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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by herpills on September 26, 2012, at 19:39:01
A Call for Caution on Antipsychotic Drugs
By RICHARD A. FRIEDMAN, M.D.
Published: September 24, 2012
You will never guess what the fifth and sixth best-selling prescription drugs are in the United States, so Ill just tell you: Abilify and Seroquel, two powerful antipsychotics. In 2011 alone, they and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion, a 13 percent increase over the previous year, according to the market research firm IMS Health.
Those drugs are used to treat such serious psychiatric disorders as schizophrenia, bipolar disorder and severe major depression. But the rates of these disorders have been stable in the adult population for years. So how did these and other antipsychotics get to be so popular?Antipsychotic drugs have been around for a long time, but until recently they were not widely used. Thorazine, the first real antipsychotic, was synthesized in the 1950s; not just sedating, it also targeted the core symptoms of schizophrenia, like hallucinations and delusions. Later, it was discovered that antipsychotic drugs also had powerful mood-stabilizing effects, so they were used to treat bipolar disorder, too.
Then, starting in 1993, came the so-called atypical antipsychotic drugs like Risperdal, Zyprexa, Seroquel, Geodon and Abilify. Today there are 10 of these drugs on the market, and they have generally fewer neurological side effects than the first-generation drugs.
Originally experts believed the new drugs were more effective than the older antipsychotics against such symptoms of schizophrenia as apathy, social withdrawal and cognitive deficits. But several recent large randomized studies, like the landmark Catie trial, failed to show that the new antipsychotics were any more effective or better tolerated than the older drugs.
This news was surprising to many psychiatrists and obviously very disappointing to the drug companies.
It was also soon discovered that the second-generation antipsychotic drugs had serious side effects of their own, namely a risk of increased blood sugar, elevated lipids and cholesterol, and weight gain. They can also cause a potentially irreversible movement disorder called tardive dyskinesia, though the risk is thought to be significantly lower than with the older antipsychotic drugs.
Nonetheless, there has been a vast expansion in the use of these second-generation antipsychotic drugs in patients of all ages, particularly young people. Until recently, these drugs were used to treat a few serious psychiatric disorders. But now, unbelievably, these powerful medications are prescribed for conditions as varied as very mild mood disorders, everyday anxiety, insomnia and even mild emotional discomfort.
The number of annual prescriptions for atypical antipsychotics rose to 54 million in 2011 from 28 million in 2001, an 93 percent increase, according to IMS Health. One study found that the use of these drugs for indications without federal approval more than doubled from 1995 to 2008.
The original target population for these drugs, patients with schizophrenia and bipolar disorder, is actually quite small: The lifetime prevalence of schizophrenia is 1 percent, and that of bipolar disorder is around 1.5 percent. Drug companies have had a powerful economic incentive to explore other psychiatric uses and target populations for the newer antipsychotic drugs.
The companies initiated dozens of clinical trials to test these drugs against depression and, more recently, anxiety disorders. Starting in 2003, the makers of several second-generation antipsychotics (also known as atypical neuroleptics) have received F.D.A. approval for the use of these drugs in combination with antidepressants to treat severe depression, which they trumpeted in aggressive direct-to-consumer advertising campaigns.
The combined spending on print and digital media advertising for these new antipsychotic drugs increased to $2.4 billion in 2010, up from $1.3 billion in 2007, according to Kantar Media. Between 2007 and 2011, more than 98 percent of all advertising on atypical antipsychotics was spent on just two drugs: Abilify and Seroquel, the current best sellers.
There is little in these alluring advertisements to indicate that these are not simple antidepressants but powerful antipsychotics. A depressed female cartoon character says that before she starting taking Abilify, she was taking an antidepressant but still feeling down. Then, she says, her doctor suggested adding Abilify to her antidepressant, and, voilą, the gloom lifted.
The ad omits critical facts about depression that consumers would surely want to know. If a patient has not gotten better on an antidepressant, for instance, just taking it for a longer time or taking a higher dose could be very effective. There is also very strong evidence that adding a second antidepressant from a different chemical class is an effective and cheaper strategy without having to resort to antipsychotic medication.
