Saturday, December 25, 2010

Neuroleptic Drugs

Neuroleptic Drugs
The agents inflicted upon Alexandria are known by a variety of designations, including major tranquilizers, antipsychotics, and neuroleptics. These words are synonyms. The original ones, including Thorazine and Mellaril, are called phenothiazines, and sometimes that term is used too loosely to designate the entire group. In psychiatry, the term neuroleptic is now preferred. Neuroleptic was coined by jean Delay and Pierre Deniker, who first used the drug in psychiatry, and means "attaching to the neuron." Delay and Deniker intended the term to underscore the toxic impact of the drug on nerve cells (see chapter 4).
List of Neuroleptics
The public identifies most psychiatric drugs by their trade names-the proprietary trademarks under which the companies own and market them. With generic names in parentheses, a list of trade names of neuroleptics in use today includes Haldol (haloperidol), Thorazine (chlorpromazine), Stelazine (trifluoperazine), Vesprin (trifluopromazine), Mellaril (thiorldazine), Prolixin or Permitil (fluphenazine), Navane (thiothixene), Trilafon (perphenazine), Tindal (acetophenazine), Taractan (chlorprothixene), Loxitane or Daxolin (loxapine), Moban or Lidone (molindone), Serenfil (mesoridazine), Orap (pimozide), Quide (piperacetazine), Repoise (butaperazine), Compazine (prochlorperazine), Dartal (thiopropazate), and Clozaril (clozapine).(1)
The antidepressant Asendin (amoxapine) turns into a neuroleptic when it is metabolized in the body and should be considered a neuroleptic. Etrafon or Triavil is a combination of a neuroleptic (perphenazine) and an antidepressant (amitriptyline), and it combines the impact and the risks of both.
The neuroleptics are the most frequently prescribed drugs in mental hospitals, and they are widely used as well in board-and-care homes, nursing homes, institutions for people with mental retardation, children's facilities, and prisons. They also are given to millions of patients in public clinics and to hundreds of thousands in private psychiatric offices. Too often they are prescribed for anxiety, sleep problems, and other difficulties in a manner that runs contrary to the usual recommendations. And too often they are administered to children with behavior problems, even children who are living at home and going to school.
The Numbers of Patients Treated
No one knows the total numbers of neuroleptic drugs taken by patients each year, but estimates are possible. While the overall number of beds in state hospitals is down, annual admissions are up from the 1950s, and most of the several hundred thousand patients admitted each year are diagnosed as schizophrenic. Nearly all of these are prescribed neuroleptics. Hundreds of thousands more are getting them through outpatient clinics. Well over a million people a year are treated with neuroleptics on the wards and in the clinics of state mental health systems.
Additional millions more are receiving neuroleptics or antipsychotics through sources outside the state mental hospital system and long-term clinics. Of the estimated two million patients in nursing homes, many of them are on neuroleptics. Add to these patients the tens of thousands being treated with these drugs in private psychiatric hospitals, and in the psychiatric and medical wards of general hospitals, plus the tens of thousands in institutions for people with retardation, the untold thousands in board-and-care homes, still more in prisons, and hundreds of thousands in private practice-and the total swells to many millions. Even homeless people in shelters are sometimes forced to take them.
The National Prescription Audit provided by the FDA reported twentyone million prescriptions for neuroleptics in 1984. These figures are drawn from retail pharmacies and therefore do not include patients in institutions or patients dispensed medications directly from clinics. Of course, many patients obtain more than one prescription a year, but the figures suiz2est that at least several million individuals are obtaining neuroleptics rrom retail pharmacies each year.
That huge numbers of people are treated with neuroleptics is confirmed by the figures occasionally released by the pharmaceutical companies. The first neuroleptic was chlorpromazine, whose trade name is Thorazine. In a 1964 publication entitled Ten Years'Experience with Thorazine, the manufacturer, Smith Kline and French, estimated that fifty million patients had been prescribed chlorpromazine in the first decade of use (1954 to 1964). The figure probably was worldwide. In recent years, haloperidol, sold by McNeil Pharmaceutical under the trade name Haldol, has become the most prescribed neuroleptic. In a letter to attorney Roy A. Cohen dated August 13, 1987, McNeil's director of medical services, Anthony C. Santopolo, provided a glimpse at Haldol's escalating use. The figures for patients first treated with Haldol grew from 600,000 in 1976 to 1,200,000 in 1981.(2)
Overall, the estimate I made in my 1983 medical book, Psychiatric Drugs, of five to ten million persons per year in America being treated with neuroleptics probably remains valid today. The sheer size of these numbers should motivate us to learn everything we can about the impact of these agents on the brain and the mind.
