It may come as a surprise to learn that 11% of Americans over age 6 are taking one or more psychoactive drugs (also called psychotropics) daily for various forms of mental illness. In fact the fastest growing population being prescribed psychoactive drugs are children between 2 and 11. Would it surprise you to learn that more people take second-generation (aka atypical) antipsychotics–Seroquel, Zyprexa, and others–than take statin drugs to lower cholesterol? Or that 15% of teenagers are taking psychoactive drugs on a maintenance basis—that is, regularly.
Some of you might be thinking, “The world is a mess and so are we. I’m just glad we have these drugs available,” or “Lay off me! I take my meds every day and they make me feel better” or “I know they work. When I stop them, I feel terrible.”
Others of you might be saying “Yikes! There’s something truly wrong with this scenario. Did you say 11% of all Americans?”
As a primary care physician who joins most of my colleagues in writing prescriptions for psychoactive meds, I undeniably see good results. I want my patients to feel well, and when they’re in emotional pain I’ll continue to prescribe these drugs as needed. But as often as I see a drug live up to its advertised reputation in one patient, it does nothing for the next one, and makes the third worse. This raises my skeptical hackles generally about psychoactive drugs.
Altering brain chemistry
Since this whole group of medications actually changes the chemistry in our brains, perhaps we should figure out how we’ve reached a point where 11% of us “need” one or two or six of these drugs, in combination called psychotropic cocktails.
These issues have been addressed in several thoughtful (and sometimes angry) books over the past few years. The situation was summarized in an elegant article published in the New York Review of Books by Marcia Angell, MD, former editor of the New England Journal of Medicine.
The story of psychoactive/psychotropic medication use begins in the 1950s when researchers became aware that chemicals could be developed into medicines that changed “abnormal unacceptable” into “normal acceptable” behavior. Delusional psychotics and, soon after, the chronically anxious could be calmed down. The seriously depressed could be made to feel happier and patients catapulting between mania and depression (later called bipolar disorder) stabilized. Even irritating children with low grades became compliant, manageable, and even smarter.
From the ‘50s onward, psychotropic drug use grew from a few thousand institutionalized schizophrenics on Thorazine to 45 million Americans swallowing billions of antidepressants, anti-anxiety meds, mood stabilizers, atypical antipsychotics, cerebral stimulants, and hypnotics (sleeping pills), as well as a dozen others to treat the side effects of these meds. Sleepy from your anti-anxiety drug? Add Nuvigil. Your once manly erection a distant memory since taking an SSRI? Add Viagra. Obese and diabetic from your atypical antipsychotic? See your internist for insulin.
How did we reach this point?
If you go slowly through the years and follow all the steps, you’ll see a painful inevitability, sort of like the Greek play “Oedipus Rex,” one event following another until Oedipus gouges out his eyes.
- With Freud, psychiatry became a real field of medicine, but always vaguely suspect by many conventional doctors because the treatment was talk therapy. If you could afford it, you went “into analysis.”
- At least mental illness came out of the closet. It became okay to talk to your doctor about your sadness or your fears. But even Freud remarked at the end of his life that he hoped medicines would be developed to speed up the process. Psychoanalysis was s-l-o-w.
- Faced with more patients than they could talk to in one work day, psychiatrists allowed psychologists, non-physician talk therapists, into the fold. Then the medications appeared and psychiatrists added the caveat that they, and only they, could write these prescriptions.
- As patient numbers grew, psychiatrists and psychologists were increasingly challenged to decide what exactly was “mental illness.” Diagnosis was highly subjective and so unscientific, given that there were no positive test results. Faced with this, the American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its 947-page fifth edition (DSM-V). The problem with the DSM is that diagnostic standards for mental illness are very loose. The current edition lists approximately 360 individual diagnoses, and if you follow its guidelines nearly 50% of all Americans fulfill the criteria for at least one of the illnesses…even if they report feeling fine.
- Since medical doctors were the only ones who could write prescriptions for psychoactive drugs, psychiatrists, who wrote most of them, became the darlings of the pharmaceutical industry, which was creating these meds at a dizzying pace. Most psychiatrists now think of themselves as psychopharmacologists, their offices visited by bevies of attractive, engaging drug reps. Today psychiatrists see dozens of patients daily (30 to 40 a day is not unusual), matching symptoms with DSM-V data (which also provides codes for maximum reimbursement from insurance companies), burning through prescription pads or giving away goodie bags bulging with free samples.
- Unfortunately, the DSM-V seems to have been written by the pharmaceutical industry. New drugs get approvals as fast as new diseases get named. Think “social anxiety disorder” (Zoloft) or “premenstrual dysphoric disorder” (Prozac).
- The health insurance industry loves psychotropic drugs. Your annually renewed Prozac prescription costs them pennies a year (literally), a tiny fraction of what a non-prescription-writing psychologist would charge to work with you in talk therapy.
The most chilling facts debate whether psychotropic drugs actually do anything.
For example, we know:
- The success rate for antidepressants is that they work for one-third of users, do nothing for the second third, and have unacceptable side effects in the last third. This is precisely what occurs when patients are given a sugar-pill placebo.
- The success rate of a placebo matches and may even exceed the effectiveness of an actual drug when patients are given what’s called an “active placebo,” a sugar pill with an added harmless ingredient that creates a side effect. In other words, taking any pill that has a perceptible side effect will work for depression if the patient is told it will help her depression.
- But because in so many cases patients tell their physicians that the antidepressants are helping, the doctors themselves (myself included, BTW) believe the meds are working.
- And the whole mess brings to mind the Hans Christian Andersen story, “The Emperor’s New Clothes,” substituting “psychotropic drug” for the emperor’s invisible wardrobe.
So what should you do?
- First and foremost, if you’re taking one or more psychoactive meds, don’t, under any circumstances, stop them abruptly on your own. Remember, they have changed your brain and you need to wean slowly off them to get your brain used to functioning on its own.
- Second, if you feel you’re doing well on your med and you’re not troubled by side effects, stay on it. You might give a knowing chuckle here that you’re responding well to a placebo, but (hate to tell you this) a lot of the meds we take and believe are doing something are also placebos.
- Third, if you’re having side effects from your psychotropics, talk to your doctor about lowering your dose or, better yet, discontinuing them altogether.
I’m going to end this rather lengthy health tip with a quote from one of the books reviewed in Dr. Angell’s article. This is from Robert Whitaker’s Anatomy of An Illness, and he calls it a “quick thought experiment.”
“Imagine that a virus suddenly appears in our society that makes people sleep twelve, fourteen hours a day. Those infected with it move about somewhat slowly and seem emotionally disengaged. Many gain huge amounts of weight—twenty, forty, sixty, and even one hundred pounds. Often their blood sugar levels soar, and so do their cholesterol levels. A number of those struck by the mysterious illness—including young children and teenagers—become diabetic in fairly short order… The federal government gives hundreds of millions of dollars to scientists at the best universities to decipher the inner workings of this virus, and they report that the reason it causes such global dysfunction is that it blocks a multitude of neurotransmitter receptors in the brain—dopaminergic, serotonergic, muscarinic, adrenergic, and histaminergic. All of those neuronal pathways in the brain are compromised. Meanwhile, MRI studies find that over a period of several years, the virus shrinks the cerebral cortex, and this shrinkage is tied to cognitive decline. A terrified public clamors for a cure. Now such an illness has in fact hit millions of American children and adults. We have just described the effects of Eli Lilly’s best-selling antipsychotic, Zyprexa.”
David Edelberg, MD