Lethal or Unintended Side Effects

Why ARE so many people being labelled bipolar? More and more celebrities say they have it, but here a top psychiatrist warns the disorder is far too readily diagnosed, leaving many trapped on ‘zombie’ pills

  • What it means to be bipolar has undergone  a transformation
  • Once seen as rare and disabling, it now  vaguely refers to ‘mood swings’
  • The drugs used to treat the condition are  powerful, harmful – and profitable

By  Dr Joanna Moncrieff

PUBLISHED: 16:08 EST, 23  September 2013 |  UPDATED: 16:12 EST, 23 September 2013

Bipolar disorder has become the  ‘fashionable’ mental health diagnosis – helped, no doubt, by the fact that many  celebrities, including Catherine Zeta-Jones and Stephen Fry, have said they,  too, are sufferers.

But as a new book reveals, the readiness  with which so many people are being diagnosed as bipolar means they’re  needlessly prescribed heavy-duty drugs – with serious consquences for their  health…

Psychiatrists are interested in drugs because  we use a lot of them. Most people who visit a doctor for a mental health problem  will come away with a prescription for at least one.

Celebrity sufferer: Stephen FryCatherine Zeta-Jones

Celebrity sufferers: Both Stephen Fry and Catherine  Zeta-Jones are bipolar, contributing to its increasing vogue as a  diagnosis

 

The most powerful and controversial are the  antipsychotics. Heavyweight tranquillisers, they transformed the treatment of  schizophrenia 60 years ago.

But remarkably for drugs designed for a  relatively small number of very disturbed patients, antipsychotics are now among  the most profitable drugs in the world, just behind statins and on a par with  diabetes medications.

Indeed, newer versions of the drugs, such as  Zyprexa and Seroquel, have become some of the most profitable drugs in history.

In the last ten years prescriptions for  antipsychotics for adults in the UK have increased by 67 per cent – last year  nearly 8 million prescriptions were written in England alone.

But only a minority of these prescriptions  will have been for  schizophrenia, suggests the evidence – antipsychotics  are no longer used only to treat severe mental disturbance, but have broken into  the mainstream.

This rapid expansion of their use may be good  news for the pharmaceutical companies, but often it’s far from being in the best  interests of patients and we should be worried about their increasing  use.

For while antipsychotics can be useful for  those who are severely psychotic, these are dangerous drugs.

The growing popularity of antipsychotics has  occurred partly because of the newly fashionable diagnosis of bipolar  disorder.

Bill OddieKerry Katona

What do they have in common? Bill Oddie and Kerry Katona  both suffer from the disorder

 

Once considered rare and seriously disabling,  bipolar disorder has been transformed – under pharmaceutical industry influence  – into a vaguer notion of ‘mood swings’ that can apply to almost  anyone.

As a result, if you now visit your GP with  depression or anxiety or if you have symptoms such as irritability, and  moodiness, there is a significant possibility you will be given a diagnosis of  bipolar disorder and prescription for an antipsychotic.

Worryingly, the drugs have also been  suggested as a preventative measure in young people who are not psychotic, but  might be ‘at risk’, and have been widely prescribed to elderly patients with  dementia.

And these drugs are harmful. I first became  aware of how harmful they can be when as a junior doctor 20 years ago I worked  in one of those vast asylums that was in the process of being closed  down.

Some of the old inmates were still shuffling  stiffly and aimlessly along the endless corridors. They looked heavily doped up  and it struck me that the drugs hadn’t returned patients to normality, as we  were told they did.

I got a strong feeling that as a doctor I was  not being told the whole story about antipsychotics.

The text books had almost nothing about the  experiences of the people who took them. I was determined to find out more about  their effect.

THE MYTH OF A  ‘CHEMICAL IMBALANCE’

When these drugs were discovered – more than  60 years ago – they were embraced by psychiatrists.

Unlike the straitjacket or electric shock  therapy, they were said to treat not just the symptoms of schizophrenia –  dulling the voices and the visions – but also to correct the underlying  disease.

