A psychiatrist ushers a 22-year-old out-patient into a room for an assessment. According to his medical notes, the young man has been stabilised on the ‘antipsychotic’ olanzapine several weeks after a first episode of ‘psychosis’. After asking the patient some provocative questions, the doctor tells him that his face is like a mask and he seems unresponsive and flat. The psychiatrist goes on to confirm a prior provisional diagnosis of ‘schizophrenia’, and relates this to the young man. The doctor also decides that prescribing an ‘antidepressant’ on top of the olanzapine might help address his observed flatness.
Such a lack of expressiveness tends to be characterised in presumed cases of ‘schizophrenia’ as among its ‘negative symptoms’. These are described as; apathy, blunted emotional responses, disorganised speech, impaired attention and inability to enjoy things. Considered to be deficits of functioning rather than the ‘florid delusions or hallucinations’ said to mark a psychotic episode.
Now let’s imagine a different scenario. A healthy volunteer agrees to take olanzipine (known as Zyprexa in the US). They soon show some of the known ‘adverse effects’ of the drug which can include; a change in personality, loss of interest or pleasure, difficulty concentrating, delayed speech, and ‘masked facies’ (the face appears somewhat puffed up, losing some of its expressiveness). The point I’m making here is that the putative ‘negative symptoms of schizophrenia’ are essentially indistinguishable from many of the adverse effects produced by olanzapine.
Other potential effects can be more harmful, including impaired movement. In fact, trials of antipsychotics on drug-naive healthy volunteers, with even small doses, are recommended against. When tested on macaque monkeys, olanzapine exposure was found to cause brain shrinkage.
In the young man’s case, his blankness and ‘facial masking’ from olanzapine treatment were taken as symptoms confirming the diagnosis ‘schizophrenia’, and necessitating further drug treatment. Thus leading to further drug-induced harm, some of it long-lasting. Years later, at 36 and after a period of unsuccessful olanzapine treatment, he had developed an even worse facial masking effect. It was, once again, taken by a psychiatrist as a sign of his illness. According to her assessment, he probably had ‘treatment-resistant schizophrenia’. She, therefore, prescribed him a more heavy-duty ‘antipsychotic’.
Taking that drug was to have a marked impact on his health: high prolactin levels, weight gain, hair loss. It would soon, though, become clear that his case was not ‘treatment-resistant’. Although a ‘slowness’ was observed and ascribed as being a ‘negative symptom’, that might call for upping his dose. This ‘slowness’ was really an impairment of his reactions and functioning, the cumulative result of all the drugging in the preceding weeks and months.
‘Antipsychotic’ is really a drug marketing name for ‘neuroleptics’, or ‘major tranquilizers’ as they used to be called. Joanna Moncrieff explains:
‘Prior to the 1950s drugs were classified according to the nature of the psychoactive effects they produce. Existing drugs were crudely classified as having either sedative or stimulant effects on the nervous system. After the 1950s, however, drugs came to be named and classified according to the disease or disorder they are thought to treat; antidepressants, antipsychotics and anxiolytics, for example.’
‘Antipsychotics’ are often used ‘off-label’ for other diagnoses, such as dementia, ‘obsessive compulsive disorder’, ‘childhood behavioural disorder’ and insomnia, among others. All this demonstrates that ‘antipsychotics’ don’t target some disease – “psychosis”, as the name might suggest. They are used for their general suppressing effects on the function of the brain and nervous system. They are a blunt tool, to put it mildly. Moreover, it is acknowledged that a significant proportion of patients with ‘psychotic symptoms’ will be unresponsive to treatment
The two instances of the facial masking drug effect being mistaken for a symptom of ‘underlying illness’ are examples, among others, from one person’s history that illustrate how psychiatric treatment tends to snowball. As Kendra Campbell writes:
‘The general theme is the same: someone starts having ‘psychiatric symptoms’, they are diagnosed with a psychiatric disorder and prescribed medication. Due to the medication, they experience even more severe psychiatric symptoms and then they are diagnosed with another, and usually more severe, psychiatric disorder.
