In a belated new-year blog, I thought it would be useful to set out what I think someone needs to think about if they are considering taking a drug for a mental health problem, especially if they think they might end up taking the drug for a long time. These are the questions you might want to ask your doctor if you take a ‘drug-centred’ approach to the use of drugs in mental health (https://joannamoncrieff.com/2013/11/21/models-of-drug-action/).
1. What immediate effects will the drug have?
We need to know how taking a drug for a short time is likely to affect our feelings, thoughts and behaviour. Data from animal studies and ‘human volunteer’ studies can establish how a particular drug changes ordinary behaviour, feelings and mental capacities, but unfortunately, for many sorts of drug, this sort of research remains scanty or unpublished. However, the internet provides increasing opportunities for people to record their experiences after taking prescribed medication (on sites like https://www.rxisk.org/Report/About.aspx; http://www.askapatient.com/). Although data from people with diagnosed mental health problems is often dismissed because it is difficult to disentangle the effects of the underlying problem from the effects of the drug, if it is considered carefully, it can provide useful insights. Further animal and volunteer studies are also necessary to clarify certain subtle and complex effects, however.
2. What does the drug do if you take it for a long time?
As well as knowing what sort of changes occur after one or two doses of a drug, we need to know what happens to feelings and behaviour when the drug is consumed for the weeks, months and years that drugs are typically prescribed to humans with mental health problems. Since there are ethical, practical and financial limitations to the length of time volunteers or animals can be subjected to active drugs, we need to pay attention to other sources of information on what sort of mental and behavioural changes result when people take prescribed drugs for long periods of time. Drug monitoring programmes and other systems (including internet sites) that allow users to record what has happened to them while taking a drug are essential therefore to gathering information about what effects a drug can have when it is taken for long periods of time.
3. How does the drug affect the body as a whole?
We need to know how the drug affects the body as a whole, in all its systems, including the brain and nerves, the heart, the digestive system, the reproductive system, other hormones etc. We need information on bodily effects that occur after short term use and long-term use. We need data on measures of physical disease and impairment such as cognitive function, hormone levels, cardiac function and metabolic efficiency, as well as data on how taking a drug for short or long periods influences death rates. Animal and volunteer studies are sometimes conducted to investigate particular, drug-induced effects, usually over the short-term. Again, however, we need to rely on recording effects that occur in people who are taking medication for diagnosed mental health problems in order to assess the impact of drugs on all bodily systems after long-term use.
4. What happens when you stop the drug?
We need to know what happens when someone stops taking a drug they have been taking for a while. What sort of mental and physical effects occur after withdrawal? How long do the effects last for, and how do they relate to factors such as the duration of time the drug was taken for and the dose the drug was used at? How severe can they be, and can they persist for a long time? How can withdrawal effects be minimised?
5. How will taking the drug affect my mental health problems?
We need information on how all these effects – the physical, mental and behavioural effects of different drugs over short and long periods – interact with the sorts of problems that people are seeking help for when they go to see a mental health practitioner. Does taking the drug reduce the intensity of distressing feelings, for example? Does it reduce unwanted behaviours like verbal and physical aggression? This is the point at which conventional randomised controlled trial (RCT) can be useful. RCTs can help establish whether a particular drug is superior to a similar intervention like a placebo tablet for particular problems or symptoms. Of course there are numerous difficulties in formulating the nature of mental health problems, and the ‘diagnoses’ we currently use are not necessarily helpful for pin-pointing the effects of prescribed drugs. Nevertheless, with simple problems like insomnia, for example, a trial can provide useful data on whether a drug is superior to a placebo, taking into account other influences like the ‘active placebo’ effect. Unfortunately most RCTs last only a few weeks, and none provide any data about whether the effects of a drug are sustained for months and years, or how they change over time with continued use of the drug.
6. How will taking the drug affect the rest of my life?
If we think we are likely to end up taking a drug for weeks, months or years, then it is essential that we know how the drug might affect all the various aspects of our life, from our ability to work or just read a book, to our emotional and sexual relationships. A drug may effectively wipe out symptoms by making someone sleep most of the time, for example, but this would obviously be a hindrance to getting to work or doing the shopping. Some RCTs provide a little information on global wellbeing or functioning, but again, we need to listen to the experiences of people who have taken prescription medications to understand the range of effects use of a particular drug might have on a person’s daily life.
7. Are there alternative ways of achieving the same effects?
In some situations other measures, such as taking more exercise or relaxation techniques, might be able to produce the same effect as taking a drug with fewer complications. When, and if, we can establish that taking a drug is likely to provide some real, concrete benefits, we then need to compare the use of the drug with other methods of achieving the same result.
It is clear from setting out these considerations that the existing research base is completely inadequate. Your family doctor or psychiatrist is therefore most unlikely to have this knowledge at their finger-tips, because much of it does not exist. One of the most important implications of the drug centred model of psychiatric drug treatment is therefore that we need much more comprehensive scientific data about the drugs that we use for mental health problems. We should have had this data before we started on the sort of mass prescribing that has now become established, but it is not too late to provide a proper evidence base for future generations to make properly informed decisions. If we start asking the right questions, we might eventually persuade funders and scientists to do some more informative research, and to collate the wealth of existing information on the experiences of people who have already used these drugs.