Dramatic growth in antipsychotic drug use even targets infants, experts say. By Sharon Kirkey, Postmedia News May 20, 2013. Source: http://www.canada.com. Dr. Dina Panagiotopoulos’s investigations into some of the most potent psychiatric drugs on the market began when other doctors started calling for help.
Could she see a child on an antipsychotic drug who had developed a potentially lethal condition that can end in a diabetic coma?
Another child on an antipsychotic was now experiencing uncontrollable twitching and muscle spasms. Still another had returned to her psychiatrist a year after starting a similar drug, 50 pounds heavier and almost unrecognizable.
In a sign of what experts are calling an unprecedented spree in the prescribing of mood-altering pills, drugs once reserved for the floridly psychotic are now being given to children still in diapers.
According to Panagiotopoulos, a pediatric endocrinologist at BC Children’s Hospital, so-called “second-generation” antipsychotics, or SGAs, are being prescribed to two- and three-year-olds for aggression. Doctors have become so used to seeing side effects in children on these drugs — including sudden and massive weight gain and diabetes — that they no longer bother reporting them to Health Canada.
“A lot of parents come to me as a specialist and say, ‘No one ever told me about the side effects, and I didn’t think to ask,’ ” said Panagiotopoulos, an associate professor at the University of British Columbia. “They can’t understand why their kid went from drinking water, to seven litres of Coke every week.”
There appears to be no limit to how much we’re willing to allow doctors to medicate our apparent psychological angst. Last year, more than 74 million prescriptions worth $2.6 billion were filled for psychiatric drugs in Canada — more than 203,000 prescriptions a day, and up from 58 million prescriptions in total in 2008, according to data compiled by prescription drug research firm IMS Brogan for Postmedia News.
The growing embrace of medications to treat “broken” minds is a triumph of drug company marketing, experts say, the selling of new diagnoses and overzealous prescribing of pills for conditions for which they have never been approved.
Many of the drugs have been marketed as more effective and safer than the opiates, barbiturates and benzodiazepines of the past. But emerging research shows that many of the newer drugs are no more effective than the ones they unseated, psychiatrist Dr. Daniel Carlat writes in his book, Unhinged: The Trouble with Psychiatry — A Doctor’s Revelations about a Profession in Crisis. What’s more, “even our newer drugs’ supposed advantage — fewer side effects — is being called into question,” he said.
Many antidepressants are said to work by fixing “chemical imbalances” in the brain. But no consistent chemical abnormality has ever been found in the brains of patients with mental disorders, said Dr. Joel Paris, professor and past chair of the department of psychiatry at McGill University in Montreal.
Use of some of the heaviest-hitting psychotropic drugs — so called “atypical,” or second-generation antipsychotics — is increasing dramatically. One drug alone, paliperidone, increased in use nearly 30-fold between 2008 and 2012, according to IMS Brogan. Prescriptions for another, ziprasidone, increased 700 per cent.
Antidepressants, meanwhile, have become so popular, they fit “so neatly into every day life”, that 11 per cent of the U.S. adult population now takes them, Dr. Allen Frances, professor emeritus at Duke University writes in his new book, Saving Normal. In 2002, six per cent of Canadians were on antidepressants.
Increasingly, people are on not just one drug, but multiple pills, including pills to chase the side effects of the drugs the doctor started with, writes Carlat, an associate clinical professor of psychiatry at Tufts University School of Medicine in Boston.
Furthermore, the bulk of the prescribing is being done not by psychiatrists, but by family doctors, often with little training in their use beyond what drug sales reps have told them.
“Pharma did the math,” Frances writes. “There are only 40,000 psychiatrists in the United States (and about 4,100 in Canada) but about ten times as many PCPS (primary care physicians). Why not recruit PCPs to write prescriptions for psychiatric drugs?”
The message to doctors, he said, was “loud, clear and heavily promoted — psychiatric disorders are often missed and easy to treat with a magic pill … Who needs a psychiatrist when the medicine is so safe and easy to use?”
But Paris, of McGill, said even psychiatrists are turning away from psychological theories and treatments and embracing drug therapy. “They want to be like other doctors,” he said. “They want to make diagnoses and write prescriptions.” Psychotherapy is harder to learn, he said. It also doesn’t pay as well. Increasingly psychiatrists are performing what Carlat, of Tufts University School of Medicine in Boston calls the “15-minute med check,” sending patients off with a pill “and a few words of encouragement.”
