“Most psychiatric drugs in use today originated in serendipitous discoveries made many decades ago,” according to a recent article on Science News by Laura Sanders. And it’s true — we can trace back today’s most popular psychiatric drugs to discoveries made over 30 — and in some cases, 40! — years ago.

Because of the heady cost of drug development — costing hundreds of millions of dollars to bring a new drug to market — most pharmaceutical companies have been playing it safe these past few decades. They’ve been working on developing “me too” drugs — subtle molecular changes to existing compounds.

Which means the pipeline is darned near empty of truly new drugs likely to come out in the next 5 to 10 years for the most common types of mental illness.

This provides the drug company with two things. The first is a new medicine they can patent and sell at a significant markup over the old, generic drug it’s based off of. The second is the illusion of progress, of releasing something that is “new and better” than the old thing — but which additional research almost always demonstrates is simply as good — not better — than the old thing (and usually with a different — not better — side effect profile).

So the “new” SSRIs of the 1990s did away with tricyclics’ side effects, but brought on a whole host of their own, new side effects (chief among these, sexual dysfunction… as though nobody cared much about the quality of their sex lives).

The one thing these “me too” drugs don’t provide is any additional, substantial relief to patients.

So it should come as no surprise that most pharmaceutical companies’ psychiatric drug pipelines are… how shall we say?… empty.

Not a single drug designed to treat a psychiatric illness in a novel way has reached patients in more than 30 years, argues psychiatrist Christian Fibiger of the University of British Columbia in Kelowna, who described the problem in a 2012 Schizophrenia Bulletin editorial. “For me, the data are in,” says Fibiger, who has developed drugs at several major pharmaceutical companies.

“We’ve got to change. This isn’t working.”

The biggest problem, from mine and other researchers’ perspective, is the simple lack of understanding of the organ we’re trying to impact with these drugs — the brain.

Perhaps the largest impediment to the development of new psychiatric drugs is the brain itself. A complex web of interconnected systems constantly altered by the environment, the brain is difficult to study.

Even though it’s nestled right in our heads, the brain is hard to reach. A blood pressure cuff can be slapped on for an instant and objective measure of what’s happening with the heart. A needle biopsy can physically pull out suspected breast cancer cells for further tests. But when it comes to the brain, there is no easy way to identify and measure the thing that isn’t working.

As neuroscientist Steven Hyman of the Broad Institute of MIT and Harvard says in the article, “You can’t just open up the hood, take out a chunk and see what’s happening.”

Thomas Insel, director of the National Institute of Mental Health, believes there is hope by pursuing a new path in research — understanding the very basics of the brain’s functioning. Combined with Obama’s announcement of the Brain Activity Map project to be undertaken by the U.S. later this year, there is hope that we can greatly increase our understanding of the body’s most vital organ.

The situation is grim, but not hopeless, says Insel. At a time when major pharmaceutical companies are abandoning psychiatric drug development, Insel says he is doubling down, investing federal grant money in places where investors fear to tread.

“There are a whole series of pretty amazing developments that I think are worth investing in,” he says.

That’s the good news… But it’s going to take years — and more likely, decades — before we will see the benefit of such research efforts.

But it Hasn’t Stopped Drug Sales…

But that hasn’t stopped the sales of all of these me-too psychiatric drugs:

Which only goes to show you that pharmaceutical company marketing works better than perhaps some would give it credit for.

Read the full Science News article (lengthy, but gives many examples and further details about this issue): No New Meds

Much harder than most physicians and many psychiatrists are willing to admit.

That’s because most physicians — including psychiatrists — have not had first-hand experience in withdrawing from a psychiatric drug. All they know is what the research says, and what they hear from their other patients.

While the research literature is full of studies looking at the withdrawal effects of tobacco, caffeine, stimulants, and illicit drugs, there are comparatively fewer studies that examine the withdrawal effects of psychiatric drugs. Here’s what we know…

Benzodiazepine withdrawal has a bigger research base than most classes of medications — SSRI withdrawal has much less research. So what’s that research say? Some patients are going to have an extremely difficult and lengthy time trying to get off of the psychiatric drug prescribed to them. Which ones? We don’t know.

One study nicely summarizes the problem experienced in many such patients:

Various reports and controlled studies show that, in some patients interrupting treatment with selective serotonin reuptake inhibitors or serotonin and noradrenaline re-uptake inhibitors, symptoms develop which cannot be attributed to rebound of their underlying condition. These symptoms are variable and patient-specific, rather than drug specific, but occur more with some drugs than others. [...]

There is no specific treatment other than reintroduction of the drug or substitution with a similar drug. The syndrome usually resolves in days or weeks, even if untreated. Current practice is to gradually withdraw drugs like paroxetine and venlafaxine, but even with extremely slow tapering, some patients will develop some symptoms or will be unable to completely discontinue the drug.

Psychiatrists and other mental health professionals have known ever since the introduction of Prozac that getting off of benzodiazepines or the “modern” antidepressants (and now add the atypical antipsychotics too) can be harder than getting symptom relief from them. Yet some psychiatrists — and many primary care physicians — appear to be in denial (or are simply ignorant) about this problem.

Back in 1997, a review of the literature on SSRIs (selective serotonin receptor inhibitors) outlined the problem (Therrien, & Markowitz, 1997):

Presents a review of 1985–96 literature on withdrawal symptoms emerging following the discontinuation of selective serotonin reuptake inhibitor (SSRIs) antidepressants. 46 case reports and 2 drug discontinuation studies were retrieved from a MEDLINE search.

All of the selective serotonin reuptake inhibitors were implicated in withdrawal reactions, with paroxetine most often cited in case reports. Withdrawal reactions were characterized most commonly by dizziness, fatigue/weakness, nausea, headache, myalgias and paresthesias.

The occurrence of withdrawal did not appear to be related to dose or treatment duration. Symptoms generally appeared 1–4 days after drug discontinuation, and persisted for up to 25 days. [...]

It is concluded that all of the SSRIs can produce withdrawal symptoms and if discontinued, they should be tapered over 1–2 weeks to minimize this possibility.

Some patients may require a more extended tapering period. No specific treatment for severe withdrawal symptoms is recommended beyond reinstitution of the antidepressant with subsequent gradual tapering as tolerated.

The conclusion is quite clear — some patients are going to suffer from more severe withdrawal effects than others. And, just like psychiatry has no idea which drug is going to work with which patient and at what dose (unless there’s a prior medication history), psychiatry also can’t tell you a damned thing about whether a patient is going to have difficulty getting off of the drug when treatment is completed.

It’s simple trial and error — every patient that enters a psychiatrist’s office is their own personal guinea pig. That is to say, you are your own personal experiment in finding out what drug is going to work for you (assuming you’ve never been on a psychiatric drug in the past). Our scientific knowledge hasn’t yet advanced to be able to tell what drug is going to work best for you, with the least amount of side or withdrawal effects.

The U.S. Food and Drug Administration (FDA) doesn’t require pharmaceutical companies to conduct withdrawal studies in order to analyze a drug’s impact when it’s time to discontinue it. It only requires a broader safety evaluation, and a measure of the drug’s efficacy. The FDA is concerned about adverse events while a patient is taking the drug — not adverse events when the drug is removed. In recent years, some have been calling on the FDA to require pharmaceutical companies to conduct more analysis on a drug’s discontinuation profile, so that the public and researchers can get a clearer picture.

While all SSRIs have these problems, two drugs in particular appear to stand out in what little research is out there — Paxil (paroxetine) and Effexor (venlafaxine). The Internet is littered with horror stories of people trying to discontinue one of these two drugs.

And they’re not alone — benzodiazepines can also be extremely difficult to stop. “Withdrawal reactions to selective serotonin re‐uptake inhibitors appear to be similar to those for benzodiazepines,” says researchers Nielsen et al. (2012).¹

What Do You Do About Withdrawal?

Most people are prescribed a psychiatric medication because it’s needed to help alleviate the symptoms of a mental illness. Not taking the medication is often simply not an option — at least until the symptoms are relieved (which often can take months, or even years). Psychotherapy, too, can often help not only with the primary symptoms of mental illness, but also as a coping mechanism during medication withdrawal.²

The important thing is to go into the process with your eyes wide open, understanding the potential that discontinuing the medication may be difficult and painful. A very slow titration schedule — over a period of multiple months — can sometimes help, but may not always be enough. In some extreme cases, a specialist who focuses on helping people discontinue psychiatric drugs might prove helpful.