A more recent and worrisome trend is the use of atypical antipsychotic drugs many of which are acutely sedating and calming to treat various forms of anxiety, like generalized anxiety disorder and even situational anxiety. A study last year found that 21.3 percent of visits to a psychiatrist for treatment of an anxiety disorder in 2007 resulted in a prescription for an antipsychotic, up from 10.6 percent in 1996. This is a disturbing finding in light of the fact that the data for the safety and efficacy of antipsychotic drugs in treating anxiety disorders is weak, to say nothing of the mountain of evidence that generalized anxiety disorder can be effectively treated with safer and cheaper drugs like S.S.R.I. antidepressants.
There are a small number of controlled clinical trials of antipsychotic drugs in generalized anxiety or social anxiety that have shown either no effect or inconsistent results. As a consequence, there is no F.D.A.-approved use of an atypical antipsychotic for any anxiety disorder.
Yet I and many of my colleagues have seen dozens of patients with nothing more than everyday anxiety or insomnia who were given prescriptions for antipsychotic medications. Few of these patients were aware of the potential long-term risks of these drugs.
The increasing use of atypical antipsychotics by physicians to treat anxiety suggests that doctors view these medications as safer alternatives to the potentially habit-forming anti-anxiety benzodiazepines like Valium and Klonopin. And since antipsychotics have rapid effects, clinicians may prefer them to first-line treatments like S.S.R.I. antidepressants, which can take several weeks to work.
Of course, physicians frequently use medications off label, and there is sometimes solid empirical evidence to support this practice. But presently there is little evidence that atypical antipsychotic drugs are effective outside of a small number of serious psychiatric disorders, namely schizophrenia, bipolar disorder and treatment-resistant depression.
Lets be clear: The new atypical antipsychotic drugs are effective and safe. But even if these drugs prove effective for a variety of new psychiatric illnesses, there is still good reason for caution. Because they have potentially serious adverse effects, atypical antipsychotic drugs should be used when currently available treatments with typically fewer side effects and lower costs have failed.
Atypical antipsychotics can be lifesaving for people who have schizophrenia, bipolar disorder or severe depression. But patients should think twice and then some before using these drugs to deal with the low-grade unhappiness, anxiety and insomnia that comes with modern life.
Dr. Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College in Manhattan.
A version of this article appeared in print on September 25, 2012, on page D6 of the New York edition with the headline: A Call for Caution on Antipsychotic Drugs.
Posted by jono_in_adelaide on September 26, 2012, at 20:25:06
In reply to recent new york times article on antipsycotics, posted by herpills on September 26, 2012, at 19:39:01
I was taking Zoloft, Edronax and Xanax and was still feeling depressed, anxious and plauged by intrusive, negative thoughts.... I brought some 1mg risperidone off of the internet from india and took 1mg (a low dose) at bedtime, and work up the enxt morning feeling a lot better. The only side effect was drowsiness for a couple of days. The effect has been maintained for 2 years now, and it would take a lot to get me to stop it.
I agree, they should be a last resort, but they can be damned usefull even in affective disorders that prove stuborn.
They need to be givin in the right dose to the right patient in the right circumstances, like any drug.
Posted by phillipa on September 26, 2012, at 20:54:04
In reply to Re: recent new york times article on antipsycotics, posted by jono_in_adelaide on September 26, 2012, at 20:25:06
I think I also have a newsletter with this information. I know personally I would not take these med did once and passed out. For me benzos after 40 some odd years I take less than I started out on diabetes runs in my family. Would not take them. Phillipa
Posted by jono_in_adelaide on September 26, 2012, at 21:52:18
In reply to Re: recent new york times article on antipsycotics, posted by phillipa on September 26, 2012, at 20:54:04
In the dose I'm taking (1mg per day) risperidone doesnt act as an antipsychotic, it only blocks the 5ht2 receptors that are involved in anxiety and depression.
I wish I didnt need it, but the imrpovement was so meaningful I couldnt ignore it.
