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Are Psychiatric Drugs Doing More Harm Than Good? Kings College London Maudsley Annotated Debate

This is a commentary, video and transcript of the 52nd Maudsley Debate at Kings College London which is asking the question ‘Are Psychiatric Drugs Doing More Harm Than Good?’.  This is a critical question of our time, and as prescriptions for psychiatric medications sore along with drug company profits, the civic, scientific and medical worlds are driven towards analysing the efficacy of their use.

psychiatry-warning

This is an issue as big as climate change and the destruction of the natural environment on which we depend. Analogically, this issue is about the internal environment of our psychologies and how that environment is facing catastrophy.

With emotions around the subject high, we are reliant on the balanced attempts of scientific method and analysis to understand the truths.  Moving away from the kind of ideological arguments which come to colonize highly emotive subject areas, it is critical that we tap into the studies, thinking and evidence that is presented by people who have dedicated their lives to the field.

Intrinsic in achieving this is valuing the knowledge of those who have lived their lives on psychiatric medication as they are the carriers of both the physical and intellectual knowledge which constitutes the realities.  Their contribution is the keystone which leads to building a representative understanding which we need to go forward.  Their contribution is of equal importance in reaching to the science as it constitutes the first hand experience of the effects of living long term on psychotropic drugs.

The Maudsley debate house believes that the long term use of psychiatric medications are causing more harms than good.  Please watch the video and read through the annotated transcript of the speakers.  Comment, criticise, add to the discourse.  The danger is that without this open debate we will end up medicating normal behaviours, shortening people’s lives, and also mistake side effects for the stated illnesses.  This concerns everyone.

 

 

til-wykes
Prof Til Wykes

The Chair is Professor Til Wykes, who is Professor of Clinical Psychology & Rehabilitation and Vice-Dean of Psychology & Systems Sciences, IoPPN

 

Arguing For More Harm Than Good:

  • Professor Sami Timimi, Consultant Child & Adolescent Psychiatrist; Director of Postgraduate Education, NHS Lincolnshire; Visiting Professor of Child & Adolescent Psychiatry, University of Lincoln
  • Professor Peter Gøtzsche, Director, The Nordic Cochrane Centre, Denmark

 

Arguing Against More Harm Than Good:

  • Professor Allan Young, Professor of Mood Disorders, IoPPN
  • Mr John Crace, Journalist, The Guardian

 


professor-peter-gotzsche
Professor Peter Gøtzsche

Professor Peter Gøtzsche, Director, The Nordic Cochrane Centre, Denmark

13 minutes 50 seconds: Cochrane Reviews have shown that psychiatric drugs are generally pretty ineffective. People think they are effective and that is because of the spontaneous improvement is mistaken for a drug effect. It is also because the randomized trials are pretty biased. Most of the trials are formed around patients who are already taking a drug, then you have a short wash out period, and then they are randomized to a placebo or a similar drug.

That means that you introduce withdrawal symptoms in the placebo group.  Abstinence symptoms and cold turkey, and that cold turkey can create depression, psychosis and so on which is then misinterpreted as the return of the disease. That is a common reason why the trials are flawed.

Another reason why psychiatric drug trials are flawed is that they are not adequately blinded. These drugs have conspicuous side effects, so there are studies which show that most doctors and patients know who is getting the active drug and who is getting placebo.

There is a very important Cochrane Review in depression that only looked at trials that had something in the placebo – namely atropine, as it gives you similar side effects to tricyclic antidepressants. That review found an effect of only one on the Hamilton scale – that is nothing because the least difference that people can perceive is five to six. So one equals nothing.

 

 

Cochrane Reviews

 

If you put something in the placebo so that you blind your trials you don’t see an effect. The trials are also short term.  We need long term trials and there are not many of these. And I should say that the ‘cold turkey’ design has actually driven some patients into suicide. Patients with Schizophrenia committed suicide because of Akathisia when they got abstinence symptoms. Trials in Schizophrenia are also disappointing. Newer submissions to the FDA for new drugs found an effect of only six on the positive and negative syndrome scale – and the least clinically relevant difference is fifteen.