I wouldn’t let the problems with withdrawing from some of these medications prevent me from taking the drug in the first place.

But I would want to know about it beforehand. And I’d want to be working with a caring, thoughtful psychiatrist who not only acknowledged the potential problem, but was proactive in helping his or her patients deal with it. I would run — not walk — away from a psychiatrist or physician who claimed the problem didn’t exist, or that I shouldn’t worry about it.

This article was edited to clarify a few sentences on Feb. 14, 2013.

References

Kotzalidis, G.D. et al. (2007). The adult SSRI/SNRI withdrawal syndrome: A clinically heterogeneous entity. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 4, 61-75.

Nielsen, M., Hansen, E.H., & Gøtzsche, P.C. (2012). What is the difference between dependence and withdrawal reactions? A comparison of benzodiazepines and selective serotonin re-uptake inhibitors. Addiction, 107, 900-908.

Therrien, F. & Markowitz, J.S. (1997). Selective serotonin reuptake inhibitors and withdrawal symptoms: A review of the literature. Human Psychopharmacology: Clinical and Experimental, 12, 309-323.

1. Thanks to Beyond Meds for the suggestion of this blog topic.
2. Tellingly, I could find no similar withdrawal syndrome associated with leaving psychotherapy, although certainly some people have difficulty with ending psychotherapy.

Medications used to treat mental disorders continue to enjoy the best sales they’ve had ever. Meanwhile, psychotherapy usage continues to decline.

We started tracking the top 25 psychiatric medications prescribed in the U.S. back in 2005, with the help of IMS Health and their innovative Xponent service, which tracks the vast majority of prescriptions dispensed in the U.S.

The top 5 are below, while the rest of the list follows.

1. Xanax (alprazolam) – 47,792,000
2. Celexa (citalopram) – 37,728,000
3. Zoloft (sertraline) – 37,208,000
4. Ativan (lorazepam) – 27,172,000
5. Prozac (fluoxetine HCL) – 24,507,000

To put the percent changes below into perspective, the U.S. total population rose approximately 1.6 percent from 2009 to 2011. That suggests that anything above 1.6 percent change was driven by other factors — more people seeking treatment, more pharmaceutical advertising and marketing, or some other factor.

The biggest movers and shakers on the list were Celexa — moving up 15 spots to grab the second most-prescribed psychiatric drug in 2011 — and Wellbutrin XL, moving from 22 to 13.

Drugs used to treat attention deficit hyperactivity disorder (ADHD) — generic amphetamine salts and methylphenidate — enjoyed big gains as well. The rise of generics is not surprising, since once a medication goes off-patent, it becomes cheaper to purchase. Cheaper meds makes them available to more people who can now afford them.

Check out the Top 25 Psychiatric Medication Prescriptions for 2011 now.

However, for some moms-to-be, anxiety becomes so severe and distressing that they’re unable to function day-to-day.

It’s only recently — over about the last decade — that researchers have begun exploring anxiety in pregnancy. Consequently, much more work is still needed.

But here’s what we do know.

1. Even though we don’t hear as much about anxiety disorders in pregnancy, they’re actually more common than depression. Estimates of anxiety disorders vary greatly. In their book Wiegartz and Gyoerkoe note that researchers have found that 5 to 16 percent of women struggle with an anxiety disorder during pregnancy or postpartum.

2. Untreated anxiety holds risks for both mom and baby. According to Wiegartz and Gyoerkoe, “severe, prolonged, or incapacitating anxiety can be harmful and needs to be addressed.” They cite several studies that suggested various risks for both mom and baby.

For instance, research has shown that moms-to-be with clinical anxiety are at increased risk for postpartum depression and postpartum anxiety. (You can learn more about postpartum depression here.)

They also noted that women with anxiety reported more physical aliments during pregnancy and may be at risk for post-traumatic stress symptoms after childbirth.

Some research has found that babies of anxious mothers may be susceptible to premature birth. (This study, however, didn’t find a link between anxiety in pregnancy and preterm birth.) There’s also evidence that mom’s anxiety may affect her infant’s temperament and lead to behavioral and emotional issues later on (see this study and this one on impulsivity).

While the above findings may stress you out even more, the good news is that anxiety during pregnancy is treatable. But obstetricians don’t regularly screen for anxiety. That’s why if you’re struggling with anxiety or anxious thoughts, it’s very important to talk to your obstetrician.

If your obstetrician doesn’t appear to be knowledgeable about anxiety disorders or dismisses your concerns, find another doctor for a proper diagnosis and treatment. For instance, you might make an appointment with a mental health professional or a psychiatrist. Below is a list on how to find help.

3. Cognitive-behavioral therapy helps to treat anxiety during pregnancy. Research has established that CBT is highly effective for anxiety disorders. But very little research has been done on CBT in pregnant women. One study found that CBT reduced anxiety in pregnancy and improvements lasted postpartum.

4. Taking medication during pregnancy may be OK — or not. Antidepressants – specifically selective serotonin reuptake inhibitors (SSRIs) — and benzodiazepines are commonly prescribed for anxiety disorders and have been shown to reduce symptoms.

Unfortunately, it’s unclear whether taking these medications during pregnancy harms the baby. This article in Psychiatric Times provides insight into pharmacological treatment.

Mental health blogger Anne-Marie Lindsey shares her experiences and what she’s learned about medication during pregnancy in this excellent piece, which also includes links to additional information and resources.

Essentially, some research has shown that medication may lead to adverse effects. But untreated anxiety also has risks. In some cases, moms-to-be do need to take medication. If there’s any consensus, it’s that taking medication is an individual decision that must be thoroughly discussed with your doctor.

Finding Professional Help

If you’d like to seek professional help, check out these resources from Wiegartz and Gyoerkoe’s The Pregnancy & Postpartum Anxiety Workbook:

Cognitive Behavioral Therapy

• Anxiety Disorders Association of America
• Association for Behavioral and Cognitive Therapies (ABCT)

Medication Management

• MedEdPPD Provider Search Directory
• Postpartum Progress
• The Motherisk ReproPsych Group

Pre- or Postnatal Care

• American College of Obstetricians and Gynecologists
• National Women’s Health Information Center, 800-994-9662

They just got dinged with a $158 million settlement in a Medicaid fraud case in Texas for “making false or misleading statements about the safety, cost and effectiveness of the expensive anti-psychotic medication Risperdal, and improperly influencing officials and doctors to push the drug.”

But we won’t feel too badly, because Janssen got off easy with this one. They don’t have to admit to any liability with the settlement, and Johnson & Johnson — who made billions off of the sale of Risperdal — will barely blink their corporate eyeballs as they make out the check.

This is the third state settlement for Johnson & Johnson in connection to their promotion and marketing of Risperdal, an atypical antipsychotic medication that was touted to be a drug better than sliced bread — and with far less side effects. (Too bad corporations don’t eat, my friend.) They’ve been ordered to pay $327 million in South Carolina, and $258 million in Louisiana in similar state lawsuits.

That brings the grand total to $743 million the company will pay for allegedly fraudulently marketing the drug Risperdal. That’s a pretty crazy number for a company claims that it’s done nothing wrong.

The really sad part of it for me is that our fellow person, Janssen, is either is in denial about what it’s done wrong with regards to marketing of Risperdal, or simply lying:

At the start of the trial, lawyers for New Brunswick, N.J.-based Johnson & Johnson had insisted the company did nothing improper in marketing the drug.

“Janssen is committed to ethical business practices and had policies in place to ensure its products are only promoted for their FDA-approved indications,” the company said in its settlement statement

Maybe we should sign-up Mr. Janssen for some Freudian psychoanalysis.

Nothing improper? Then why have two states already found you guilty of doing activities you consider “proper,” and why are you so willing to pay out three-quarters of a billion dollars so far?? Innocent parties rarely would be willing to pay out such enormous sums of money unless they knew there was something more to all of this.

You should also check out the interview Pharmalot has just published with Allen Jones, the whistleblower on the Risperdal cases (without his standing up for what’s right and ethical, the states probably would’ve never had a case to make). It’s sad to see the end result is a much more cynical man:

Pharmalot: What have you learned from all this?

Jones: I live in a world that seems very different to me than the one I stumbled into since this began. There were so many layers of disillusionment after seeing what I thought were supposed to be good intentions of the pharmaceutical industry and government. I see greed and cynicism and bureaucrats protecting their fat bellies and fat pensions. But I’ve acquired more skills to live in a cynical world in which I see I live in. I lost of a heck of a lot of innocence along the way.

