Thursday, September 19, 2013

“…so we decided to go ahead and publish it.”

Mad in America recently highlighted Nancy Andreasen’s public acknowledgment that “anti-psychotic” drugs lead to the loss of brain tissue. The posts at PsychCentral and Science Daily to which MIA links are infuriatingly bad, but the story of Andreasen’s reluctant admission is important to publicize for reasons social and scientific.

I remember reading years ago in various places about this research that showed an association between schizophrenia and the loss of brain tissue. The articles painted a picture of schizophrenia as a degenerative disease that ate away at the brain, with psychotic symptoms being the first indications of trouble, but celebrated the fact that medication could address the symptoms and arrest this progression. This seemed like a clear justification for maintaining people on medications which would treat the disease and thus stop the deterioration. I would also have seen this research as evidence of the biological basis of mental illness, had I even suspected at the time that this biological basis wasn’t well established. I didn’t have those suspicions, so I was horrified to learn a few years ago – first from Anatomy of an Epidemic, I believe – that not only has no biological basis for “schizophrenia” been found, but the drugs themselves cause brain shrinkage.

This is shocking. It appears that what's happened is that the damaging effects of the drugs have been claimed for, and used as evidence of the existence of, the disease of schizophrenia, a claim which has then been used to promote the use of the very drugs that cause the damage! As the articles MIA links to show, they will continue with this spin: the demonstrated effects of the drugs are sidelined while the emphasis is on the alleged effects of the disease. But as Whitaker explains in a comment at the MIA post:
As for the evidence that there is shrinkage associated with the “disease,” meaning that people so diagnosed have smaller brain volumes, JOnathan Leo and Joann Moncrieff did a very good job of investigating this literature, and what you find is that most of the studies that claim to be of drug naive patients (and thus report smaller brain volumes), are not in fact of drug naive patients, but in patients who have been exposed to the drugs for a brief time. IN the three studies where patients trully were drug naive, they did not show significant brain shrinkage comparable to controls.

Now, it may be that trauma and other environmental factors that may lead to psychosis and the other “symptoms” that lead to a schizophrenia diagnosis are associated with brain shrinkage. I don’t know. But the real news here, for the field, is that Andreasen is, within the article, acknowledging that the drugs shrink the brain. [my emphasis]
I think Whitaker is right about the pertinent issues here. MIA chose to highlight the interview, despite Andreasen’s continuing claims about schizophrenia causing brain tissue loss and their uncritical acceptance by the writer, because the admission about the drugs is an important one:
In her last publication [here], the one referred to here, she so completely obscured the fact that she had previoiusly found declining brain volumes associated with drug usage, that many readers of that article started discounting that association, saying Andreasen had back away from it. I hear this all the time now when I speak–oh, Andreasen no longer believes that to be so. So, from that context, that is the news here, that she acknowledges (again) the drugs do cause this shrinkage.
Back in 2011 when Andreasen published about the relationship between drugs and tissue loss, Whitaker recognized the significance of these findings and published an article in Psychology Today – “Andreasen Drops a Bombshell: Antipsychotics Shrink the Brain.” In it, he wrote:
In this February report, Andreasen does not tie the drug-related brain shrinkage to an increase in negative symptoms, functional impairment, and cognitive decline. But in earlier articles, she did just that. And it is that larger context that makes this February report such a bombshell: When pieced together, this is a story of drug treatment that, over the long-term, causes long-term harm.

The other reason this is such a bombshell is that antipsychotics are widely prescribed now to children, often to control their "behavior," and to adults with bipolar diagnoses. They are being used to treat "non-psychotic" conditions. The risk-benefit analysis for those patients will be dramatically changed by the findings of this study.

One hopes that the study will be widely publicized in the media, and it will stir a vigorous discussion. Here are a few of the questions that I believe need to be asked:

• Does long-term use of antipsychotics for people diagnosed with psychotic disorders need to be rethought?

• Is there reason to prescribe these drugs to people with non-psychotic disorders?

• Should the prescribing of these drugs to children and youth, whose brains are still developing, be halted (or, in essence, banned?)

• Many adults diagnosed with psychiatric disorders are mandated by court orders to take antipsychotics. Should society have the right to require such treatment, given that the drugs shrink brain volumes and this shrinkage is associated with cognitive decline?
While Andreasen and her coauthors spun the article, they did include a recognition of at least some of the issues to which the findings would, and should, give rise. As noted in the article itself (the full text is available here):
Understanding the long-term effects of antipsychotics on the brain has wider clinical ramifications beyond treatment of patients with schizophrenia. Given the sharp rise in antipsychotic utilization,27 especially among pediatric and geriatric populations,27- 30 examining the possibility of antipsychotic-associated brain tissue loss has important implications for assessing the risk-benefit ratio in a large number of psychiatric patients.
But the bombshell failed to explode, as was probably predictable. The questions posed by Whitaker haven’t been seriously considered. The article wasn’t that widely publicized, no vigorous discussion was stirred, and the prescribing and forcible administration of these drugs doesn’t seem to have been affected. As Whitaker describes, Andreasen, for her part, has subsequently played down these findings, leading others both to do the same and to believe that she’s backed off from them.

