and suddenly,8:40 and we would expect some of them to die from pneumonia. Psychosis drugs and forced admission to a closed ward make people inactive, and when they lie still in their bed, the risk of pneumonia and pulmonary emboli from a venous thrombosis increases, which might go unnoticed before it is too late. Psychosis pills also kill patients because of huge weight gains, hypertension, and diabetes.

Considering that these drugs do not have a clinically relevant effect on psychosis, and that benzodiazepines are far less dangerous and even seem to work better for acutely disturbed patients,165 the conclusion must be that psychosis pills should not be used for anyone. They should be taken off the market.

The psychiatrists do not blame their drugs or themselves for the considerably shorter lifespan patients with schizophrenia have, but the patients. It is true that the patients have unhealthy lifestyles and may abuse substances, in particular tobacco. But it is also true that some of this is a consequence of the drugs they receive and the way they are treated. Some patients say they smoke because it counteracts some of the harms of psychosis pills, which is correct because tobacco increases dopamine while the drugs decrease it. And when people are locked up for weeks or months on end and have nothing to do, is it then strange that they smoke? Or drink? Or overeat? Or kill themselves? I don’t think so.

When I tried to find out why young people with schizophrenia die, I faced a roadblock, care-fully guarded by the psychiatric guild. It is one of the best kept secrets that psychiatrists kill many of their patients, also young ones, with psychosis drugs. I described my experiences with the roadblock in 2017, “Psychiatry Ignores an Elephant in the Room,”166 but subsequent events were even worse. This is a summary of a more comprehensive account.8:40

Large cohort studies of people with a first-episode psychosis provide a unique opportunity for finding out why people die. However, there is too little information in these studies, or no information at all, about the causes of death. In 2012, Wenche ten Velden Hegelstad and 16 colleagues published 10-year follow-up data for 281 patients with a first-episode psychosis (the TIPS study). Although their average age at entry into the study was only 29 years, 31 patients (12%) died in less than 10 years.167 But the authors’ detailed article was all about recovery and symptom scores. They took no interest whatsoever in all these deaths.

I wrote three times to Hegelstad but did not get the missing data. The third time she replied they would be published soon, but the new paper did not present the data I had requested.168 Two months later, Robert Whitaker and I wrote to the editor of the journal, World Psychiatry, professor Mario Maj, asking for his help. He did not want to help us either in finding out why young people died so quickly.

We wrote again, explaining that people I had talked to in several countries about deaths in young people with schizophrenia—psychiatrists, forensic experts, and patients—all agreed that we desperately need the kind of information we asked Maj to ensure became known. We called on him to make this happen as his ethical duty, both as a journal editor and as a doctor instead of telling us that he did not have space for our letter about this in his journal. We did not hear from Maj again.

In contrast to the authors of the TIPS study, Danish psychiatry professor Merete Nordentoft was forthcoming when I asked her about the causes of death for 33 patients after 10 years of follow-up in the OPUS study, also of patients with a first-episode psychosis.169 I specifically mentioned that suicides, accidents and sudden deaths could be drug related.

Nordentoft sent a list of the deaths and explained that the reason cardiac deaths were not on the list was probably because the patients had died so young. But in the death certificates, she had seen some patients who had dropped dead, one of them while sitting in a chair, which is what we call cardiac deaths.

This is how it should be. Openness is needed if we want to reduce the many deaths that occur in young mental health patients, but very few psychiatrists are similarly open as Nordentoft.

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To see the list of all references cited, click here.

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9 COMMENTS

  1. It’s about time someone went down this road. I don’t work in the field but I do have experience with mental illness and the powerful psychotropic drugs that are used to treat my wife’s bipolar and incidental psychosis. She did not like taking the medicine. Many times I spoke with her doctor to validate her complaints that the doses he was prescribing may be too high because after more then a month of taking the pills as prescribed there was no improvement whatsoever in her mental state. She was more irritable, had less patience and more aggression and hostility. She constantly complained of lethargy and brain fog. She would sleep constantly and complained that her sleep was disrupted with vivid dreams, terrors, night sweats, sleep walking, drooling and restless movement. I consider myself a compassionate, conscientious man and wanted to be able to understand what she was experiencing so I took the same pills she took one night. It was one of the most shocking experiences of my life. The medicine was strong. I’m 1 foot taller than my wife at 6’3. I am a full 50lbs heavier. I could not lift my head out of the pillow to drink water. I had the most fitful sleep with vivid dreams and uncontrolled movements. The affects of the medicine were so strong I could not work the following day. My wife had been describing the same debilitating effects of the medicine that I experienced. I explained this at her next doctor visit and asked him to lower the doses. His answer was to scold me for taking her prescription illegally and he belligerently doubled the dose of each of her medicines. That was it. He wrote the script and left the room. That was the last time we went to a psychiatric care and the last time she took any psychotropic drugs. That doctor killed himself in his office about a year later. My wife has since developed tardive dyskinesia, restless leg syndrome, high blood pressure, 2 auto immune conditions and experiences memory loss. I witnessed first hand the apathy this physician had for his patient and his reliance on treatment with drugs that he had no personal experience with and no accountability for the negative effects. The audacity he displayed that day in doubling the dose when we were suggesting lowering them by half to start and going from there(which I believed to be a reasonable suggestion)…it was troubling to say the least. It was not the first time I had this experience with psychiatric doctors. 4 out of 5 doctors we visited had this same penchant for high doses of powerful psychotropic drugs with no other options for treatment. I happen to know that there is a high incidence of dental problems in people taking these drugs because they cause extremely dry mouth which effects the mouth biome which in turn may effect and change the gut microbiome and introduce bacteria thru the mouth. The connection between dental health and overall health has long been known and may be a contributing factor to mortality in these patients with cardiovascular diseases. I applaud your work and look forward to your next installment.