But maybe that’s the inevitable result of pharmaceutical companies who put profit ahead of all else — even ethical marketing of their products.

Hence my continued skepticism about any new psychiatric medication to hit the market. Over the past decade, we’ve seen virtually all the psychiatric pharmaceutical companies be indicted or pay settlements or fines for their unethical behavior when it comes to marketing and selling such medications.

We can only hope these kinds of settlements make them think twice for behaving badly in the future. But when it comes to shareholder profits versus a possible future fine and a slap on the wrist, my gut tells me to trust companies will continue to pursue shareholder profits at all expenses… Even when what it appears they are doing is illegal and unethical, and appears to cause very real health complications to millions of people.

Read the full interview with Allen Jones at Pharmalot: Risperdal Whistleblower: J&J Credo Is ‘Empty Words’

Read the news story on the settlement: Johnson & Johnson settles Texas lawsuit for $158M

You have asked me about the cause of your mood disorder, and whether it is due to a “chemical imbalance”. The only honest answer I can give you is, “I don’t know”—but I’ll try to explain what psychiatrists do and don’t know about the causes of so-called mental illness, and why the term “chemical imbalance” is simplistic and a bit misleading.

By the way, I don’t like the term “mental disorder”, because it makes it seem as if there’s a huge distinction between the mind and the body—and most psychiatrists don’t see it that way. I wrote about this recently, and used the term “brain-mind” to describe the unity of mind and body.¹ So, for lack of a better term, I’ll just refer to “psychiatric illnesses.”

Now, this notion of the “chemical imbalance” has been much in the news lately, and a lot of misinformation has been written about it—including by some doctors who ought to know better ². In the article I referenced, I argued that “…the “chemical imbalance” notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.”¹ Some readers felt I was trying to “re-write history”, and I can understand their reaction—but I stand by my statement.

Of course, there certainly are psychiatrists, and other physicians, who have used the term “chemical imbalance” when explaining psychiatric illness to a patient, or when prescribing a medication for depression or anxiety. Why? Many patients who suffer from severe depression or anxiety or psychosis tend to blame themselves for the problem. They have often been told by family members that they are “weak-willed” or “just making excuses” when they get sick, and that they would be fine if they just picked themselves up by those proverbial bootstraps. They are often made to feel guilty for using a medication to help with their mood swings or depressive bouts.

… most psychiatrists who use this expression feel uncomfortable and a little embarrassed…

So, some doctors believe that they will help the patient feel less blameworthy by telling them, “You have a chemical imbalance causing your problem.” It’s easy to think you are doing the patient a favor by providing this kind of “explanation”, but often, this isn’t the case. Most of the time, the doctor knows that the “chemical balance” business is a vast oversimplification.

My impression is that most psychiatrists who use this expression feel uncomfortable and a little embarrassed when they do so. It’s a kind of bumper-sticker phrase that saves time, and allows the physician to write out that prescription while feeling that the patient has been “educated.” If you are thinking that this is a little lazy on the doctor’s part, you are right. But to be fair, remember that the doctor is often scrambling to see those other twenty depressed patients in her waiting room. I’m not offering this as an excuse–just an observation.

Ironically, the attempt to reduce the patient’s self-blame by blaming his brain chemistry can sometimes backfire. Some patients hear “chemical imbalance” and think, “That means I have no control over this disease!” Other patients may panic and think, “Oh, no—that means I have passed my illness on to my kids!” Both of these reactions are based on misunderstanding, but it’s often hard to undo these fears. On the other hand, there are certainly some patients who take comfort in this “chemical imbalance” slogan, and feel more hopeful that their condition can be controlled with the right kind of medication.

They are not wrong in thinking that, either, since we can get most psychiatric illnesses under better control, using medication—but this should never be the whole story. Every patient who receives medication for a psychiatric illness should be offered some form of “talk therapy”, counseling, or other kinds of support. Often, though not always, these non-medication approaches should be tried first, before medication is prescribed. But that’s another story—and I want to get back to this “chemical imbalance” albatross, and how it got hung around the neck of psychiatry. Then I’d like to explain some of our more modern ideas of what causes serious psychiatric illnesses.

Back in the mid-60s, some brilliant psychiatric researchers—notably, Joseph Schildkraut, Seymour Kety, and Arvid Carlsson– developed what became known as the “biogenic amine hypothesis” of mood disorders. Biogenic amines are brain chemicals like norepinephrine and serotonin. In simplest terms, Schildkraut, Kety, and other researchers posited that too much, or too little, of these brain chemicals was associated with abnormal mood states—for example, with mania or depression, respectively. But note two important terms here: “hypothesis” and “associated”. A hypothesis is just a stepping-stone along the path to a fully-developed theory—it’s not a full-blown conception of how something works. And an “association” is not a “cause”. In fact, the initial formulation of Schildkraut and Kety ³ allowed for the possibility that the arrow of causality might travel the other way; that is, that depression itself might lead to changes in biogenic amines, and not the other way around. Here is what these two researchers actually had to say back in 1967. It’s pretty dense biology-speak, but please do read on:

“Although there does appear to be a fairly consistent relationship between the effects of pharmacological agents on norepinephrine metabolism and on affective state, a rigorous extrapolation from pharmacological studies to pathophysiology cannot be made. Confirmation of this [biogenic amine] hypothesis must ultimately depend upon direct demonstration of the biochemical abnormality in the naturally occurring illness. It should be emphasized, however, that the demonstration of such a biochemical abnormality would not necessarily imply a genetic or constitutional, rather than an environmental or psychological, etiology of depression.

Whereas specific genetic factors may be of importance in the etiology of some, and possibly all, depressions, it is equally conceivable that early experiences of the infant or child may cause enduring biochemical changes and that these may predispose some individuals to depressions in adulthood. It is not likely that changes in the metabolism of the biogenic amines alone will account for the complex phenomena of normal or pathological affect. Whereas the effects of these amines at particular sites in the brain may be of crucial importance in the regulation of affect, any comprehensive formulation of the physiology of affective state will have to include many other concomitant biochemical, physiological, and psychological factors.”^{3 (italics added)}

Now remember, Mrs. ——, these are the pioneers whose work helped lead to our modern-day medications, such as the “SSRIs” (Prozac, Paxil, Zoloft and others). And they certainly did not claim that all psychiatric illnesses—or even all mood disorders—are caused by a chemical imbalance! Even after four decades, the “holistic” understanding that Schildkraut and Kety described remains the most accurate model of psychiatric illness. In my experience over the past 30 years, the best-trained and most scientifically-informed psychiatrists have always believed this, despite claims to the contrary by some anti-psychiatry groups.⁴

Unfortunately, the biogenic amine hypothesis got twisted into the “chemical imbalance theory” by some pharmaceutical marketers,⁵ and even by some misinformed doctors. And, yes, this marketing was sometimes aided by doctors who—even if with good intentions–didn’t take the time to give their patients a more holistic understanding of psychiatric illness. To be sure, those of us in academia should have done more to correct these beliefs and practices. For example, the vast majority of antidepressants are prescribed not by psychiatrists, but by primary care physicians, and we psychiatrists have not always been the best communicators with our colleagues in primary care.

Neuroscience research has moved beyond any simple notion of a “chemical imbalance”…

All that said, what have we learned about the causes of serious psychiatric illness in the past 40 years? My answer is, “More than many in the general public, and even in the medical profession, realize.”  First, though: what we don’t know, and shouldn’t claim to know, is what the proper “balance” is for any given individual’s brain chemistry. Since the late 1960s, we have discovered more than a dozen different brain chemicals that may affect thinking, mood, and behavior. While a few seem particularly important—such as norepineprhine, serotonin,  dopamine, GABA, and glutamate—we have no quantitative idea of what the optimal “balance” is for any particular patient. The most we can say is that, in general, certain psychiatric illnesses probably involve abnormalities in specific brain chemicals; and that by using medications that affect these chemicals, we often find that patients are significantly improved. (It is also true that a minority of patients have adverse reactions to psychiatric medications, and we need further study of their long-term effects).⁶

But neuroscience research has moved beyond any simple notion of a “chemical imbalance” as the cause of psychiatric illnesses. The most sophisticated, modern theories posit that psychiatric illness is caused by a complex, often cyclical interaction of genetics, biology, psychology, environment, and social factors. ⁷ Neuroscience has also moved beyond the notion that psychiatric medications work simply by “revving up” or toning down a couple of brain chemicals. For example, we have evidence that several antidepressants foster the growth of connections between brain cells, and we believe this is related to the beneficial effects of these medications.⁸ Lithium—a naturally occurring element, not really a “drug”—may help in bipolar disorder by protecting damaged brain cells and promoting their ability to communicate with each other. ⁹

Let’s take bipolar disorder as an example of how psychiatry views “causation” these days (and we could have a similar discussion of schizophrenia or major depressive disorder). We know that a person’s genetic make-up plays a major role in bipolar disorder (BPD). So, if one of two identical twins has BPD, there is better than a 40% chance that the other twin will develop the illness, even if the twins are reared in different homes. ¹⁰ But note that the figure is not 100%–so there must be other factors involved in the development of BPD, besides your genes.

