Addiction Treatment Blog

Separation Liability

Liability for drug induced injuries did not become an issue of general concern until quite recently. However, a number of drug-induced problems from thalidomide in the 1960s to Opren and diethylstilbestrol in the 1970s have caused widespread public disquiet and led to increasing awareness of issues to do with liability. In psychiatry, concern in the UK focuses on the question of benzodiazepine prescribing, while in the US the paramount issue concerns the occurrence of tardive dyskinesia in individuals taking neuroleptics. The question has become an emotive one with some commentators who survey the problem referring to the appalling frequency of drug-induced injury, while others comment on its astonishing tray (1). Whatever the absolute frequencies, contrary probably to public belief, the evidence suggests that the larger the pharmaceutical company, the better its practice regarding drug safety is likely to be (2).

Drug-induced problems may stem from toxic effects of a drug, or toxic effects caused by an impure additive, or from allergic reactions to the drug or its additive. Problems may also stem from over prescribing. For instance, in the case of someone who dies from a resistant bacterial infection, a relative could claim that the subject’s death arose in part from the excessive prescription of antibiotics that in its own right brings about the production of resistant infections. In the case of neuroleptics, problems may be brought about by the overuse of these drugs but this overuse, far from being solely promoted by drug companies stems in part from the current politics of mental health – deaths have stemmed from rapid tranquillisation often by harassed staff in psychiatric units. Read more…

Dementia Treatment

It is not clear yet that damage to the cholinergic pathway is the central deficit in Alzheimer’s dementia. Indeed, it has recently become clear that a number of other neurotransmitters are affected in both Alzheimer’s and other cortical dementias. It is also clear that, because of the interactions between various neurotransmitter systems, it is almost impossible to manipulate one neurotransmitter systems, it is almost impossible to manipulate one neurotransmitter without affecting the others.

Finally, from the vantage point of the 1990s, it seems that many cortical dementias may involve cell protective mechanisms that have been thrown out of gear. Normally, there are a range of mechanisms within cells for neutralizing toxins of various sorts. These often involve the binding of a protein to the toxin, which labels it so that the cell’s own degredative processes destroy the offending agent. In the dementias, however, such mechanisms seem to have been stimulated to the point where the large amounts of cell-protective proteins are produced, to the point where large amounts of cell-protective proteins are produced, to the point that they themselves poison the cell. Whether the stimulus is genetic, viral, toxic (as in aluminium) or some combination of these and other factors is uncertain. The treatment options are to find compounds that will switch off the process or else compounds that will compensate for it. Read more…

Schizophrenia can be dangerous to yourself and others around you if treated incorrectly.

In any consideration of the dopamine hypothesis of schizophrenia, one of the arguments invariably put forward is that psychostimulant drugs, in particular the amphetamines, lead to a mental disorder characterised by prominent paranoid feelings, or outright paranoid delusions. This many authorities have suggested, is a state that is very similar to some schizophrenic states. As the psychostimulants increase brain dopamine levels or neurotransmission, schizophrenia must therefore involve increased dopamine functioning and accordingly dopamine antagonists are its appropriate treatment.

However, the picture in real life is considerably more ambiguous. In the first place there has long been a substantial amount of evidence that up to a third of individuals with ‘schizophrenia‘ actually do well on psychostimulants. Read more…

History of the Neuroleptics

There is considerable controversy over who discovered the neuroleptics, one that is highly relevant to the question of just what these drugs do. Chlorpromazine was first synthesised in 1950, with the intention of producing centrally acting antihistamine for the control of cardiorespiratory sock or collapse. It was first used widely in humans in 1952, along with other agents, as part of an anaesthetic cocktail, when its effects were noted by a chlorpromazine – they were neither sedated in the usual way with anaesthetic agents or analgesic, but rather appeared to become indifferent. This he described as an ataractic effect. A notable point here is that the effect must have come on within an hour or so after having had the drug – and it came on in normal subjects.

In 1952, Jean Delay and Pierre Deniker reported that chlorpromazine was of benefit in controlling states of manic and psychotic agitation. Around the time of its launch in 1954, there was no suggestion that chlorpromazine was likely in any way to be specific to schizophrenia. That came later. In the mid-1950s, chlorpromazine was being reported as being useful for almost every psychiatric condition (hence its trade name Largactil – Large Action).

