Another Perfect Storm

Factors Contributing to the Over-Valuation of Medications as a

Treatment for Psychiatric Disorders

Attribution Theory

Attributions are explanations of the cause(s) for events

Causes may be internal or external, enduring or unstable

People preferentially interpret events in a manner that maintains a positive self-image

Attributions may lead to cognitive distortions

Attribution in Psychiatry

Diagnosis and treatment recommendations

Assessment of treatment responsePerceived efficacy of various

treatment modalities

Data Regarding the Efficacy of Antipsychotic Medications Levine et.al. (2011): During CATIE study,

only 11.7% of subjects attained and maintained remission of at least 6 months; 55.5% experienced no period of symptom remission.

Levine et.al. (2012): During the CATIE study, only 18.9% of subjects were treatment “responders” by trajectory analysis.

Data Regarding the Efficacy of Antipsychotic MedicationsPoor outcomes for vocational

recovery and quality of life indicators.Outcomes for treatment of first onset

schizophrenia in programs utilizing little or no psychotropic medications were equivalent or better than conventional treatment with medications.

Risks Associated with Antipsychotic Medications

Metabolic complications including diabetes, metabolic syndrome, and resulting cardiovascular disease have been implicated in the declining life expectancy of individuals having psychiatric disabilities.

NASMHPD (2006): life expectancy for individuals having psychiatric disabilities is 25 years below the average in the United States

Risks Associated with Antipsychotic Medications

Serious, and sometimes life-threatening adverse effects, such as seizures, hyperthermia, osteoporosis, hypothyroidism, breast cancer, suicidality, cardiac arrhythmias, and tardive dyskinesia are not uncommon.

A Balanced View of Psychotropic Medications

Very beneficial to a relatively small percentage of individuals

Partial benefit to some individuals Risk for very serious and potentially life-

threatening adverse effects May produce no therapeutic effect or even

paradoxical worsening of various conditions Effects of psychotropic medications are highly

individualized No useful tools to predict treatment response

Prescription Drug Utilization

The U.S. Centers for Disease Control report on prescription drug utilization in 2007-2008

Stimulant medications were the most commonly used prescription drugs in the 12-19 year age range

Antidepressant medications were the most commonly used prescription medications among adults ages 20-59

Conclusion:

Factors that are unrelated to scientific inquiry and empirical evidence are powerfully driving perceptions of psychotropic medications that exaggerate their efficacy and their legitimacy as a preferred therapeutic tool.

Historical Context

Commercial synthesis and marketing of PCN in 1945

Chlorpromazine, marketed in the US in 1950 as Thorazine

Diazepam marketed in 1963 Fluoxetine (Prozac), released in 1987

Historical Context

Dramatic achievements in medical sciencepublic optimism passivity concerning health issues

Psychopharmacology helped “medical-ize” psychiatry

Family members of psychiatric consumers

Psychological Motivations

Obtaining a diagnosis and prescribing a medication relieves feelings of powerlessness.

Prevent harm Intervention during crisis must be

incisive, targeted, and therapeutic Exaggeration of the efficacy of the

prescribed medication is reassuring

Psychological Motivations

Motivation for psychiatrists to inflate their perception of psychotropic medication as a therapeutic tool External pressures to have definitive

answers Wish to have recognition for expertiseWish to preserve credibility

Pharmaceutical Marketing

Physicians tend to perceive themselves as neutral with respect to marketing strategies, but numerous studies continue to show that pharmaceutical sales representatives have a major impact upon prescribing patterns, often to the detriment of quality of care.

Pharmaceutical Marketing

Gift cycleBefriend and betrayObfuscation of marketing intent with

“educational opportunities”Visual images to imply benefits and

indications that are not substantiated by research

Solicitation to participate in false studiesPublication planning Direct to consumer marketing

Pharmaceutical MarketingTrue extent of contamination of medical

science and medical care by pharmaceutical marketing is staggering. Lobbying Insertion into the political economy Impact upon regulatory policy Dilution of the medical literature Impact on day to day practice of psychiatry Promotion of new, unsubstantiated diagnoses Under-representation of risk Undermining of treatment alternatives Promotion of self-diagnosis and aggressive consumerism

Academia

Funding for research Publishing

Positive reporting bias in journals Ghost writing

Program developmentPersonal financial gainShapes medical education and

imparts significance to pharmacology

Other Financial Considerations

Third party payersMedications impact length of stay in

hospitalizationA central criterion for continued payment

for inpatient treatment is on-going adjustment of medications

Cost savings when primary care physicians treat with meds rather than referring for mental health services

Consumers

Acculturation to a passive recipient role in treatment

Easier to have a chemical imbalance than to confront life’s problems, change lifestyle

Quick fixFaith in Western medical science

Regulatory Considerations

Relatively permissive criteria for approval of medications and new indications for medications

FDA approval is translated by most professionals and consumers to mean that the drug is safe and effective

Loopholes to regulations that would support more transparent disclosure Medical journals.

The Perfect Storm:Implications

Clinical practiceOutpatient commitment for

medicationsDrug courtsMedication of children, especially

those in public custody