Modern theories of BPD hold that abnormal genes lead to abnormal communication between various inter-linked regions of the brain—so-called “neurocircuits”—which in turn increases the likelihood of profound mood swings.  There’s growing evidence that BPD may involve a sort of top-down, “failure to communicate” within the brain.  Specifically, the frontal regions of the brain may not adequately dampen over-activity in the “emotional” (limbic) parts of the brain, perhaps contributing to mood swings. ¹¹

So, you ask—is it still all a matter of “biology”? Not at all—the person’s environment certainly matters. A major stressor may sometimes trigger a depressive or manic episode. And, if a child with early-onset BPD is raised in an abusive or unloving home, or is exposed to many traumas, this is likely to increase the risk of mood swings in later life¹²—though there is no evidence that “bad parenting” causes BPD. (At the same time, abuse or trauma in childhood may change the “wiring” of the brain permanently, and this in turn may lead to more mood swings—truly, a vicious circle).¹³ On the other hand, in my experience, a supportive social and family environment can improve the outcome of a family member’s BPD.

Finally—while the individual’s approach to “problem-solving” is not a likely cause of BPD—there is evidence that how the person thinks and reasons makes a difference.  For example, cognitive-behavioral therapy and family-focused therapy may reduce the risk of relapse, in BPD.¹⁴ And so, with appropriate support, the person with bipolar disorder can take some control of her illness–and maybe even improve its course– by learning more adaptive ways of thinking.

So, boiling it all down, Mrs.——–, I certainly can’t tell you the exact cause of your or anybody’s psychiatric illness, but it’s a lot more complicated than a “chemical imbalance”.  You are a whole person–with hopes, fears, wishes, and dreams—not a brain filled with chemicals! The originators of the “biogenic amine” hypothesis understood this over forty years ago—and the best-informed psychiatrists understand it today.

Sincerely,

Ronald Pies MD

Note: The above “letter” was addressed to a hypothetical patient. A full disclosure statement for Dr. Pies may be found at: http://www.psychiatrictimes.com/editorial-board

References

1. Pies R: Psychiatry’s new brain-mind and the legend of the chemical imbalance. Psychiatric Times, July 11, 2011. http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1902106
2. See, for example, M. Angell MD, in the New York Review of Books: “The shift from “talk therapy” to drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs…”  http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/
3. Schildkraut JJ, Kety SS. Biogenic amines and emotion. Science. 1967; 156:21-37.
4. See, eg, “The cornerstone of psychiatry’s disease model today is the theory that a brain-based, chemical imbalance causes mental illness.” http://www.cchr.org/sites/default/files/Blaming_The_Brain_The_Chemical Imbalance_Fraud.pdf (PDF)
5. Lacasse JR, Leo J. Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature. PLoS Med. 2005; 2(12): e392. doi:10.1371/journal.pmed.0020392
6. El-Mallakh RS, Gao Y, Jeannie Roberts R. Tardive dysphoria: the role of long term antidepressant use in-inducing chronic depression. Med Hypotheses. 2011; 76:769-73.
7. Moran M: Brain, Gene Discoveries Drive New Concept of Mental Illness. Psychiatric News, June 17, 2011.
8. Castrén E, Rantamäki T. The role of BDNF and its receptors in depression and antidepressant drug action: Reactivation of developmental plasticity. Dev Neurobiol. 2010;70:289-97.
9. Machado-Vieira R, Manji HK, Zarate CA Jr. The role of lithium in the treatment of bipolar disorder: convergent evidence for neurotrophic effects as a unifying hypothesis. Bipolar Disord. 2009;11 (Suppl 2):92-109.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800957/?tool=pubmed

10. Kieseppä T, Partonen T, Haukka J et al. High concordance of bipolar I disorder in a nationwide sample of twins. Am J Psychiatry. 2004 161; 1814-21.
11. Lagopoulos J, Malhi G. Impairments in “top-down” processing in bipolar disorder: a simultaneous fMRI-GSR study. Psychiatry Res. 2011; 192:100-8.
12. MacKinnon D, Pies R. Affective instability as rapid cycling: Theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disord. 2006;8:1–14.
13. Heim C, Newport DJ, Bonsall R, et al: Altered pituitary-adrenal axis responses to provocative challenge tests in adult survivors of childhood abuse. Am J Psychiatry. 2001;158:575-81.
14. Zaretsky AE, Rizvi S, Parikh SV. How well do psychosocial interventions work in bipolar disorder? Can J Psychiatry. 2007;52:14-21.

Recommended reading:

Kramer P: In defense of antidepressants. New York Times Sunday Review, July 9, 2011. http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html?pagewanted=all

The problem?

Antipsychotic medications haven’t always been well-researched on older populations, and fewer still on people with a disease like Alzheimer’s. And when the research has been done, the results are often underwhelming.

Take the latest research, for instance, by Vigen and colleagues (2011). In a robust study conducted on “modern” atypical antipsychotic medications, the researchers found that patients on any of the antipsychotic medications tested suffered from a statistically and clinically significant decline on a number of cognitive measures, compared with a placebo control group.

CATIE-AD included 421 outpatients with Alzheimer’s disease and psychosis or agitated/aggressive behavior who were randomly assigned to receive masked, flexible-dose olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), or placebo.

Based on their clinicians’ judgment, patients could discontinue the originally assigned medication and receive another randomly assigned medication. Patients were followed for 36 weeks, and cognitive assessments were obtained at baseline and at 12, 24, and 36 weeks. Outcomes were compared for 357 patients. [...]

Overall, patients showed steady, significant declines over time in most cognitive areas, including in scores on the Mini-Mental State Examination (MMSE; –2.4 points over 36 weeks) and the cognitive subscale of the Alzheimer’s Disease Assessment Scale (–4.4 points). Cognitive function declined more in patients receiving antipsychotics than in those given placebo on multiple cognitive measures.

Despite these cognitive declines, the researchers suggest it still may be preferable to prescribe one of these medications to help control aggressive behavior in a person with Alzheimer’s:

Despite the evidence for worsening cognitive function and other adverse events with antipsychotics, improvement in psychotic and aggressive behavior may still warrant use of these agents in individual cases.

To aid in choosing the best medication for a given patient, the relative adverse effects on cognitive function within this class of medication need to be addressed in further studies that include assessments of attention, psychomotor function, and executive function.

The recommendation shouldn’t be surprising. Here’s the disclosure statement that accompanies the study:

Dr. Schneider has been a consultant for Pfizer, Eli Lilly, Johnson & Johnson, AstraZeneca, and Bristol-Myers Squibb. Dr. Keefe has received research support from AstraZeneca, Eli Lilly, and NIMH and has served as a consultant, adviser, or speaker for Abbott, Acadia, BiolineRx, Bristol-Myers Squibb, Cephalon, Cortex, Dainippon Sumitomo Pharma, Eli Lilly, Johnson & Johnson, Lundbeck, Memory Pharmaceuticals, Merck, Orexigen, Organon, Pfizer, Sanofi/Aventis, Schering-Plough, Wyeth, and Xenoport. Dr. Sano has served as a consultant or adviser for Aventis, Bayer, Bristol-Myers Squibb, Eisai, Elan, Forest, Genentech, GlaxoSmithKline, Janssen, Martek, Medivation, Novartis, Ortho-McNeil, Pfizer, Takeda, United BioSource, and Voyager. Dr. Sultzer has received research funding or lecture honoraria from or served as a consultant to AstraZeneca, Eli Lilly, Forest, and Pfizer. Dr. Lyketsos has received research funding, lecture honoraria, or travel support from or served as a consultant or adviser to Adlyfe, Associated Jewish Federation of Baltimore, AstraZeneca, Bristol-Myers Squibb, Eisai, Eli Lilly, Forest, GlaxoSmithKline, Ortho-McNeil, Monitor, Novartis, NIMH, National Institute on Aging, Pfizer, Supernus, Takeda, and Wyeth. Dr. Tariot has received research support or consulting or educational fees from Abbott, AC Immune, Alzheimer’s Association, Arizona Department of Health Services, AstraZeneca, Avid, Baxter Healthcare, Eisai, Elan, Epix, Forest, GlaxoSmithKline, Institute for Mental Health Research, Lundbeck, Memory, Merck, Merz, Mitsubishi Pharma, Myriad, National Institute on Aging, Neurochem, NIMH, Ono, Pfizer, Sanofi-Aventis, Takeda, and Wyeth; he is also a contributor to the patent “Biomarkers of Alzheimer’s Disease.” Dr. Stroup has received speaking or consulting fees from Eli Lilly, Janssen, and Lundbeck. The other authors report no financial relationships with commercial interests.