‘The story continues with more and more medications and diagnoses being added over time. In addition, patients also begin experiencing side effects to the medications, which are often labelled as new symptoms, leading to even more diagnoses and of course even more medications. Once the vicious cycle of medications, symptoms, and diagnoses is started, it’s like a runaway train.’
As we have just seen, psychiatrists often won’t attribute a patient’s deterioration to drug effects but conclude the patient’s illness has worsened — although any mechanism for this ‘illness’ will likely be left mysterious. Perhaps the case will be deemed ‘treatment-resistant’. Perversely, the inevitable response to such ‘resistance’ will be to administer heavier-duty drugs. When all you have is a hammer, every problem looks like a nail!
The young man’s case is just one way the story can play out for an individual. But at an institutional or bureaucratic level, what is it about a psychiatric practice that leads to countless such counterproductive and harmful outcomes? I suggest that a concept, which bubbled up from the lower officer class of the US military during the Vietnam war, is also very apt for pharma-led psychiatry. A lecturer in War Studies summed it up:
‘A self-licking ice cream cone is a programme or policy that costs money and resources, generating a great deal of activity; produces indicators of its own success, preferably quantitative; but does not actually achieve its announced goals. Indeed, a proper self-licking cone undermines the very purposes for which it was created, while at the same time sucking in ever more resources from worthy and effective activities.’
In the case of antipsychotic-based treatment, such a warped outcome is clearly discernible. The guidance and ‘trial-based evidence’ available to doctors assure them that ‘antipsychotics’ are ‘effective’. And they will feel duty-bound to follow such professional guidance. Nevertheless, it has been found that rates of recovery from psychosis are often better in ‘non-industrialised’ countries — where there has been less demand for drugs — than in the higher GDP economies. What explains this paradox? A few factors:
- That the evidence base is plagued by highly selective trials where “up to 80–90% of patients are excluded”. Marginal benefits are often presented out of context to make them seem more significant, whilst adverse results can be suppressed. In the case of olanzapine, internal documents from Eli Lilly revealed that they knowingly played down the risks of the drug for patients. They were eventually forced into a settlement and paid, at the time, the largest individual corporate criminal fine in history.
- Whilst their tranquilizing effects may be of limited utility in acute phases, their longer-term effectiveness in preventing ‘relapses’ is clearly lacking. The brain compensates for its dopamine-blocking effect by developing more receptors. That adaptation is thought to increase the person’s susceptibility to recurring psychotic-like symptoms. In fact, when administered to patients with no history of ‘psychosis’ and then stopped abruptly, the ‘withdrawal’ effects suffered may include ‘hallucinations’ or ‘paranoia’ among others like restlessness, tremors, cold sweats and potentially worse. The longer the patient’s exposure to the drugs has been the greater the risk for these ‘rebound effects’. Mental Health services will tend to treat these effects as ‘relapses’. This goes some way to explaining why longer ‘maintenance treatment’ after ‘an episode of psychosis’ tends to result in poorer long-term outcomes.
- On the more positive side of the ledger, we see a much better chance of long-term recovery from these types of experiences with greater social integration and support and more accepting cultural attitudes — often absent in the more individualistic Westernised societies. Where sufferers are more likely to feel alienated or excluded.
- It also seems that doctors in countries such as India may be more open to seeing ‘psychosis’ as a transient experience. And one that can happen to reasonably healthy people. For instance, in Africa and the sub-continent there are more diagnoses of ‘acute transient psychosis’, and much fewer ‘cases’ of ‘schizophrenia”. It is clearly implausible that this is the result of some great difference in genetics or the nature of people’s experience, rather than simply the result of differences in the way doctors and services tend to proceed. In the West, guidelines following doctors seem to be precluded from such open-mindedness. The presumption is to see an ‘episode’ as marking the onset of a lifelong condition — also implying that there must have been some ‘pre-existing disposition’. Assumptions such as these bias services towards more prolonged treatment programmes. The diagnoses thus become self-fulfilling prophecies.
