Psychiatric Drugs Explained E-Book , livre ebook

Table of Contents

Cover Image
Preface
1. Introduction
2. Antipsychotics
3. Antipsychotic side effects and their management
4. Antidepressants
5. Side effects of antidepressants
6. Management of acute bipolar disorder
7. Mood-stabilisers
8. Drugs for children
9. Anxiety disorders
10. Benzodiazepine anxiolytics
11. Anxiolysis and the serotonin system
12. Beta-blockers and anxiety
13. Sleep disorders and insomnia
14. Non-pharmacological management of insomnia
15. Hypnotics
16. Sedatives
17. Cognitive enhancement and the dementias
18. Cognitive enhancement and neuroprotection
19. The range of sexual difficulties
20. Effects of drugs on aspects of sexual functioning
21. Physical dependence type 1
22. Physical dependence type 2
23. Physical dependence type 3
24. Consent
25. Pharmacological abuse
26. Liability
27. The ethical industry
28. Evidence-biased psychiatry
29. The marketing of psychiatric disorders
30. From health care to Pharmageddon
Appendix. Mental health websites
Index



Preface
While the pace of drug development has slowed to a trickle, and we are looking at a drought of truly breakthrough drugs, the past few years have seen a series of remarkable changes in the psychotropic drug scene. These changes are primarily to do with the increase in companies abilities to manage the perceptions of all of us, both as drug consumers when we are ill, and as health professionals if we are involved in treatment. This can be seen clearly in a number of areas. One is the increasing use of psychotropic drugs for children. Another is a developing craze for bipolar disorders. And yet another is the marketing aimed at sexual dysfunctions.
Against this background, the last thing that anyone might have expected was the sight of a psychopharmacological juggernaut hitting the bumpers, but this is what happened in the second half of 2003. At that point Lilly had received, and GlaxoSmithKline and Pfizer were looking to receive, licences to market their selective serotonin-reuptake inhibitors (SSRIs) to children. The scientific literature on these drugs given to children universally portrayed them as safe, well tolerated and effective. Newsweek featured a depressed teenager on the front page of its issue in world mental week in 2002, and on the inside claimed that 3 million teenagers in the USA were depressed and at risk of suicide as a result. However, when the regulators in Britain fi nally saw the raw data behind these scientific trials, they concluded the drugs were neither safe nor effective and, far from preventing suicides, were likely to trigger suicidality.
How could this happen? In part this must be because an increasing propor-tion of the so-called scientific literature in therapeutics is ghostwritten and, in scientific terms, is ornamental rather than substantive. It has the appearance of science, but is increasingly a set of infomercials aimed to sell drugs rather than inform science. Clinicians look at journals and see the adverts for a drug on one page and details of a randomised controlled trial on the other and fail to realise that it is actually the trial rather than the advert that carries the main weight of company marketing.
In this new situation, a book like this is increasingly relevant as it has, from the start, encouraged the takers of medications to pay heed to their own experiences on treatment, and not to be cowed by professional statements of what the drugs do, which are typically little more than a crude biomythology.
Ten years ago this approach seemed desirable, but not necessary. But the picture has changed, as an increasing number of patients have had their reports of distress on drugs ignored by physicians who recommend, instead, a doubling of the treatment dose, or have had their reports of dif-ficulties on withdrawal interpreted as evidence of an illness in need of fur-ther treatment. Whereas encounters like this were always unpleasant, it is now clear that this disconnection between physicians over-infl uenced by company marketing and the rest of us who take the drugs they prescribe may have fatal consequences. [ce:sup]1[/ce:sup]
Indeed, recent events suggest that informed consumers and, perhaps, other health care professionals might need to take action to reshape the contract be-tween pharmaceutical companies and society. Hitherto, companies have been granted a great deal of licence, including the sequestration of data generated by people taking risks with their medicines and doing so for free, only to fi nd that they distort or otherwise conceal these data when they do not suit them. The contract hitherto has put physicians in a key position as our advocates, but it seems that physicians when put in a position of vulnerability vis-a-vis com-panies rather like the position patients are put in with their physicians do not even have the courage to speak up, as the average patient has had to over the years when questioning the physician. It may be time, therefore, to revisit some fundamentals of the contract, especially as pharmaceutical companies and physicians appear to have overcome whatever compunction they might once have had about putting the most vulnerable in society our children at risk.
David Healy