That’s quite the list. But granted, there were 13 researchers for this study and only 7 of them noted the above conflicts.

Can atypical antipsychotic medications be used in Alzheimer’s disease to help address aggressive behaviors? Yes, I believe they can — but not as a primary method of treatment, because they come with a lot of other problems when used in older populations. It’s my opinion that they should only be used when other methods have been tried unsuccessfully and the behavior has become extreme enough to warrant it.

Reference

Vigen et al. (2011). Cognitive Effects of Atypical Antipsychotic Medications in Patients With Alzheimer’s Disease: Outcomes From CATIE-AD. The American Journal of Psychiatry, 1-9. doi: 10.1176/appi.ajp.2011.08121844

Dr. John M. Grohol: So you’ve had a distinguished career, but it all seemed to start with your diagnosis of schizophrenia when you joined the Marines.

Dr. Frederick Frese: Actually, I was in the Marine Corps for about four years when I had the diagnosis and was discharged. Then spent 10 years, in 10 different hospitals, being hospitalized and re‑hospitalized, at one point being committed as insane. Then I went back to school, got my doctorate, became a psychologist functioning in a state hospital. I was actually director of psychology. I was being told not to tell anybody about my condition.

But one day, and thanks in large part to the last lady you just interviewed, Pam Hodge… She changed the laws in Ohio and encouraged persons in recovery to sit on mental health boards and become open about their conditions. So I did.

Since then, I’ve had quite a career. I’ve given over 2,000 talks. I’ve had movie contracts. No movie, but I’ve had a couple contracts!

Dr. Grohol: How was it that you had an interest in psychology and decided to go get your doctorate?

Dr. Frese: The truth of the matter is that I just happened to have a bachelor’s degree in psychology. But I really wanted to be an international businessman. I actually went to this graduate school called Thunderbird in Phoenix, then went out and got a job. But shortly thereafter I had another breakdown, so that pretty much closed all the doors to me, except working in the back wards of a prison psychiatric security hospital. So I took the job, and I’ve been essentially in that line of work ever since.

Dr. Grohol: Did you find it particularly challenging to apply and to be a grad student, given your background, your history, your diagnosis and stuff?

Dr. Frese: Well, I didn’t tell them.

Dr. Grohol: Because if you had told them…

Dr. Frese: It’s highly unlikely that I would have been accepted. Then when I had breakdowns while I was in school, there was some question about whether I would be allowed to continue. But they were very clever, the senior professors. They sort of spread the word around that I had an alcohol problem. That was sort of my cover.

Dr. Grohol: So alcoholism is acceptable, but having schizophrenia would not be.

Dr. Frese: Oh, no. But now there are a few of us that have… In fact, I just wrote an article identifying 10 psychiatrists, psychologists, and a few other doctoral folks in mental health with schizophrenia. So I’m not the only one.

Dr. Grohol: Oh, absolutely not. I think that’s the message of hope that your story brings to so many people.

Dr. Frese: Well, I would hope so. I meet so many judges and professors with the same disorder, but they won’t tell anybody. Much as Ellen Sachs would not tell anybody until she got tenure. And that meant the world.

Dr. Grohol: The floodgates opened.

Dr. Frese: And I was pretty quiet about it until I was reasonably close to retirement. So there’s certain risk to it.

Dr. Grohol: It still seems to be one of the more stigmatized conditions.

Dr. Frese: Oh, I think I have a lot of agreement with that statement.

Dr. Grohol: I think one of the confusing components of schizophrenia is the false belief that it’s a diagnosis that imprisons you for life.

Dr. Frese: Yeah. And that was the belief of most professionals when I first came down with this. I was told I would not recover and I would spend the rest of my life in state hospitals, essentially. But things have changed.

Dr. Grohol: Yeah, absolutely. Is there any particular type of treatment or anything that you did that really was the main thing was effective for you?

Dr. Frese: For me, medications have been helpful, certainly. And once I got married 33 years ago, I haven’t had another hospitalization. I’ve had breakdowns, but I could stay home and be cared for. And it is an episodic disorder for most of us. We tend to be able to recover fairly well, with some residual symptoms. Short‑term memory problems tend to come with the contract here.

Dr. Grohol: So what do you think is the reason that there seems to be so much misinformation and these beliefs about this disorder that continue to…

Dr. Frese: Well, for one thing, it’s you guys in the media. Your movies. The top villains of the movies of the whole 20th century, covered by AFI, we took the number one spot with Hannibal Lecter, and the number two slot, Norman Bates. I mean, about half of those people were mentally ill. That’s been the image. But fortunately we’ve got “A Beautiful Mind,” and more recently, “The Soloist” and some big‑time, silver‑screen portrayals of us that are more realistic.

Dr. Grohol: Yep, I agree.

Dr. Frese: There’s also a big spectrum of degree of disability. And so, as in the “The Soloist,” there’s some of us that are very disabled. And as in “A Beautiful Mind,” some of us can function fairly well, even with the disorders.

Dr. Grohol: Where would you put yourself on that spectrum?

Dr. Frese: Oh, I’m not that disabled. I’ve got the condition, no question about it. But I’m very fortunate not to have some of the difficulties of the more seriously disabled. And I’m well‑educated, I’ve got lots of schooling. When you can’t get a job, you find yourself going to school a lot.

Dr. Grohol: And some people never stop. What was one of the accomplishments, or some of the accomplishments, that you were most proud of while serving as director of psychology at Western Reserve Psychiatric Hospital?

Dr. Frese: Oh, that’s very… I think probably the biggest thing was when the new drug, clozapine, came out. And it’s still considered the gold standard. As the psychology director, I was able to have our psychologists… We had maybe 700 or 800 patients then, actually become the people who gave the instruments to measure whether or not individuals were improving from the drug. And we found out that, lo and behold, this drug worked as we hoped it did. I think that would be the major in my 15 years as psychology director there.

But there were so many changes, as we got the folks out of the state hospitals. We’ve gone from over a half million, when I first started out, to about 50,000 nationally now. So big changes.

Dr. Grohol: Besides what you just mentioned, has there been other important of exciting advances in this area of mental health treatment/research that you’ve been excited about?

Dr. Frese: One thing you could really help us with… And I just had a one‑on‑one conversation with a director of NIH last weekend. Marijuana, we now know, definitely increased the probability of your coming down with schizophrenia. And increases difficulty with relapse. But that word is not getting out there. Every now and then the New York Times will say something. That needs to get out better. All you have to do is Google “schizophrenia and marijuana” and you’ll see a plethora of studies. It increases the probability of one percent overall to maybe two, three or four percent.

That needs to… That’s a recent finding, in the last five years. But it’s a major finding. So that would be very helpful.

Dr. Grohol: OK. And what are you doing now at the Summit Valley Recovery Project? What is that?

Dr. Frese: The Summit County… Summit County is Akron’s county. We’ve got a little over half a million folks there. We have a lot of folks with serious mental illness. I run a recovery group every week. And I also liaison with a couple of consumer‑operated services. One of them, we hand out, make available, educational materials, getting the word out that people can recover. And actually in the National Public Television program that we just released about a year ago, we had the Supreme Court Justice Breyer, Nobel Laureate Eric Handel, Pulitzer Prize… We had lots of big guns.

