So Many Pills And So Little Progress

At a study done in Austria they looked at a University hospital, a general hospital, and a psychiatric clinic. They found a BIG problem – and not just in Austria: People are taking too many psychotropic drugs, even though there are no systematized justifications for prescribing patterns.  This seems to happen the most in folks who have a diagnosis or either depression or schizophrenia.

Although some people take only one psychotropic drug, most are on many.  A study by our own government agency (a noble attempt to trace psychotropic prescriptions in a general hospital in the United States) decided this was a general pattern. All right, this is what happens.

When someone is in a hospital they expect to get pills.  Everyone — and I do not mean the just those in the psych unit — gets stuff to help them relax during the day, sleep at night, and defecate.

I remember back when I first worked in a hospital (remember when I was the lowly ER receptionist working my way through undergrad school?) and read whatever doctor’s orders I could (the same way I read package inserts and the like) that everybody on the cardiac unit got Valium (diazepam) and a doctor told me it was better for their hearts that they were all calm and in bed.

And of course, since they were away from home (and staff don’t like to be bothered at night), they all needed some kind of pills to sleep.  And of course, since they didn’t walk around much, they all needed laxatives.

Most of these medications were given like boiler plates on the admission orders, things that everybody needed.  And of course, they generally did NOT make it to the discharge orders, since it was assumed they would not be needed when the patients got home.

In later years, I have had the dubious pleasure of working with patients who suffered withdrawal from all of the above noted classes of medications when they got home after hospitalization.  They went home from the hospital uncomfortable, nervous, and unable to sleep.  If they came to me, I helped them comfortably get off the drugs. If they went to just about any doctor, they ended up getting open-ended prescriptions for as long as they wanted – and usually staying addicted for life (aren’t HMOs just wonderful?)

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Do you want to get off of prescription drugs, but can’t?

Would you like to take natural supplements instead of pharmaceuticals?

Do you even need to be on medication?

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I doubt the practice has stopped, because I have seen people fitting this description quite recently. We are a pill-oriented society.  We have — not just in psychiatry but in all specialties — accepted medications (pills, most frequently) as the logical if not the only outcome of a medical or hospital visit.

In a recent article from the American Journal of Public Health, (NOTE: Link opens a PDF File – you may need to download the free Adobe Acrobat reader) patients rated their doctors as better communicators and seemed more pleased with the interaction when they did not get a prescription.

Contrast this with the fact that direct-to-consumer advertising of medication sends more people to the doctor, presumably to get the advertised medication. Flash forward to me, working in a clinic for street people in Los Angeles that frightens the Maimonides out of me.

Response time for emergency services averages eight hours, and what little staff I have does not seem to understand what I want or need.  Many of the clients of the clinic came from Mexico with great difficulty and hardship that compares with the journey my own grandmother of blessed memory from her native Russia.

Many of the male patients I saw in this clinic wore the “(brown) scapular” – a religious relic believed by some to offer protection from the dangers and woes of a puzzling and hostile world.

In this situation, I was cleaning up after a psychiatrist who seemed to have had a drug problem and whose competency, even on a good day, was questionable at best.  Most people were on medications that made no sense to me at all, combined in ways that made less sense.

This is the kind of thing I’m often hired to do, much like the sheriff who comes in to clean up Dodge City, and then moves on to Tombstone when the job is done.  There are no shortages of facilities in messes like this and it is a satisfying way for me to actually make a difference in health care in a world that is more worried about administrative functions than patients.

Those patients who valued America and its medicine, who attributed to it some kind of mystic aspect, perhaps as a retrospective validation of what they had been through to get to our country, seemed to do amazingly well.  This was evident, even though I was shocked at the medication treatments to which they had been subjected. Yes, despite what I consider abominable medical care, the patient’s mystical “belief in the pill” actually did some good.

This is great for the patient, but it indirectly finances an enormous pharmaceutical industry.

We’ve all heard about the placebo effect for medications.  In most studies I have seen, somewhere between a third of the patients in studies of depression and a whopping half of patients in studies on anxiety get better — really much better — with chalk or milk powder or the so-called “sugar pills” (nobody actually gives a human sugar – since that can screw up lots of other things in the body) that is expected to be totally and absolutely inactive.

Yes the body – especially the brain – is a marvelous miracle.  That’s why I fell in love with it at an early age and have spent the majority of my life learning as much as I can.

Studies looking at the reasons have speculated that the placebo effect might have something to do with the body’s own opioids.  One study has shown placebo effects to be blocked by naloxone.

So I’m sure your next question is, “If the placebo effect is so prevalent, why not try placebos as first-line treatments (in certain situations) and save the money for spending on the half or two-thirds who don’t respond and need real medicine?”

