Helping consumers add years to their lives, III: Psychoactive drug dependence and harm reduction

This is the third in a series of articles and blogs that I’ve written devoted to the issue of mental health consumers’ premature deaths and the documented causal link to atypical neuroleptic drugs. Part I appeared on this site on February 17, Part II on March 4 (c.f. References, below).

My focus is the direct consequence of my own experience overseeing a New York City case management program for persons with serious mental illnesses, where in the last several years of my 16-year tenure, program consumers began to die from cardiac-related illnesses at a rate much higher than the national norm, much higher even than the rate revealed in the 16 state study conducted by the State Mental Health Program Directors (c.f References, below). Their average age at death was identical to that of subjects in the Program Directors’ study, 55 years of age.
 
My staff and I asked then and I ask again now, why do psychiatrists continue to prescribe zyprexa and seroquel and the other atypical neuroleptics despite the evidence that these medications are dangerous for those prescribed them?

I had written in Part II that the NY State Office of Mental Health had recently introduced a QA initiative in its licensed community-based clinics aimed at reducing the prescription of zyprexa and seroquel by 30% over the course of the current calendar year. The director of a clinic near to my home informed me that the initiative had met with great success and that his psychiatrists had exceeded their 30% goal in only a few short months. He then reminded me that a clinic’s participation was still voluntary.

So I now wonder why “voluntary” and why not a higher goal when the link between atypicals and consumers’ premature deaths appears unequivocal?

An answer of sorts was provided by Dr. Donald Levin, a psychiatrist in private practice in Pennsylvania. Dr. Levin was featured in a front page article in the Sunday New York Times on March 6, where he was portrayed as representative of many psychiatrists in this country. By his own admission, Dr. Levin’s following the money. Insurance companies have so reduced the reimbursement rates for psychotherapy, that Levin is quoted as saying he can’t maintain himself and his family at the standard of living to which they’ve become accustomed if he continues to spend valuable office time practicing psychotherapy.

He does admit to great ambivalence over the decision he believes he’s been obliged to make. Like most psychiatrists, he’s been trained as a psychotherapist. At the mental health center in Brooklyn where I worked for nearly twenty years, the psychiatry residency training program was rooted in psychoanalytic psychotherapy. I myself conducted seminars in family therapy for the psychiatry residents for several years.

Increasingly, particularly since the coming of managed care to behavioral health in the 1990’s, psychiatrists’ time with their patients, whether in Medicaid-financed public clinics or in private practice, has been allocated in fifteen minute chunks. This permits at best a cursory review of patients’ symptoms, i.e., whether the symptoms have improved or not, and the issuance of a new scrip. If a patient has any other immediate problems – loss of housing, income or relationships; or serious medical problems – Dr. Levin, and most other psychiatrists, will tell the person, “Talk to your therapist.”

So why don’t psychiatrists protest this infringement of their professional autonomy and distortion of their mission? More importantly, how have they come to transfer their accountability from their patients to the insurance companies?

The above allocation of resources – more for psychiatry, or, more precisely, for the prescription of medications by psychiatrists, and less for psychosocial interventions – has been determined by Federal and State governments, working in conjunction with the insurance and pharmaceutical industries. It carries with it an explicit endorsement of the biomedical or disease model of behavioral health treatment as well as the pre-eminent role of psychiatrists, the primary prescribers, in a hierarchical, non-collaborative treatment system. In short, it mirrors what has occurred throughout the U.S. economy and our society.

In our larger society, the wholesale transfer of wealth from the public to the private sector has gone hand-in-hand with a transfer of governmental accountability from the ordinary taxpayer to the wealthy. Further, these transfers have been validated by “free market economics,” an ideology or belief system not rooted in any scientific analysis of accumulated data. (For those of us older folks, its original name was “voodoo economics, “ a term eventually discredited by neoconservatives.) Similarly, in our mental health system, the biomedical or disease model has shifted power and accountability away from the person in treatment.

Further, the model itself is more of an ideology than a scientifically validated treatment model. Specifically, a disease is an entity where a direct link between symptoms and cause can be uncovered via scientific inquiry. Accordingly, treatment for a disease can be devised and tested for efficacy. While hypotheses abound, schizophrenia and bi-polar disorder and all other major mental illnesses have no documented causes and no known cures. Hence, their appropriate designations as illnesses or disorders, not diseases.

After forty years in the field, I’ve come to view serious mental illnesses less as biologically-determined than as adverse life experiences with adverse social consequences for the persons who live through them. All the individuals I encountered who had been given an Axis I diagnosis had lived horrendous lives … victims of sexual and physical abuse, of poverty, of racism; with histories of substance abuse and dependence; abandoned or scapegoated by families, schools, friends; caught up in the criminal justice system; caught up in the mental health system. Those in the latter group, caught in the public mental health system, were faced with the choice of rejecting or conforming to the demands of that system; which included surrendering their personal identity and accepting long-term medication maintenance; which brings me back to my starting point, viz., Parts I and II of this series of blogs.

Thanks to Bob Whitaker, whose name I’ve dropped throughout my blogs, we know that the positive results reported by the pharmaceuticals regarding virtually all the psychoactive drugs they produce and market have no scientific basis. We further know that these drugs are essentially iatrogenic, i.e., they cause the symptoms they’re presumably alleviating. The oft-quoted “proof” for the need for drug compliance, viz., the “relapse” or recrudescence of symptoms that occurs when an individual stops taking prescribed medication, can be better understood as an indication of drug dependence and the symptoms that emerge as signs of drug withdrawal not illness relapse.

