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Long-acting injections of antipsychotics: pharma can’t shake the stigma, or the data! 05/17/2012

Posted by ALT in Pharmaceuticals, Treatments, Uncategorized.
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In honor of Robert Whitaker’s recent kick-ass article beautifully re-affirming the central premise of Anatomy of an Epidemic (namely that anti-psychotic medications worsen long-term outcomes for patients, making schizophrenia into a chronic, lifelong disease when in its natural state it is episodic; and therefore that patients who refuse treatment with antipsychotics are scientifically justified in doing so), I thought we might launch our own little expedition into the stormy seas of antipsychotic/neuroleptic discourse.

I’m steering us straight towards the tempest, towards the ever-blurrier line between “compliance,” “adherence,” and outright “forced treatment,” towards a history of Orwellian language shift that simply can’t seem to shake the truth.

Long-acting injections of antipsychotic medication

Long-acting injections are monthly, time-released, intramuscular injections of antipsychotic medications.  They figure prominently in current “assisted outpatient” therapeutic practice (ie, forced drugging outside the walls of the psychiatric institutions), and are being heavily promoted by drug companies who see expiration dates on patents for oral antipsychotic medications looming in the near future or already arrived.  Can the pharma marketing machine succeed in making LAIs the next wave of antipsychotic blockbuster drugs?

It’s going to take a serious makeover.  You see, long-acting injections have got something of a “bad image” in the press, and in the hearts and minds of the people.  Perceived as brain-altering drugs violently administered to unwilling subjects, clinicans’ last resort to enforce adherence to an un-agreed-upon reality [treatment plan], a hideously efficient way for pharma to make a buck or two [hundred].

But is this really a case of “bad image”, of misperception… or is it an accurate appraisal of long-acting injections’ intended and fully acknowledged clinical applications?

As clinicians we struggle on a daily basis with patients who do not want treatment because they do not perceive that medication helps or because they do not conceptualise their experiences within a medical illness framework.  Long-acting injections have often been used to enforce adherence in patients who do not or will not take medication; they can be a mechanism allowing clinicians to take control.

-Richard Gray, RN, PhD*in “Antipsychotic long-acting injections in clinical practice: medication management and patient choice” [emphasis added]

And furthermore…

According to systematic reviews approximately 40–60% of patients with schizophrenia are known to be partially or totally non-adherent to oral antipsychotic medication. Long-acting injections are indicated where medication adherence is a cause for concern. Thus it is argued by some that it might seem reasonable to consider such injections for approximately half of patients with schizophrenia.

- authors Maxine Patel, Mark Taylor and Anthony S. David** in “Antipsychotic Long-Acting Injections: Mind the Gap” [emphasis added]

Yep.  We had you guys all wrong.  This isn’t about forcing patient adherence to clinicians’ treatment plans, and it certainly isn’t about expanding the market for LAIs.

Funny thing.  “Long-acting injections,” when first introduced in the 1960s, were referred to as “depot injections” … but the name acquired a strong stigma and had to be changed:

Many proponents of LAIs [long-acting injections] have attempted to dodge this [image problem] by rejecting the term ‘depot,’ which was perceived to be stigmatizing, in favour of ‘long-acting injection’ … this was partly an attempt to move away from stigmatizing stereotypes, and also to promote therapeutic optimism for a population for whom hope can be all too scarce.

- Patel et al in “Antipsychotic Long-Acting Injections: Mind the Gap

As late as 2008, long-acting injections of Risperidone were still being called “depot” injections, but by 2009 articles like the one cited above made clear that this terminology had been abandoned.

But they couldn’t shake the stigma

Not only that, but serious, data-based challenges to the forced administration of long-acting injections –- and, more fundamentally, the existence of any clinical value for antipsychotics whatsoever —  are rapidly multiplying.  As one example:

We are embracing the increased use of outpatient commitment laws that force people to take antipsychotic medications, and we do so under the belief that these drugs are a necessary good for those people. This is an extraordinary thing for a society to do, to force people to take medications that alter their minds and experience of the world.

