New Republic - Psychiatry’s Drug Addictio n (1979)

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[sSRI-Research] New Republic - Psychiatry's Drug Addictio n

(1979)

 

 

 

(Decade by decade, Big Medicine's money machine just keeps rolling

along, right over the dead bodies of it's victums)

 

 

 

For 25 years, doctors have been making their mental patients sicker.

 

Psychiatry's Drug Addiction (1979)

by Peter Sterling

 

Dr. Peter Sterling does brain research at the University of

**Pennsylvania School of Medicine. He testified for the plaintiffs

in the New Jersey case discussed in this article.

<comment in original article>

 

" Judge Rules Mental Patients Sane, Doctors Crazy. " Thus the headlines

might have read on September 14. The inmates of New Jersey's five

state mental hospitals had sued the state in a class action for the

right to refuse psychoactive drugs. The patients claimed that the

drugs with which they were being forcibly treated, far from relieving

their illness, were causing them intolerable distress, impeding their

recovery, and producing irreversible brain damage.

 

The federal judge ruled that refusal of a drug, even by a patient who

is psychotic, can " be prompted by a quite rational desire to avoid

unpleasant side effects and a realistic appraisal that the medication

is not helping The judge chastized hospital physicians and state

authorities for administering the drugs irresponsibly, often

punitively, and for their " conscious and deliberate indifference to

breaches of patients rights. "

 

The treatment of the insane in New Jersey reflects standard practice

across the country. Over the last 25 years psychotropic drugs have

become virtually the universal and sole treatment for mental patients.

But these drugs are toxic. The drugs at issue are the phenothiazines

such as chlorpromazine and the butyrophenones such as haloperidol.

They affect transmission of chemical signals between nerve cells,

especially neurons sensitive to the neurochemical, dopamine. Since

these neurons are widely distributed in the brain from the retina to

the frontal lobe/no single brain region remains unaffected.

 

The toxic effects of these drugs are extraordinarily varied. Some

effects such as chronically dry mouth, blurred vision, and inability

to ejaculate stem from the suppression of neural mechanisms that

control glands and " involuntary " muscles. Other more serious effects

stem from the disruption of normal neurochemical activity in " motor "

areas of the brain. For example, the drugs commonly induce the

symptoms of Parkinson s disease: trembling of the limbs, rigidity of

the muscles, and " akinesia, " literally an inability to move.

 

" Akathisia " is another common toxic effect, and one that would drive a

sane man crazy. Its external signs are a motor restlessness, constant

pacing, and fidgeting of the fingers, legs, lips, and jaws. Akathisia

is experienced subjectively as an inability to find a comfortable

position for one's body, so that the desire to move is constant and

compelling.

This toxic syndrome often is accompanied by states of intolerable

anxiety or abject terror. Mistaking this toxic condition for mental

illness frequently leads the psychiatrist to increase the drug dose,

intensifying the akathisia to unbearable levels.

 

The most disfiguring and disabling of all the to,dc drug effects is

" tardive dyskinesia. " This is a rapid, wholly involuntary writhing of

the face, lips, tongue, jaws, and occasionally the limbs and trunk.

These movements are so severe in one of the New jersey plaintiffs that

she is unable to wear dentures and must live on ground food. Another

plaintiff suffers tardive dyskinesia as a Dante-esque torture: he

continually bites his tongue. This disorder reflects permanent damage

to

certain parts of the brain's motor system; by the time it is diagnosed

in most patients, it is too late to be reversed. Paradoxically, the

syndrome is frequently exacerbated by withdrawal of the drugs which

caused it. Despite a frantic search for new drugs to counteract it,

tardive dyskinesia is without cure or prospect for one, except to

restore the offending drugs. This may suppress temporarily some of the

symptoms, but it will continue to cause unseen damage to the brain.

 

Tardive dyskinesia appears almost inexorably after years of chronic

drug

use, and older patients bear the highest risks. Roughly half the

geriatric patients in New Jersey's sfate hospitals suffer tardive

dyskinesia. As a result of this iatrogenic (physician-caused)

disorder, a patient who recovers from his mental disorder continues to

look crazy because of his bizarre movements. He is an object of

suspicion and taunts by other patients and staff and, following

release, as one may well imagine, by the general public.

 

The hospital staffs in New jersey systematically ignore these toxic

effects and attribute complaints about them to the patients'illness.

The medical director of one state institution conceded at the trial

that a quarter to a half of the patients at his hospital might suffer

from tardive dyskinesia, yet not a single patient's chart in that

hospital bears the diagnosis. A nurse who insisted on charting one

patient's abnormal movements was chastized for doing so by her superiors.

 

A psychiatrist for the defense testified that most patients suffering

drug-induced tardive dyskinesia are unaware that they have the

disorder and " are not troubled by it. " He went on to say that refusal

to take drugs is an expression of the patients' illness and that

" miniepidemics " of drug refusal occur when " a couple of patients go

around agitating each other to refuse medication.... "

 

Such attitudes displayed by the psychiatrists quite naturally lead the

rest of the staff to deny the toxic effects of the drugs they

administer, and to respond with cruelty rather than sympathy to

complaints. The plaintiff who couldn't wear her dentures because of

tardive dyskinesia was taunted by staff, who implied she was faking.