The prevention of ‘psychotic symptoms’ is a tick-box measure of effectiveness. But it must be weighed against the patient being allowed to recover in a fuller sense. Not living interminably with the detrimental effects to their physical, cognitive, and emotional well-being that prolonged use of these drugs carries. Mental health services tend to prioritise ‘prevention’, looking to minimise any potential for ‘disruption’. But in so doing they increase the toll on patients’ overall health, without really addressing those so-called ‘negative symptoms’, that so impoverish people’s lives. Now, thanks to the work of researchers like Mark Horowitz, there is more ‘authoritative’ evidence about how to safely manage drug withdrawal, with the use of more appropriately structured tapering regimes. This is evidence that mental health services cannot easily discount, and they should not be allowed to ignore it!
Countries in the industrialised west have seen the proliferation of psychiatric prescribing and increasing polypharmacy. Twenty per-cent of UK adults are on some psychiatric drug, with ever more and ever younger patients exposed to the risks of taking multiple ‘medications’. The result: greater dependence and morbidity. And causing, in the end, more of the kind of ‘symptoms’ the drugs are said to counter. People are left feeling trapped.
The economic costs are massive. Naturally, their burgeoning use has been highly profitable for the pharma concerns. Who anticipate more profits as the global market for antipsychotics expands further. How many more lives are to be damaged in this way? Whilst doctors and bureaucrats are able to justify themselves, saying they follow ‘best practice’ and that patients receive ‘standard of care’. A true self-licking ice cream cone!
Far less reliance on these toxic drugs is clearly called for. It is, though, evident that a movement towards resolving this problem cannot be separated from the wider need to address the capture of healthcare research and provision by interests that demand sustained cash flow. Increasing rates of iatrogenic harm from psychiatric treatment can be seen as just one symptom of an underlying sickness — financial and corporate control of the economy and public services.
Thank you Neil. Your post is of utmost importance.
Physical, psychological, emotional and behavioural psychotropic Adverse Drug Reactions (ADRs) appear more likely to be misdiagnosed as ‘mental illness’ rather than correctly recognised as potentially life threatening prescription drug toxicities.
The result is that instead of a tapered withdrawal of the causative drug, misdiagnosis is likely to be followed by inappropriate dose increase, change of psychotropic drug within the same class, ‘augmentation’ by adding a second class of psychotropic drug (eg ‘Antipsychotic’ or ‘Mood Stabiliser’) or psycho-polypharmacy.
“Once the vicious cycle of medications, symptoms and diagnoses is started, it’s like a runaway train”.
The failure to differentiate between common, serious psychotropic drug adverse reactions and serious mental illness is the basic common denominator underlying this vicious cycle. Unrecognised AKATHISIA induced by SSRIs/SNRIs (and many other drugs) is especially vulnerable to misdiagnosis.
Meticulous prescription drug history and temporal relationship of drug/dose changes to the often rapid-onset of perceived psychiatric symptoms can improve diagnostic accuracy. Increasing prescriber awareness of akathisia would improve ADR recognition and management.
Sadly, this does not appear to be a clinical (or Quality of Outcomes) priority.
The current priority appears to be more psychotropic drugging, even resorting to detention in order to to so. The treatment given has become the unrecognised and/or denied cause of a problem which is then treated by adding more drugs. The vicious cycle deepens, akathisia intensifies, and additional ‘diagnoses’ are applied alongside presumption of ’emergent psychiatric illness’ and/or ‘treatment-resistance’.
Akathisia is by definition treatment-resistant to the drugs which have caused it.
Much appreciated. I am meaning to write also about the risks of antidepressant type drugs, among them induced mania or over-stimulation, which tend to lead to escalating treatment and diagnoses. Not to mention akathisia and suicidality.
Madinamerica.com just published my article “I Can Barely Breathe” by Lori Daniels is personal story and is the perfect example of your article.
I’m familiar with with the distressing akathisia that comes with Abilify. Typically, the health authority would present it being the option with the least side effects.
I think that you having the level of consciousness you do, must be a source of strength. It shows the potential you have and can believe in.