Involuntary Commitment Part III: A System Built on Lies

Involuntary commitment and forced psychiatric drugging are based on several lies and misrepresentations, all of them broadly and continuously disseminated for decades by the psychiatric industry and its allies. Among them are the following:

• Mental and emotional problems are best understood as the result of abnormal brain chemistry (imbalances in neurotransmitters).
• Antipsychotic drugs are substantially effective in treating psychotic states.
• Individuals who stop taking antipsychotics do so because of their “mental illness,” not for the same reasons that non-mentally disabled individuals stop taking medications.
• Forcing individuals to take antipsychotics is an effective treatment for psychotic states.
• Relapse is prevented by treatment with antipsychotic drugs.
• Violence is prevented by antipsychotics drugs.

We will address these falsehoods in order and discuss the implications.

Abnormal brain chemistry: The chemical imbalance theory of psychiatric disorders has now been so thoroughly discredited that few psychiatrists defend it. Four years ago two prominent psychiatrists, Richard A. Friedman, Professor of Clinical Psychiatry at Weill Cornell Medical College, and Andrew Nierenberg, Professor of Psychiatry at Harvard Medical School referred to the chemical imbalance theory of depression as “outdated and disproven.”¹ According to Harvard psychiatrist Joseph Glenmullen, “we have had no shortage of alleged biochemical imbalances for psychiatric conditions. Diligent though these attempts have been, not one has been proven.”² Though psychiatrists continue to describe their disorders as “biological disorders,” they are forced to admit, as did Thomas Insel, director of the National Institute of Mental Health, that psychiatric disorders are not based on “any objective laboratory measure.”³ Forced drugging with psychiatric drugs is therefore a “treatment” based on a disproven theory and unsupported by any objective lab testing.

Antipsychotic Efficacy: The most important study of antipsychotic drugs of the past several years, the National Institute of Mental Health’s (NIMH) 2005 Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, published in the New England Journal of Medicine, found that 74% of the patients quit the antipsychotic drug they were taking “owing to inefficacy or intolerable side effects or for other reasons.”⁴ Newer atypical antipsychotics were neither better tolerated nor more effective than the older ones – drugs like Haldol and Thorazine.

In 2000, a team of English researchers led by John Geddes at the University of Oxford reviewed results from 52 studies, involving 12,649 patients. They concluded: “There is no clear evidence that atypicals are more effective or are better tolerated than conventional antipsychotics.” Conventional antipsychotics are drugs like the notorious Thorazine and Haldol. The researchers noted that Janssen, Eli Lilly and other manufacturers of atypicals had used various ruses in their clinical trials to make their new drugs look better than the old ones. In particular, the drug companies used “excessive doses of the comparator drug.”⁵

Research conducted by the Washington State Institute for Public Policy also reveals the very low effectiveness of current treatment methods. Eligibility for public mental health services in Washington State is determined by scores on the 100-point Global Assessment of Functioning scale (GAF).⁶ The GAF measures a patient’s psychological and social functioning. A May 2008 report from the Washington State Institute for Public Policy (WSIPP) found that only 5.7 to 12.5 percent of adult consumers of public mental health services achieve a meaningful improvement in their GAF scores as a result of those services – regardless of their service utilization patterns.⁷ Clients who receive ongoing monthly services fare little better than those who have breaks of several months between services, or those who receive services for a short a short period of time and do not continue.

Outcomes are so poor in Washington State that they are no longer measured in terms of psychiatric diagnostic criteria. In response to a March 5, 2013 public disclosure request from CCHR Seattle, the Department of Social and Health Services, Division of Behavioral Health and Recovery, admitted, “The Department does not collect information from treatment providers to directly measure an individual’s improvement or decline in terms of the psychiatric disorder for which they are being treated.” King County’s mental health report card measures progress in terms of factors like employment and housing. Imagine if we measured heart health or recovery from cancer in terms of jobs and housing.

