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feelings and mental capacities, but unfortunately, for many sorts of drug, this sort of research remains scanty or unpublished.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.
Joanna Moncrieff 
Reblogged this on Chrys Muirhead .
Reblogged this on Beyond Meds and commented:
Joanna Moncrieff MD outlines several questions that one might want to ask when considering whether taking a psychiatric drug makes sense or not. I think it’s very significant that she repeatedly suggests people take to the internet to get the answers. This, in my opinion, is because she knows doctors don’t generally have the answers. Well, in fact, no one has all the answers. There is far too much we simply don’t know about these drugs which is why it behooves us to know as much as possible. Beyond Meds came to be as a result of my having been gravely harmed by these medications. And I, in fact, asked these questions but was told, unequivocally, at the time, that the drugs were safe. Let’s not let that happen anymore. People are free to choose these drugs, but let it be as informed a choice as possible.
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Reblogged this on: http://emocionesarribaabajo.blogspot.com/2015/02/lo-que-usted-necesita-saber-antes-de.html and commented:
For my concept I have a mental problem, I’m a patient who has been treated with psychotropic drugs for about 30years, some of the questions that you mention in the post I’ve made them before, without obtaining further explanation, having no idea what subjected me to take them, they just told me, you’re sick and should take pills for the rest of life.
On several occasions I have refused to take psychotropic drugs, when I’ve felt better in my symptoms of mental imbalance, I have suspended without either asking many questions, at first I felt bad, but then I get to be better without taking these drugs when taking, however, when I feel too unbalanced, I turn back to psychiatric consultation and restarting the medication.
I felt that with psychotropic drugs I managed to improve my personal condition, but I think it may not need to take much pill, or take it for so long since my last days have been improved with only two drugs not as strong and even letting them spend time possible without feeling symptoms of my mental problem.
I agree on many issues with what you posed in several of the writings I’ve read, on this basis have come to the conclusion that the approach has given the management of mental problems is wrong, what is sought to sell many expensive drugs not to solve or alleviate the symptoms clear, but to maintain a chronicity.
Starting from his approach, it would be possible to treat mental problems with adequate medicines to costs low doses, however, this situation is difficult to achieve because this approach does not have a business opportunity.
i have had to take psychiatric medications for many years and have always not felt right by taking them. that is i wouldn’t get any form of relieve from my conditions. i have been forced by the government to take psychotropics and ECT treatments. i have developed metabolic syndrome and have become disabled by these treatments and the false believe that i was being helped.
I love the article. But beyond knowing the questions, I am never sure how hard I can push the Doctor to answer? When can you confidently withhold your informed consent based on the grounds that they have not sufficiently informed you? In a regular doctors setting, perhaps doctors are civilized about this. But imagine this …
I am in an acute psych ward, and my status is voluntary. The blackmail being enacted is that if I do not cooperative, then my status might become compulsory. But my psychiatrist isn’t properly answering questions, and ruthlessly shortens the interviews. My diagnosis – “Oh, some kind of bipolar, isn’t it”. I ask for info about the meds, and recieve a useless authorless glossy pamphlet from a drug company’s marketing dept. Nothing quantitative, nothing reliable, and nothing scientific. Evasion.
So, to get answers, I need to push him hard. And to do that, I need to staunchly refuse to consent until properly informed. But if I have already caught him lying to me, or in deceptive half-truths, then can I demand a higher level of info – something published, quantitative, and peer reviewed. Can I refuse to accept info from studies that is neither peer reviewed nor data transparent? Can I refuse to accept info from studies without seeing the methods they used. Can I insist on internet access, such that I can establish the information’s validity.
In short, if you want to push your doctor harder, then you need to know you are on a firm legal footing. That if he tries to change your status to “compulsory”, you can successfully argue that he was witholding relevant information, or access to information. That I withheld consent because I never had enough info to judge with any certainty that the benefits of treatment would outweigh the harms for patients just like me.
I suspect most patients are timid with their doctors, and subsequently get owned. Its almost like we need to lawyer up.
Reblogged this on Chaos Theory and Human Pharmacology.
I try my best to answer these questions for my patients and found that what my patients appreciate most is that I give them options and weigh the risks/benefits of each (non-med approach vs med approach vs differences between the different available medications). great post!