The Clinical Impact of the Neuroleptics
Textbooks of psychiatry and review articles claim that the neuroleptics have a specific antipsychotic effect, especially on the so-called positive symptoms of schizophrenia, such as hallucinations and delusions, marked incoherence, and repeatedly bizarre or disorganized behavior.
Meanwhile, very little is written in professional sources about the apathy, disinterest, and other lobotomylike effects of the drugs. Review articles tend to give no hint that the medications are actually stupefying the patients and that life on a typical mental hospital ward is listless at best. And so we must turn to the earliest research reports on the drugs. The pioneers, eager to show the potency of their new discovery, were far more candid and graphic in describing the effects to doctors as yet unfamiliar with them.
The Nature of Lobotomy - To grasp what the pioneers said about the neuroleptic effect, it's important first to understand the lobotomy effect to which it is compared. This link contains the history and description of the surgical lobotomy.
The Birth of Chemical Lobotomy - Reports from the Drug Pioneers & How Neuroleptics Produce Lobotomy - In 1952, the first shot in the "revolution in psychiatry" was fired in Paris by the two pioneers Delay and Deniker. They published their findings on chlorpromazine (Thorazine) in French in Congres des Medecins Alienistes et Neurologistes de France. Read the straightforward description of the apathy and lack of initiative typical of lobotomy.
The neuroleptics also are used in tranquilizer darts for subduing wild animals and in injections to permit the handling of domestic animals who become vicious. The veterinary use of neuroleptics so undermines the antipsychotic theory that young psychiatrists are not taught about it.(3)
The Fundamental Principle of Psychiatric Treatment
The brain-disabling principle applies to all of the most potent psychiatric treatments-neuroleptics, antidepressants, lithium, electroshock, and psychosurgery. The principle states that all of the major psychiatric treatments exert their primary or intended effect by disabling normal brain function. Neuroleptic lobotomy, for example, is not a side effect, but the sought-after clinical effect. It reflects impairment of normal brain function.
Conversely, none of the major psychiatric interventions correct or improve existing brain dysfunction, such as any presumed biochemical imbalance. If the patient happens to suffer from brain dysfunction, then the psychiatric drug, electroshock, or psychosurgery will worsen or compound it.
If relatively, low doses produce no apparent brain dysfunction, the medication may be having no effect or producing a placebo effect. Or, as frequently happens, the patient is unaware of the impact even though it may be significant. Anyone familiar with the behavior of people drinking alcohol knows how easily a slightly intoxicated person may deny being impaired or even claim to be improved. Most people coming off cigarettes become abruptly aware of missing the sedative and tranquilizing effects that previously were taken for granted.
Iatrogenic (Treatment-Caused) Helplessness
Brain dysfunction, such as a chemical or surgical lobotomy syndrome, renders people much less able to appreciate or evaluate their mental condition. Surgically lobotomized people often deny both their brain damage and their personal problems. They will loudly declare, "I'm fine, never been better," when they can no longer think straight. Sometimes they deny that they have been operated on, despite the dime-size burr holes in their skulls palpable beneath their scalp. Superficially, the denial looks so sincere that prolobotomists cite it to justify the harmlessness of the treatment.
Even without the production of brain dysfunction, the giving of drugs or other physical interventions tends to reinforce the doctor's role as an authority and the patient's role as a helpless sick person. The patient learns that he or she has a "disease," that the doctor has a "treatment," and that the patient must "listen to the doctor" in order to "get well again." The patient's learned helplessness and submissiveness is then vastly amplified by the brain damage. The patient becomes more dutiful to the doctor and to the demoralizing principles of biopsychiatry. Denial can become a way of life, fixed in place by brain damage.
Suggestion and authoritarianism are common enough in the practice of medicine but only in psychiatry does the physician actually damage the individual's brain in order to facilitate control over him or her. I have designated this unique combination of authoritarian suggestion and brain damage by the term iatrogenic helplessness. Iatrogenic helplessness is key to understanding how the ma'or psychiatric treatments work .
There is little or no reason to anticipate a physical treatment in psychiatry that will control severely disturbed or upset people without doing equally severe harm to them. If psychosurgery, electroshock, or the more potent psychiatric drugs were refined to the point of harmlessness, they would approach uselessness. In biopsychiatry, unfortunately, it's the damage that does the trick.
Clarifying a Confusing Point
Whether or not some psychiatric patients have brain diseases is irrelevant to the brain-disabling principle of psychiatric treatment. Even if someday a subtle defect is found in the brains of some mental patients, it will not change the damaging impact of the current treatments in use. Nor will it change the fact that the current treatments worsen brain function rather than improving it. If, for example, a patient's emotional upset is caused by a hormonal problem, by a viral inflammation, or by ingestion of a hallucinogenic drug, the impact of the neuroleptics is still that of a lobotomy. The person now has his or her original brain damage and dysfunction plus a chemical lobotomy.