Yet, here is the story told in Anatomy of an Epidemic: If we look closely at Harrow’s study [citation here] and a long list of other research, there is good reason to believe that these medications increase psychotic symptoms over the long-term, increase feelings of anxiety, impair cognitive function, cause tardive dyskinesia with some frequency, and dramatically reduce the likelihood that people will fully recover and be able to work. If this is so, how can we, as a society, defend our increasing embrace of forced treatment laws?

-Robert Whitaker, author of Anatomy of an Epidemic, in the aforementioned kick-ass essay

From pharma’s perspective, another Orwellian language shift is needed.  Time to reset the dial of public opinion on long-acting injections… and so I give you the newest name for an old terror:

Intramuscular Medication

That does sound better!  It doesn’t make me think of needles.  Doesn’t even sound like an injection… sounds more like a “muscle relaxer,” only more intra.

I first saw the term a few weeks ago in Dr. H. Steven Moffic’s delightful little Psychiatric Times blog entitled “Is it time for Re-institutionalization?

Recently, I was asked to write a request to possibly extend the outpatient commitment of a patient of mine. What for, I said to myself? This would be a waste of time because he had not exhibited any more dangerous behavior, was taking care of himself, and was compliant with his intramuscular medication. However, when as part of the ongoing monitoring of my patient’s improvement, I asked him to rate on a 0-10 (best) scale how well the medication was working, he said “0”. When I asked why, he said it was because he didn’t need the medication. Uh, oh, I thought. Could this be Anosognosia?…

There’s no way he’ll be committed longer, but will he stay on the medication voluntarily? Without it he’d surely relapse into psychosis and possible dangerousness. If he then went inpatient again, would he only stay a few days, not enough to address his ideas about the medication? It didn’t help enough the first time around.

-Dr. Steven Moffic

But it’s cropping up elsewhere, too – in the academic literature, and in drug company advertising materials, of course.  You can even see the shift in brand names as new antipsychotic injections are approved over time; the earliest approved LAI, Janssen’s Risperdal, is frequently referred to as LARI [Long-acting Risperidone Injection], while the more recently approved Zyprexa injection’s official brand name is “Zyprexa Intramuscular.”

I forecast the increasing encroachment of the term “intramuscular medication” into the official, APA/pharma-approved, “therapeutic” language, until our fears of “long-acting injections” are a half-forgotten nightmare that no longer sees the light of day.

OR

Or we could insist on calling a spade a spade.

So-called “antipsychotics” are nothing of the kind (they’ve actually been shown to cause psychosis), and are much more appropriately referred to by their first given name, neuroleptic, which literally means “brain damage inducing.”  Why?  Because that is what the research proves, over and over again, they do.

From now on let’s choose names that accurately describe the items to which they’re attached.  For example, “rose” = a pretty flower that smells good.  A few other examples:

Intramuscular Medication = Neuroleptic (brain damage inducing) Injection

Non-compliant Patient = Conscientious Objector to the Chemical Takeover of His Mind

That sums it up pretty clearly, doesn’t it?


* (Oh, and by the way, Richard Gray has received funding and/or fees from AstraZeneca Pharmaceuticals, Bristol-Myers Squibb, Janssen Pharmaceuticals, Eli Lilly, Otsuka Pharmaceuticals and Pfizer.)

** (And it should come as no surprise that the authors have been reimbursed for attendance at scientific conferences and have received consultation fees from Janssen-Cilag and Eli Lilly, received investigator-initiated grants from Janssen-Cilag and Eli Lilly, have worked on two clinical drug trials for Janssen-Cilag, and have received hospitality and advisory or speaker fees from AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Janssen-Cilag within the past 5 years.)

Magnolias 04/07/2011

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Spring at last!

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If this is satire (and it is), what does that say about society? 03/14/2011

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I love to laugh, and I endeavor to make my readers do so as well.  Besides its very real therapeutic value, laughter is a pasasgeway into other perspectives and viewpoints (what we see one day through humor we may be able to consider seriously the next).