Good question and one I get all the time.  The main reason is because of that sticky-wicket that seems on the way to becoming an endangered species: Medical Ethics. As I often point out — for better or for worse, American medicine is dominated by the legal system.  There is no way to get a placebo effect through an informed consent.  First of all, it is considered inhumane to deny a sick person medicine and give them fake cures (like the snake-oil salesmen of the old west).  Second, stop and think what “placebo” means.  Hello — if you tell anyone that something is a placebo, it just is not a placebo any more.

There must be that element of belief.

The bottom line for me is, as interesting as this is, most of the really meaningful studies of placebo response are — foreign.  Our government won’t finance studies of placebos and no pharmaceutical company would be able to patent a placebo.  Can you imagine the label warning or the package insert?

There are very few words or topics for which I cannot find a blessed thing on the internet.  One of them is “pill worship.” The “boiler plate” pill orders on hospital admissions may or may not work.  I know and use a tremendous amount of non-drug (and thus, non-pill) technologies that would replace sleep and anxiety pills.

And here’s a freebie for you — a little movement and some nutritional additives, some fiber in your diet, as well as some good old water an you wouldn’t need the laxatives.

As for the (presumably) international tendency to use a lot of psychotropic drugs, I can tell you this: I know from a long time ago that if someone has been taking three medications simultaneously they have about a 75% chance of having a drug-drug interaction.  If they take five, they are having a drug-drug interaction for sure.

Some of these are postulated, some of these are known. I have NEVER known a psychiatrist (except me) to check them systematically.

There have been several recent studies in psychiatry that try to derive systematic ways, in particular in depression and in schizophrenia, to try drugs or to try one combination of drugs after another, and to show what is best.  This is “evidence based medicine.”  I try to go with it if someone is on the prescription track. I have heard estimates that no more than 5% of psychiatrists are actually trying to do this.

The state of New York is trying, to their credit, to teach psychiatrists about what this is.

Most of the good sources on evidence based medicine are foreign; I love the British ones.  Yet in Germany, older doctors prescribe older drugs and to their credit, people admit they have no idea how doctors really choose pills.

In the past, I have seen studies, in general medicine, suggesting that doctors use the drug promoted by the last pharmaceutical company representative who visited with them.  I certainly could name a bunch of doctors who work this way.  Their preferred method of treatment seems to change every week.  Hmmmm….

In severe illnesses – such as schizophrenia — I can understand why doctors might be overwhelmed and go to standard prescription pharmaceuticals.  But in easily-managed complaints like anxiety and depression and maybe even some common general-medical illnesses, I am sick of pill-worship.

I’m not saying anxiety and depression aren’t serious matters, only that there are methods of treating them that are effective and safe – and short-term.

It is common for third-party payers – government agencies and insurance companies – to compare pills against each other.  Unfortuately, we get into the realm of cost effectiveness instead of effectiveness in curing or managing illness.

In most institutional practice situations – and private practices that are dependent upon insurance “reimbursement” – a formulary is provided the doctor.  It ranks the pills not by a four-star system of excellence, but a series of dollar signs — $ being the cheapest pill and $$$$ being the most effective.  If you prescribe a $$$$, expect a call from some “utilization review” person at the insurance company (probably a high-school graduate) who will advise you that you are not practicing cost-effective medicine and the prescription is denied.

SIGH!

Statistical studies have proven that a very basic (to me) kind of therapy, cognitive behavioral, does at least as well as an antidepressant, and better at relapse prevention.

There are also electrical devices and natural substances, and other alternatives to pharmaceutical treatments.

At times I feel like I should be a one-woman protest group — picketing clinics with a sign that says “Stop pill worship”.

People are doing a lot of paid, granted research on which pill works better than which other pill.  This is because people who make pills pay for research.  They are corporations which have usurped medicine.  Why would a pharmaceutical manufacturer bankroll studies of alternative methods to the very thing they are selling?

Studies of alternative medicines such as the one I completed last year are rarely funded enough to have large samples.  (NOTE: it is the first study listed on the link page)

They are almost never published in major medical journals, which make nearly 100% of their revenue from the sales of full page advertising to pharmaceutical companies.

Many people thought the article from Nature regarding cognitive behavioral psychotherapy, cited above, would change the world.  It has not.

The people who refuse medication for their condition and choose psychotherapy do not usually find me since that’s not really my game. I do get some who are interested in Emotional Freedom Technique, of which I am a master practitioner, but that is a fledgling field and not the first things people think of when they want help.

The scientific community – flush with pharmaceutical funding — keeps adding study upon study, looking more closely at doses and combinations of medications, trying to build this alchemy into science but totally missing the boat.

Schizophrenia is still largely an only marginally solved puzzle, although there are things that can help and things that can be done. Also, the diagnosis, often hastily made, is wrong surprisingly often.

With that major exception, everything else known to me in the realm of psychiatric medicine can be treated with natural substances and/or devices.

Everything.

Pick up your sign and join me in my march — Stop the pill worship.