I pointed out there that what we do is have a lending library type thing, run by folks in recovery. And we give them 3‑hour‑a‑week jobs paying minimum wage, so it doesn’t cost too much. But it puts somebody into a job, so then they can have some pride. Then they’re going to have two units of it, so it’s a six‑hour week.

Right now, because of the economic situation, we can’t really fund things without paying attention to cost, as you could a few years ago. I think the initial interest that we’ve got in that area is something that’s gotten a lot of positive attention. It’s certainly been on the program that we had.

Dr. Grohol: That’s great. Thank you very much for your time today.

Dr. Frese: Thank you.

Last week, The New York Times covered the story of Kyle Warren, a boy who began risperidone (Risperdal) treatment at age 2. Yes, you read the right — age 2.

He was rescued from this unbelievable prescription by Dr. Mary Margaret Gleason through a treatment effort called the Early Childhood Supporters and Services program in Louisiana. Dr. Gleason helped wean young Kyle off of the medications from ages 3 to 5, and helped understand that Kyle’s tantrums came from his stressful and upsetting family situation — not a brain disorder, bipolar disorder, or autism.

Imagine that — a child responding to a family situation that is stressful and involves his two primary role models — his parents.

After carefully reviewing the limited amount of research in this area, Psych Central recommends that parents should never accept an atypical antipsychotic medication prescription for a child age 5 or younger. If your doctor makes such a prescription, you should (a) look for another doctor and (b) consider filing a complaint with your state’s medical board against the doctor.

There is an astonishing lack of empirical or clinical data that suggest prescribing these kinds of medications to such young children — age 5 or younger — results in any significant change in mood or behavior. Lacking such data, it our opinion that it is simply irresponsible and inappropriate for medical professionals to prescribe such medications to young children.

There have been virtually no longitudinal studies conducted on children younger than 13 on these medications. We have no idea what the long-term effects of prescribing risperdal to a 2-year-old has on their long term cognitive and personality development. What few studies have been conducted and use the term “longitudinal” measure results and side effects at time periods like 6 months or 12 months (the maximum time of study we could find in a literature search). Yet few children are prescribed these kinds of medications for only 6 or 12 months. There’s continues to be a serious disconnect between how medications are prescribed in practice, and how they are researched.

The amount and number of tiny studies done on young children — those younger than 13 — for most of these medications is equally heart-stopping. They are few and far between, with typically small sample sizes (often in the 20 to 30 person range).

What brought this on was a recent article in The New York Times about a 3-year-old who was on an atypical antipsychotic. He was eventually diagnosed as simply having attention deficit disorder later on, but who knows what damage was done by the medication to his young, developing brain in the meantime.

It’s time to put a stop to this out-of-control prescription of atypical antipsychotics off-label. The American Academic of Child and Adolescent Psychiatry apparently agrees:

Dr. Lawrence L. Greenhill, president of the American Academy of Child and Adolescent Psychiatry, concerned about the lack of research, has recommended a national registry to track preschoolers on antipsychotic drugs for the next 10 years. “Psychotherapy is the key to the treatment of preschool children with severe mental disorders, and antipsychotics are adjunctive therapy — not the other way around,” he said.

So why do doctors continue to prescribe clearly inappropriate medications to younger and younger children? Costs and time. Medication is cheaper than psychotherapy in most cases. And psychotherapeutic interventions require a time and commitment on the family’s part to embrace change. Changing the family dynamics, changing the nature and quality of the parenting relationships, and changing how a parent copes with stress and the behavior of their child. Many parents fear a therapist will also be more judgmental — telling them that their parenting styles may have led to the child’s current problematic behavior. Some parents just aren’t able to hear that (even if therapists are usually far more tactful than looking to place blame — therapy is about helping produce beneficial changes, not blame).

But it is cheaper to medicate children than to pay for family counseling, a fact highlighted by a Rutgers University study last year that found children from low-income families, like Kyle, were four times as likely as the privately insured to receive antipsychotic medicines.

Texas Medicaid data obtained by The New York Times showed a record $96 million was spent last year on antipsychotic drugs for teenagers and children — including three unidentified infants who were given the drugs before their first birthdays.

In addition, foster care children seem to be medicated more often, prompting a Senate panel in June to ask the Government Accountability Office to investigate such practices.

In the last few years, doctors’ concerns have led some states, like Florida and California, to put in place restrictions on doctors who want to prescribe antipsychotics for young children, requiring a second opinion or prior approval, especially for those on Medicaid. Some states now report that prescriptions are declining as a result.

A study released in July by 16 state Medicaid medical directors, which once had the working title “Too Many, Too Much, Too Young,” recommended that more states require second opinions, outside consultation or other methods to assure proper prescriptions.

In a followup to the main article, Dr. Gleason responds to some readers’ questions, in an article entitled A Child Psychiatrist Responds. She confirms our reading of the research:

There is no scientific support for the use of psychiatric medications in infants and toddlers and limited support in preschoolers. However, parents know better than anyone else that there few available resources for families worried about their young child’s emotional or behavioral well being.

While the latter may be true, that’s little excuse for what’s happening with these kinds of crazy young prescriptions. Doctors, of course, should know better. But parents too have a responsibility to read up and become educated about the treatments a doctor is recommending for their toddler or preschooler.

The program Dr. Gleason is associated with sounds ideal — I wish we could replicate it across the country:

In our program, we also do consider the role of medication as part of the treatment plan in older preschoolers whose severe symptoms persist after therapy and who have a diagnosis that has been shown to respond to medications. We try to use all available research to guide these considerations. It is important in psychiatry — just like in other medical specialties — that we make treatment recommendations based on careful assessment and understanding of the child’s symptoms, relationships and life stressors. We also need to track how treatment is working and stop medications that are not improving a child’s functioning or are causing side effects that interfere with the child’s optimal functioning. Our goal is to help children and families enjoy each other, function at the highest level they can, and maintain physical health.

In my mind, a treatment approach that uses comprehensive assessment, and considers biological, psychological, and social factors in the patient’s life and uses treatments supported by the strongest evidence is far from anti-psychiatry. It is the best kind of psychiatry we can offer.

I understand the problems parents face when dealing with an out-of-control 2 year old. But the answer is not an atypical antipsychotic medication. The answer lies in gaining better parenting skills, and getting the child into a child psychologist or other early intervention child care program that understands the value of examining a family’s dynamics to get the whole story.

Because a 2 or 3-year-old should never be prescribed an atypical antipsychotic psychiatric medication.

Read the original article about Kyle and his family’s ordeal: Child’s Ordeal Shows Dangers of Antipsychotic Drugs

My first suggestion to you would be to talk to your doctor or psychiatrist. Nobody should go off of any medication without first getting their doctor’s consent and, hopefully, cooperation (or, if not their consent, at least their grudging acceptance that it’s your body and you can do with it what you want). Ideally, you’re seeing a psychiatrist for your psychiatric medications and not just your family doctor. If you are just seeing your family doctor, you may need a little more help than someone seeing a psychiatrist, because psychiatrists have much greater familiarity with helping people get off of the medications they previously prescribed to them. (In my experience, I’ve found many family doctors simply have little clue about the idiosyncrasies of discontinuing psychiatric medications, because of their unique tapering properties.)

Second, enough cannot be said about the importance of tapering for a majority of psychiatric medications — whether it be an antidepressant, an anti-psychotic medication, or something else. Tapering is simply the process of decreasing the dose of a medication a little bit over time. The key for most successful psychiatric drug discontinuation is slow, gradual tapering over a long period of time — many months even. I simply cannot emphasize this point enough. I’ve heard of many, many horror stories of patients being asked to taper off of a psychiatric medication they’ve been on for years over the course of a few weeks. That’s just criminal, in most cases.

This article offers only the most basic of introductions to this topic, because others have covered this area far more extensively than I have. A great place to start is this psychiatric drug withdrawal primer. While not succinct, it does contain all of the information you’ll need to know to successfully end your psychiatric medication treatment.

I cannot emphasize this enough — discontinuing psychiatric medications on your own is not recommended. You should enlist your doctor in your efforts to stop the meds.

Ah. Yeah. Every time I write about this controversial topic, I usually get hammered by the left, right, and center. This is obviously delicate ground, so let me tread lightly.

In a recent Johns Hopkins Health Alert called “The Challenge of Antidepressant Medication and Intimacy,” I read this:

While sexual dysfunction is a frequent symptom of depression itself (and successful treatment of depression may eliminate it), antidepressant medication can sometimes worsen or even cause sexual problems. In fact, sexual dysfunction is a potential side effect of all classes of antidepressants.

