Friday, November 23, 2007

Antipsychotics for the Masses?

When it comes to antipsychotic medication, it appears that psychiatry has come full circle. The very first antipsychotic, Thorazine, was introduced in 1952, and had originally been considered to be an antihistamine, a bit like Benadryl. Eventually, we understood that it had extraordinary effects on the delusions and hallucinations of schizophrenia.

Over the years, many other antipsychotics have been introduced, and they are all effective at reducing psychotic symptoms, as their name implies. But over the past decade, they have also won FDA approval for treating bipolar disorder. Now, the companies marketing these drugs have their eyes on depression, which represents a far larger potential market than either schizophrenia or bipolar disorder. On November 21, Abilify received FDA approval as an add-on treatment for major depression (see the news item here). This follows closely on the heels of a study published a couple of weeks ago in the Annals of Internal Medicine showing that Risperdal was effective as an adjunctive depression treatment.

How effective are these drugs for depression? Not terribly. The Abilify data, for example, shows a remission rate of 26% vs. 16% for placebo augmentation, meaning that 1 out 10 patients would be expected to respond to an Abilify-induced boosting of their current antidepressant. The design of this study was somewhat manipulated in order to make sure Abilify beat placebo, a fact brought to my attention by this excellent post in Cl Psych. Nonetheless, the Risperdal data are very similar, and I'm convinced that atypicals provide a small antidepressant effect. Enough of an effect to overcome the potential side effects? That's unclear.

What is abundantly clear is that drug companies are going to be pushing both psychiatrists and primary care doctors to think of "antipsychotics" as "antidepressants." Look closely at the data before you buy the message!

8 comments:

Stephany said...

That is exactly what I think is going to happen, is antipsychotics will be "labeled" or regarded as anti depressants, due to the marketing. The average person who walks into the PCP and receives Abilify for depression, will never know it's an anti psychotic. Maybe that doesn't matter. I find this entire situation alarming, because Abilify is not Benadryl, just like Thorazine wasn't good for pregnant morning sick mothers.

Biggest pet peeve is the OTC cold medication being in the headlines more than Risperdal and Abilify.

Give me Dimetapp any day vs. antipsychotics. That goes for kids too.

Dr. Shock said...

Fully agree with you there. They will probably earn more money with antipsychotics as antidepressants.
There are some publications and editors that allow negative publications on antipsychotics and depression happily.
http://ectweb.blogspot.com/2007/11/again-antipsychotics-for-depression.html

Mark said...

Firstly there is no such thing as an anti-psychotic, the medicine/drugs known as anti-psychotics are long term tranquilizer. Psychotic is in the eye of the beholder, there is no lab test to measure the amount of psychosis in a patients body. The correct amount to be "given" to patients is speculation.
The effects from anti-psychotics on the human mind and body are open to interpretation. Usually biased favourably for the drug, as who is paying for the research? and who defines what a psychiatric symptom is?
Schizophrenics and other seriously ill patients (in general) can not complain about adverse effects. Now that average people are voluntarily consuming it , psychiatrists might have to respond to complaints, how convenient you now question the medicine. I hope the people who have no voice in consuming anti-psychotics are not forgotten in the clean up of the "science" of the efficacy of long term tranquilizers.

William Rhoads said...

Perhaps bad science was used to get Abilify appproved as an add-on drug for depression, and any drug that starts out as anti-psychotic should always be called that, but I personally have just benefited in the last month from Abilify, and my psychiatrist would never have prescribed it if someone, whether venturesome psychiatrists or Bristol, had not experimented with it for depression.

I have had depression for the last two years, and have tried just about all the antidepresssants on the market, without success, and ended up with a combination of gabapentin, nortriptyline,and Xanax that just kept me going. In four days, with 2.5 mg of Abilify per day, my depression lifted and now less than three weeks later, I know what it is to be cheerful again. I hope it lasts.

My depression is unusual,and has a long complicated history, so I have no idea how many others will benefit as I am doing now, but for me Abilify is a true antidepressant first and foremost, and for all the others who suffer from treatment resistant depression, I hope this proves to be true also.

Anonymous said...

Upon information and belief...

Current Depression Medications: Do The Benefits Outweigh the Harm?