Bangor, 2008

Reference

[1] C. Medawar, A. Herxheimer, A. Bell, S. Jofre, Paroxetine, panorama, and user reporting of ADRs. Consumer intelligence matters in clinical practice and post-marketing drug surveillance , International Journal of Risk and Safety in Medicine 15 ( 2003 ) 161 – 169 .



1. Introduction

Consumers and compliance 2

Individual end-points 3

Pharmacopsychology 3

There are typically three parties to the act of taking any psychotropic drug: the taker, the prescriber and the company that produces and markets the drug. All three are bound up by the history of our attitudes to psychological problems, to psychotropic drug-taking and to the processes of industrialisation that take place both within the pharmaceutical industry and within medicine. All three are also shaped by changing attitudes in society at large, one of which involves an increasing awareness of the rights of individuals, included in which is a right to information about treatments they may be given.
These forces have conspired in recent years to bring about the production of handbooks about drugs that cover their mode of action, their potential benefits and their possible side effects. However, such handbooks consist mostly of lists of drugs with bold statements of reputed modes of action and comprehensive lists of side effects. These give little flavour of how the drugs concerned may interfere with individual functioning or impinge on individual well-being.
One of the aims of this book, in contrast to these others, is to produce a text that makes the issues live. To this end, there is a lot of detail about the history of different drugs. On the question of what the various drugs do, both current thinking and current confusions are outlined. Too much certainty is, I believe, the enemy of both progress and science. And apparent academic certainty tends to invalidate the perceptions of a drug taker – who is actually one of the individuals best placed to contribute to the further development of psychopharmacology.
I also include an attempt to assess the influence of the pharmaceutical industry on the perceptions of both clinicians and patients.
More importantly, rather than simply give a list of benefits and side effects, I attempt to give a fuller description of what the experience of the side effects may be like and how these impinge on normal living. To try to put some flesh on the bare bones of a list of side effects means that I have compromised between being comprehensive and being significant. Readers should be aware that this book does not include every known side effect. It does not include precise figures as to the frequency of each side effect. It does not include all known interactions with other compounds. What it does include are the reactions and interactions that occur regularly, and the book attempts to give some feel for how important or otherwise these are.
What emerges, nevertheless, is a list of side effects that, in many respects, is rather fearsome – to add to a set of motives on the part of both prescribers and the pharmaceutical industry that are often venal. Many of my colleagues wonder whether taking this course of action is advisable. I have a number of reasons for thinking it is.

CONSUMERS AND COMPLIANCE
The final arbiter of whether psychotropic medication is useful or not is the taker. The taking of any psychiatric drug involves a trade-off between the benefits the drug confers and the risks it entails. Until recently, prescribers have been accustomed to making this trade-off for those for whom they prescribe. In general medicine, where respiratory or cardiac function is concerned, this is often the only possible course of action. But where psychotropic drugs are concerned, this is not the only option and – arguably – it is not the best option.
In psychiatry, prescribers often moan about non-compliance with the regimens they prescribe. In the absence of any systematic work on why the takers of the drugs we prescribe are non-compliant, the vacuum tends to be filled with a vague view that patient recalcitrance amounts almost to a culpable or moral failing. It seems that we rarely stop to appreciate that anyone worth their salt is going to think seriously about continuing treatment with medications that may obliterate their sex life, make them suicidal or generally make them feel worse than they were before they began treatment. There have always been prescribers sensitive to issues like this but there have also been far too many of us who, when faced with complaints about the medications we prescribe, have tended almost reflexly to increase the dose of what has bee