But this interview shows that this isn’t the case - Andreasen refers to the association as a “solid finding.” The interview also reveals the depth of the desire in the psychiatric community for this not to be so. Whitaker continues in his comment, “You can see too in this article how she didn’t want to acknowledge this, or even really publish it. That is news here too.” It certainly is! From the interview:
“This was a very upsetting finding,” Andreasen said.

“We spent a couple of years analyzing the data more or less hoping we had made a mistake. But in the end, it was a solid finding that wasn’t going to go away, so we decided to go ahead and publish it.

“The impact is painful because psychiatrists, patients and family members don’t know how to interpret this finding. ‘Should we stop using antipsychotic medication? Should we be using less?’”
Their research suggested that drugs that are very widely prescribed and also forcibly or coercively administered, including to children, have serious harmful effects. This is of major, urgent importance for public health and human rights. Of course, it’s advisable to reexamine your work for errors and weaknesses before submitting your findings for publication. But the long delay of two years in this case appears to have been motivated more by a dislike of the results than by an abundance of caution. In fact, they seem more disturbed by the prospect of a decline in the use of the drugs than by the harm being caused to the millions of unsuspecting people taking them.

And apparently, even though the research was publicly funded, the decision to publish or not was at the discretion of the researchers. Despite this being a serious public health and human rights concern, they could, it seems, have chosen not only to delay publication and to downplay the results, as they did, but not to publish them at all. Andreasen’s and another author’s financial connections to a pharmaceutical company are listed in the paper. Given the history of pharmaceutical companies with regard to psychiatric drug research, I have to imagine that if the work had been privately funded it would have been buried entirely.

Andreasen’s behavior looks even more ethically problematic if we consider the context. “Antipsychotic” drugs are among the most used, including involuntarily, and the most profitable. They’re being prescribed in increasing numbers to people with a variety of psychiatric diagnoses, and their use in children has skyrocketed in the past few years. There are investigations underway across the US into the use of these drugs in children, and particularly children in the Medicaid and foster care system. As a recent WSJ article describes:
In 2008, the most recent year for which complete data are available, Medicaid, the government health program for the poor, spent $3.6 billion on antipsychotic medications, up from $1.65 billion in 1999, according to Mathematica Policy Research, a Washington firm that crunches Medicaid data for HHS. The growth came even as pharmacy benefits for millions of Medicaid recipients shifted to Medicare in 2006.

…Medicaid spends more on antipsychotics than on any other class of drugs. Abilify, made by Otsuka Pharmaceutical Co., appears on lists of the top 10 drugs paid for by Medicaid in various states.

…The number of people under age 20 receiving Medicaid-funded prescriptions for antipsychotic drugs tripled between 1999 and 2008, according to an analysis by Mathematica.

…Government Medicaid data indicate that some of the prescriptions are being written for very young children. An analysis by Mathematica found that in 2008, 19,045 children age 5 and under were prescribed antipsychotics through Medicaid, 3% of recipients under 20, up from 7,759 in 1999, according to James Verdier, a senior fellow at the organization.

Data from the inspector general's five-state probe indicate that 482 children 3 and under were prescribed antipsychotics during the period in question, including 107 children 2 and under. Six were under a year old, including one listed as a month old. The records don't indicate the diagnoses involved.* [my emphasis]
The nonconsensual use of these drugs, particularly in vulnerable populations, is increasingly recognized as a human rights violation and the movement to stop it is growing.

So, the disease these drugs are supposed to treat hasn’t been shown even to exist. The scientific invalidity of “schizophrenia” has been publicly acknowledged by the top figures in psychiatry. The history of the use of the drugs shows convincingly the shift from a drug model to the disease model that has been used to market these drugs as treatments for mental disease and how it was driven by politics and profits rather than scientific evidence. There is now very good evidence that the drugs are not only ineffective in any sort of longer term, but actually lead to worse outcomes, while knowledge of the social roots of these experiences continues to advance and psychosocial interventions have proven successful. The drugs appear to cause the “increase in negative symptoms, functional impairment, and cognitive decline” Whitaker referred to in 2011 (and there’s no real reason to expect that they wouldn’t, given how they act in the brain). There’s good evidence that they lead to the loss of brain tissue, with all that this entails, as well as a host of other significant physical harms, as described in this report to the UN Human Rights Committee and in the books by Whitaker and Moncrieff.

And still they continue to promote these drugs. The pharmaceutical corporations and the psychiatric profession have not shown in this context any commitment to science-based practice, public health or well being, or human rights. It’s well past time for, at the very least, the ban Whitaker suggests on the use of these dangerous drugs in children and an end to their involuntary use in adults.

* The use of these drugs to control and “discipline” children is often not even hidden:
Dr. Fernando Siles, a pediatric psychiatrist in the Dallas area who treats many poor foster children, says he sometimes prescribes such medications to treat serious behavior problems. "A child that continues to be aggressive will be kicked out from his foster home," he says. "The antipsychotic is to stabilize the behavior of the child, to keep him from being moved and moved again."

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