Unwelcome side-effects: For many people, the dampening down of feelings that results from taking antipsychotics is intolerable 

Unwelcome side-effects: For many people, the dampening  down of feelings that results from taking antipsychotics is  intolerable

 

They did it, said leading researchers, by  reversing a ‘chemical imbalance’ in the brain (although the evidence never  really stacked up – a rival, and I believe far more plausible, theory said the  drugs worked by damping down brain activity, but this was rapidly  forgotten.)

As a result, the drugs came to be seen as a  cleverly targeted and sophisticated, and essentially benign, treatment. It was a  seductive claim, but it was a myth; one swallowed hook, line and sinker by the  medical profession at the time.

The claim is still being propagated today,  but it has been extended – now it’s said that large numbers of people may need  antipsychotics to rebalance the malfunctioning chemicals that cause bipolar  disorder.

The notion that they can restore some form of  biochemical harmony has allowed these unpleasant and risky substances to be  misleadingly portrayed as essentially harmless.

These are some of the things that patient  information leaflets should tell you, but don’t.

Antipsychotics are likely to make you feel  slow and groggy and they will sap your initiative, reduce your sex drive and  dampen your emotions.

The bitterest pills: Antipsychotics are likely to make you feel slow and groggy 

The bitterest pills: Antipsychotics are likely to make  you feel slow and groggy

 

When I looked at how patients described the  drugs’ effect, typically they used terms such as ‘sluggish’, ‘inhibited’,  ‘feeling nothing’, ‘feeling weird’, ‘spacey’, ’empty’.

(Not for nothing are antipsychotics also used  as animal tranquillisers in veterinary medicine.)

For people who are acutely psychotic, the  damping down of feelings may be welcomed, but for many they are intolerable.  This is one patient’s memorable description: ‘Beware. This medication is Satan  in a flipping pill.’

FEARS ABOUT BRAIN  SHRINKING

Then you need to know about the variety of  metabolic changes they can induce in your body; major weight gain, high  cholesterol and other harmful fats, along with raised glucose that can lead to  diabetes and heart disease (the drugs have been linked with 1,800 deaths from  stroke and heart disease a year in people with dementia).

Despite these now well-recognised effects,  two years ago the British Medical Journal reported that out of 300,000  psychiatric patients on antipsychotics, fewer than half were getting a metabolic  check.

Antipsychotics can also shrink the brain.  This had long been suspected but it was difficult to prove because schizophrenia  is believed to have the same effect.

However, earlier this month a long-running  brain scanning study, reported in the American Journal of Psychiatry, concluded  that ‘the higher the antipsychotic medication, the greater the loss of both grey  and white brain tissue’.

‘This is one  patient’s memorable description: Beware. This  medication is Satan in a flipping pill.”‘

 

Long-term treatment can also cause an  irreversible form of brain damage called tardive dyskinesia which results in  embarrassing involuntary movements and may be associated with some mental  decline.

This was clearly recognised in the early days  of the drug, but as the idea that antipsychotics could treat disease became more  widely accepted, psychiatrists increasingly dismissed or downplayed these  involuntary movements, saying they were an effect of the disease and that anyway  they were infrequent and unimportant.

But these disturbing side-effects – jerky  uncontrolled movements, particularly around the face, mouth and tongue – do  occur, and I regularly see patients who suffer from them.

Some will claim that the benefits of the  drugs outweigh such risks, and point to ‘good’ evidence that antipsychotics are  an effective treatment for bipolar disorder.

However, the trials testing the effectiveness  of antipsychotics on bipolar disorder have been done on patients suffering from  manic depression.

What we now call bipolar is a greatly  expanded version of this rare condition, which is characterised by a manic  period lasting weeks (but possibly months), when the patient becomes  hyperactive, elated, disinhibited; they don’t sleep, barely eat and act quite  out of their normal character.

This is often followed by a crash and a  period of deep depression.

TOO EASY TO END UP  ON THESE DRUGS

 

The symptoms that can get you a diagnosis of  bipolar disorder today are quite different from those of classic manic  depression.