So enjoy this piece of satire from the Onion.  And if it inspires any deeper questions about the state of our mad society, so much the better…

***

Grown Adult Actually Expects to Be Happy

NORMAL, IL—According to incredulous sources, local hardware store employee and grown adult human being Rob Peterson, 37, actually expects to be happy in life.

Peterson, who is not a small child, believes he can and should lead a happy life.

Despite possessing a fully developed brain and a general awareness of the fundamental nature of existence, sources said Peterson apparently continues to believe that achieving long-lasting happiness is somehow possible.

“It’s almost like he thinks reaching a place of enduring contentment with yourself and your life is some sort of obtainable outcome,” friend Brian McDougal said of Peterson, who reportedly lives on Earth, has experienced life, and is not mentally disabled or abusing narcotics of any kind. “He even gets upset sometimes when things don’t go his way, as if misery and disappointment weren’t a foregone conclusion. And then, on top of that, he’ll cheer himself up by saying that ‘it’s all going to work out in the end.’”

“I just want to shake him and scream, ‘Wake up!’” McDougal added. “Jesus Christ, he’s such a downer.”

Sources confirmed that while Peterson has been supplied over the years with a glut of compelling evidence that life is a zero-sum game at best—including a thwarted career as a graphic designer, multiple failed relationships, and limited financial mobility—he nevertheless continues to cling to the misguided expectation that he can and will experience real serenity and joy in the long term.

The baffling man has also reportedly read a newspaper before, interacted with coworkers, knows how economies and political systems work, and is undergoing the process of aging, yet has made no effort to revise his original assumption.

“What really gets me is the confidence he seems to have that one day he will be able to shed all of the fears and anxieties that are hardwired into his DNA and the modern world will decide to stop being unrelentingly brutal and allow him some happiness,” said coworker Miles Sagal, adding that the delusional Peterson inexplicably presumes that this not only could, but should, occur. “Whenever he’s feeling low, he’ll allude to some time down the road when he’ll have it all ‘figured out.’ When exactly does he think that will happen?”

“Seriously, what the fuck is wrong with this guy?” Sagal added. “He’s aware that he’s going to die, right?”

Stunned sources told reporters that Peterson recently expressed genuine disappointment when something he hoped would happen did not happen, despite the fact that such a scenario is an elegant microcosm of life itself. He has also been heard to say on numerous occasions that he “just [wants] to be happy,” as though returning to a state of childlike bliss were a reasonable request and not something human beings had already tried and failed to do for many thousands of years before he was born.

While modern psychiatric science maintains that long-term happiness is possible only in the realm of fairy tales, Hollywood romantic comedies, and the naïve imaginings of the youthful mind, experts said Peterson has not picked up on this universally acknowledged truth and may be suffering from the severe misapprehension that life can be what he makes of it.

“Frankly, science cannot explain this man,” confirmed noted psychologist Dr. Eli Wasserbaum, adding that most people have their first realization that enduring happiness is an utter fallacy sometime in their late teens or early ’20s, when their dreams for the future endure the first fissure in the process of eventual disintegration. “Anyone with the smallest degree of perceptiveness knows that happiness is, at best, a temporary emotional phenomenon. Seeing as Peterson is a college-educated adult, and not a 5-year-old kid on Christmas morning, he should really know better than to think otherwise. We’re all just barely hanging on for our entire lives.”

“Hell, I’m a respected doctor who makes over $300,000 a year,” Wasserbaum added. “You think I’m happy?”

At press time, Peterson was still under the mistaken impression that anything really matters at all in the end.

THE PATHOLOGIZING GAME: Didn’t get picked by Team Psychiatry? You can still play! 03/06/2011

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Here’s the thing about pathologizing: once you start, it’s hard to stop. 

If you approach people (humans) from a flaw-seeking point of view, you will find flaws and faults galore.  From a position of power — the power to deem behaviors deviant — normalcy is… whatever you want it to be. 

Pathologies paint a picture, in negative, of what normalcy is for the pathologizers.  What definition of normalcy can be extracted from psychiatry’s listed pathologies? 

