Another Perfect Storm
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Transcript of Another Perfect Storm
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Another Perfect Storm
Factors Contributing to the Over-Valuation of Medications as a
Treatment for Psychiatric Disorders
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Attribution Theory
Attributions are explanations of the cause(s) for events
Causes may be internal or external, enduring or unstable
People preferentially interpret events in a manner that maintains a positive self-image
Attributions may lead to cognitive distortions
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Attribution in Psychiatry
Diagnosis and treatment recommendations
Assessment of treatment responsePerceived efficacy of various
treatment modalities
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Data Regarding the Efficacy of Antipsychotic Medications Levine et.al. (2011): During CATIE study,
only 11.7% of subjects attained and maintained remission of at least 6 months; 55.5% experienced no period of symptom remission.
Levine et.al. (2012): During the CATIE study, only 18.9% of subjects were treatment “responders” by trajectory analysis.
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Data Regarding the Efficacy of Antipsychotic MedicationsPoor outcomes for vocational
recovery and quality of life indicators.Outcomes for treatment of first onset
schizophrenia in programs utilizing little or no psychotropic medications were equivalent or better than conventional treatment with medications.
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Risks Associated with Antipsychotic Medications
Metabolic complications including diabetes, metabolic syndrome, and resulting cardiovascular disease have been implicated in the declining life expectancy of individuals having psychiatric disabilities.
NASMHPD (2006): life expectancy for individuals having psychiatric disabilities is 25 years below the average in the United States
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Risks Associated with Antipsychotic Medications
Serious, and sometimes life-threatening adverse effects, such as seizures, hyperthermia, osteoporosis, hypothyroidism, breast cancer, suicidality, cardiac arrhythmias, and tardive dyskinesia are not uncommon.
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A Balanced View of Psychotropic Medications
Very beneficial to a relatively small percentage of individuals
Partial benefit to some individuals Risk for very serious and potentially life-
threatening adverse effects May produce no therapeutic effect or even
paradoxical worsening of various conditions Effects of psychotropic medications are highly
individualized No useful tools to predict treatment response
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Prescription Drug Utilization
The U.S. Centers for Disease Control report on prescription drug utilization in 2007-2008
Stimulant medications were the most commonly used prescription drugs in the 12-19 year age range
Antidepressant medications were the most commonly used prescription medications among adults ages 20-59
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Conclusion:
Factors that are unrelated to scientific inquiry and empirical evidence are powerfully driving perceptions of psychotropic medications that exaggerate their efficacy and their legitimacy as a preferred therapeutic tool.
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Historical Context
Commercial synthesis and marketing of PCN in 1945
Chlorpromazine, marketed in the US in 1950 as Thorazine
Diazepam marketed in 1963 Fluoxetine (Prozac), released in 1987
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Historical Context
Dramatic achievements in medical sciencepublic optimism passivity concerning health issues
Psychopharmacology helped “medical-ize” psychiatry
Family members of psychiatric consumers
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Psychological Motivations
Obtaining a diagnosis and prescribing a medication relieves feelings of powerlessness.
Prevent harm Intervention during crisis must be
incisive, targeted, and therapeutic Exaggeration of the efficacy of the
prescribed medication is reassuring
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Psychological Motivations
Motivation for psychiatrists to inflate their perception of psychotropic medication as a therapeutic tool External pressures to have definitive
answers Wish to have recognition for expertiseWish to preserve credibility
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Pharmaceutical Marketing
Physicians tend to perceive themselves as neutral with respect to marketing strategies, but numerous studies continue to show that pharmaceutical sales representatives have a major impact upon prescribing patterns, often to the detriment of quality of care.
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Pharmaceutical Marketing
Gift cycleBefriend and betrayObfuscation of marketing intent with
“educational opportunities”Visual images to imply benefits and
indications that are not substantiated by research
Solicitation to participate in false studiesPublication planning Direct to consumer marketing
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Pharmaceutical MarketingTrue extent of contamination of medical
science and medical care by pharmaceutical marketing is staggering. Lobbying Insertion into the political economy Impact upon regulatory policy Dilution of the medical literature Impact on day to day practice of psychiatry Promotion of new, unsubstantiated diagnoses Under-representation of risk Undermining of treatment alternatives Promotion of self-diagnosis and aggressive consumerism
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Academia
Funding for research Publishing
Positive reporting bias in journals Ghost writing
Program developmentPersonal financial gainShapes medical education and
imparts significance to pharmacology
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Other Financial Considerations
Third party payersMedications impact length of stay in
hospitalizationA central criterion for continued payment
for inpatient treatment is on-going adjustment of medications
Cost savings when primary care physicians treat with meds rather than referring for mental health services
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Consumers
Acculturation to a passive recipient role in treatment
Easier to have a chemical imbalance than to confront life’s problems, change lifestyle
Quick fixFaith in Western medical science
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Regulatory Considerations
Relatively permissive criteria for approval of medications and new indications for medications
FDA approval is translated by most professionals and consumers to mean that the drug is safe and effective
Loopholes to regulations that would support more transparent disclosure Medical journals.
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The Perfect Storm:Implications
Clinical practiceOutpatient commitment for
medicationsDrug courtsMedication of children, especially
those in public custody