It’s all so vague you can now be diagnosed as  bipolar simply as a result of going through changes of mood caused by the ups  and downs of daily life.

But a diagnosis of bipolar disorder can lead  to lifelong prescriptions for heavyweight drugs that should be reserved for  serious psychiatric conditions. And yet almost all the drug trials testing  antipsychotics have been conducted on people suffering from classic manic  depression.

This means they tell you nothing about what  the drugs will do for people with milder emotional problems.

Brain damage: Long-term treatments can cause tardive dyskinesia, which results in embarrassing involuntary movements and may be associated with mental decline 

Brain damage: Long-term treatments can cause tardive  dyskinesia, which results in embarrassing involuntary movements and may be  associated with mental decline

 

Another serious problem with the trials done  to test the effectiveness of antipsychotics in general is that the patients who  go in the placebo group – those given a ‘dummy’ pill to compare against the  patients having the real treatment – will virtually all have been on drug  treatment prior to the study, often for years, since they have serious long-term  conditions such as schizophrenia and manic depression.

They then have to come off their treatments  to be part of the drug trial, usually quite abruptly.

But coming off antipsychotics, like many  other mind-altering drugs, is known to have all sorts of very unpleasant effects  – agitation, insomnia, anxiety, restlessness and irritability.

In other words, the group getting the drug is  being compared with a group who are in a state of cold turkey.

These flaws mean you can’t be certain the  trial results are reliable, even for the classic version of manic depression.  Given the brain damage, diabetes and heart disease associated with these drugs,  not to mention the sexual impairment, weight gain, mental clouding and emotional  suppression, trends towards this unfounded and increasingly unrestrained  prescribing represent a serious threat to public health.

Other senior psychiatrists share my  reservations about the value of expanding the definition of bipolar disorder so  widely.

The editor of the Canadian Journal of  Psychiatry has described it as ‘bipolar imperialism’, while journalist Robert  Whitaker sums up the recent history of antipsychotics like this: ‘Behind the  public façade of medical achievement is a story of science marred by greed,  death and the deliberate deception of the American public.’

I think it is going to be seen to be just the  latest in a series of scandals that have engulfed these drugs in recent  years.

THERE ARE  ALTERNATIVES

'Bipolar imperialism': Several senior psychiatrists share Dr Moncrieff's reservations about the value of expanding the definition of bipolar disorder 

‘Bipolar imperialism’: Several senior psychiatrists  share Dr Moncrieff’s reservations about the value of expanding the definition of  bipolar disorder

 

So what are the alternatives for people who  might be offered antipsychotics for emotional problems? What will work is going  to be different for each person.

It depends on why they are feeling the way  they are and what is going on in their lives that has led to this.

Therapy might be the best thing, some sorts  of short-term medication might be appropriate but most importantly, you have to  look at the circumstances. Antipsychotics have not been properly tested on  people troubled by milder emotional issues.

They can be helpful in reducing the symptoms  of an acute attack of schizophrenia or classic mania,  but the benefits of  long-term treatment are less certain, even in these serious  conditions.

Going on any drug for a psychological  disorder is a serious step. Patients need to be very clear about what is  involved. What is the benefit, what are the risks? There’s a long history of  failing to warn people about all the effects of antipsychotics.

If an antipsychotic drug is suggested for  you, make sure you ask your doctor some hard questions before starting a  prescription. Such as: How is this drug meant to work? How will it make me feel?  Will you be monitoring me for any metabolic changes? How much weight is it safe  to put on?

Your doctor probably won’t have the answer to  all of these questions because the research hasn’t been done. And that is the  problem.

There just hasn’t been enough attention paid  to the toxic effects of these drugs and how they impact on people’s everyday  lives.

But what we do know indicates they are often  unpleasant and can be dangerous. You may decide you are better off without  them.

Dr Moncrieff is Senior Lecturer in  Psychiatry at University College London. Her book, The Bitterest Pills: the  Troubling Story of Antipsychotic Drugs, is published by Palgrave Macmillan  £19.99.

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