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Another Perfect Storm

Another Perfect Storm. Factors Contributing to the Over-Valuation of Medications as a Treatment for Psychiatric Disorders. Attribution Theory. Attributions are explanations of the cause(s) for events Causes may be internal or external, enduring or unstable

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Another Perfect Storm

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  1. Another Perfect Storm Factors Contributing to the Over-Valuation of Medications as a Treatment for Psychiatric Disorders

  2. 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

  3. Attribution in Psychiatry • Diagnosis and treatment recommendations • Assessment of treatment response • Perceived efficacy of various treatment modalities

  4. 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.

  5. Data Regarding the Efficacy of Antipsychotic Medications • Poor 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.

  6. 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

  7. 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.

  8. 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

  9. 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

  10. 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.

  11. 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

  12. Historical Context • Dramatic achievements in medical science • public optimism • passivity concerning health issues • Psychopharmacology helped “medical-ize” psychiatry • Family members of psychiatric consumers

  13. 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

  14. 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 expertise • Wish to preserve credibility

  15. 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.

  16. Pharmaceutical Marketing • Gift cycle • Befriend and betray • Obfuscation of marketing intent with “educational opportunities” • Visual images to imply benefits and indications that are not substantiated by research • Solicitation to participate in false studies • Publication planning • Direct to consumer marketing

  17. Pharmaceutical Marketing • True 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

  18. Academia • Funding for research • Publishing • Positive reporting bias in journals • Ghost writing • Program development • Personal financial gain • Shapes medical education and imparts significance to pharmacology

  19. Other Financial Considerations • Third party payers • Medications impact length of stay in hospitalization • A 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

  20. Consumers • Acculturation to a passive recipient role in treatment • Easier to have a chemical imbalance than to confront life’s problems, change lifestyle • Quick fix • Faith in Western medical science

  21. 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.

  22. The Perfect Storm:Implications • Clinical practice • Outpatient commitment for medications • Drug courts • Medication of children, especially those in public custody

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