[Akathisia is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting. MedicineNet.]

 

British Medical Journal Press Release

 

BMJ press release on antidepressants
Click to Download

 

So what was found was much less than what was clinically relevant. And you should remember that most of these trials were deeply flawed by cold turkey problems and inadequate blinding, which benefit the active drugs. So the real effect is even less than this. Now the benefits of ADHD drugs is also uncertain. Whether there is a short term effect, that is possible, but also they suffer from cold turkey and non blinding effects. Moreover, nearly all of these trails carefully selected responders – so they randomized only people who responded to these drugs.

This is a deeply flawed design.  They call it an ‘enriched design’ – I call it a design which makes the drug companies rich.  If there is a short term effect on ADHD it surely is replaced by long term harm. There are very few long term trials, and those which have been done indicate long term harm. And animal studies show evidence that these drugs most likely give permanent brain damage. This is likely the case for all psychotropic drugs; if you use them more than a few weeks.

So these drugs are incredibly harmful and I have estimated that in people older than 65 they kill around half a million people annually in the USA and in Europe – only benzodiazepines, anti-psychotics and antidepressants. They kill very very many people. There are no beneficial effects which can justify this enormous harm on people.  So I have estimated that we could get away with using only 2% of the drugs we use now.  Mostly for acute situations with a firm plan for tapering off as quickly as possible.

We need new guidelines to reflect this, and we need withdrawal clinics all over the country because very few doctors know how to withdraw patients from psychiatric drugs.


 

Professor Allan Young, Professor of Mood Disorders, IoPPN

19 minutes 34 seconds: First thing is that psychiatric conditions are common, complex and costly – they are over a fifth of healthcare problems. It is a huge area; to selectively choose one small part and generalize is almost certainly going to be wrong – for therapy and for other things. It is also true to say they are important.  On average, psychiatric patients lose 10 to 15 years of life. That is true to say in Schizoid disorders and in personality disorders.

So they are illnesses and they need to be treated. All interventions – whether it is pharmacology, or surgery or psychotherapy – are a balance between benefits and harms, and that should be evaluated in the round for everything.  And that is true for these drugs as much as for anything else. To take one part of the evidence, criticize and generalize it to everything is simply wrong; and indeed unhelpful, and may cause people to lose their lives.

If we look at the evidence in the round, as has been done by my colleague Stephan Leucht, psychiatric medications are on average as beneficial as common medical interventions – things like antihypertensives. Nevertheless, there are some very trenchant critics who oppose the use of these drugs. Now based on an evidence based approach, that is a very good thing. Now we have already heard the Cochrane Reports quoted, of which I am an author myself and Cochrane has weighed into the debate which I shall be going over later.

 

Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia

 

Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia
Click to Download

 

If we look at the evidence, not just randomised control trials, there’s regulatory agencies, there’s marketing surveillance; these cause drugs to be withdrawn. We have had psychiatric drugs withdrawn from the market in the last ten years which where perceived not to do much or to do harms. The notion that we should simply follow the rule of getting rid of 98% of them is simply a grotesquely bizzare argument which will actually damage many.

Now let’s go into some of the details about the over inflated concerns.  Now it is true that most trials are 8, 12 or a few weeks; but there are a few long term studies on things such as Lithium – something which we have not heard about so far. In the hospital and institution this was called a toxic placebo in the 1950s and 60s.

That has been shown to be wrong; it has been shown to be efficacious and the side effects – although still present and still significant to some extent – are far less than previously thought. It also reduces suicide rates, and that’s pretty important.  Suicide is a pretty hard outcome, and if we can make an impact in that, it is important.

