Intended for healthcare professionals

News

Research into treatments for mental illness is under threat

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3747 (Published 14 June 2011) Cite this as: BMJ 2011;342:d3747

Re:companies who stop research in Psychotropic drugs. Flawed drug evidence: a tip of the iceberg in medicine?

The loss of interest in research of drug treatment for psychiatric
illness is becoming more and more evident1.

I concur with Thomas 2 that the evidence for effectiveness of i.e.
antidepressant drug is not robust due to the lack of publication of
negative clinical results . Unfortunately, following an unclear
'emperor' in our thinking and handling of patients is not restricted to
medication or the psychiatry profession. The medical profession has been
trained to study positive results in research, outliers and results of
small number of cases are assigned to be ignored. As evidence for any
medical result, whether positive or negative starts off as anecdotal such
information which is appraised as low class tends to get dismissed.

Though medical training focuses on comprehensive assessment and
treatment with logical and sensible decision making trees, lack of
differential diagnoses processes in the medical profession can also result
in refractory treatment, which stretches beyond pharmacological
interventions.

Basic textbooks of psychiatry and psychopharmacology describe a
psychotropic drug induced aggravation of psychiatric symptoms, i.e. in
antipsychotic drugs, which has also been found in serotonergic drugs3
and severe dysphoria with aggressive attacks and suicidal gestures has
been ascribed to Strattera, a favourite drug for ADHD symptoms. This is a
pitfall in treatment. Medication can get even more increased when these
paradoxical side effects are not taken into consideration.

In terms of the renowned universal assessment tool for ADHD there
is not even one Conners item which is pathognonomic for the condition,
all criteria can be explained by other issues i.e. autonomic hyper-
arousal due to PTSD symptoms, specific learning difficulty and autism.
However, ADHD medication can be effective for these differential issues,
but still not the most ethical option in terms of side-effects and
plastering rather than treating the core problem. 'Severe depression and
suicidal ideation' in a person with a borderline personality disorder can
be attachment related with a complete resolution of depressive features
at the finding of a new partner or any resolving of issues with a
significant other. Their depressive symptoms also wax and wane as part of
a mood split in themselves resulting in dramatic mood instability.

I suppose that due to the direct effect of drugs on the central
nervous system drugs psychotropic withdrawal due to a reduction of
receptor (activity) is a more common phenomenon in psychiatry than other
areas of medicine, though similar principles apply in terms of rebound
infections at the cessation of long term use corticosteroids. This gives
a false picture of medication need.

The term co-morbidity is becoming more popular in medicine. However
this medical/psychiatric complexity could be better ascribed to
complication of one core-morbidity i.e. multi-organ dysfunction in
relation to an auto-immune condition and more or less all main
psychiatric diagnoses as a complication of severe personality disorder or
autism spectrum disorder.
Though many businesses thrive on co-morbidities, fragmentation of input
puts their survival at risk.

Taking Timimi's point4, social issues are not sufficiently taken in
to account in high prescribing cultures; i.e. in child and adolescent
psychiatry, it is not uncommon for children to be expelled from school
'until they are properly medicated or to have to undergo a psychiatric
assessment before 'Social Services' accepts a referral.

It is time for all medics to revamp more cohesive and logically
reasoned appraisal of assessments and treatment by allowing ourselves to
look outside the box, acknowledging pitfalls and side effects of
interventions in service of our patients.

References:

1. Wise J. Research into treatment for mental illness is under threat. BMJ
2011;342:d3747. (14 June.)

2. Thomas N. Drug evidence is flawed BMJ 2011;343:d4381

3. Hogberg, G. Riktlinjer for vard av unga med angest och depression
bar revideras lokartidningen 2011;108/1:36-37.

4. Timimi S. Concentrate on human factors BMJ 2011;343:d4377.

Competing interests: No competing interests

25 July 2011
Ruth L. Brand Flu
locum Consultant Developmental Child Psychiatrist
Derbyshire Mental Health Foundation Trust