The death of atypical antipsychotics

The British Journal of Psychiatry has just published the latest in a long line of studies to find that the newer ‘atypical’ or ‘second generation’ antipsychotic drugs are barely better than the old style medications and has a stinging editorial that accompanies the piece calling out years of drug company marketing spun as an illusory advance in medical science.

Unfortunately both are locked (after all, you’d just worry yourself with all those facts) but here is the last paragraph of the editorial. It leaves no ass unkicked.

In creating successive new classes of antipsychotics over the years, the industry has helped develop a broader range of different drugs with different side-effect profiles and potencies, and possibly an increased chance of finding a drug to suit each of our patients. But the price of doing this has been considerable – in 2003 the cost of antipsychotics in the USA equalled the cost of paying all their psychiatrists.

The story of the atypicals and the SGAs ['second-generation antipsychotics'] is not the story of clinical discovery and progress; it is the story of fabricated classes, money and marketing. The study published today is a small but important piece of the jigsaw completing a picture that undermines any clinical or scientific confidence in these classes.

With the industry reputation damaged by evidence of selective publishing and its deleterious effects, and the recent claims that trials of at least one of the new atypicals have been knowingly ‘buried’, it will take a great deal for psychiatrists to be persuaded that the next new discovery of a drug or a class will be anything more than a cynical tactic to generate profit. In the meantime, perhaps we can drop the atypical, second-generation, brand new and very expensive labels: they are all just plain antipsychotics.

Link to locked editorial ‘The rise and fall of the atypical antipsychotics’.

View the original article here

Antipsychotics and the profit panacea

Aljazeera has an interesting if not worrying article about the fact that antipsychotic drugs have become “the single top-selling therapeutic class of prescription drugs in the United States, surpassing drugs used to treat high cholesterol and acid reflux.”

The huge rise in prescriptions has been sparked by the availability of a relatively new class of drugs called ‘atypical antipsychotics’.

All antipsychotics block the D2 type of dopamine receptor and their effect on the mesolimbic dopamine pathway is what largely causes the reduction in psychotic symptoms.

The older drugs block D2 receptors fairly indiscriminately in the brain, including in the nigrostriatal pathway.

This pathway is involved in movement regulation and blocking dopamine here leads to similar problems to Parkinson’s disease (tremors, rigid and uncontrollable movements) – a type of dementia where this brain area starts to break down due to disease.

The newer ‘atypical antipsychotics’ usually also block serotonin 2A (5HT-2A) receptors in the key movement pathway.

Serotonin normally reduces dopamine release but because serotonin is being blocked, more dopamine is released in the movement pathway with the newer atypical antipsychotic drugs than with the older typical antipsychotic medications.

This means less Parkinson’s-like movement side-effects with the atypicals – a genuine advance – but unfortunately, the serotonin effect causes additional problems with weight gain and often obesity, diabetes and heart problems.

However, these problems are perhaps easier to control and more ‘socially acceptable’ (compare with someone who make strange contorted movements during conversation).

On the commercial side, many newer atypicals are still under patent, meaning one company has sole control over their manufacture and sale, while other companies are not able to make cheaper copies.

Over time, these newer drugs have been promoted, legally and illegally, by drug companies for a wider and wider range of problems – everything from depression to dementia.

Despite limited evidence for their effectiveness in these areas, the sales campaign has been a huge success and the drugs are now being widely prescribed.

Once upon a time, antipsychotics were reserved for a relatively small number of patients with hard-core psychiatric diagnoses – primarily schizophrenia and bipolar disorder – to treat such symptoms as delusions, hallucinations, or formal thought disorder. Today, it seems, everyone is taking antipsychotics. Parents are told that their unruly kids are in fact bipolar, and in need of anti-psychotics, while old people with dementia are dosed, in large numbers, with drugs once reserved largely for schizophrenics. Americans with symptoms ranging from chronic depression to anxiety to insomnia are now being prescribed anti-psychotics at rates that seem to indicate a national mass psychosis…

What’s especially troubling about the over-prescription of the new antipsychotics is its prevalence among the very young and the very old – vulnerable groups who often do not make their own choices when it comes to what medications they take. Investigations into antipsychotic use suggests that their purpose, in these cases, may be to subdue and tranquilize rather than to treat any genuine psychosis.

Antipsychotic drugs have been one of the great advances of 20th century medicine. For the first time we have an effective treatment for psychosis, one of the most disabling of any of the disorders, that works for at least a fair proportion of patients.

The side-effects of both the older and newer drugs, however, are among the worst of any medication and they should genuinely be used with caution.

Unfortunately, the well-being of patients has become secondary to the profit margins of large pharmaceutical companies who continue to promote these drugs to as many patients as possible, regardless of their benefits or adverse effects.

The Aljazeera article tracks this campaign to the point where they have become top selling medications.

Link to ‘How Big Pharma got Americans hooked on anti-psychotic drugs.’

View the original article here