Christian was slouched in a chair in Bradford psychiatric unit. He was, seemingly, only half-conscious, half alive. He could hardly speak, let alone raise his head.
Christian had been diagnosed with schizophrenia. Two days before, in a haze of paranoia, he had punched a colleague of mine at a day centre. So Christian was sectioned and medicated, heavily, with neuroleptics. Most, on seeing Christian would have described him as being so whacked out he was a dribbling wreck. Treatment-advisory body, the National Institute of Health and Clinical Excellence (Nice) would say the neuroleptics had successfully “calmed” Christian, in preparation for treating the “underlying psychiatric condition”.
Neuroleptics – such as Clozapine, Olanzapine, Risperidone and Seroquel – are the “primary treatment” for psychosis, particularly schizophrenia. Indeed, 98-100 per cent of people diagnosed with schizophrenia inside our psychiatric units – and 90% living in the community – are on neuroleptics, also called anti-psychotics. “There is well established evidence for the efficacy of anti-psychotic drugs”, Nice told mental health professionals in its guidelines for the treatment of schizophrenia.
Nice claims a similar efficacy for the widely-prescribed SSRI anti-depressants in treating depression. Some researchers disagree. A recent widely-publicised meta-analysis asserted that SSRIs are no more clinically beneficial than placebo for mild and moderate depression. London NHS psychiatrist Joanna Moncrieff is one such dissenting researcher. But she has conducted a far wider examination of psychiatric drugs, and has endeavoured to expose the “myth” of anti-psychotics. She claims there is no sufficient evidence to support their long-term use and they cause brain damage, a fact which is being “fatally” overlooked. Plus, because of a cocktail of vicious side-effects, anti-psychotics almost triple a person’s risk of dying prematurely.
Moncrieff, also a senior lecturer at University College London, particularly strikes out at her own profession, psychiatry, claiming it is ignoring the negative evidence for anti-psychotics. In her book, The Myth of The Chemical Cure, Moncrieff argues the increasing prescribing of these drugs is unleashing an epidemic of drug-induced problems. She argues, effectively, that psychiatry is guilty of gross scientific misconduct.
Having scrutinised decades of clinical trials, Moncrieff’s first point is that once variables such as placebo and drug withdrawal effects are accounted for, there is no concrete evidence for antipsychotic long-term effectiveness.Moncrieff’s interpretation of the relevant meta-analyses and trials is radically different to Nice which arrived at an opposite conclusion for antipsychotic effectiveness.
At the heart of dissent against psychiatry through the ages has been its use of drugs, particularly anti-psychotics, to treat distress. Do such drugs actually target any “psychiatric condition”. Or are they chemical control, a socially-useful reduction of the paranoid, deluded, distressed, bizarre and odd into semi-vegetative zombies? Historically, whatever dissenters thought has been largely ignored. So, it appears, have new studies which indicate anti-psychotics are not effective long-term. For example, a US study last year in the Journal of Nervous and Mental Disease reported that people diagnosed with schizophrenia and not taking anti-psychotics are more likely to recover than those on the drugs. The study was on 145 patients, and researchers reported that, after 15 years, 65 per cent of patients on anti-psychotics were psychotic, whereas only 28% of those not on medication were psychotic. An intriguing finding, surely? So what about the mainstream media headlines of “breakthrough in schizophrenia treatment”? After all, broadsheets react positively to the plethora of alleged genetic “breakthroughs” in schizophrenia, even when it comes to genetically-engineered schizophrenic mice. But there wasn’t a squeak.
Interestingly, the researchers of the Journal of Nervous and Mental Disease paper hypothesised that it was patients with “inner strength”, “better self esteem” and “inner resources” who were more likely to recover long-term without neuroleptics. However, not one peer-reviewed study examining the necessary individual characteristics and support networks to live through psychosis without drugs has, in the last 48 years, appeared in The British Journal of Psychiatry, the publication that each month drops through the letter box of every psychiatrist in the land.
The “psychological factors” of, for example, inner strength, are, perhaps more the terrain for clinical psychologists. Such as Rufus May who was compulsory treated with anti-psychotics when diagnosed with schizophrenia as an 18-year-old.