“Going off their meds”: The CATIE study examined the various reasons for discontinuation of antipsychotic drugs. This was the primary outcome that the study’s authors wanted to measure. Patients had monthly visits with the study doctors. The researchers wrote,

The primary outcome measure was the discontinuation of treatment for any cause, a discrete outcome selected because stopping or changing medication is a frequent occurrence and major problem in the treatment of schizophrenia. In addition, this measure integrates patients’ and clinicians’ judgments of efficacy, safety, and tolerability into a global measure of effectiveness that reflects their evaluation of therapeutic benefits in relation to undesirable effects.⁸

The study reported, “The key secondary outcomes were the specific reasons for the discontinuation of treatment (e.g., inefficacy or intolerability owing to side effects such as weight gain, extrapyramidal signs, or sedation as judged by the study doctor).”⁹ The authors also stated, “The time until discontinuation owing to the patient’s decision (i.e., the patient independently chose to stop treatment) was similar to that for discontinuation for any cause.”¹⁰ The researchers measured the “duration of successful treatment” of all the antipsychotic drugs and found it was around one month for all of them except the antipsychotic olanzapine, which averaged 3 months. Clearly, patients did not quit because they “decompensated” or “lacked insight” or thought they did not have a problem. They quit for the same reasons anyone would quit. They quit for the same reasons that their own doctors decided were reasons to discontinue use of the drug.

Efficacy of forced drugging: Forcing someone to take an ineffective treatment is not going to increase the treatment’s effectiveness. Moreover, research has consistently shown that, while antipsychotic drugs may suppress symptoms in the short term, they make people more vulnerable to chronic psychosis and deterioration in the long-term.¹¹

A 20-year follow-up study funded by the National Institute of Mental Health and published in the Journal of Nervous and Mental Disease in 2007, found that schizophrenics treated without antipsychotic drugs were functioning significantly better than those given drug treatment at 4.5, 7, 10 and 15 years. The authors stated,

Starting at the 4.5-year follow-ups and continuing thereafter, SZ [schizophrenia] patients not on antipsychotics for prolonged periods were significantly less likely to be psychotic and experienced more periods of recovery; they also had more favorable risk and protective factors. SZ patients off antipsychotics for prolonged periods did not relapse more frequently.¹²

In one 7-year Dutch follow-up study, published in JAMA Psychiatry, patients assigned to a dose reduction/discontinuation strategy achieved more than twice the recovery rate of the maintenance therapy group (40.4% vs 17.6%).¹³

The World Health Organization found that outcomes for schizophrenia are consistently better in developing nations where the drugs are used much less.^14,15 There’s a good reason for this. MRI studies have shown that antipsychotics cause structural changes in the brain that are associated with an increase in the severity of symptoms.^{16, 17, 18} The decompensation of an individual who “goes off his meds” is inextricably linked to the brain damage and severe withdrawal effects produced by the drugs.

The question of relapse: As the 20-year follow up study found, schizophrenia patients off antipsychotics for prolonged periods do not relapse more frequently over the long term. The Dutch study also found that at seven years relapse rates were the same for people in the group who had been maintained on antipsychotics and those who had been assigned to a group that reduced and discontinued antipsychotic use. They were also more than twice as likely to have recovered.

Short term results are different. Over the short term, antipsychotics appear to suppress symptoms enough to give those taking the drugs a better chance of not relapsing. The researchers who conducted the Dutch study found that after 18 months there were twice as many relapses in the group that reduced or discontinued antipsychotics versus those who were maintained on the drugs (43% vs. 21%).¹⁹ A Chinese study published in 2010 found that after one year, the risk of relapse was 41% for those receiving antipsychotic treatment, and 79% for those given placebo.²⁰

The overall picture with regard to relapse looks like this:

• A high percentage of patients relapse even when they continue to take their “meds” – 20% to 40% or even higher in the first year. Again, they are not relapsing as a result of being “off their meds” but as a consequence of the meds not working.
• A significant percentage of patients can stop taking antipsychotics and not relapse, but the current system does nothing to identify those patients or help them.
• The longer patients are on antipsychotics the worse they do.  The damage done by the drugs takes its toll and within a few years the difference in relapse rates between those taking antipsychotics and those who have discontinued appears to even out and begin to favor those who have stopped.