Laborit has always claimed priority in the discovery of chlorpromazine. Delay and Deniker and others have disputed this. To some extent taking sides in the dispute depends on whether you see the neuroleptics as being in some way curative of psychotic illness or as producing an anti-agitation effect – an effect that is produced equally in all takers who are agitated, whether or not they have a psychological problem. Laborit’s descriptions are in line with the approach that is adopted in this article, which is that neuroleptics act by inducing a state of psychic indifference – in everyone who has them, and that they do this within a short period of time. Delay and Deniker’s approach is the approach that later led to the notion that neuroleptics were anti-schizophrenic.

Within a few years of their use, it became  clear that the new group of drugs produced extrapyramidal side effects. As further compounds came on stream, it seemed that only those that produced extrapyramidal effects brought about benefits in the psychoses. This led to two things. One was that the drugs as a group came to be called neuroleptics by Delay, a term which literally means ‘nerve seizing‘. The second effect was that, for 30 years, little effort was put into finding ‘antipsychotic‘ agents that would not produce extrapyramidal effects – atypical neuroleptics as such agents are now called. It is only in recent years with the rediscovery of clozapine – a drug almost devoid of extrapyramidal effects – that the picture is changing.

Are Neuroleptics Anti-Schizophrenic?

It is commonly believed that neuroleptics drugs are anti-schizophrenic.

The evidence that neuroleptics are anti-schizophrenic comes from a series of research projects which have shown that subjects who take them after discharge from hospital are much less likely to be readmitted than those who do not.

The dopamine hypothesis of schizophrenia has been developed based on this kind of evidence. Briefly, this hypothesis states that as all neuroleptics block the dopamine system in the brain, and as they are beneficial in schizophrenia, therefore there must be something wrong with the dopamine system in the brains of individuals with schizophrenia. A major research enterprise has developed around attempts to test this hypothesis. From a sociological point if view, there have been two consequences of this. One is that many current researchers have had a vested interest in believing that neuroleptics are anti-schizophrenic. Another has been given the ‘known’ abnormalities in the dopamine system in schizophrenia, the fact that the drugs work on the dopamine system means that they are anti-schizophrenic.

For those who take the approach that neuroleptics do reverse the core disturbance in schizophrenia, the usual response to patients not getting better has been to give more of the drugs, and the idea that an individual might not take their drugs is viewed very seriously. In addition, the idea of paying much heed to what the takers of the drugs have to say about whether they are helpful or not seemed irrelevant – after all, these drugs are curative of an illness, a cardinal manifestation of which is supposedly lack of judgement.

The view taken throughout this chapter is that neuroleptics are not specifically anti-schizophrenic but that they are useful for anyone who is agitated, rather than just for people who have schizophrenia. The evidence for this comes from daily practice. Anyone who is agitated will usually be prescribed neuroleptics, whether or not they have schizophrenia. They may have depression, mania or just be agitated. Read more…

Traditionally, three psychoses or major categories of psychiatric illness have been described. These are schizophrenia, manic-depressive psychosis and a third group, variously termed the paranoid, reactive or sensitive psychoses, which more recently have been called the delusional disorders.

This seeming diagnostic precision, however, masks a situation in which, since World War II, there has been a tendency to label all serious psychiatric conditions as schizophrenia. Accordingly, the pharmacological management of the psychoses, in practice, reduces to the management of schizophrenia. It has also reduced in the past 30 years, to the clinical employment of a group of drugs called the neuroleptics, which have been supposed to be in some way specifically therapeutic for schizophrenia. Read more…

The number of children contemplating suicide has increased by fourteen per cent over the past year.

Up to fifteen to twenty per cent of unresponsive manic depressives kill themselves. When the condition is poorly controlled through incorrect medication, or combinations of them, and in harrowing life circumstances, suicide can happen, and it is vital to encourage sufferers to keep as much contact with carers as they can and, if possible, so that when things start to go wrong there is help to prevent these crises.

Statistics

Around 4500 people kill themselves in England and Wales each year (one in 100 deaths), while at least ten times that number of people attempt suicide.

In almost all cultures, the suicide rate rises with age, with the highest rates in the UK for those over seventy-five. In recent years, suicide has also increased in young man, and it is now the second leading cause of death in the fifteen to twenty-four age group, after accidents.

Certain factors are known to be associated with increased risk, including drug and alcohol misuse, unemployment, social isolation and family breakdown. People with diagnosed mental health problem are at  particular risk. Indeed, up to ninety per cent of suicide victims have been reported to have been suffering from a psychiatric disorder at the time of their death. Read more…

Schizophrenia can be dangerous to yourself and others around you if treated incorrectly.