Presently, for the treatment of depression and other what some claim are mental disorders, as they are questionable, selective serotonin reuptake inhibitors are the drugs of choice by most prescribers. Such meds, meds that affect the mind, are called psychotropic medications. SSRIs also include a few meds in this class with the addition of a norepinephrine uptake inhibitor added to the SSRI, and these are referred to SNRI medications. Examples of SNRIs are Cymbalta and Effexor. Some consider these classes of meds a next generation after benzodiazepines, as there are similarities regarding their intake by others, yet the mechanisms of action are clearly different, but not their continued use and popularity by others.
Some Definitions:
Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrist’s bible, which is the DSM, states that the definite etiology of depression remains a mystery and is unknown. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected with limited scientific evidence. In fact, diagnosing diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.
Norepinephrine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med.
And depression is only one of those mood disorders that may exist, yet possibly the most devastating one. An accurate diagnosis of these mood conditions lack complete accuracy, as they can only be defined conceptually, so the diagnosis is dependent on subjective criteria, such as questionnaires. There is no objective diagnostic testing for depression. Yet the diagnosis of depression in patients has increased quite a bit over the decades. Also, few would argue that depression does not exist in other people. Yet, one may contemplate, actually how many other people are really depressed?
Several decades ago, less than 1 percent of the U.S. populations were thought to have depression. Today, it is believed that about 10 percent of the populations have depression at some time in their lives. Why this great increase in the growth of this condition remains unknown and is subject to speculation. What is known is that the psychiatry specialty is the one specialty most paid to by certain pharmaceutical companies for ultimately and eventual support of their psychotropic meds, as this industry clearly desires market growth of these products. Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders are suspected by a health care provider. Yet these meds discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related disease states.
Over 30 million scripts of these types of meds are written annually, and the franchise is around 20 billion dollars a year, with some of the meds costing over 3 dollars per tablet. There are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to being promoted for treatment for menopause. The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.
Furthermore, these meds have received additional indications besides depression for some really questionable conditions, such as social phobia and premenstrual syndrome. With the latter, I find it hard to believe that a natural female experience can be considered a treatable disease. Social phobia is a personality trait, in my opinion, which has been called shyness or perhaps a term coined by Dr. Carl Jung, which is introversion, so this probably should not be labeled a treatable disease as well. There are other indications for certain behavioral manifestations as well with the different SSRIs or SRNIs. So the market continues to grow with these meds. Yet, it is believed that these meds are effective in only about half of those who take them, so they are not going to be beneficial for those suspected of having certain medical illnesses treated by such meds. The makers of such meds seemed to have created such conditions besides depression for additional utilization of these types of medications, and are active and have been active in forming symbiotic relationships with related disease- specific support groups, such as providing financial support for screenings for the indicated conditions of their meds- screening of children and adolescents in particular, I understand, and as a layperson, I consider such activities dangerous and inappropriate for several reasons.
Danger and concerns by others primarily involves the adverse effects associated with these types of meds, which include suicidal thoughts and actions, violence, including acts of homicide, and aggression, among others, and the makers of such drugs are suspected to have known about these effects and did not share them with the public in a timely and critical manner. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others, such as those in the medical profession as well as citizen watchdog groups. The reasons for this attention are due to the potential off-label use of these meds in this population, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, including the decreased efficacy of SSRIs in general, which is believed to be less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding such important information- Elliot Spitzer specifically, as I recall.
And there are very serious questions about the use of SSRIs in children and adolescents regarding the effects of these meds on them. For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect could cause harm rather than benefit? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring in their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist. It is observed in some who take such meds, but not all who take these meds. Yet health care providers possibly should be much more aware of these possibilities
Finally, if SSRIs are discontinued, immediately in particular instead of a gradual discontinuation, withdrawals are believed to be quite brutal, and may be a catalyst for suicide in itself, as not only are these meds habit forming, but discontinuing these meds, I understand, leaves the brain in a state of neurochemical instability, as the neurons are recalibrating upon discontinuation of the SSRI that altered the brain of the consumer of this type of med. This occurs to some degree with any psychotropic med, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs, it is believed.
SSRIs and SRNIs have been claimed by doctors and patients to be extremely beneficial for the patient’s well -being regarding the patient’s mental issues where these types of meds are used, yet the risk factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug. Considering the lack of efficacy that has been demonstrated objectively, along with the deadly adverse events with these meds only recently brought to the attention of others, other treatment options should probably be considered, but that is up to the discretion of the prescriber.
“I use to care, but now I take a pill for that.” --- Author unknown
Dan Abshear

Cleuren said...

At the University of Leuven Belgium) there is no more place for antidépressants in bipolair disorders. Atypical antipsychotics are everywhere. Now the concomittant problems of obesitas and diabetes have a solution : Abilify.

Anonymous said...

I've had schizophrenia and depression from a young age. Several people on my dad's side have/had mental illness, too. My grandma had schizophrenia, as did my dad. I've never met my grandma because she committed suicide before I was born. When my dad was a teenager he found her dead on New Year's Day. My dad self-medicated with drugs/alcohol. He had diabetes...the drugs/alcohol took a toll on his health and he died at 46. Would the fate of my grandma and dad had been the same if they had taken antipsychotics?

When used appropriately, antipsychotics aren't the most evil thing in the world. They're just the lesser of two evils. They only become bad when they're used when they shouldn't be used. I don't care what Mark wants to call them...he can them tranquilizers or pumpkin spice lattes with an extra shot of espresso no whip. They're still the same drug.

It would be great if medication CURED? I have asthma and epilepsy. Every month I give drug companies a nice, steady stream of income because they only TREAT me. Without the medication I have asthma attacks in between seizures. Using medications is one of the ways I can improve my quality of life. How do you decide whether to use a long-term medication? You ask yourself, "What's better: life with side-effects of the medication or life with the actual illness?"

Schizophrenia is no different than any other chronic illness, such as asthma and epilepsy. If you can honestly say that life with schizophrenia is better than life with less or no schizophrenia and the side-effects of antipsychotics, then taking antisychotics isn't the right things for you. Hopefully your psychiatrist will support you if you make that decision. If you're psychotic and don't want medication...I don't think you'll get much support from your psychiatrist ;)

I realize I'm a little off topic, but that's my two-cents.

Anonymous said...

(Unfortunately I cannot paste up images on this site. The following poem was accompanied by a CAT scan image of my brain.)

my beautiful brain

This is my beautiful brain! I was astonished when I first saw it...the secret inside bits, the biology of me. A beautiful intrigue of grainy image...this I carry inside. And all my lived moments....where are they? My passions, my history, my fears, my great loves...not to be seen. Not one sacred jot evident. We are so much more than the sum of our parts.
If you look at me like this you will not see my soul, my humour, my warmth but a set of parts that may or may not need fixing. You may prescribe me medication/chemicals that alter this beautiful brain...then what? Have you done your job? Can you spot the dysfunctions in there?...pinpoint them...reprogram them? And if your drugs don't work what then? Prescribe the next lot...and the next...I wonder have you lived through that?
Within this beautiful brain is me...you need to look deeply to see.