In an essay published in the January 10, 2010, edition of The New York Times Sunday Magazine, psychiatrist Ethan Watters, citing the work of cross-cultural anthropologists and psychiatrists, wrote that the insistence on medication compliance in the U.S. mental health system was rooted in cultural bias not scientific evidence; further, as evidenced in the WHO worldwide schizophrenia studies conducted over a thirty-year span commencing in the 1970’s , our utilization of a disease model to explain serious mental illnesses has only served to increase the stigma against and impede the recovery of persons so diagnosed.

So are we to tell individuals prescribed neuroleptic or other psychoactive drugs to stop taking their medications? That would be unfortunate and foolhardy. As I wrote above, these medications, which, much like “street” drugs, alter brain chemistry, can create dependence. As in all other drug dependence, sudden cessation would result in withdrawal symptoms: physical pain, emotional distress, re-emergence of psychotic symptoms. The severity of these symptoms would depend on the dosage of the prescribed drugs and, principally, the length of time the drugs had been consumed. In studies conducted in the U.K. – the British are far ahead of us in allowing the consumer the decisive voice in determining treatment regimen – only 44% of individuals who have taken psychoactive drugs for five or more years have been able to fully wean themselves off the drugs. Will Hall, founder of the Freedom Center in the U.S., has taken a page from the drug addiction treatment handbook and written a very useful and commonsensical pamphlet entitled “Harm Reduction Guide to Coming Off Psychiatric Drugs.”

First and crucially, he regards all drugs that cause dependence, whether prescribed or “street”, as being problematic for the dependent person, and, second, the dependence itself as potentially responsive to a harm reduction approach. After all, most folks can’t simply say “no”, can’t come off drugs on which they’ve become dependent in one fell swoop. They must suffocate their dependence slowly, step by step, with lots of determination, personal courage, help and support. My own experience in a supportive role came in helping some of our case management consumers come off methadone. All began with a determination to come off the drug while maintaining their sobriety. A very few just stopped their methadone; many took their time, lowering their dosage incrementally; others succeeded in lowering their dosage but couldn’t go further, fearful they would resume abusing heroin if they stopped their methadone.

Apparently the experience for persons in the U.K. has been similar. Hall himself recommends a slow but steady approach, acknowledging the difficulties individuals are sure to encounter, suggesting strategies and specific remedies that can be employed to help them stay on track. It’s important to remember that most folks who have been taking psychoactive drugs for extended periods of time might never fully stop taking the drug. That would certainly apply to the several thousand individuals I worked with or had clinical and administrative responsibility for over the course of my career, most of whom had taken many neuroleptic and other psychoactive drugs for long periods of time. The key determinant is the individual’s own goal, with no time limitation for achieving that goal. The objective, it must be remembered, is harm reduction.

For the practitioners reading this, how important is your help and support? Very! As I wrote in an earlier blog (c.f. 2/7/11 posting), our mission is to promote the recovery of the persons we serve and their reclamation of their community citizenship; our accountability must first and foremost be to them; and our commitment must be to develop with them a post-psychiatry model of care, collaborative in nature, that emphasizes psychosocial interventions and employs psychoactive medications as adjunctive tools.

Finally, is our help essential to an individual’s goal achievement? Actually, no. In the U.K. experience, about half of those who succeeded in coming completely off their drugs did so despite their psychiatrists’ or therapists’ active or tacit opposition. Nonetheless, help if asked. Read Whitaker’s book, if you haven’t already. Read Hall’s “Guide …”, which can be downloaded from the websites of the two co-publishers, the Icarus Project , www.theicarusproject.net , and the Freedom Center, www.freedom-center.org. Share it with your consumers. It’s free!

UPDATE:
Continue reading Jack Carney's series in his next blog post: "Helping consumers add years to their lives Part IV: The beginning of the end of institutionalized housing in New York City."

References:

Carney, J, “Helping Consumers Add Years to Their Lives, I: Training Consumers and Case Managers as Health Care Advocates,” February 17, 2011; “… II: The Metabolic Syndrome Monitoring Protocol and Other Tools,” March 4, 2011; available at www.behavioral.net

Hall, Will, “Harm Reduction Guide Coming Off Psychiatric Drugs,” The Icarus Project, New York, N.Y. & The Freedom Center, Northampton, Mass, 2007, free download at www.theicarusproject.net and www.freedom-center.org

Harris, Gardiner, “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” The New York Times, March 6, 2011

National Association of State Mental Health Program Directors, “Morbidity and Mortality in People with Serious Mental Illness,” October, 2006, available at Psychiatric News: https://pn.psychiatryonline.org, and https://www.nasmhpd.org

Ricketts, S., “Cardiometabolic Risk Factors and Antipsychotic Medications: Changing Prescribing Practices, Promoting Wellness,” NYS Office of Mental Health, Bureau of Evidence-Based Services and Implementation Science, December, 2010, powerpoint presentation

Watters, Ethan, “The Americanization of Mental Illness,” The New York Times, January 10, 2010

Whitaker, Robert, Anatomy of an Epidemic: The Hidden Damage of Psychiatric Drugs, Crown Publishers, New York, 2010