May argues withdrawal effects of anti-psychotics often get wrongly interpreted as “relapse”. So, he has launched a website advising people how safely to come off psychiatric drugs. Many patients, like May (who perhaps had the required “inner strength”), have successfully come off anti-psychotics and gone on to recover. The irony is that they frequently have had to do it behind the backs of their psychiatrists, who fear relapse.
Moncrieff’s second point is that the psychiatric establishment, underpinned by the pharmaceutical industry, has glossed over studies showing that anti-psychotics cause extensive damage, the most startling being permanent brain atrophy (brain shrinkage) and tardive dyskinesia. As in other neurological conditions patients suffer involuntary, repetitive movements, mental impairment, memory loss and behaviour changes. Brain scans show that anti-psychotics cause atrophy within a year, alerts Moncrieff. She accuses her colleagues of risking creating an “epidemic of iatrogenic brain damage”. Moncrieff is a hard-nosed scientist, so she is respectfully reserved. But her carefully-chosen words are still alarming. “It is as if the psychiatric community can not bear to acknowledge its own published findings,” she writes.
How worrying it is, also, that the Healthcare Commission should report last year that almost 40 per cent of people with psychosis are on levels of anti-psychotics exceeding recommended limits. Such levels cause heart attacks. Indeed the National Patient Safety Agency claims heart failure from anti-psychotics is a likely cause for some of the 40 average annual “unexplained” deaths of patients on British mental health wards. Other effects of anti-psychotics include massive weight gain (metabolic impairment) and increased risk of diabetes. Two years ago, The British Journal of Psychiatry – Britain’s most respected psychiatry journal – published a study reporting that people on anti-psychotics were 2.5 times likely to die prematurely. The researchers warned there was an “urgent need” to investigate whether this was due to anti-psychotics. But so engrained is the medication culture in mental health that many psychiatrists regard that not medicating early with anti-psychotics amounts to negligence, Moncrieff notes.
Moncrieff does acknowledge there is evidence for the short-term effectiveness of anti-psychotics. But again Moncrieff asks psychiatry to be honest. Moncrieff points out that when anti-psychotics, such as chlorpromazine, were first used in the fifties they were called “major tranquillisers.” Why? Because that’s an accurate description of their effect, particularly short term. They sedate, numb, or tranquillise, the emotions, so reducing the anxiety of paranoia and delusions. Any person on anti-psychotics would verify this (Go to askapatient.com). So, in this respect, they are effective. Nowadays, however, these drugs are referred to as “anti-psychotics”. For Moncrieff, this is a wheeze because there’s no evidence that anti-psychotics act directly on the “symptoms” – paranoia, delusions, hallucinations – of those diagnosed with psychosis. There’s nothing anti-psychotic about anti-psychotics.
Embedded in Moncrieff’s thesis is that, unlike other medical conditions, there is no evidence that psychiatric illnesses, including schizophrenia, are caused by physical abnormalities. As clinical psychologist Mary Boyle penned it, schizophrenia is a “scientific delusion” which drugs can never cure.
The alternatives? Moncrieff – like her fellow psychiatrists in a group called the Critical Psychiatry Network – asks services to look seriously at non-drug approaches, such as the Soteria Network in America. She believes psychiatrists such as herself should no longer have unparalleled powers to forcibly detain and treat patients with anti-psychotics. Instead, they should be “pharmaceutical advisers” engaging in “democratic drug treatment” with patients. Psychiatrists should be involved in “shared decision-making” with patients, and would have to go to civil courts to argue their case for compulsory treatment. “Psychiatry would be a more modest enterprise” writes Moncrieff, “no longer claiming to be able to alter the underlying course of psychological disturbance, but thereby avoiding some of the damage associated with the untrammeled use of imaginary chemical cures.”
Mental health policy is, it appears, swinging away from a reliance on antidepressants. Surely a deep re-examination of the true validity of anti-psychotics is also due?
* A previous version of this article was published at Guardian Unlimited