A good article and I admire your work in this important field.
I’d like to reiterate Dru8274’s points: how can patients press harder for answers when told outright that the drugs are not toxic, as happened to me today? Not conforming to taking medicine is seen as a sign of unbalanced decision making rather than one based on the concern over the effects, simply because they do not agree? There seems to be no way of being referred to more open minded psychiatrists.
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“The thing that’s important to know is that you never know, you’re always sort of feeling your way.”
Diane Arbus
For me the greatest photographer of humanity of the Twentieth Century. And she would hate that description. In trying to escape my own lot of poverty and working as a restaurant dish washer at age 16 ( had managed to get an ‘O’ level at school, was good at drawing ) I enrolled to study art and photography evening class, that progressed to doing a few A levels. However I took exception to my A level Photography teacher describing Arbus as a ‘glorified photojournalist’, wrote an essay on why he was wrong, referenced my own lot in life to what she was doing and got kicked out of the class. She OD’d on barbiturates and slit her wrists in a bath tub. I’ve wondered if she and Mark Rothko (OD’d on antidepressant, very violent suicide) had Akathisia. I’ve asked the people who look after the estates, didn’t expect a reply and didn’t get one. As a matter of history into the devastating results of these drugs, the crime of the implementation, it’s affect on humanity and the history of art, I can only hope someone finds out so that we can better feel our way .
It’s interesting to find out what psychiatrists are up to. Professor Edward D Levin has filed a number of patents over a few decades. He starts with ‘Agonist-antagonist combination to reduce the use of nicotine and other drugs’. And ends up with using nicotine substitutes to treat what seems to be almost everything:
http://patents.justia.com/inventor/edward-d-levin
phenyl-substitued nicotinic ligands and methods of use thereof
“addiction, pain, obesity, schizophrenia, epilepsy, mania and manic depression, anxiety, Alzheimer’s disease, learning deficit, cognition deficit, attention deficit, memory loss, Lewy Body Dementia, Attention Deficit Hyperactivity Disorder (ADHD), Parkinson’s disease, Huntington’s disease, Tourette’s syndrome, amyotrophic lateral sclerosis, inflammation, stroke, spinal cord injury, dyskinesias, obsessive compulsive disorder, chemical substance abuse, alcoholism, memory deficit, pseudodementia, Ganser’s syndrome, migraine pain, bulimia, premenstrual syndrome or late luteal phase syndrome, tobacco abuse, post-traumatic syndrome, social phobia, chronic fatigue syndrome, premature ejaculation, erectile difficulty, anorexia nervosa, autism, mutism, trichotillomania, hypothermia, and disorders of sleep.”
Nicotinic acetylcholine receptors respond to Acetylcholine which is a neurotransmitter responsible for activating muscles “This property means that drugs that affect cholinergic systems can have very dangerous effects ranging from paralysis to convulsions.”
https://en.wikipedia.org/wiki/Acetylcholine
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I was in a car accident due to menopausal psychosis at age 46 and broke a woman’s arm. I had postpartum psychosis at age 22. Then I worked full time for 24 years as a labor and delivery and psychiatric RN with only mild depression on and off during that time, no mania; I have always had a quieter disposition. I was court supervised for 10 years on high doses of antipsychotics. My kidney gfr dropped to 40 on lithium after hovering at 60 for 10 years. I made very poor eye contact and could not carry on a conversations. This suffering was horrible. I developed constant hand contractions and mouth movements which did not concern her in the least. I informed my psychiatrist many times about this. She would not lower my dose for years. The courts would not allow me to get a new psychiatrist. I sat on a parole bench once a month for ten year with criminals. I was treated as an mentally ill nonhuman. I have been seeing a naturopathic board certified psychiatrist, Dr. Aruna Tummala, for the past 2 1/2 years. She is respectful, thorough and brilliant. Since my court discharge a year ago (they wanted to court commit me because I was seeing a naturopath so I lied and lied to get out of this torture). I am on a number of natural treatments which are working well and not very expensive (much cheaper than the monthly injection I was getting). Mostly I feel human, intelligent and social again! It was a living death for 10 years. I would like to advocate for persons with brain malfunctions. Let me know if I can do anything to help you.
Sincerely, Jennifer Dunn
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