A pill to take away your madness

The potential benefits of taking antidepressants seem underwhelming when set against their costs. A similar but subtly different argument applies to long-term so-called 'antipsychotic' medication. There are some benefits for people in acute distress, and with particular problems, from taking antipsychotic drugs. But taken longer term, these drugs have serious, life-changing adverse effects. These negative effects, sometimes euphemistically called 'side-effects', can include a condition that resembles Parkinson's disease - with shaking, muscular rigidity and problems with walking and movement - and even reduced brain size in people who have been taking 'antipsychotic' medication for a long time. Because they affect various physical systems, such as our heart, liver and kidneys, as well as our brains, and because one of the common adverse effects is a significant gain in weight (itself physically dangerous), these drugs can have a significant impact on our health.

Dr Joanna Moncrieff reports on her blog a story of a woman who was very distressed by frightening psychotic experiences. The woman was scared that she had a gadget implanted in her body and that she was being watched and manipulated by malignant forces. Psychotic experiences like this are surprisingly common, and obviously very distressing for the person involved. Dr Moncrieff reports how, as we might expect, the young woman began taking an antipsychotic drug. As is common, Joanna reports that as the dose was gradually increased the young woman 'became increasingly quiet, subdued, emotionless, expressionless and physically sluggish'. Dr Moncrieff contrasts the medical consensus - that the young woman was 'better' - with her own perspective - that the young woman's life 'seemed empty and lifeless . .. although admittedly less distressed'.

To me, this sums up both my own experience of observing people taking antipsychotic drugs and the scientific consensus. These powerful drugs are effective at helping people calm down and can sometimes reduce distress, but can hardly be considered cures. They have very clear effects on people, and those effects can be helpful. But they don't target biological abnormalities specific to psychosis, and don't return people to 'normal'. They just have the kinds of effects that psychoactive drugs are recognised to have.

I need to be clear here. I understand that antipsychotic drugs can be very helpful. In acute emergencies (especially, perhaps, when people are very agitated), antipsychotic medication can be enormously helpful and even life-saving. Decisions about medication are, or certainly should be, individual issues. Blanket advice one way or another would be foolish. But it does appear that antipsychotic medication can be helpful in suppressing acute psychotic symptoms. And it's important to recognise that many people experience highly distressing psychotic phenomena for years, either on an on-going or a recurrent basis. Again, that means that for some people, as Jo Moncrieff puts it: 'life on long-term drug treatment, even with all its drawbacks, might be preferable to life without it'.12

There is a great deal of debate about the changes that have taken place in inpatient psychiatric care over the past six decades, and particularly about the reasons for the dramatic reduction in the number of in-patient residents in psychiatric hospitals. One line of argument suggests that this was the result of profound changes both in society and in nursing practices. The most widely-accepted opinion is that the development of chlorpromazine in the 1950's allowed, for the first time, many thousands of people to achieve some form of relief from their distress. It's clear that many people in the early decades of the 20th century, and before, could spend many years of their lives in extreme distress. It would be stupid and cruel to deny people such help.

But we also need to be clear what the effects of these drugs are, and whether they are either 'cures' or, in fact, 'antipsychotics'. That is, do they target an underlying biological abnormality, return a person to a state of normality and substantially remove the problems? We might also add: do they prevent relapse? It seems clear, and seems to have been clear back in the 1950s, that antipsychotic drugs such as chlorpromazine numb people's emotions. These can reduce emotional distress (so can, I repeat, be a good thing), but is not quite the same thing as reducing psychosis. People who are convinced that others mean them harm (with 'paranoid delusions', in psychiatric language), and who are very frightened that they are in imminent danger, will often find their fears much less preoccupying and distressing if they take chlorpromazine.13 That sounds a lot like the effects of opioid street drugs like heroin.

A study of the recent history of psychiatry also tells us that the ways in which medication has been used, and discussed, have changed over time. Initially, psychiatrists appeared to use medication pragmatically to help reduce distress and agitation, and acknowledged its direct effects (some psychiatrists quite overtly described them as damaging the brain). But over time, psychiatrists began to think of drugs as 'treatments' for underlying conditions. The drugs shifted from being practical shortterm solutions to long-term or prophylactic preventative remedies. Current clinical guidelines recommend long-term treatment with antipsychotic medication for people who have been given the diagnosis of 'schizophrenia'.14 Those recommendations parallel the growing assumption that the antipsychotic drugs are sophisticated treatments, specifically designed to correct an underlying biological abnormality that causes their problems.

It seems clear that 'antipsychotic' medication is helpful for some people, especially in the short term and if they are very distressed. It seems much less clear that antipsychotic medication prevents relapse. This, again, needs to be considered very carefully. Some people have on-going problems, and may find that medication which helps to lessen their distress is useful for long periods. But that isn't quite the basis on which antipsychotic medication is often recommended, namely that it prevents a 'relapse' - a return of the psychotic experiences. That seems a much less certain prospect.

The use of antipsychotic medication on a long-term basis (daily or even injected as a 'depot') is so ubiquitous that it is quite difficult to find comparisons between groups of people who have, and have not, taken the drugs for long periods of time. These kinds of comparisons are also difficult because the medications are very powerful, so that when people stop taking their drugs (especially without expert medical advice), they often experience profound and distressing withdrawal effects, which can either resemble or induce the return of their previous psychotic experiences. However the emerging evidence, summarised in books by Richard Bentall, Robert Whitaker and Jo Moncrieff15 strongly suggests that for most people the long-term benefits of antipsychotic medication are significantly outweighed by their profound adverse effects. And it looks very much as if the levels of psychosis, and 'relapse' rates, are no higher in people who live medication-free lives than in people who take antipsychotic medication on a long-term basis. In other words, these drugs don't appear to prevent relapse. And, because these drugs have very profound side-effects, those people who take the medication on a long-term basis often experience significant physical health problems, as well as emotional blunting, sedation and suppression of creativity and imagination. Many wise and intelligent psychiatrists therefore conclude, as Joanna Moncrieff has done, that 'these are not innocuous drugs, and people should be given the opportunity to see if they can manage without them, both during an acute psychotic episode and after recovery from one' and that 'if you reduce people's antipsychotics in a gradual and supported manner, people are better off in the long-term. Some will manage to stop their antipsychotics completely and do well, and overall people will not suffer higher levels of symptoms or relapses than if they had stayed on their original level of medication.'

It is worth pointing out that many of these concerns also apply to medication used to 'treat' so-called 'bipolar disorder'. People experience episodes of depression, and some people experience episodes of mania (feeling very agitated or 'high', sometimes leading to actions you later regret such as running up large bills) or hypomania (the same but to a slightly lesser degree). Let's leave aside for a moment the issue of whether this diagnosis is valid or helpful, except to say that in my view it adds nothing to label a tendency to experience extreme moods 'bipolar disorder'.16 Manic episodes can be distressing and dangerous, and people who experience a manic episode once are highly likely to experience another one. That does demand a response. Antipsychotic medication can be helpful as an immediate or emergency response, but there is much less evidence for the effectiveness of the two main medications that are often used to prevent 'relapse'.17 Because recurrent episodes of mania and depression can be disabling, there is real pressure to prescribe drugs that can be effective not only in an acute episode, but as prophylaxis - that is, to reduce the likelihood of future episodes. Lithium (a so-called 'mood stabiliser' is the most commonly-used medication, but long-term antipsychotics are also commonly prescribed. And here too there are major doubts as to their effectiveness. Just as with psychosis, there is precious little evidence that the medication is targeting any underlying biological abnormalities.

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