Book Review: The Bitterest Pills – The Troubling Story Of Antipsychotic Drugs

The Bitterest Pills – The Troubling Story Of Antipsychotic Drugs

Joanna Moncrieff. (2013). Basingstoke: Palgrave Macmillan.

Dr Moncrieff embodies a calm yet forceful passion for her beliefs. A few years ago, I was fortunate to have attended a forum discussion of the Society for Existential Analysis conducted by Dr Moncrieff and found her to be immensely well-informed and patient in her manner. This book reflects the same approach throughout, successfully negotiating the tricky task of being both meticulously researched, not shying away from the detail of scientific studies, and maintaining an accessible style. I cannot recommend it highly enough to anyone working with people confronted with the possibility of psychiatric medication.

Many existential psychotherapists may start from a position similar to that espoused by R.D. Laing, (1967) positing that schizophrenia could be described as a 'sane response to an insane world' and would not be surprised that recent research has revealed 'high levels of previous physical and sexual abuse and victimisation in people diagnosed with psychotic disorders, (Read et al., 2003; Gracie et al., 2007).' Mainstream views within the field of mental health however, seem to be more readily aligned with a biologically deterministic view of schizophrenia, and a disease centred understanding of psychosis maintains a strong grip on both medical and political policy, as well as permeating across wider society.

Whilst acknowledging the existence of such polarised positions in the understanding of so-called 'psychotic symptoms' Moncrieff cleverly avoids entering this debate directly, and instead constructs a narrative in which the reader is forced to adopt a critical way of thinking to all arguments presented, in which self-reflection and scepticism become the watchword. No doubt this will be a familiar and comfortable position for existentially trained practitioners. By carefully recounting a history of the birth, growth and now widespread use of antipsychotic drugs, Moncrieff allows the constant twists and turns of the story to reveal their own truths. This proves also to be an adept way for the illumination of the history of 'psychotic illness' to reveal itself too, and subsequently challenges the reader to dismantle and question many popular beliefs held about the effectiveness

of drug 'treatment' across the field of mental health as a whole. This challenge to the reader leads to consideration of the impact on society of the creeping use of highly toxic drugs into areas where the risks far outweigh the benefits. As Moncrieff points out in England alone in 2010,

7.5 million prescriptions were issued for antipsychotics in the community... (excluding the large number of prescriptions issued to patients in psychiatric hospitals) – a 61% increase on the number of prescriptions issued in 1998.

(p 5)

The cornerstone of Moncrieff's argument is based on a distinction between a disease-centred model and a drug-centred model for the use of antipsychotic drugs. The first works on the supposition that 'the beneficial effects of drugs are derived from their effects on a presumed disease process, e.g. insulin for diabetes'. The second suggests that 'drugs alter the expression of psychiatric problems through the superimposition of drug-induced effects, e.g. alcohol for social anxiety' (p 8).

In other words, insulin treatment for diabetes helps correct the insulin deficiency that leads to symptoms. This does not claim to correct the underlying cause of the medical problem but helps to manage the symptoms of a condition. Prior to the 1950s Moncrieff tells us, psychiatric drugs were known as 'psychoactive drugs' which actually affect brain functioning and as a consequence alter mental experience and behaviour (p 10).So rather than treating a supposed physical abnormality, they act by creating an abnormal or altered mental state themselves. A familiar example of this is from states of induced intoxication, whether from alcohol, nicotine, caffeine or even LSD.

Moncrieff also demonstrates the inherent challenge in drawing conclusions when evaluating research into the efficacy of antipsychotics and their effects, both desired and their many side effects, such as 'tardive dyskinesia,' which is considered at length. Throughout the book she draws our attention to the flaws in the processes or interpretation of research both for and against a disease-centre model, which has often acted as justification for substantial change in policy. Amongst others she describes the difficulties in drawing conclusions from the 1964 (NIMH) study, funded by the United States National Institute for Mental Health, which claimed to have demonstrated the disease targeted effects of chlorpromazine and two other phenothiazine compounds. These were compared against a placebo, using what could be described as a randomised control trial (RCT). The difficulties include amongst others, the categorisation of the very symptoms they aim to alleviate, as being either disease based, medication effects or withdrawal effects and the subjective elements in doing so. Due to the strength of impact of the antipsychotic drugs, it is also not possible to conduct a simple, placebo

based, 'double-blind' RCT, and subsequently tranquillizers used for comparison, frequently appear to show similar effects. Many subjects, including 50% in the NIMH study had periods of in-patient treatment prior to the test, and had already been exposed to medication. The emerging message is that definitive evidence of universally positive effects become scarce or even impossible to find.