When john Rennie, the leading plaintiff in the suit, refused to take

drugs, he was beaten by an attendant ( " human services technician " ).

Rennie's protest at the beating was dismissed as paranoia until he

showed an official " patient advocate " where the stick was kept at the

nurses' station. A more subtle way of intimidating patients who try to

refuse medication is the threat of " Prolixin. " This drug produces

especially high incidence of akathisia and akinesia and, not

uncommonly, a dramatic exacerbation of psychosis. Prolixin is given by

needle in a long-lasting form patients know that in refusing tablets

of Thorazine or Haldol, they risk a two-week shot of Prolixin.

 

The staff of mental hospitals are not moved by idle cruelty, but

rather by a rigid determination to continue administering the drugs.

What is the source of this compulsion? The behavior of the psychiatric

profession in this regard has the earmarks of a drug addiction. All

the classic requirements for addiction were present in 1954 when

chlorpromazine was introduced: a vulnerable population, pushers, and a

powerful substance. Psychiatry was vulnerable because it suffered from

the scorn long heaped upon it by the other medical specialties for

having no therapy to offer but " talk. " It was being encroached upon,

furthermore, by the professions of psychology and social work with

equally valid claims to provide talk therapy. And the nation's mental

hospitals were bulging with more than half a million patients.

The availability of " medicine " to treat the insane reinforced the

concept that insanity is a medical illness. The drug gave psychiatry a

chance to establish decisively its own niche in medicine, and hegemony

in the treatment of the insane.

 

The drug was pushed hard with only the briefest glance at its toxicity.

In 1953 Smith, Kline, and French purchased the rights to

chlorpromazine ( " Thorazine " ), based on its demonstrated efficacy as an

" anti-emetic, " to control nausea and vomiting. As late as December

1953, only five months before it was marketed, chlorpromazine had been

tested as a tranquilizer on only 104 psychiatric patients in the

United States.

 

 

Thirteen months later it was being administered to about two million

American patients. SKF mounted an impressive sales drive, adding a

special Thorazine task force of 50 salesmen to its regular sales force

of 300 for all products. The company convinced state legislatures to

increase mental health appropriations and convinced hospitals to use

the funds for the purchase of Thorazine. Much of SKF's growth, from

net sales of $53 million in 1953 to $347 million in 1970, came from

the success of Thorazine.

 

The other drug companies were not far behind, and chlorpromazine was

followed by a variety of similar drugs. Next came other drugs intended

to counteract some of the side effects of the tranquilizers.

Psychotropic drugs, now manufactured by the ton, filled about 250

million prescriptions in 1974. Today it is common for a schizophrenic

patient to receive up to six drugs simultaneously that have both

reinforcing and opposing effects on the brain. Only psychiatrists,

among mental health professionals, are permitted to determine the

proper ingredients for this bouillabaisse.

 

The drugs are undeniably potent in treating the symptoms of psychosis.

When a patient arrives strait-jacketed at the hospital raving that he

is Christ or the Alpha-Omega, a shot of chlorpromazine appears to work

a miracle. In a few hours he is calmer. He may still be deluded, but

the intensity with which he presses his claims has abated. The

chemical is not merely a sedative like the barbiturates: it can

moderate the stark withdrawal of a catatonic as dramatically as it

calms the excited patient. " Double-blind " studies prove that patients

maintained on drugs within the hospital are more manageable. Compared

to patients on placebos, their scores are low on the " Behavioral

Disturbance Index " and high on the " Hospital Adjustment Scale. "

 

This impressive effect led many psychiatrists to claim that the drugs

act on the " core " of psychosis, that they are true " antischizophrenic "

agents. Some hoped, too, that patients released with their symptoms

suppressed by " maintenance " doses could rejoin the general community.

But 25 years after chlorpromazine was introduced, these hopes have not

been realized. It has become clear the drugs do not strike the core of

psychosis. Studies have shown that patients treated with drugs,

despite their apparently greater lucidity, are not more amenable to

psychotherapy. In fact, patients on the drugs generally do not benefit

at all from traditional psychotherapy.

 

This finding probably reflects the harmful effects of the drugs, but

it has been used as a reason for allowing psychotherapeutic programs

of all kinds to deteriorate.

 

Most patients released from the hospital on " maintenance " drugs have

not successfully rejoined the community. Typically these patients lead

isolated lives in rooming houses at the community margins, where they

often are cheated of their welfare checks by unscrupulous landlords.

Roughly half to three- quarters of the patients on " maintenance " drugs

relapse and return to the hospital. Patients treated with drugs in the

hospital and taken off the drugs at release also relapse at high

rates. Patients who never received drugs fare best when released.

