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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

Another Perfect Storm

Factors Contributing to the Over-Valuation of Medications as a Treatment for Psychiatric Disorders

attribution theory
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
attribution in psychiatry
Attribution in Psychiatry
  • Diagnosis and treatment recommendations
  • Assessment of treatment response
  • Perceived efficacy of various treatment modalities
data regarding the efficacy of antipsychotic medications
Data Regarding the Efficacy of Antipsychotic Medications
  • Levine (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 (2012): During the CATIE study, only 18.9% of subjects were treatment “responders” by trajectory analysis.
data regarding the efficacy of antipsychotic medications1
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.
risks associated with antipsychotic medications
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
risks associated with antipsychotic medications1
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.
a balanced view of psychotropic medications
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
prescription drug utilization
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


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.

historical context
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
historical context1
Historical Context
  • Dramatic achievements in medical science
    • public optimism
    • passivity concerning health issues
  • Psychopharmacology helped “medical-ize” psychiatry
  • Family members of psychiatric consumers
psychological motivations
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
psychological motivations1
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
pharmaceutical marketing
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.
pharmaceutical marketing1
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
pharmaceutical marketing2
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
  • Funding for research
  • Publishing
    • Positive reporting bias in journals
    • Ghost writing
  • Program development
  • Personal financial gain
  • Shapes medical education and imparts significance to pharmacology
other financial considerations
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
  • 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
regulatory considerations
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.
the perfect storm implications
The Perfect Storm:Implications
  • Clinical practice
  • Outpatient commitment for medications
  • Drug courts
  • Medication of children, especially those in public custody