SSRI's have never done much of anything for me, so I guess this is my substitute (I still take Zoloft because the alogorythum sems to be anxiety/depression = ssri these days, but it does very little)
They certainly shouldnt be handed out like candy, they should be reserved for resistant cases IMHO, where SSRI's, other antidepressants, Buspar, Atarax and Benzos havent gotten the person where they need to be. Also, mybe, in addixction prone people where using benzos might be a bad idea, though that is a pretty grey area i think
Posted by bleauberry on September 27, 2012, at 8:56:33
In reply to recent new york times article on antipsycotics, posted by herpills on September 26, 2012, at 19:39:01
I believe antipsychotics are over used. I was on zyprexa for 8 years and most of that time it was a good med for me. So I am not bashing the APs, just sayin, prescribed too often. In my case, it was a third-line choice. But these days it is closer to a first line or second line choice. I think they should remain third and fourth tier choices.
I say that because the risks are real, and high. I say that because these powerful chemicals do a wide variety of mysterious things we know very little about. We know that whatever they do, they impact a lot of biological systems in the body besides just the symptoms. We know that because of movement disorders, diabetes, weight gain, hormonal changes, all directly correlated to the AP.
Emergency rooms are great places for APs. Quick calming, quick control. For longterm patients though, I am more hesitant. There are other safer more benign, yet equally effective, choices to try first.
What really bothers me is that if the reason for prescribing an AP is any of these....
-mood stability
-depression
-mania
-agitation
-sleep
-anxiety
....there are some very good plant medicines that have the same or better potential as the APs, except with near zero toxicity, very low almost nonexistent risk, and very low almost nonexistent side effects, with the additional side benefit of having multiple other built in mechanisms to improve a wide variety of health issues independent of the symptoms at hand.In some cases, APs are the only thing that work. In those cases it becomes a personal benefit/risk decision whether to stay with it or not. If nothing else works, then it makes sense. The thing is, not many people can say they have truly given more benign approaches a good try. Most don't know a darn thing about plant medicines except maybe the St Johns Wort and ginkgo biloba on the shelf at WalMart. Very sad. Those two plants by the way, as popular as they are, are losers compared to the ones I'm talking about.
With such better choices available to patients, it boggles my mind to see them blindly accept a doctor's prescription. I saw that happen the other day at work. A woman was prescribed something by her doctor to calm her down. I asked her what it was. She didn't know. She didn't know! She said it must be good because it was a prescription.
Meanwhile, just down the street at the health food store, is a bottle of something as good or better than the prescription, that costs less than $10.
It's so sad how America has been dumbed down over recent years. It's a tragedy patients do not take a more proactive role in their own care and education.
Posted by phidippus on September 27, 2012, at 17:30:02
In reply to recent new york times article on antipsycotics, posted by herpills on September 26, 2012, at 19:39:01
The article failed to address the treatment of OCD with atypical antipsychotics.
Eric
Posted by SLS on September 27, 2012, at 17:43:08
In reply to Re: recent new york times article on antipsycotics, posted by jono_in_adelaide on September 26, 2012, at 21:52:18
A friend of mine came up with an interesting idea today. It might make sense in severe cases of depression to use a drug like Zyprexa as a temporary bridge between the initiation of treatment with a standard antidepressant and the 4 - 8 weeks the antidepressant might take to begin working.
- Scott
Posted by jono_in_adelaide on September 27, 2012, at 18:17:59
In reply to Re: recent new york times article on antipsycotics » jono_in_adelaide, posted by SLS on September 27, 2012, at 17:43:08
SLS - An Australian Professor of Psychiatry who runs the Black Dog Institurte said on his site that he often does exactly that - gives a benzo or an atypical for a few weeks at the start of therapy to get the patient through the first few weeks, then quickly tapers it off.
I also think that mirtazapine could serve well in many of the off lable applications for atypicals in nonpsychotic disorders, it shares the properties they manifest in the low doses typicaly used (sedation, releif of anxiety and depression through blocking the 5HT2 receptors)
Not sure why it isnt more widely used in these situations (well, I do, its off patent, so noone is promoting it to doctors)
Posted by herpills on September 29, 2012, at 23:09:54
In reply to Re: recent new york times article on antipsycotics, posted by bleauberry on September 27, 2012, at 8:56:33
bleauberry- I agree with almost everything you are saying here, but I feel that it is worth pointing out that not everyone has the means to experiment with these other therapies...consider this, someone who is low to very low income, comes into the public/community mental health clinic. They have to take what they can get, and do you think rhodiola and cordyceps are on the formulary?? NO its free samples of Seroquel and Saphris...herpills
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