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    • To hell with that doctor. Somebody’s death is not something to joke or feel gleeful about, but I feel nothing but disdain for him even if he is gone. Ordinarily, I understand that doctors can be extremely stressed and they have to deal with all kinds of a-hole patients. They may sometimes lash out due to that because they feel insecure and go into self-defense mode. It’s only human and it happens to us all. I generally respect doctors and the sacrifices they make. However, with psychiatrists (and non-psychiatry doctors who blindly support them), my empathy is quite diminished. If you remove “illegality” and all that crap, what you did was commendable (even if others may say it is irresponsible). It is the only way you could have understood your loved one’s pain.

      That being said, what do you mean by “my wife’s bipolar”? Why was she categorised that way? Was she categorised with even more psychiatric categorisations after that? What are her life experiences? Was, by any chance, that categorisation applied to her due to the effects of prior psychiatric drug use? SSRIs/SNRIs prescribed for depression and anxiety, and also stimulants prescribed for a lack of focus or problems concentrating both cause mania in a subset of the population who take them. All those people are categorised as “bipolar” by psychiatrists even with no prior history of mania before those drugs were taken. Some times street drugs also do those things.

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  2. Here in Finland there is a story that psychosis treatment with antipsychotics protects patients from death. It is based on public registers that are studied later on and there is an extremely shady method for reviewing that data.

    It seems that trying to get off drugs causes more mortality and that is described as a benefit of the drug. Also because the majority of those who try to get off drugs face withdrawal symptoms and do not succeed and lose the ability to take care of themselves for a while it causes a weird phenomenon: They are forcibly medicated with using stronger medications to “prevent relapse” happening again and as a end results the “medication free” group likely contains those that have the most medication.

    I once found Moncrieff and Whitaker commenting on that study, but it seems that critique is never mentioned, and that study is used here at health care as an objective fact that antipsychotic medication prevents deaths.

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  3. I find it reassuring that there are those that are interested in deaths caused by antipsychotics and are willing to uncover the real data.

    That was an interesting story. It might not be easy to get that data, but it might well be the thing that finally gets media attention and attention of the scientific audience if evidence is strong enough.

    Giving a longer and happier life should be the purpose of those who have studied medical sciences. If some treatment kills people then it should be discussed openly by families and politicians – not just by psychiatrists.

    If normal people kill other people then instead of a high salary and the right to be heard as the experts they spend half of their life in prison. And if they kill multiple people they spend the rest of their life in prison or get death sentences in some countries. Only exception are soldiers, because they do not kill those living in the same country as they serve which makes possible the narrative of “protecting”.

    Psychiatrists get really special treatment, because their service is extremely useful for authorities and for families. It is similar to the case of soldiers. There is that narrative of “protecting”. Antipsychotics are “first in line defense against psychosis” – weapons against irrationally behaving dangerous people. In that narrative society is divided into normal sanes and dangerous insanes and possibly hurting dangerous insanes does not feel like hurting someone belonging to the same group, but pacifying an enemy.

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  4. Actually, a facility like Zucker Hillside “Hospital” that sees tens of thousands of patients each year -inpatient and outpatient – can have researchers go in there and do a large study on patient outcomes by anonymizing the patient records and seeing what happened to patients who remain in treatment for decades. But they would never do that since they know that outcomes are very poor long term! Psychiatry will claim that “stabilization” of the patient is key and that “treatment” is crucial NO MATTER WHAT THE OUTCOME IS! What happened to teenagers who started “treatment” in the middle 1980’s and continued “treatment”. Many died prematurely likely by at least 20 years!

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