Much of the research cited by pharmaceutical companies and accompanying research institutes, at best points to the direction of travel for trends in treatment, rather than providing evidence of a targeted effect. I am reminded of the words of Wittgenstein, who said in his Philosophical Remarks, 'Tell me how you are searching, and I will tell you what you are searching for.'

As a psychotherapist working as part of a Child and Adolescent Mental Health Service in which antipsychotic drugs do play a very small, but nonetheless present part of the options of support for adolescents, I was particularly fascinated to read a critique in Chapter 10 of the 'Early Intervention in Psychosis' movement. Chapter 11 discusses the spreading use of antipsychotic drugs into the 'treatment' of bipolar disorder and, most alarmingly, with 'paediatric bipolar disorder.' Moncrieff describes the impact of recent research into the effectiveness of antipsychotics, frequently funded by commercial companies developing fertile new markets. Later chapters also include the experience of moving cases, such as that of Rebecca Riley, a 4 year old girl in Massachusetts, USA, who died, following heart failure in 2006, after being diagnosed with bipolar disorder and ADHD. At the time of her death she had been prescribed quetiapine, (an atypical anti-psychotic) along with Depakote, and another sedative drug, clonidine, (an adjunct to traditional stimulant treatment for ADHD).

On the night she died her parents admitted to giving her extra doses of clonidine, along with an over-the-counter cold remedy... Rebecca's preschool reported that prior to her death she was so drugged she had to be helped up the stairs ...

(Able (2007) cited in Moncrieff, 2013: p 201)

We may feel that such issues are limited to the US, but a medicalization and pathologising of childhood is increasingly prevalent in the UK. According to ONS statistics cited in 2013 NICE guidance, 'behaviour or conduct disorders' accounted for 30% of child related consultations with GPs, 45% with Child Health professionals and 28% of outpatient appointments with paediatricians.

One possible cause for the current victory of the disease based model, is in its offer of a guilt free 'treatment,' a 'therapeutically' based help if you will, as opposed to a 'chemically based suppressant' which may be harder for much of society to swallow. It is certainly easier and appears more humane to provide a patient with highly toxic chemicals if there is a belief that it may be eradicating an illness, rather than suppressing unwanted or unmanageable behaviours. Undeniably the historical transition from managing, to treating people suffering with mental disturbance not only provides a clearer sense of purpose for mental health workers, but also acts to contain the anxiety of wider society. It seems that the desire for the disease centred understanding to be true is as much driven by the preoccupation of contemporary western society to treat rather than understand, a position that large drug companies have been all too happy to exploit. Prior to the early 1900s treatment or cure did not appear such a preoccupation and as Moncrieff states:

The usual account of early psychiatry suggests that few people recovered and that, after being admitted to an asylum, people were rarely discharged. This picture has been challenged, however, by a considerable amount of historical research, which shows that 40-60% of people admitted to asylums in England and Wales were discharged within a year. By the last years of the nineteenth century, two thirds of patients admitted stayed less than two years (Wright, 1997; Ellis, 2006)

(p 21)

It is important to ask ourselves when, if ever the benefits do indeed outweigh the risks for drugs which certainly can cause, 'metabolic impairment, cardiac toxicity and neurological damage' in anyone, regardless of their mental state or diagnosis. Moncrieff's final plea is, appropriately, not for collective condemnation of drug companies, growing rich from the increasing frequency of use of antipsychotics, but for all of us to 'wake up to the real nature of antipsychotic drugs' (p 220). The historical account Moncrieff describes could, in fact, be read like a crime novel, twisting and turning with social changes. If this is indeed the case, we must conclude at the end, that it is not the drug companies who are the perpetrators ultimately accountable for the tranquillising of society, but all of us, as part of a culture which struggles to accept or tolerate the disturbance it creates.

References

Able, D. (2007). 'Hull parents arrested in girl's poisoning death,' Boston Globe, 6th Feb.

Ellis, R. (2006). The asylum, the Poor Law, and a reassessment of the four-shilling grant: admissions to the county asylums of Yorkshire in the nineteenth century. Social History of Medicine, 19: 55-71.

Gracie et al. (2007). The association between traumatic experience, paranoia and hallucinations: a test of the predictions of psychological models. Acta Psychiatrica Scandinavica, 116: 280-9.

Chris Scalzo