Between 30% and 70% of people who take antidepressant medications experience sexual problems, which can begin within the first week to several months after starting treatment. Antidepressant-related sexual dysfunction can affect almost any aspect of your sex life. In men, it frequently causes erectile dysfunction (the inability to achieve or sustain an erection), and in women, antidepressants may cause vaginal dryness and decreased sensation in the genitals. In both genders, antidepressants can diminish sex drive and make achieving orgasm difficult or impossible.

Sexual dysfunction due to any cause, including antidepressants, can have effects that range far beyond the bedroom, including psychological distress and a decrease in self-esteem and overall quality of life. This causes many people to stop taking their antidepressant medication. Up to 90% of people who experience antidepressant-related sexual dysfunction stop taking their medication prematurely. Fortunately, you can regain your sex life without stopping your medication and risking your symptoms worsening. For example:

From my research on this topic, psychiatrists usually recommend a few things:

• Switching to an antidepressant like Wellbutrin that has a lower rate of sexual side effects. Or adding Wellbutrin to your current antidepressant because recent research says that small doses of Wellbutrin (75 to 150 mg) in combination with another antidepressant can actually be helpful in decreasing the sexual side effects of those antidepressants.
• Another possibility is adding Viagra into the mix. It has been proven to help BOTH men and women with sexual dysfunction.
• Your doctor may experiment with decreasing your antidepressant ever so slightly, to see if that helps with sexual side effects.
• You could change the time you take your medication. For example, if you usually have sex sometime after dinner but before bed, it would be best to take your meds after sex but before bed, because the blood levels of the drug are going to be lowest the next day after dinner (when you typically have sex).
• Dividing your doses is also a possibility.
• And finally, implementing a “drug holiday” might be an option. That is, not taking your meds for two days or so. According to Karen Swartz, M.D. of Johns Hopkins Mood Disorders Center, “evidence shows that periodic two-day breaks from antidepressant therapy can lower the rate of sexual side effects during the drug holiday without increasing the risk of a recurrence of depressive symptoms.”

My plan? To experiment with a few of these when I reach a more stable place.

I’ve been saying that for about three years, because right as I think I’ve hit even ground and can do a drug holiday or try adding Wellbutrin or go to sex school, something happens and the black dog has my ankle again. So for now, I stay a tad challenged in this area.

What have been your experiences with sex while on antidepressants? Share below.

Many of us hear voices in our heads, but usually it’s our own voice acting as our conscious (“You really shouldn’t eat that second piece of cake!”). That’s not schizophrenia. And many of us believe in something that isn’t true (“Life is fair.”). That’s not schizophrenia either. The symptoms of schizophrenia need to be serious and significantly impact your daily life.

Regular contributor and author of the blog Weightless, Margarita Tartakovsky, has put together 13 myths regarding schizophrenia. Here’s the list of common myths about schizophrenia:

1. Individuals with schizophrenia all have the same symptoms.
2. People with schizophrenia are dangerous, unpredictable and out of control.
3. Schizophrenia is a character flaw.
4. Cognitive decline is a major symptom of schizophrenia.
5. There are psychotic and non-psychotic people.
6. Schizophrenia develops quickly.
7. Schizophrenia is purely genetic.
8. Schizophrenia is untreatable.
9. Sufferers need to be hospitalized.
10. People with schizophrenia can’t lead productive lives.
11. Medications make sufferers zombies.
12. Antipsychotic medications are worse than the illness itself.
13. Individuals with schizophrenia can never regain normal functioning.

Schizophrenia is usually a life-long disorder, and one that makes having what most of us would consider a “normal” life challenging. It can be done, but it requires a commitment on the part of the person with schizophrenia, often with the support of their family. While not common, it is one of the most disabling of the mental disorders — and the most misunderstood.

You can read more about these myths and the actual facts in the article, Illuminating 13 Myths of Schizophrenia.

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

The problem is simple — there are fewer psychiatrists who take Medicaid payments (which are lower than what private insurance generally pays), so most of these antipsychotic medications are being prescribed by family physicians or pediatricians who simply don’t know better (or think they’re helping when they’re really not). As the article notes, “it is often a pediatrician or family doctor who prescribes an antipsychotic to a Medicaid patient — whether because the parent wants it or the doctor believes there are few other options.”

The worst part? Antipsychotics to treat ADHD? Diagnosing bipolar disorder in children 3 years of age? I feel like I’m in a horror movie that never ends:

The F.D.A. has approved antipsychotic drugs for children specifically to treat schizophrenia, autism and bipolar disorder. But they are more frequently prescribed to children for other, less extreme conditions, including attention deficit hyperactivity disorder, aggression, persistent defiance or other so-called conduct disorders — especially when the children are covered by Medicaid, the new study shows.

You see, once a drug gets pediatric FDA approval for one condition, doctors see that as a green light to prescribe it off-label for any childhood disorder or problem (because, the reasoning goes, it’s been proven “safe”). So while only approved for very serious childhood problems like schizophrenia and bipolar disorder, you’ll see docs turning to it because it’s New and Improved (and hey, covered by Medicaid, so why not?).

Bizarrely, the article notes the “upside” to the over-prescription of atypical antipsychotics for virtually any childhood disorder a doctor feels like:

“Maybe Medicaid kids are getting better treatment,” said Dr. Gabrielle Carlson, a child psychiatrist and professor at the Stony Brook School of Medicine. “If it helps keep them in school, maybe it’s not so bad.”

Really? “Not so bad”?! Does this sound like a researcher who’s received a few grants from pharmaceutical companies over the years? Yeah, if you look at this recent Open Access article, you’ll see the disclosures the New York Times failed to mention to its readers:

Dr. Carlson has received research support or has consulted with the following companies: Abbott Laboratories, Cephalon, Eli Lilly and Company, Janssen, McNeil, Otsuka, and Shire Pharmaceuticals.

Hmmm.

One solution is pretty simple and straightforward — psychiatrists (and related professionals who have prescribing privileges in psychiatry or mental health) are the experts when it comes to choosing the right medication for the right patient. That’s what they’re trained for and that’s what they excel at. When we come to rely on other generalist professionals, we’re bound to get care that — while well-intended — is likely not the best available.

Children, of all people, certainly deserve the best available care, provided by the best professionals to provide it. And children — because their brains are still developing and we have zero long-term studies done on children and these medications — should turn to medications as only one possible solution to these mental health concerns. Psychotherapy is another possible solution and one that should be utilized as much as possible for children, especially for concerns that have a solid empirical research base to support therapeutic interventions (like ADHD).

The Rutgers-Columbia study that found that Medicaid children are prescribed four times the amount of antipsychotic medications compared to non-Medicaid children will be published early next year, in the journal Health Affairs.

Read the full article: Children on Medicaid Found More Likely to Get Antipsychotics

I’ll be perfectly honest — it’s a battle. As someone with a history of an eating disorder, I’ve had to work very hard on getting to a place where I eat when I’m hungry. For that reason, I won’t go near drugs like Zyprexa, because the 20 pounds that I gained in one month made me feel almost as bad as my depression.

I totally understand that body image is important to your self-esteem. I wish I wasn’t so shallow, but look at the ads around us. What’s the message that they’re screaming?

“Thin people are beautiful. Overweight people aren’t.” I hate that.

So, since this is Friday’s question that is usually answered by an expert, I read through my Johns Hopkins’s literature and found some helpful modification guidelines by Karen Swartz, M.D., Director of the Clinical Programs and one of the physicians who evaluated me in March of 2006 (and then sent me directly into the inpatient unit!). I hope her guidelines help. In the “Fall 2008 Depression and Anxiety Bulletin,” she writes:

In 2006 a study funded by the National Institute of Mental Health and published in the Archives of General Psychiatry reported that nearly one in four cases of obesity is associated with a mood or anxiety disorder. Among newly diagnosed patients with a mood disorder or anxiety complaint, weight gain is often a serious concern. Many fear that they’ll become fat–or get fatter–if they start medical treatment. A rapidly expanding waistline is also one of the major reasons why patients prematurely discontinue an otherwise effective treatment, fall back into depression and experience a poor outcome. Building a strong doctor-patient relationship and proactively discussing concerns such as weight gain are essential to a positive outcome.