 

The blunting of consciousness, motivation, and the ability to solve

problems under the influence of chlorpromazine resembles nothing so

much as the effects of frontal lobotomy. The lobotomy syndrome was

familiar to psychiatrists in 1954 because so many lobotomized patients

had accumulated in mental hospitals. Research has suggested that

lobotomies and chemicals like chlorpromazine may cause their effects

in the same way, by disrupting the activity of the neurochemical,

dopamine.

 

At any rate, a psychiatrist would be hard-put to distinguish a

lobotomized patient from one treated with chlorpromazine. Psychiatry

once hoped that lobotomy also would make patients " amenable " to

psychotherapy. It is clear in retrospect that neither surgery nor drug

treatment could have that result because progress in psychotherapy

requires not lack of interest from the patient, but wits and drive.

 

Mental hospitals began to empty after 1955. New Jersey state

hospitals, for example, held 15,000 patients then , and only about

4000 today. This massive " decarceration " is widely credited to the

success of the psychotropic drugs, but there is really no evidence for

this. The rates of release from mental hospitals began to rise in the

United States and England in the late 1940s and early 1950s, before

the drugs were introduced.

 

Prison release rates also began to rise shortly afterward. The trend

toward decarceration in both kinds of institutions resulted from a

recognition of the astronomical costs of the new hospitals and prisons

that would be required without a reversal of the trend toward

incarceration. The availability of drugs cannot explain the increased

release rates in prisons, nor for the high release rates for patients

with chronic brain syndromes who rarely were treated with drugs.

 

`The practice of Dr. Thomas Monro, physician of Bedlam in 1815, was to

bleed, vomit, and purge all patients, beginning at the end of May.

Conceding to investigators from Parliament the uselessness of these

therapies, he explained. " That has been the practice invariably for

years. . . . It was handed down to me by my father, and I do not know,

any better practice. " The admission was particularly poignant, for by

that time the success of " moral therapy " in treating the insane was

well established.

 

Since 1792 the York Retreat in England had calmed agitated

patients by establishing an atmosphere of tranquillity.

The Retreat relied on gentle supervision, warm baths, ample food, and

porter, a malt liquor. Liquor was not used as an intoxicant, but to

help patients recapture their sense of well-being. The physical design

of the Retreat affirmed its therapeutic concept-private rooms lit by

unbarred windows.

 

Moral treatment was effective. Between 1796 and 1861 the York Retreat

discharged 71 percent of the patients who had been admitted within

three months of illness onset.

 

Worcester State' Hospital in Massachusetts, using the same approach

during the years 1833-46, discharged 70 percent of those admitted

within a year of illness onset. This figure is the more impressive

since 10 to 20 percent of the admissions were for general paralysis

(syphilis). Worcester's monumental 50-year follow-up study completed

in 1893 showed that half of those released experienced no relapse and

of the relapsing cases, only half were permatiently rehospitalized.

Few studies of drug treatment can claim so good a record.

 

The practice of moral therapy deteriorated under the impact of the

industrial revolution, but has been revived during periods of social

optimism. Following World War II, many hospitals again abolished

physical restraints and solitary confinement. Staff once more

mobilized patients to govern themselves on the wards and devised for

them useful activities such as in- hospital work. Hospital staffs were

reeducated to appeal to every possibility a patient might offer for

reintegration and growth. The results, after almost a century of

purely custodial care, were dramatic. This was the period in which

lobotomy declined and mental hospital release rates began to rise.

 

These social techniques demand more skill, dedication, and money than

drug therapy does. Some psychiatrists hoped that drugs would provide a

useful adjunct to moral treatment, but the opposite occurred. Patients

numbed by drugs could not benefit from moral treatment, so it

declined, leaving the psychiatrists, now addicted, ever more starkly

dependent on the drugs. Today, when a patient has received his

medications and been introduced to the ward boob tube, he has had all

of what psychiatry offers in state hospitals.

 

Yet certain hospitals continue to experiment with moral therapy. The

judge in the New Jersey case heard testimony about a small ward in a

National Institute of Health facility where acutely psychotic patients

were maintained without medication while they established

relationships with other patients and staff. Patients contrasted

sharply their experiences on and off the drug. On drugs they felt more

comfortable and less frightened. " They cared less about things but

they also had a feeling that they were somehow stuck in their

experience

 

Off drugs, they had more anxiety, panic, and sleeplessness, but a

greater " sense of being able to master their own experiences and some

sense of being able fo get out of something they'd been stuck in for

many years. " Off medication, patients had " a sense of at least

experiencing their own experiences " and gained confidence, as they saw

themselves improving without medication, that they were people who

could cope.

 

The federal court in New Jersey ruled that patients must be informed

of the potential harmful effects of the psychotropic drugs and told

they have a right to refuse medication even after they have signed a

consent form. The hospitals will have trouble ignoring or

circumventing the ruling because New Jersey has a strong Division of

Mental Health Advocacy. It was this division that employed the

dedicated patient advocates to conduct the case on behalf of the

patients. With luck, the case may even help psychiatry to kick its

drug habit and focus once again on the more demanding, yet rewarding,

practice of modern moral therapy.