Right to the end

When drugs can be forced upon the mentally ill, when is pharma's job finished?

Last month I attended a debate at the Guardian which asked whether psychiatric drugs do more harm than good. On the day of the debate, the papers had carried a story about how SSRIs might be causing birth-related problems in babies born to mothers on these drugs.

During the debate, Dr Peter Breggin, an American psychiatrist who wrote a con-troversial book entitled Toxic Psychiatry, proposed the motion eloquently. His premise is that neuroleptic medication is simply poison and, essentially, lobotomises the synapses of the brain, leaving patients with rotten side effects and little ability to control their lives.

He advocates the use of non-drug therapies for mental illness. His language is polemic and his views of his colleagues in psychiatry are uncompromising.

Many patients and carers in the audience related harrowing experiences of their use of psychiatric drugs. These included a woman addicted to benzodiazepines for over 25 years, and many parents who described massive polypharmacy on very large doses of these drugs.

A debate such as this, with a speaker like Dr Breggin, is bound to attract an audience that is self-selecting, but it was clear from the testimony at this event that psychiatry and the pharmaceutical firms making psychiatric medications need to be careful about reputation.

No drug is risk free, though many people forget this. If we think about the toxic nature of cancer chemotherapy, the potential side effects of antibiotics, or treatments for HIV infection, it is clear that in many disease areas, balancing risk and potential benefits is tricky.

There is much we do not know about the brain and the ways in which it actually impacts on how we think and feel. There is little certainty in the genesis of mental illness, and this stick is often used to beat psychiatrists; but is it entirely fair?

There is a lot we do not know about renal diseases of certain kinds, and the genesis of many cancers remains a mystery. Yet, we still develop options for managing as best we can; and nobody beats up the oncologists or renal physicians.

a real headache
The difference in mental health, where we still have so much to learn, is that the state allows the detention and treatment of people against their will. In the rest of medicine, decisions over difficult issues are reached through discourse between patients and professionals.

Occasionally, the lawyers and courts will get involved in tricky cases, but this is rare.

In psychiatry, however, it is so different. Professionals work under a panoply of legislation, and the lawyers, courts and tribunals are frequent features of practice.

To liken schizophrenia to diabetes is understandable, but disingenuous. Your diabetes consultant cannot detain you against your will and force treatment upon you! So, mental health medicine is different.

A few days after the Guardian debate, the media reported a potential breakthrough
in treating depression: a new approach which has been developed by neurologists, not psychiatrists.

By using scanning techniques, the researchers targeted those parts of the brain thought to be responsible for mood in patients living with long-term chronic depression. They then make two small bore holes in the skull and insert tiny receptors into the brain, linked to a piece of kit which emits a tiny electric current, similar to a cardiac pacemaker.

The current constantly pulsates, but is far weaker than the current used in electro-convulsive therapy (ECT), and early reports suggest that the treatment is providing good results in long-term depression.

If such a treatment works effectively, might we then witness the end of ECT and even antidepressants? Anything, it seems, is possible.

a world to explore
With the development of atypical anti-psychotic medications, we are now able to offer an apparently more tolerable side effect profile, but do we yet know the likely long-term effects for patients taking these drugs? Problems involving weight gain and medication-induced diabetes are already being reported.

In mental health, can it really be wise to leave patients taking powerful medicines every day for a lifetime? That is exactly the prospect offered to many patients by psychiatrists; what this does, in many cases, is damaging to the reputations of psychiatrists and the neuroleptic medications.

It may be easy to shrug off such criticisms as being simply anti-psychiatry, but I have seen too much abuse of these drugs by doctors all over the world. The long-term effects of taking neuroleptic medicines for many years are not good.

So what might the solutions be? We have known since ancient Greece that the mind and body are closely linked and that psychosomatic conditions, such as conversion hysteria, can bring about dramatic physical change in the body.

The brain is a complex and powerful organ and is influenced by all kinds of factors, including physical, spiritual and environmental. To reduce mental illness (and people living with its consequences) to a cluster of neurones which simply need chemical manipulation to fix things is limiting in the extreme.

Good mental health professionals take a more holistic view of the misery caused by mental illness. I have worked with people who have used mental health services for many years in the UK and overseas, and count many as friends.

The majority are not against medications, but what they all demand is some choice in taking their medication, alongside other life choices. Mental distress causes a lot of poverty and unemployment, leading to inadequate diet, poor housing, weak social networks, loss of educational potential and an overall poor quality of life.

I have met many who have attempted to tackle these quality of life issues in a holistic manner, using medication appropriately alongside other lifestyle issues. People with long-term mental illness are not static in their condition, they change constantly. Good services recognise this, offer regular reviews and listen carefully to what the patient has to say about their experiences of living with mental illness, including the effects of any medication.

I know of many good psychiatrists who always discuss choices and options surrounding the use of medicine, aiming for the lowest possible effective dose. These doctors also offer patients the opportunity of a drug-free period under safe and supportive conditions, to see how they might be without drugs, offering non-drug treatments along with medication.

These doctors and other smart mental health professionals will also ensure that softer quality of life issues, such as housing, employment, educational opportunities and social networks, are given proper consideration.

In my experience, the outcomes for professionals working in this holistic way are more rewarding and their patients have a better experience.

the question is...
What are the responsibilities, if any, of pharma in ensuring the appropriate use of its neuroleptic and other products?

It is easy to say that if a manufacturer clears the hurdles of the regulators for use of a product, then here responsibility ends. It is, thereafter, up to prescribers and health providers to control how drugs are used.

This is fair enough, but where citizens can be held against their will and have medication enforced upon them, I suggest that pharma has some responsibility for safe and appropriate use of its products in psychiatric practice.

It does not make commercial sense for a firm to allow its drug to be over-prescribed and misused. Good, and clear, advice to prescribers regarding the appropriate dose range, the need to avoid polypharmacy, attention to exercise and diet, and regular review would all make sense.

Crucially, firms working with patient groups can do much to assist the holistic use of a product. Reputable information about products to patient organisations and carer organisations can go some way towards ensuring safe and holistic use of psychiatric medication.

There will be times when people living with mental illness become more detached from their immediate reality and need acute intervention, including medication, but this is not their daily experience. The majority want a reasonable quality of life, a degree of choice and respect for what they are as people, not diagnostic labels.

Enlightened psychiatrists should be working more closely with pharma for the holistic and safe use of medication, promotion of information and greater choice for those who live with long-term mental health needs. Improved concordance and better quality care are the likely outcomes of such strategies.

The author
Ray Rowden is a director of Mental Health International Development