This seems pretty fair to me –

normalcy: an emotionally static buy-in to consumerism, coupled with an overriding desire and single-minded focus on becoming “a productive member of society” not inhibited in any way by cultural value systems, family, community, or humanity.

   

Two can play this game

Actually, many people have played this game (labeling certain behaviors as deviant or pathological to reinforce your own values system/life-world). 

Peter Chadwick, psychiatric survivor and author of Schizophrenia: The Positive Perspective, does it here:

Are there people suffering from ‘pathologically middle-of-the-road personality disorder’?  Or perhaps ‘reality obsession’, ‘rationality fixation’, ‘pathological blandness’, ‘non-existent personality syndrome’… ‘mania logica’, ‘mania psychoanalytica’ or ‘aspiritual personality’?

(Peter Chadwick in Schizophrenia: The Positive Perspective)

I couldn’t help but come up with a few of my own:

Brand Fixation Disorder

It's not her fault! Due to a chemical imbalance of the brain... or heart... or something.

Excessive Feminine Liberation Syndrome

(as exemplified by this real quote from a young lady in a college class of mine several years ago: “I actually found it liberating to have beer spilled on me for the wet T-shirt contest at [local college bar].  That’s my sexuality and I can express it if I want! Years ago women couldn’t do stuff like that.  And I won the contest!”)

Pathological Apathy

(Sub-categories: Institution-induced, Drug-induced)

Compulsive Electronic Device Mania

(Does it amaze you – the number of people that go out to bars and other public places merely to play video games on their phones under the tables while feigning interest in their friends)

Hanging out has never been so... solitary. And electronic.

Your submissions are welcome…

On the dehumanization of Sylvia Plath… 02/22/2011

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Sylvia Plath was a human being. She lived and breathed, she feared, she loved, she picked daffodils.

Skipping around in her unabridged journals this morning, I had that revelation. Why should it be a revelation? Because the mental health field has made her an ICON; something entirely separate from humanity. According to them, she IS clinical depression, suicide; she IS tortured genius. 

Even worse, she is entertainment. This poem was written by Ms. Plath’s daughter, Freida Plath, in response to the 2003 film Sylvia, starring Gwenyth Paltrow.

My Mother (by Freida Plath)

They are killing her again,
She said she did it
One Year in every ten,
But they do it annually, or weekly,
Some do it daily,
Carrying her death around in their heads,
And practicing it. She saves them
The trouble of their own;
They can die through her
Without ever making
The decision. My buried mother
Is dug up for repeat performances

Now they want to make a film
For anyone lacking the ability
To imagine the body, head in oven,
Orphaning children. Then
It can be rewound
So they can watch her die
Right from the beginning again.

The peanut eaters, entertained
At my mother’s death, will go home,
Each carrying their memory of her,
Lifeless — a souvenir.
Maybe they’ll buy the video
Watching someone on TV
Means all they have to do
Is press ‘pause’
If they want to boil a kettle,
While my mother holds her breath on screen
To finish dying after tea.

The filmmakers have collected
The body parts.
They want me to see.
But they require dressings to cover the joints
And disguise the prosthetics
In their remake of my mother.
They want to use her poetry
As stitching and sutures
To give it credibility.
They think I should love it-
Having her back again, they think
I should give them my mother’s words
to fill the mouth of their monster,
Their Sylvia Suicide Doll.
Who will walk and talk
And die at will,
And die, and die
And forever be dying.

They – mental health activists, feminists, moviemakers – leave little room for her to have been Sylvia. But she was! She was — vividly, starkly, truly.  

There’s a lesson here for each and every one of us that has been dehumanized in one way or another by this society that doesn’t leave much room for human beings to just be.  Don’t let them convince you that it is better to be the “action figure” version of yourself; that plastic is better than living flesh; that 144 characters are sufficient to say your peace; that a a sound byte represents the multitude of your thoughts.  Don’t let them turn you into a Doll, ever.

    

Sylvia Plath with children Freida and Nicholas:

   

 

 

 

 

 

 

 

 

 

    

     

   

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