In addition to discussing your weight with your physician, I hope you’ll find the following behavior modification guidelines helpful.

1. Set realistic goals.

Instead of attempting to lose a specific number of pounds, make it your goal to adopt healthier eating and exercise habits. If you feel compelled to set a weight goal, losing 10 to 15 percent of your current body weight is a realistic objective. The good news is that weight loss of as little as 5 to 10 percent of body weight can significantly improve heart disease risk factors such as blood pressure, blood glucose, and triglyceride and cholesterol levels. The safest rate of weight loss is 0.5 to 2 pounds a week. And added bonus: If you lose weight at this rate, you are more likely to keep it off.

2. Seek support from family and friends.

People who receive social support are more successful in changing their behaviors. Request help from family and friends, whether this means asking them to keep high-fat foods out of the house, relieving you of some chore so that you have time to exercise, or even exercising with you to keep you motivated. It will be easier to stick to your new eating plan if everyone in your home eats the same types of foods. You might also want to consider joining an online or local weight support group to talk with others about dieting and exercise challenges.

3. Make changes gradually.

Trying to make many changes too quickly can leave you feeling overwhelmed and frustrated. Instead, ease into exercise; do not overdo it. If you can only walk on the treadmill for 10 minutes, that’s fine. However, in a week or two try to increase the time to 15 minutes. In addition, adopt a healthy diet in stages. For example, if you typically drink whole milk, switch to reduced-fat (2 percent) milk, then to low-fat (1 percent), and then to fat-free.

4. Eat slowly.

Many people consume more calories than needed to satisfy their hunger because they eat too quickly. It takes about 20 minutes for the brain to recognize that the stomach is full, so slowing down helps you feel satisfied on less food. In addition, eating slowly allows you to better appreciate the flavors and textures of your food.

5. Eat three meals a day, plus snacks.

Skipping meals or severely reducing your food intake is counterproductive, since such strict changes are impossible to maintain over the long terms and are ultimately unhealthy. In addition, eating the bulk of your calories at one sitting may slow down your metabolism. You will be more successful in the long run if you allow yourself to eat when you are hungry, eat enough nutritious low-fat food to satisfy that hunger, and spread your calorie intake over the course of the day.

6. Plan for exercise.

Choose activities that are convenient and enjoyable for you to do on a regular basis, and then treat exercise like any other appointment: Set a time and jot it down in your date book. Many people find it easier to exercise first thing in the morning, before the demands of the day interfere.

7. Record your progress.

Start a food diary and exercise log to keep track of your accomplishments. This may seem cumbersome, but it can help you stay motivated, and reviewing your entries can help reveal problem areas. The information can also help your nutritionist or doctor treat your eight problem more effectively.

8. Evaluate your relationship with food.

Behavioral and emotional cues all to often trigger an inappropriate desire to eat. The most common cues are stress, boredom, sadness, anxiety, loneliness, and the use of food as a source of comfort or as a reward. Eating may appear to soothe uncomfortable feelings, but its effect is temporary at best and ultimately does not solve any problems. In fact, eating may distract you from focusing on the real issues.

9. Recall your accomplishments.

Over your lifetime, you have probably been successful in tackling many challenges, including coping with your mood or anxiety disorder. Reminding yourself of your own strength can help you feel more confident about making the changes that will lead to weight loss.

10. Don’t try to be perfect.

While losing weight requires significant changes in eating and exercise habits, not every high-calorie food must be banished forever, and you do not need to exercise vigorously every day. On some days, you will go off your weight-loss plan. This is normal, so don’t let these “bad” days deter you from returning to your healthier eating and exercise habits as soon as you can.

But many myths surround bipolar disorder — what it is, what it means, and how it’s treated. Here’s to busting a few of the most common ones.

1. Bipolar disorder means I’m really “crazy.”

While bipolar disorder is a serious mental disorder, it is no more serious than most other mental disorders. Having a mental disorder doesn’t mean you’re “crazy,” it just means you have a concern that is negatively impacting how you live your life. Left unaddressed, this concern can cause a person significant distress and problems in their relationships and life.

2. Bipolar disorder is a medical disease, just like diabetes.

While some marketing propaganda might simplify bipolar disorder into a medical disease, bipolar disorder is not — according to our knowledge and science at this time — a medical disease. It is a complex disorder (called a mental disorder or mental illness ) that reflects its basis in psychological, social, and biological roots. While it has significant neurobiological and genetic components, it is no more of a pure medical disease than ADHD or any other mental disorder. Treatment of bipolar disorder that focuses solely on its “medical” components often results in failure.

3. Manic depression is different than bipolar disorder.

Manic depression is simply the old name for bipolar disorder. The name was changed to more accurately describe the type of mood disorder it is — someone who experiences swings between two poles of mood (or emotion). Those two poles are mania and depression.

4. I’ll have to be on medications for the rest of my life.

While the default assumption by most mental health professionals is that most people with bipolar disorder will need to be on medications for the rest of your life, nobody can predict how exactly you, as an individual, will react to such medications or what the future holds for your specific needs. So it is a myth to say that all people with bipolar disorder will absolutely be on medications for the rest of their lives. As many people age with this disorder, they find their swings between mania and depression lessen significantly, and the need for medication may decrease, and may even be discontinued without any harmful repercussions.

5. I’m feeling better since taking my medications, which means I probably don’t need them any more, right?

Wrong. Once a person starts feeling better because of the medication, they often discontinue taking the medication, leading to an eventual relapse. This is a common problem in the treatment of bipolar disorder and is something professionals like to call “treatment compliance.” This is just a fancy way of saying that a person needs to continue taking their medication as prescribed, no matter how good they may be feeling. It is perhaps one of the most insidious issues in the treatment of bipolar disorder, and leads many people to greater distress than if they just kept taking their medications.

6. There’s no need for psychotherapy in bipolar disorder.

This varies from person to person (just as the need for taking medications does), but this is a myth insomuch that many people and professionals believe that psychotherapy doesn’t help much in the treatment of bipolar disorder. Psychotherapy can be very helpful and effective in the treatment of bipolar disorder, since medications alone can’t teach a person new coping skills or how to deal with feelings of an impending manic or depressive episode. Psychotherapy can help a person with bipolar disorder learn to live with the disorder in their lives without as much stress or upset. While many people with bipolar disorder forgo psychotherapy, it is usually a helpful treatment to consider when first diagnosed.

7. Atypical antipsychotics are only for schizophrenia.

In the U.S. in 1990, a new class of medications was introduced called “atypical antipsychotics.” These newer medications are not used to treat only psychosis (such as that found in schizophrenia), but also a wider range of psychiatric symptoms. One of their approved uses is in the treatment of bipolar disorder in adults. They may also be approved in short time for use in teenagers and children 10 years and older (although they are already sometimes prescribed by doctors for “off label use” in teens and children). So don’t let the name of the class of medications fool you — they treat far more than just psychosis.

8. Atypical antipsychotics have little to no side effects.

Atypical antipsychotics are often the primary drug doctors use to treat bipolar disorder. In the U.S., the Food and Drug Administration has determined that such drugs are both safe and effective for this use. However, like all medications, atypical antipsychotics have their own set of risks and side effects.

These medications have a different side effect profile than the medications they replace. While initially marketed as a “better” side effect profile, research since 1990 has shown that the side effects they do produce in many people can be just as worrisome as older medications. Chief among the typical side effects are weight gain and metabolism problems, which can be precursors to type 2 diabetes, increased risk of stroke, and heart problems (including an increase in cardiac arrhythmias which can lead to sudden death).

9. I may just have depression.

Many times, bipolar disorder mimics clinical depression, because one of the primary symptoms of bipolar disorder is clinical depression. Up to 25 percent of people who have bipolar disorder are initially misdiagnosed with depression. Why does this occur? Because many people first go to their primary doctor for a diagnosis, and primary doctors do not always ask enough questions to make the proper diagnosis. This can occur with mental health professionals who also fail to probe enough when a person presents with clinical depression in their office.

An incorrect initial diagnosis can lead to incorrect treatment, such as the prescription of antidepressant. Generally, antidepressants are not used in the treatment of bipolar disorder, and in fact, can make the disorder worse in the person. So if you’ve ever had an episode of increased energy for no particular reason (not because you just drank a liter of Coke), make sure you share that information with your mental health professional.

Want to learn more?
Stay up-to-date on the latest bipolar news, research, information and opinions over at our bipolar blog, Bipolar Beat!