The split in schizophrenia refers to a splitting of the mind, not the personality. It is a label given to people who have a number of emotional and cognitive or thought-based symptoms.

DSM IV defines schizophrenia as a collection of symptoms that have been present for month or longer against a background of symptoms present for at least six months. The symptoms are associated with social dysfunction. Two of the following symptoms are required for the diagnosis; delusions; hallucinations; disorganized or incoherent speech; disorganized behaviour; and ‘negative’ symptoms, which describe a lack of emotional and verbal responses.

The best-known symptoms are delusions and hallucinations that include hearing voices. Delusions are erroneous beliefs that cannot be shifted regardless of the evidence to the contrary. They are often part of a complex belief system, which may include a belief about being persecuted. Read more…

Schizophrenia

Originally named by Swiss psychiatrist Eugen Bleuler in 1908, Schizophrenia is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. Distortions in perception may affect all five senses, including sight, hearing, taste, smell and touch, but most commonly manifest as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction.

The condition is thought to affect around 1% of people at some point in their lives, often appearing first in late adolescence or early adulthood, and can cause untold human misery. Social problems, such as long-term unemployment, poverty and homelessness, are common and the lifetime occurrence of substance abuse is estimated to be around 40%. Furthermore, the average life expectancy of people with the disorder is 10 to 12 years less than those without, due to increased physical health problems and a higher suicide rate, according to the British Journal of Psychiatry. In addition to the toll the disease takes on its sufferers, it also has massive economic and social implications. The British taxpayer is estimated to spend around £2bn per year on care and treatment for the disorder and according to Professor David St Clair of the University of Aberdeen the global bill for drugs alone runs to around £12.5bn in society’s attempts to fight the affliction.

However, an article appearing on the front cover of The Independent has today given new hope to researchers and professionals dealing with the illness, together with its millions of sufferers, worldwide. Entitled “Unlocked: the secrets of schizophrenia”, the article explains how researchers in three locations across the world have combined their efforts and data on more than 15,000 patients and 50,000 healthy “control” individuals to come up with new information about the genetic roots of schizophrenia. Read more…

The use of medications for psychiatric disorders is often justified by observing symptom improvement and stating that the drug responsiveness proved that the patient had a specific diagnosis. … For people with intellectual disability, the false argument type of drug working = solid diagnosis has been particularly important for it justified the use of antipsychotic medications for challenging behavior for many decades.

…We are often unsure of diagnosis, so we may measure improvement by changes in those signs and symptoms, as in your example of the patient who cannot sleep, but whose sleep returns to normal with an antidepressant.

…So you are saying that a symptom may improve because a drug treats symptoms common to several psychiatric disorders, or can relieve a symptom by side-effect, that several different classes of drug could relieve a symptom by side effect, and this lack of drug specificity makes it impossible to use drug response to prove a diagnosis.

…They are specific for the neurotransmitters to which they respond, but each neuroreceptor is really a family of neuroreceptors. There are, for example, seven known subtypes of serotonin (5HT) receptors, at least four subtypes of dopamine (DA) receptors, at least two norepinephrine (NE) receptors, and similarly large families of histamine (HIS), gamma-amino butyric acid (GABA) receptors and glutamine (Glu) receptors. Read more…

Psychiatric Drugs Explained

The revised edition of this highly-respected book builds on the success of the first edition with enhanced coverage of current issues and developments in psychotropic drug use, in both hospital and community settings. Using clear language, Psychiatric Drugs Explained explores the effects, benefits and side effects of psychotropic drugs and the impact these can have on person’s life. It will be an essential guide for those involved in the care of people following psychotropic drug regimens.

Organised by condition, the management of schizophrenia, depression, mania, obsessive compulsive disorders, anxiety, insomnia, cognitive impairement and sexual difficulties are all considered. The major drug categories are listed and the clinical uses, modes of action and side effects of principal drugs in each category are described. Issues such as consent to treatment, liability for side effects and dependence on psychotropic drugs are also discussed.

Psychiatric Drugs Explained will allow both clients and those advising them to be better informed when considering available treatment options. It is an essential handbook for psychiatric nurses (hospital and community), student nurses (including Project 2000), GPs, social workers and psychiatrists. Read more…