Wednesday, June 8, 2011

The Epidemic of Psychoactive Drugs and Mental Illness

Unhinged: The Trouble with Psychiatry - A Doctor's Revelations about a Profession in CrisisAnatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
The Emperor's New Drugs: Exploding the Antidepressant Myth
Marcia Angell has provided an article that all adults, particularly parents with small children should read. It appeared in the New York Review of Books and is titled The Epidemic of Mental Illness: Why? Angell is reviewing three books by three separate authors.

The Emperor’s New Drugs: Exploding the Antidepressant Myth
by Irving Kirsch
Basic Books, 226 pp., $15.99 (paper)

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
by Robert Whitaker
Crown, 404 pp., $26.00

Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis
by Daniel Carlat
Free Press, 256 pp., $25.00

There is so much material to cover here that Angell breaks her effort into two articles—with the second yet to come.

In a previous post we looked at Angell’s discussion of Kirsch’s work in which he demonstrated that the drug company’s own clinical data showed that six popular antidepressants—Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor (all approved by the FDA between 1987 and 1999)—were of little or no value in treating depression. Angell lead us through the processes by which the FDA allows this to happen, and how the drug companies, by controlling the information reaching medical providers, can mislead the community concerning the effectiveness of their products.

Here we will discuss the book by Whitaker who considers the treatment of all mental illness with psychoactive drugs, not just depression. Whitaker suggests that psychoactive drugs are not just worthless—they are harmful. He further suggests that the “epidemic” of mental illness coincides with the advent of the practice of treating mental illness with drugs, thus providing at least circumstantial evidence of causation.

Angell points out that all three authors dispute the notion that mental illness is caused chemical imbalance in the brain. If this is such a dubious claim, how did it become such a widely accepted notion?

Angell says the story begins in the 1950s when drugs like Thorazine, Miltown, and Marsilid were discovered to have the effect of dampening aberrant mental behavior. These drugs were not developed for that application, and the mechanism by which they worked was unknown. Eventually researchers discovered that these and similar drugs were altering the levels of chemicals in the brain that act as neurotransmitters.

“When it was found that psychoactive drugs affect neurotransmitter levels in the brain, as evidenced mainly by the levels of their breakdown products in the spinal fluid, the theory arose that the cause of mental illness is an abnormality in the brain’s concentration of these chemicals that is specifically countered by the appropriate drug. For example, because Thorazine was found to lower dopamine levels in the brain, it was postulated that psychoses like schizophrenia are caused by too much dopamine. Or later, because certain antidepressants increase levels of the neurotransmitter serotonin in the brain, it was postulated that depression is caused by too little serotonin. (These antidepressants, like Prozac or Celexa, are called selective serotonin reuptake inhibitors (SSRIs) because they prevent the reabsorption of serotonin by the neurons that release it, so that more remains in the synapses to activate other neurons.) Thus, instead of developing a drug to treat an abnormality, an abnormality was postulated to fit a drug.”

This was an amazingly simpleminded conclusion.

“As Carlat puts it, ‘By this same logic one could argue that the cause of all pain conditions is a deficiency of opiates, since narcotic pain medications activate opiate receptors in the brain.’ Or similarly, one could argue that fevers are caused by too little aspirin.”

After decades of trying to prove the hypothesis that mental illness is caused by chemical imbalance, there is no evidence to confirm it. Rather the evidence indicates that mentally ill patients have normal chemical levels—at least until they begin taking psychoactive drugs. Whitaker comments thusly:

“Prior to treatment, patients diagnosed with schizophrenia, depression, and other psychiatric disorders do not suffer from any known ‘chemical imbalance.’ However, once a person is put on a psychiatric medication, which, in one manner or another, throws a wrench into the usual mechanics of a neuronal pathway, his or her brain begins to function…abnormally.”

And what might be the consequences of forcing the brain to “function abnormally?”

