Saturday, May 16, 2015

Reducing psychotropic medication prescribing

Peter Gøtzsche, who I have mentioned before (eg. see previous post), has caused controversy at a Maudsley debate and in a BMJ Head to head by suggesting that psychotropic medication should be reduced to 2% of its current level of prescribing. As far as he is concerned, it "should almost exclusively be used in acute situations and always with a firm plan for tapering off, which can be difficult for many patients".

His argument is that the results of clinical trials are biased by unblinding and what he calls the 'cold turkey' effect of the washout period. Any remaining benefit, if there is any, is not justified by the mortality caused by medication.

Whether psychotropic medication increases mortality is controversial. I have mentioned before (see eg. previous post) that it may create a vulnerability to relapse. People may actually do better if they manage to work through their problems without medication. Peter Gøtzsche's stark presentation of the issue at least encourages this debate, even if it risks overstatement.

3 comments:

Chrys Muirhead said...

I agree with Prof Peter Gøtzsche about a major rethink and reduction in psychotropic prescribing, having a plan for coming off before going on the drugs. That's what I had when being forcibly drugged with antipsychotics in 1978,1984 and 2002, following puerperal and menopausal psychoses.

I didn't like the drugs so they made me comply. In my mind I put a year limit on the drugging and then I would taper and come off. With or without the support of psychiatry. And so I did, although it took longer when on the drug cocktail in 2002, getting off the Risperidone then Venlafaxine then Lithium. I met more opposition from psychiatry in 2002, to the tapering, than I did in the former decades.

However in 2012 my son was supported by his psychiatrist and me to taper Haloperidol, from 25ms to zero, in 7 months. After it had been forcibly injected into him in a locked seclusion room which had no toilet or drinking water. My son has a bipolar disorder diagnosis and has been on no psych drugs since then.

People should be supported to taper psychotropic medication by psychiatrists, the professions who prescribe them in the first place. Experts by Experience can also help in the process. Psychiatric survivors or former mental patients who have tapered the drugs and got back on with their lives, or cope with their "condition" by other means.

Chrys Muirhead said...

that should read " from 25 mgs (of Haloperidol) to zero"

MT said...

Dr Gøtzsche's comment is hardly news: all of the major world psychiatric societies include instruction to discontinue medications in certain situations. For example, in Ms Muirhead's comment above, a psychiatrist's tapering of her son's antipsychotic, used to treat his bipolar disorder, is following standard practice guidelines. Even in the treatment of schizophrenia, reducing antipsychotics to the minimal effective dose is standard (though admittedly this is not always done).

The effects of psychiatric medications on mortality are much less controversial than you think:
http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.162.10.1805
http://www.jad-journal.com/article/S0165-0327(01)00377-9/abstract

The exception is using antipsychotics and benzodiazepines in the elderly, which is why they have a black-box FDA warning to that effect. This is also why these medications are all on the Beers list with a recommendation to avoid their use in the elderly.

All told, these medications are definitely overused, but this isn't mainly due to people staying on them too long -- many people will self-continue once they feel better anyway. More likely, the problem is physicians prescribing them to people who don't need them, or using them off-label. This will remain a problem so long as PMDs receive minimal training in mental health, and so long as psychiatrists are persistently pressured to give their patients medications.