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What are your burning issues for 2018?

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k9 (Published 04 January 2018) Cite this as: BMJ 2018;360:k9

Psychiatry is a disaster area in healthcare that we need to focus on

With its liberal use of psychiatric drugs, psychiatry - which includes the work of GPs with psychiatric patients - does far more harm than good (1). Yet, not a single country has taken the UN’s handicap convention seriously, although it is impossible to argue, ethically or scientifically, that it is in the patients’ best interest to be subjected to forced treatment with neuroleptics (1).

According to the prevailing paradigm, psychiatric drugs have specific effects against specific disorders; their actions provide more good than harm; and it is often necessary to take them for years or perhaps even lifelong. Furthermore, many psychiatrists still tell their patients that they suffer from a chemical imbalance, and that taking a psychiatric drug is similar to taking insulin for diabetes (1).

This has been the paradigm in psychiatry since chlorpromazine came on the market in 1954. However, when the research in support of the paradigm is critically appraised, it becomes clear that the paradigm is unsustainable.

Firstly, the effects of psychiatric drugs are not specific. They impair higher brain functions and cause similar effects in patients, healthy people and animals, which is far from causing specific effects in specific disorders (1,2).

Secondly, the research in support of the paradigm is flawed (1-3).

Thirdly, the widespread use of psychiatric drugs has been harmful for the patients. In every country where this relationship has been examined, the increased usage of psychiatric drugs has been accompanied by an increase in the number of chronically ill people and the number of people on disability pensions (3). This speaks strongly against the idea of having specific drugs for specific disorders.

Fourthly, all attempts at showing that psychiatric disorders cause brain damage that can be seen on brain scans have failed. This research area is intensely flawed and very often, the researchers have not even considered the possibility that any brain changes they observe could have been caused by the psychiatric drugs their patients have taken for years (1,2). In contrast, it has been shown in many reliable studies - most clearly for neuroleptic drugs - that psychiatric drugs can cause permanent brain damage (1-3).

There are four main problems with psychiatric drug trials:

1) Almost all placebo-controlled trials are flawed due to their cold turkey design (1) Patients who are already in treatment first go through a wash-out period, when everyone is removed from the drug they had been on, and they are then randomised to placebo or drug. The wash-out period is too short to avoid withdrawal symptoms in the placebo group(1,4). These withdrawal symptoms can be the same as those that define the disorder, e.g. depression in depression trials, and the withdrawal effects can be very pronounced. One-third of patients in long-term treatment with sertraline or paroxetine who had been well for 4 to 24 months after remission of their depression had an increase in their Hamilton score of at least 8 during a 5-8 day period where the drug was substituted with a placebo (5).

2) The trials are insufficiently blinded (1).The drugs have conspicuous side effects and many patients and doctors have therefore guessed whether the drug is active or placebo. This is an important problem when the outcomes are subjective (1), which they virtually always are in psychiatric drug trials.

3) Psychiatrists assess the effect using rating scales, the relevance of which for the patients is often uncertain (1).

4) Selective reporting of outcomes is very common and can be very serious (1). As just one example, only about half of the suicides and half of the total number of deaths are reported in published drug trials compared with available data in trial registers (6), and we have found in our research that trial registry data may also be incomplete.

Psychiatry needs a revolution. Reforms are not enough. We need to focus on psychotherapy and to hardly use any psychiatric drugs at all.

Disclaimer: these are my views, based on ten years of research on psychiatric drugs. But they are shared by many patients.

1. Gøtzsche PC. Deadly psychiatry and organised denial. Copenhagen: People’s Press; 2015.

2. Breggin PR. Brain-disabling treatments in psychiatry: drugs, electroshock, and the psychopharmaceutical complex. New York: Springer; 2008.

3. Whitaker R. Anatomy of an epidemic. New York: Broadway Books; 2015.

4. Fava GA, Gatti A, Belaise C, Guidi J, Offidani E. Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review. Psychother Psychosom 2015;84:72-81.

5. Rosenbaum JF, Fava M, Hoog SL, et al. Selective serotonin reuptake inhibitor discontinuation syndrome: a randomised clinical trial. Biol Psychiatry 1998;44:77-87.

6. Hughes S, Cohen D, Jaggi R. Differences in reporting serious adverse events in industry sponsored clinical trial registries and journal articles on antidepressant and antipsychotic drugs: a cross-sectional study. BMJ Open 2014;4:e005535.

Competing interests: No competing interests

10 January 2018
Peter C Gøtzsche
Nordic Cochrane Centre