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Doctors debate long-term use of psychiatric drugs

Poor research overstating benefits and minimising risks – or safe, efficacious treatments?

Louise Prime

Thursday, 14 May 2015

The benefits of using psychiatric drugs have been exaggerated and the risks underplayed because of poor trial design, claimed an expert last night. But others taking part in the 52nd Maudsley debate at King's College London, including a patient and another psychiatric expert, argued that there is imperfect but reassuring evidence to support the drugs’ use.

The debate was also played out in a Head to Head* article published yesterday in The BMJ. Peter C Gøtzsche, professor at the Nordic Cochrane Centre in Denmark, claimed that almost all psychotropic drug use could be stopped without deleterious effect; and Allan H Young, professor of mood disorders at the Institute of Psychiatry, Psychology and Neurosciences at King’s College London and John Crace, psychiatric patient and parliamentary sketch writer for The Guardian, countered that evidence does support their long term use.

Professor Gøtzsche wrote that because “psychiatric drugs are responsible for the deaths of more than half a million people aged 65 and older each year in the Western world … Their benefits would need to be colossal to justify this, but they are minimal.”

He argued that almost all randomised controlled trials of these drugs were biased because they included people already taking another psychiatric drug. Further, the benefits of treatment were exaggerated by the trials’ design, and level of harm from treatment minimised, because patients in the placebo group experienced withdrawal symptoms as they went ‘cold turkey’ after only a short wash-out period. He added that, in trials in schizophrenia, this has even led to suicide among patients taking placebo. He also claimed that industry-funded trials have underreported deaths, and he estimated that there have probably been 15 times more suicides among people taking antidepressants than reported by the US Food and Drug Administration (FDA).

Because of these flaws, he said, psychiatric medicines should be used almost exclusively in acute situations – he recommended stopping the use of all antidepressant, ADHD and dementia drugs, and prescribing only a small fraction of currently used antipsychotics and benzodiazepines. He called for new guidelines to support this change, and for the establishment of withdrawal clinics to help wean many patients off these medications.

But Professor Young and John Crace argued that psychiatric drugs are just as beneficial and efficacious as treatment for other common, complex conditions and that their use is supported by rigorous research; which, although imperfect, still shows that benefits outweigh harms. They wrote: “Worldwide, regulatory agencies are responsible for ensuring that drugs work and are acceptably safe … Several approaches are used to monitor the safety of licensed drugs, including spontaneous reporting databases, prescription event monitoring, electronic health records, patient registries, and record linkage between health databases. These safeguards work to ensure drugs available do more good than harm.”

They pointed out that psychiatric conditions are the fifth leading cause of deaths worldwide, and that most sufferers have co-existing health conditions – which are a primary cause of death in this group. Also, they added, post-licensing surveillance ensures that the drugs’ safety is assessed in people with varied medical conditions.

They wrote that ‘overinflated’ concerns over drug treatment often fade as more evidence becomes available, as happened with lithium – originally accuse of being a ‘toxic placebo’ but now shown to have benefits include reduction in suicide.

They concluded: “Psychiatric drugs are rigorously examined for efficacy and safety, before and after regulatory approval … We contend that [it is incorrect] … that the long-term use of psychiatric drugs is causing more meaningful harm than good … the evidence, such as it is, suggests the contrary.”

* Peter C Gøtzsche, et al. Does long term use of psychiatric drugs cause more harm than good? BMJ 2015;350:h2435 doi: 10.1136/bmj.h2435

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