Sunday, June 12, 2016

Anatomy of a Non-Epidemic

E Fuller Torrey, legendary these last 30 years in schizophrenia research and advocacy for the biological understanding of that illness (and others), reviewed Robert Whitaker's Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, which had come out a few years before.  I had heard of Whitaker's book, touted quietly to me by a psychologist, and had run across reference to it a few other times. I was a bit surprised that it hadn't simply vanished like so many other books trying to scramble up evidence that schizophrenia was all some huge misunderstanding on the part of psychiatry and the medical profession.  Surprised because the evidence for that POV had largely not changed in the last twenty years - unless I had missed something that hadn't come to Dartmouth Medical School or the psychiatrists I work with. Somehow it persisted, but as it wasn't taking the world by storm around here I saw no need to follow up.  I just wondered.

Torrey makes a persuasive case, which I find he usually does.
In its 396 pages Whitaker got many things right, including criticism of the broad DSM diagnostic criteria for mental illnesses; the reckless prescribing of psychiatric drugs for children; and the prostitution of many psychiatric leaders for the pharmaceutical industry. Indeed, regarding the last, Whitaker may have understated the problem, based on recently released court documents detailing how the pharmaceutical industry secretly controlled the Texas Medication Algorithm Project.

When it came to schizophrenia and antipsychotic drugs, however, Whitaker got it mostly wrong. He made so many errors it is difficult to know where to begin, so I will begin where he did. In his Preface Whitaker says that his research on the book began when he encountered “two research findings that just didn’t make sense”: a 1994 schizophrenia outcome study (Hegarty et al. 1994) and the World Health Organization (WHO) studies “which had twice found that schizophrenia outcomes were much better in poor countries.”
I looked up that Texas Medication Algorithm Project reference, and it does seem to be seedy in parts, though "controlled" turns out to be a bit overstated. Janssen did end up paying $158M to settle, so that's not chopped liver. These are the sorts of reasonable complaints that can be leveled against Big Pharma, though usually not all of them at once, just one at a time: kickbacks, ignoring some studies and highlighting others, outcomes that seem to favor the expensive drugs under patent rather than the older medicines which are now generics.  But note.  This isn't Big Pharma making up illnesses that don't exist, or suppressing evidence of natural cures that are just as good, or making people believe they are sick. It's thumb-on-the-scale stuff, not denial-of-reality.  That's my default view of conspiracy theories and corporate corruption accusations, based on getting tired of investigating fevered claims.

Which is bad enough, and deserves big punishment.

Favoring newer drugs isn't all just money-chasing either (though some of it is).  There are usually specifics that pharmaceutical companies are trying to improve, because of problems with the old medications.  Side effects, because of the impact on long-term health (kidneys, livers) and the subsequent effect on compliance, just for openers. There was a reason why haloperidol replaced throrazine, and olanzepine replaced haloperidol.


Retriever said...

Tolerability, tolerability, tolerability. I want to speak for once from the perspective of the family because the end result of all this non existent care in the community and patient's rights has been to fling an ever sicker patient population back home on the mercy of totally stressed relatives, no matter how caring. Tolerability is something that patients and their families focus on more than psychiatrists.

Family members sometimes prefer less effective meds that people are willing to take Indefinitely but that do NOT turn their loved ones into obese zombies, so long as they serve the basic function of meds : which is primarily for the benefit of society not the patient. Sorry, but the patient is told they will help him or her, but really they are designed to prevent irrevocable rifts in their significant relationships which are what keep a person off the street.

You give a violent schizophrenic meds so he doesn't slice and dice his mom w a kitchen knife thinking her Evil Incarnate. You give a manic young father meds so he doesn't gamble away the family house and catch AIDS having sex w street kids on a month long wild adventure (and destroy his wife and kids' life as well as his own). You give a suicidal mom meds so she can cook dinner for her family and drive the kids to fencing and soccer and at least pretend to be supportive of her spouse's stress at work. You can't make her happy but you can help her function better. My point is, the meds we have are blunt instruments, but they are immeasurably better than the horrors of Third Workd neglect, scapegoating and abuse of the mentally ill. Which are still at Biblical levels, and not in a good way.

When someone you love goes from trying to kill you when angry to using their words, you bless meds.

Having said all that, the disparity in which meds a person will get and how willing an md is to work w a patient til they find tolerable ones is a scandal. I have a relative who died raving because no one ever bothered to do this for them, so they kept going off meds, AMA. I have other relatives who pass for normal because they have been listened to and treated respectfully and allowed to literally pick their poison.

O'Neill ( I think) wrote that we are all broken/cracked creatures, and that's what the grace of God shines thru. We are all miserable sinners, certainly. As Augustine reminded us, we will be restless until we rest in God. But meds can ease suffering a little.

So I will verbally punch anyone who carelessly says meds are useless. Now, the important thing is, they aren't the whole treatment, however much stingy insurance might like them to be. They merely make a person available for treatment...for another rant..,

Texan99 said...

I'm pretty tired of the "Big Pharma is only in it for the money" bandwagon. Granted, you can get some perverse incentives going, but I have yet to see a proposal for how to motivate people to spend their lives and fortunes creating innovative, problem-free miracle drugs that doesn't involve compensating them financially. Certainly the loudest people on the bandwagon aren't volunteering to shoulder the burden pro bono, even assuming they wouldn't be flunked out of the biochemistry programs.

Anyone who's nostalgic for the glory days of lucre-free drug manufacture can always opt to use only the drugs that existed before, say, 1950.