So, there was a fear that drugs like Clozapine in antipsychotic resistent Schizophrenia would actually make things worse because of side effects like weight gain and cardiovascular disease. This was examined in the whole of Finland by Prof Tiihonen who found that life expectancy went up in the years after the reduction of Clozapine, and this was specifically associated with Clozapine reducing suicide rates.

 

11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study) Prof Jari Tiihonen

 

11 year follow up of mortality in patients with schizophrenia a population based cohort study
Click to Download

 

So these are important data, long term and national data, which shouldnt be ignored. Lastly, in terms of mood disorders, Professor Angst, my colleague from Zurich – with respect to people here, he is the most senior academic psychiatrist in Europe at the moment; he has been following people up since 1949.  He looked at the effects of treatment; the people who remain on treatment – pharmacological treatment – are more…audio glitch… than most yet their long term outcomes are better – including a reduced suicide rate.

Suicide in 406 Mood-Disorder Patients With and Without Long-Term Medication: A 40 to 44 Years’ Follow-Up, by Jules Angst , Felix Angst , Regina Gerber-Werder & Alex Gamma 

 

That is evidence which is publicly available, and it is not…audio glitch…. opponent.  So in summary, and the evidence is persuasive, supports long term use. Thank you.


 

professor-sami-timimi
Professor Sami Timimi

Professor Sami Timimi, Consultant Child & Adolescent Psychiatrist; Director of Postgraduate Education, NHS Lincolnshire; Visiting Professor of Child & Adolescent Psychiatry, University of Lincoln

24 minutes 0 seconds: Firstly I would like to make two important points. One – if you are taking psychiatric medication and agree with this motion, please don’t stop taking your medication abruptly because this can be very dangerous and please seek further advice…

Two, psychiatric drugs do help many people, particularly in the short term. For example, someone tormented by voices may experience relief from the sedative and emotional blunting effects of some of psychiatric drugs.

This motion is about long term effects of medication, and specifically about whether the benefits outweigh the harms, and here we have to turn to the evidence. Evidence leaves little room for doubt.  We have plenty of evidence that they can cause harm – sometimes immense harms; physical, psychological, and social…

…they can cause dependency, they can cause withdrawal problems and they have very little benefits of lasting benefits that justifies exposing people to these harms. I will give you two examples of this. First, long term use of antipsychotics; this is associated with serious risk of cardiovascular, metabolic and neurologic side effects – is it worth exposing people this level of harm ?

Many findings cast doubt, for example the largest follow up study of people diagnosed with Schizophrenia were followed up by the World Health Organisation study; and that one found that the best outcomes were in developing countries where about 15% of the patients had exposure to antipsychotics.  Compared to the developed countries where about 90% exposure to antipsychotics.  Over 5 years, 64% of patients were asymptomatic compared to only 18% in the developed countries.

 

Recovery from Schizophrenia

 

Recovery from Schizophrenia
Click to Download

 

…audio glitch…a study of long term outcomes of patients with psychosis found that those who came off antipsychotics had much better functioning; fewer symptoms and were about 8 times more likely to be classified as….audio glitch… Recently Wunderink and colleagues published the first randomized control trial of maintenance antipsychotics. At follow up at 7 years they found that the withdrawn patients had much better functioning and twice the recovery.

 

jamanetwork.com/journals/jamapsychiatry

 

Now if someone can show me well conducted and impartial studies that demonstrate superior functional outcomes for those who stay on long term antipsychotics, then I would like to see them.  And if you cant, then surely it is unethical that we can continue to expose numbers of people to long term antipsychotic treatment. Indeed, one Cochrane Review recently has cast doubt on whether antipsychotics are effective even in the short term.

 

Antipsychotic medication for early episode schizophrenia
Click to Download

 

In my field, I am a podiatrist, the most widely prescribed drugs are stimulants…. harms from stimulants include cardiovascular, growth and psychiatric, and they are usually prescribed for many years despite the long term effects…. regardless of initial severity, children who are diagnosed with ADHD who don’t take stimulants have outcomes which are no worse, and in many cases much better – particularly in terms of functioning and symptoms than children who are on stimulants.