“It is well understood that psychoactive drugs disturb neurotransmitter function, even if that was not the cause of the illness in the first place. Whitaker describes a chain of effects. When, for example, an SSRI antidepressant like Celexa increases serotonin levels in synapses, it stimulates compensatory changes through a process called negative feedback. In response to the high levels of serotonin, the neurons that secrete it (presynaptic neurons) release less of it, and the postsynaptic neurons become desensitized to it. In effect, the brain is trying to nullify the drug’s effects.”

Not surprisingly, one can expect long-term effects from forcing the brain to function abnormally.

“With long-term use of psychoactive drugs, the result is, in the words of Steve Hyman, a former director of the NIMH [National Institute of Mental Health] and until recently provost of Harvard University, “’substantial and long-lasting alterations in neural function.’ As quoted by Whitaker, the brain, Hyman wrote, begins to function in a manner ‘qualitatively as well as quantitatively different from the normal state.’ After several weeks on psychoactive drugs, the brain’s compensatory efforts begin to fail, and side effects emerge that reflect the mechanism of action of the drugs. For example, the SSRIs may cause episodes of mania, because of the excess of serotonin. Antipsychotics cause side effects that resemble Parkinson’s disease, because of the depletion of dopamine (which is also depleted in Parkinson’s disease). As side effects emerge, they are often treated by other drugs, and many patients end up on a cocktail of psychoactive drugs prescribed for a cocktail of diagnoses. The episodes of mania caused by antidepressants may lead to a new diagnosis of “bipolar disorder” and treatment with a “mood stabilizer,” such as Depokote (an anticonvulsant) plus one of the newer antipsychotic drugs. And so on.”

“Some patients take as many as six psychoactive drugs daily. One well- respected researcher, Nancy Andreasen, and her colleagues published evidence that the use of antipsychotic drugs is associated with shrinkage of the brain, and that the effect is directly related to the dose and duration of treatment. As Andreasen explained to The New York Times, ‘The prefrontal cortex doesn’t get the input it needs and is being shut down by drugs. That reduces the psychotic symptoms. It also causes the prefrontal cortex to slowly atrophy’.”

“Getting off the drugs is exceedingly difficult, according to Whitaker, because when they are withdrawn the compensatory mechanisms are left unopposed. When Celexa is withdrawn, serotonin levels fall precipitously because the presynaptic neurons are not releasing normal amounts and the postsynaptic neurons no longer have enough receptors for it. Similarly, when an antipsychotic is withdrawn, dopamine levels may skyrocket. The symptoms produced by withdrawing psychoactive drugs are often confused with relapses of the original disorder, which can lead psychiatrists to resume drug treatment, perhaps at higher doses.”

This is scary stuff. And if this is what passes for medical science—then God help us!

Whitaker makes the suggestion that the concurrence of increased mental illness and the increased use of psychoactive drugs is causative. Angell describes his attempt to provide evidence as “Suggestive, if not conclusive.” One of the points made by Whitaker seems particularly compelling.

“Moreover, Whitaker contends, the natural history of mental illness has changed. Whereas conditions such as schizophrenia and depression were once mainly self-limited or episodic, with each episode usually lasting no more than six months and interspersed with long periods of normalcy, the conditions are now chronic and lifelong. Whitaker believes that this might be because drugs, even those that relieve symptoms in the short term, cause long-term mental harms that continue after the underlying illness would have naturally resolved.”

Where are we today? Angell provides this data.

“Nowadays treatment by medical doctors nearly always means psychoactive drugs, that is, drugs that affect the mental state. In fact, most psychiatrists treat only with drugs, and refer patients to psychologists or social workers if they believe psychotherapy is also warranted.....about 10 percent of Americans over age six now take antidepressants. The increased use of drugs to treat psychosis is even more dramatic. The new generation of antipsychotics, such as Risperdal, Zyprexa, and Seroquel, has replaced cholesterol-lowering agents as the top-selling class of drugs in the US.”

If these drugs are so harmful and of so little value, why are doctors continuing to prescribe them? And why doesn’t the knowledge produced by these three authors cause the public to rise up in outrage? Angell promises to explain all that in her second installment on this subject. I suspect the answer will be obvious and will relate to the ease with which everyone in the medical profession makes money out of the simple task of passing out pills. We should hope that Angell delivers quickly.

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