Transcript Another Perfect Storm - USC Gould School of Law

Another Perfect Storm
Factors Contributing to the OverValuation 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
People preferentially interpret events in a
manner that maintains a positive selfimage
Attributions may lead to cognitive
distortions
Attribution in Psychiatry
Diagnosis and treatment
recommendations
Assessment of treatment response
Perceived efficacy of various
treatment modalities
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.
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
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 Medications
Serious, and sometimes lifethreatening 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
 Very beneficial to a relatively small percentage of
individuals
 Partial benefit to some individuals
 Risk for very serious and potentially lifethreatening 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
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
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.
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 Context
Dramatic achievements in medical
science
public optimism
passivity concerning health issues
Psychopharmacology helped
“medical-ize” psychiatry
Family members of psychiatric
consumers
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 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
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 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 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
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
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
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
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
Clinical practice
Outpatient commitment for
medications
Drug courts
Medication of children, especially
those in public custody