Psychiatric drugs and violence: Psychiatric drugs frequently contribute to acts of violence. In two separate studies researchers at Yale University found that 11% and 8.1% of admissions to a general hospital psychiatric unit were the result of antidepressant-induced mania and/or psychosis.^{17, 18} Multiple incidents of schools shootings perpetrated by youth taking antidepressants confirms that manic states produced by antidepressants frequently leads to violence.  Antipsychotics and antidepressants produce a state of extreme agitation known as akathesia, a condition that has been linked in numerous studies to acts of violence.^{19,20,21,22,23,24}   Akathesia persists for an average of nearly three years following discontinuation of antipsychotic drugs.²⁵  In 2007, the Tacoma News Tribune, in a series on increasing violence at Western State Hospital, reported that one in four of the hospital’s more than 1,700 workers were predicted to be assaulted by a patient in 2007.  The report pointed specifically to drugs that “induce agitation and aggression.”²⁶   Events at Western State belie the notion that forcing individuals to take antipsychotic drugs is a “cure” for violence.

Antipsychotic drugs, however, do one thing very well.  They shorten life.  In 2006, the National Association of State Mental Health Program Directors (NASMHPD) released the results of an eight state study which found that people with serious mental illness served by our public mental health systems die, on average, more than 25 years earlier than the general population.⁴ In two states that number was 32 years.  It used to be 10 years, has been rising steadily for three decades, and may well continue to rise as more children are prescribed antipsychotics, forced drugging increases, and drug injections lasting up to 4 weeks become more available.  Antipsychotics have been proven to double and triple the risk of several life-shortening conditions, including heart disease, stroke, and diabetes.  They also damage the brain.

Will forced drugging make society safer? It’s certainly debatable.  According to a May 28, 2007 Tribune report, one in four of Western State Hospital’s more than 1,700 workers were predicted to be assaulted by a patient in 2007.

Summary

When viewed in terms of the above points, forced drugging is seen as an unjustifiable attempt to force individuals into a treatment system that virtually guarantees they will not make any real progress toward recovery and will lose 25 or more years of their life. Your typical dangerous mentally ill offender is not someone who “slipped through the cracks” in the mental health system. It is someone who grew up in and is a product of years of psychiatric treatment. We have barely even touched the surface of the evidence showing how ineffective our current mental health system is today.  Forcing anyone to participate in that system while making no effort to confront its poor results is morally wrong and legally indefensible. Before we do anything to force more treatment we are obligated to begin providing non-drug treatment to the large percentage of seriously mentally ill who – as even the director of the NIMH admits – will do much better long term not on the drugs.

References:

1. Richard Friedman and Andrew Nierenberg, “‘The Illusions of Psychiatry’: An Exchange.” New York Review of Books, August 18, 2011. One of several letters written in response to a book review by Marcia Angell.
2. Joseph Glenmullen, Prozac Backlash, p. 196.
3. Thomas Insel, “Directors Blog: Transforming Diagnosis,” April 29, 2013.  Available at http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml.
4. Lieberman, J., et al., “Effectiveness of antipsychotic drugs in patients with schizophrenia.” New England Journal of Medicine 353 (2005):1209-1233.  Available online at http://www.nejm.org/doi/full/10.1056/NEJMoa051688.
5. Geddes, J. “Atypical antipsychotics in the treatment of schizophrenia.” British Medical Journal 321 (2000):1371-76.
6. Washington State Senate Committee Services, “Public Mental Health Assistance Budget Work Session: An overview of costs and utilization,” January 23, 2014.  Available online at http://leg.wa.gov/Senate/Committees/WM/Documents/0Mental%20and%20Physical%20Health%20Work%20Session_Fina.pdf. See page 4, top left, under “Mental Health Professional.”
7. Washington State Institute for Public Policy, “Who Stays and Who Leaves? A Profile of Adult Public Mental Health Consumers,” May 2008, p. 7.  Available online at http://www.wsipp.wa.gov/ReportFile/1014/Wsipp_Who-Stays-and-Who-Leaves-A-Profile-of-Adult-Public-Mental-Health-Consumers_Full-Report.pdf.  The exact quote is: “Using this range, 5.7 to 12.5 percent of consumers in the study cohort had a meaningful improvement in GAF scores during the period of service. Improvement levels did not appear to be related to utilization patterns.”
8. Lieberman, op. cit., p. 1211.
9. Ibid.,
10. Ibid.,
11. Whitaker, Robert, “Anatomy of an Epidemic: Psychiatric Drugs and the Astonishing Rise of Mental Illness in America,” Ethical Human Psychology and Psychiatry, Vol. 7, No. 1 (2005)
12. Harrow, Martin, “Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study,” Psychological Medicine 42 (10), 2145-2155, 2012.  For a review of the results of this study go to: https://www.madinamerica.com/wp-content/uploads/2012/05/Harrow.pdf.
13. Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial. JAMA Psychiatry, 2013 Sep;70(9):913-20.  Abstract available online at http://www.ncbi.nlm.nih.gov/pubmed/23824214.
14. Jablensky, A., Sartorius, N., Emberg, G., Ansker, M., Korten, A., Cooper J., et al. (1992). Schizophrenia: Manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine, (Monograph Suppl. 20), 1095.
15. Leff, J., Sartorius, N., Jablensky, A., Korten, A., & Emberg, G. (1992). The international pilot study of schizophrenia: Five-year follow-up findings. Psychological Medicine, 22, 131-145.
16. Cahn, W., Pol H.E.H., Lems, E.B.T.E., et al., “Brain Volume Changes in First-Episode Schizophrenia,” Archives of General Psychiatry, 59: 1002-1010, 2002.
17. Madsen, AL, Keiding, N., Karle, A., “Neuroleptics in progressive structural brain abnormalities in psychiatric illness,” The Lancet, 352 (9130), 1998:  784-785, 1998.
18. Gur, R.E., Maany, V., Mosley, P.D., et al., “Subcortical MRI Volumes in Neuroleptic-Naïve and Treated Patients with Schizophrenia,” American Journal of Psychiatry, 155: 1711-1717, 1998.
19.  Lex Wunderink et al., “Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy,” JAMA Psychiatry, 2013;70(9):913-920.
20. Eric Y. H. Chen et al, Maintenance treatment with quetiapine versus discontinuation after one year of treatment in patients with remitted first episode psychosis: randomized controlled trial,” British Medical Journal, 2010;341:c4024.
21. Bowers, MB, Jr., MacLean, RW, Weiss E., et al., “Trends in prescribing psychotropic medications [letter; comment]. JAMA, 1998; 280: 133-134.
22. Preda, A., et al., “Antidepressant-Associated Manic and Psychotic Resulting in Psychiatric Admissions,” Journal of Clinical Psychiatry 2001, 62: 30-33.
23. Leong, G.B., Silva, J.A., “Neuroleptic Induced Akathesia and Violence: A Review,” Journal of Forensic Science, 2003, Vol 48, No. 1, 187-189.
24. Shear, K et al. “Suicide associated with akathisia and deport fluphenazine treatment,” Journal of Clinical Psychopharmacology 3 (1982):235-6.
25. Van Putten, T. “Behavioral toxicity of antipsychotic drugs.” Journal of Clinical Psychiatry 48 (1987):13-19.
26. Van Putten, T. “The many faces of akathisia,” Comprehensive Psychiatry 16 91975):43-46.
27. Herrera, J. “High-potency neuroleptics and violence in schizophrenia,” Journal of Nervous and Mental Disease 176 (1988):558-561.
28. Galynker, I. “Akathisia as violence.” Journal of Clinical Psychiatry 58 (1997):16-24.
29. Bratti, I.M., Kane, J.M., Marder, S., “Chronic Restlessness with Antipsychotics,” American Journal of Psychiatry 164 (11), November 2007.
30. Otto, M. Alexander, “Drugs might breed violence.  Attacks on staff rise at Western State Hospital,” The News Tribune, May 28, 2007.