No doubt there will be plenty of debate generated by a series of lectures in Australia next month by Danish physician Professor Peter Gøtzsche, managing director of the Nordic Cochrane Centre based at Rigshospitalet in Copenhagen (details here).
In a preview below, Professor Gøtzsche and two Australian colleagues, psychiatrists Professor Jon Jureidini and Dr Peter Parry, argue that the harms of psychiatric drugs have been under-played and the benefits over-sold.
Peter Gøtzsche, Prof Jon Jureidini and Peter Parry write:
The version of psychiatry that many professionals, politicians and laypeople would like to be true is that mental illnesses are specific brain disorders with specific drug treatments, to which they are very responsive if identified early.
In reality, the way we categorise mental illnesses is arbitrary, and the diagnostic criteria are overinclusive.
Furthermore, the focus on drugs means that the biopsychosocial model for understanding mental disorders has too often been reduced to a bio model.
Whilst psychiatric drugs can be helpful, the dream of a quick fix by targeted drugs has become a nightmare where we often do more harm than good in the way we use drugs, e.g. against depression, schizophrenia and ADHD.
The focus on drugs, combined with insufficient focus on what caused the patient’s problems and how to cope with them in the future, is dangerous for patients. Even though psychotherapy and other non-drug treatments are often advocated, the most common response to making a diagnosis is to prescribe a drug.
In an era of marketing-based medicine, drugs are often used in a way that is at odds with good practice and the scientific evidence, e.g. it is common to use several drugs at the same time, not only of different types but also from the same drug class. Side effects and withdrawal effects can be misinterpreted as disease symptoms, leading to even more drugs, higher doses and more harm, although a tapering off would have been beneficial for the patient.
Psychiatrists are not adept at noticing the harms done by medications, partly because vigilance in asking patients is difficult to maintain. Even when psychiatrists do ask their patients in surveys, they may sometimes ignore what they are told and believe that the patients are mistaken and need psychoeducation.
That a medication can be harmful doesn’t necessarily mean it is bad medicine; think of cancer drugs, for example. But the problem with psychiatric drugs is that the harms have been underestimated and the benefits overestimated.
This has happened at least partly because of the hold the pharmaceutical industry has over leading psychiatrists. Career advancement is contingent on research publications, networking opportunities and conference profile. The pharmaceutical industry opens the doors for early career opportunities in a way that nobody else can.
Psychiatrists have been slow to recognise the price they pay for this self-serving industry “generosity” and often remain genuinely puzzled that their patients and independent researchers see evidence of bias, both in their trials and in the way they practice.
A major problem with almost all placebo controlled trials of psychiatric drugs is that they are flawed by design. In particular there is a lack of effective blinding. The drugs have conspicuous side effects, and many patients and their doctors will therefore know if the blinded drug contains an active substance or placebo.
Many years ago, adequately blinded experiments were performed with tricyclic antidepressants. The placebo contained atropine, which causes dryness in the mouth and other side effects similar to those seen with antidepressants. A Cochrane review of these trials did not find any meaningful effect of the drugs. Clinicians, however, are being misled by their clinical experience, which is mainly the spontaneous remission of the depression.
The overuse of psychiatric drugs leads to many deaths. Based on drug sales and a meta-analysis, it has been estimated that just one antipsychotic drug, olanzapine, has caused 200,000 deaths worldwide.
The common use of antidepressants in the elderly is also lethal. A carefully controlled cohort study where the patients were their own control showed that antidepressants led to falls. These falls may lead to hip fractures, and a quarter of patients with hip fractures die. For every 28 elderly people treated for one year with a selective serotonin reuptake inhibitor (SSRI), there was one additional death, compared with no treatment. This is an extremely high death rate for any drug.
What should we do better?
First, psychiatrists need to become better educated in psychotherapy and should not earn less if they prefer psychotherapy to drugs, which they unfortunately do today.
Second, we should use far fewer drugs than we currently do, as prolonged drug treatment can maintain the problems they were supposed to alleviate and can cause even worse diseases. For example, both antidepressants and ADHD drugs can precipitate bipolar disorder, and it is likely that all psychiatric drugs can cause chronic brain impairment.
Finally, psychiatrists should stop accepting money and other favours from the drug industry, as this is harmful for their patients.
It is not possible to serve two masters. Doctors should be patient advocates, not industry apologists.
Conflicts of interest: none.
• Prof Peter Gøtzsche is Master of Science in biology and chemistry, specialist in internal medicine, and director of the Nordic Cochrane Centre, Rigshospitalet, Copenhagen. He was co-founder of the Cochrane Collaboration, an independent global organisation dedicated to providing information to assist evidence-informed decision making in health care by systematically reviewing the medical research literature.
• Prof Jon Jureidini is a child psychiatrist at the Women’s and Children’s Hospital, Adelaide where he works with ill and disabled children and their families. He is a professor in the Disciplines of Psychiatry and Paediatrics and heads Paediatric Mental Health Training Unit, and the Critical and Ethical Mental Health research group, all at the University of Adelaide. He is chair of Australian-Palestinian Partnerships for Education and Health. His other published interests include cognitive science, ethics, quality use of medicines, immigration detention, suicide, and child abuse.
• Dr Peter Parry is a child & adolescent psychiatrist, clinical director of mental health services at the Lady Cilento Children’s Hospital in Brisbane and a senior lecturer at University of Queensland and visiting senior lecturer at Flinders University. He has published on issues relating to psychiatric nosology and the deficits and problems associated with the bio-medical model compared with the more accurate biopsychosocial model in child and adolescent mental health practice.
Details of the lectures are here.