Nothing is more astounding, Frances and other say, than the growth in the use of antipsychotics once reserved for obvious psychosis and full-blown mania.
Second-generation antipsychotics are increasingly being prescribed to children for attention deficit/hyperactivity disorder, “conduct” disorders, “frustration intolerance” and even poor sleep. The drugs can cause side effects such as elevated blood fats and abnormal blood sugar levels. As of Dec. 12, 2012, Health Canada had received 17 fatal reports in children related to SGAs, and, despite guidelines to doctors, experts say the risks to children are going largely unmonitored. Only one of the drugs, aripiprazole, or Abilify, has been approved for use in children, and only then for schizophrenia in teens aged 15 to 17.
At UBC, Panagiotopoulos’s research has shown that children exposed to second-generation antipsychotics have three times the risk of developing pre-diabetes or Type 2 diabetes compared to children never treated with the drugs; more than double the risk of becoming overweight or obese; and 30 times the risk of metabolic syndrome — a cluster of health problems that increases the risk of heart attack and stroke later in life.
No one knows what the long-term effects might be on a child’s developing brain. Still, prescriptions for the drugs to children under 14 increased 10-fold in B.C. alone between 1997 and 2007. Across Canada, from 2005 to 2009, antipsychotic drug prescriptions for children and youth increased 114 per cent. Surveys suggest that 12 per cent of all prescriptions are for children aged eight and under.
The drugs — which are being used for symptoms and diagnoses in children that have never been studied — can cause potentially irreversible movement disorders if untreated, such as uncontrollable spasms and tremors, involuntary movements of the jaw and tongue, puckering of the face, and frowning. In older adults, the drugs have been linked with an increased risk of sudden cardiac death. Another rare but life-threatening side effect, neuroleptic malignant syndrome, or NMS, is fatal in about 10 per cent of cases, said David Gardner, a professor of psychiatry and pharmacy at Dalhousie University in Halifax.
Even one extra case of fatal NMS is unacceptable, Gardner said, when the drugs are used simply to calm a distracted child down.
In the United States, drug companies have been fined billions for promoting antipsychotics for unapproved uses. “The whole drug industry depends on off-label use,” said psychotherapist Gary Greenberg. “It appears the fine is just the cost of doing business.”
Panagiotopoulos said antipsychotics can be lifesaving in cases of severe aggression and behaviour problems. But there are concerns the drugs have become the default for desperate parents struggling to get help in a seriously frayed and under-resourced mental health system.
But the concerns don’t stop with antipsychotics: Last year in Canada, nearly 43 million prescriptions were filled for anti-depressants. Prozac-like drugs and other antidepressants have proven effective for moderate and severe depression. But Frances said the mother lode of prescribing is to the so-called worried well.
Last week, the Canadian Task Force on Preventive Health Care issued new guidelines for screening for depression that recommend doctors stop routinely screening people with no obvious symptoms because of the potential harms, including diagnosing depression where none exists and putting people on drugs they don’t need.
Studies have shown that, for mild depression, the difference between antidepressants and placebo is so small it’s sometimes non-existent.
“The response rate for placebo in mildly disordered people is at least 50 per cent,” Frances said in an interview. “The perfect patient for a drug company is someone who’s not too sick to start with, because they’ll get better on their own.”
For moderate or severe conditions, the drugs are “remarkably more helpful,” he said.
All the major drug categories — antidepressants, antipsychotics, mood stabilizers such as lithium — have “radically changed for the positive people’s lives,” added Dr. Roger McIntyre, professor of psychiatry and pharmacology at the University of Toronto.
Out of 100 people treated, 30 to 50 per cent benefit, he said. “I think that’s not bad, given how complicated these illnesses are.”
Susan Prins, of the College of Physicians and Surgeons of B.C., said that, when prescribing any drug, doctors are expected to make decisions “based on well-documented, comprehensive clinical assessments.”
“In the event that concerns are identified, the college holds physicians accountable for those decisions,” she said in an email.
Paris, of McGill, said doctors should stop all contact with the drug industry and refuse to attend industry-sponsored “continuing medical education” events.
True mental illness is devastating for those who live with it, Frances said. “Drugs used well,” he writes in Saving Normal, are “a godsend for the patients helped.”
But, “It’s a ridiculous marketing ploy that every problem in life is a chemical imbalance,” he said in an interview.
“Of course everything is mediated through the brain. But that doesn’t mean the treatment for it is a pill.”