Claims for Curing Specific Schizophrenic Symptoms
But what about claims that the treatments reduce psychiatric symptoms, such as so-called hallucinations and delusions? Gerald Klerman was the major figure in transforming the image of the neuroleptics from nonspecific flattening agent to antipsychotic medication. Klerman was an avid advocate of biopsychiatry from early in his career and went on to become director of NIMH. Klerman's research findings were published in various places, including Alberto DiMascio and Richard Shader's 1970 compendium The Clinical Handbook of Psychopharmacology.
Klerman found that the four most improved "symptoms," in descending order, were combativeness, hyperactivity, tension, and hostility. In short, the drugs subdue and control people. Hallucinations and delusions the cardinal symptoms of schizophrenia - ran a poor fifth and sixth.(4)
Since drugged patients become much less communicative, sometimes nearly mute, it's not surprising that they say less about their hallucinations and delusions. Had the investigators paid attention, they would have noticed that the patients also said less about their religious and political convictions as well as about their favorite hobby or sport. There's no wild cheering for the home team on the typical psychiatric ward. Furthermore, the drugs cause so much discomfort (see chapter 4) that patients often stop saying what they believe to avoid getting larger doses and to bring a more speedy end to the treatment. As many ex-patients have told me, "I learned right away I'd better shut up or I'd get more of that stuff." What's astonishing is that despite investigator bias and the global inhibition produced by the drugs, communications labeled hallucinations and delusions continued to be recorded.
Klerman vociferously claimed that his research confirmed an antipsychotic effect, and few, if any, people bothered to check his data.
They Who Are Different from Us
After I described the lobotomizing effect of the neuroleptics during a 1989 debate with an internationally known psychiatrist, the opposing doctor admitted that he himself had taken "one small dose of neuroleptic" and then experienced an overwhelming and unbearable sense of "depression" and "disinterest." But he went on to say that his patients, because of their "abnormal brains," underwent no such lobotomy effect. Unlike normal people, the patients supposedly felt better because the drug "harmonized" their biochemical abnormalities. This was not the first time I'd heard this argument made by a psychiatrist.
The outrage expressed by ex-patients in the audience contradicted his assertions about the harmlessness of the medications. So does the clinical literature cited in this and the next chapter.
What does it say about professionals when they argue that their patients are so different from themselves? Biopsychiatry lives by the principle that its patients are so different from other humans that almost anything can be done to them, including surgical, electrical, and chemical lobotomy. By contrast, the ethical helping person assumes that those seeking help possess the same human sensitivities as anyone else, including the therapist.
Drugs and Adjustment
Life in a mental hospital is so inhibited, constrained, and suppressed that patients might seem better adjusted when heavily drugged. As already noted in chapter 2, D. L. Rosenhan describes in the January 19, 1973, Science that even the most highly regarded mental hospitals are humiliating and oppressive places, even for normal volunteers masquerading as patients. Typical state hospitals, where many drug studies are conducted, are intimidating and frightfully violent. In Erving Goffman's phrase, these "total institutions" also stigmatize and demean their inmates. His analysis in Asylums (1961) helps us understand why a drugged patient would seem better adjusted than a drug-free person in such a setting; the chemically lobotomized patient fits better into the social role of mental patient, with its obedience to authority, conformity, lack of dignity, acceptance of mundane routines, and restricted opportunities for self-expression. Similarly, books and stories by former patients in all kinds of psychiatric facilities almost always describe them as wholly suppressive and demoralizing.(5) To say that patients behave better in a mental hospital when they are drugged is more a commentary on the requirements of being an inmate than on the allegedly beneficial qualities of drugs.
Unfortunately, the patient may face an equally suppressive life situation after discharge from the hospital. Board-and-care homes and nursing homes are at least as boring and stifling as psychiatric hospitals. Often they offer nothing but a bed, a TV, and perhaps a local park bench. Again, it is no surprise that patients might seem to adjust better to them when drugged. Indeed, most drug-free people would want to take flight rather than to waste away in a facility that offers nothing in the way of rehabilitation, recreation, or social life.
Nor is life necessarily less stultifying when the patient returns home to his or her family. As we saw in chapter 2, the families of children labeled schizophrenic are, at their best, unable to relate to their overwhelmed offspring. At their worst they are outright abusive. Typically the parents are overinvolved and unrelentingly critical of their son or daughter. Again, it's no surprise that drugged offspring might seem better adjusted to life in these families, while drug-free ones might continue to be resentful, rebellious, and difficult to control.
Drug experts and psychiatric textbooks that tout neuroleptics almost never concern themselves with the living conditions to which they are asking or forcing the drugged patient to adjust.

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