So this picture shows some short term benefits, little evidence of long term benefits, is typical of what you find when you examine the evidence base. We are in danger of creating morbidity on a massive scale with our clinical evidence base use of long term psychiatric medication – which seems to be increasing in volume.

Official guidelines like NICE seem to have plenty to say about starting people on these medications but have given little advice on long term treatment, and how long to give these medications, and how to help people safely withdraw. It seems like the widespread use of psychiatric medications these days is a result of good marketing and not good science.

Psychiatry is full of people, like Professor Young, who have swelled their pockets and made their careers through the corrupting influence of the pharmaceutical companies, and it would be interesting to see whether Professor Young has conflicts of interest tonight.  So the evidence is clear and the big question is not whether long term prescription does more harm than good – the question is what are we going to do about it ?

Bodies like the Royal College of Psychiatrists have, I believe, a scientific and moral duty to do something.  And if they wont, we are as psychiatrists, in danger of becoming part of the problem, rather than what we should be which is strong advocates for patients.


mr-john-crace
Mr John Crace

Mr John Crace, Journalist, The Guardian

28 minutes 58 seconds: First the disclaimer, Im no big fan of big pharma, all the medications I take are generic. But I am a person with mental health issues and I think for the patient to be left out of the debate is – to me that is insane.  I have suffered from depression and anxiety for 20 years and I have been treated in various ways.

Could I have done more to make my life easy.  Well I could have a less stressful life; being a sketch writer isnt always easy, I could always be a Spurs season ticket holder, though perhaps the team chooses you – that could be another debate. My response as a patient – in the proposal, it basically appears to me that psychiatry has got absolutely nowhere in its entire history.

If all that is being said is that we should try and prescribe less drugs and get off them as soon as possible; that is a bit like saying stop taking… until your headache’s gone. The thing is that it really isnt that binary. I have time and experience.  I have been on Fluoxetine and off Fluoxetine, and I have actually discovered that it is best to stay on it for a period and when a depressive episode occurs, to increase it temporarily.

It is trial and error.  The thing is that we may be mental but we are not stupid. We actually do know; we know what the risks are. We know there are side effects. The psychiatrist was very clear that Fluoxetine may not work in my case or whatever, but we are desperate – we have tried absolutely everything else.  Now it is possible that the proposal is absolutely right, and Fluoxetine has has absolutely no effect on my whatsoever; and that my recovery periods have been absolutely co-incidental.

That is a possibility, I have not done a trail. That is not something personaly which I want to look at.  I have also tried alternative therapies.  I dont believe that there was a single childhood trauma that could throw any light on my life. I treat that like emotional dialysis to help me get through. I have even had CBT which is often the preferred treatment in psychiatric institutions, and the CBT therapist turned out to be the most anxious person I have ever met.

She shared a line ‘being late always makes me feel anxious’ – but she was always late. When I was in residential care, I was always given a scorecard to score my level of depression and it stayed resolutely the same because they would ask questions like ‘have you felt like committing suicide today’. And I have to say, this is a question I ask myself every single day. It is maybe a sign of unwellness, it is not something which I act on but it is a fundamental part of my existential being.

If you are alive, I cannot believe why you would not ask yourself.  So the poll line stayed exactly the same as if I were eternally depressed but it actually turned out that I was getting better – something was actually working. It is imperfect, and surely it should be up to the patient to choose. Life isnt always that easy, but thanks to my shrink and therapist, we have managed it.

Ive got no doubts that I will have other depressive episodes in the future, and I am lucky to have a family and a workplace where help is not taboo.  It would be just great to not make medication a taboo as well. Thank you


 

What follows are important questions from the floor…

 


A good supplement to this discussion is the following document:

The Case Against Antipsychotics

A Review of Their Long-term Effects

Robert Whitaker July 2016

Founder of Mad in America, Robert Whitaker is a highly educated and experienced commentator

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