Oregon group wants to rein in use of mental health drugs

From the Oregonian, October 3, 2011

David Pollack was medical director of Oregon’s mental health program when he learned just how far psychiatric drugs had spread. About 250 kids between ages 1 and 6 who the Oregon Health Plan tracked were prescribed antipsychotics and antidepressants, despite no proof of early-age safety for them.

“How could that be happening?” he remembers thinking. Now he is one of many mental health care professionals asking if mental health drugs are overprescribed.

After centuries of inhumane and ineffective treatment of people with mental illness — including institutionalization and lobotomies — the discovery of psychiatric drugs in the last several decades seemed a blessing if not a cure.

Those drugs represent a more than $25 billion market. And Research shows even non-psychiatrists increasingly prescribe the drugs, and at times to patients with no mental health diagnosis.

Now, a fierce debate is brewing. Recent books and studies question the long-term efficacy of psychiatric drugs and suggest a rethinking of mental health care, a push that has found like minds in Oregon.

Pollack among them. A longtime board member of the American Association of Community Psychiatrists and a professor at Oregon Health & Science University, he joined as science advisor to the Foundation for Excellence in Mental Health Care, a new nonprofit based in Wilsonville that’s challenging conventional wisdom and urging a more cautious use of psychiatric drugs.

Landmark studies

A decade ago, seeing patients on weekends and after-hours, psychiatrist Erick Turner started to prescribe medications differently because of his day job: drug reviewer for the Food and Drug Administration. The FDA stamp of approval typically required two effective trials; contradictory trial results often were disregarded and not publicly released, Turner realized.

“If I hadn’t happened to be working at FDA, I would think these drugs never miss,” he said.

Three years ago, by then on OHSU faculty, he and four colleagues released a landmark study of unpublished FDA data obtained through the federal Freedom of Information Act.

It set off a stir. Antidepressants, the study showed, are significantly less effective than portrayed. Not only that, but studies the FDA considered negative or equivocal were reported with a positive spin in medical journals, Turner said.

Since Turner’s research put antidepressants under a spotlight, drugs that treat schizophrenia, anxiety and bipolar disorder have also come under closer examination for long-term effects. Industry-funded drug trials often judge effectiveness over six weeks.

In his “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America,” released last year, journalist Robert Whitaker cites long-term research that overuse of psychiatric drugs may be making things worse. Among the findings:

  • anti-depressants may lead to long-lasting and harder-to-treat depression, and even bipolar symptoms;
    a MRI brain scan study shows antipsychotics can accelerate brain shrinkage and cognitive decline;
    and psychiatric drugs are riskiest for young people.
  • Even psychiatrists predisposed to listen to Whitaker say his work risks glossing over their reality. Drugs sometimes seem the only way to prevent people in urgent need from harming themselves or others

    OHSU’s Turner, whose study is included in Whitaker’s book, says even weak tools are better than none. The drugs do help some people — and as a psychiatrist, “you want to do everything you can,” he said.

    Dr. Maggie Bennington-Davis, Chief Medical and Operating Officer for Cascadia Behavioral Healthcare in Portland, says Whitaker’s book has caused her “huge anxiety” over whether psychiatry has hurt people. Yet, she says, “It’s hard to imagine that there aren’t situations where medicines aren’t pretty darn necessary, and I think he left that part out.”

    A foundation

    A trained therapist, Gina Nikkel ran successfully in 1993 for Tillamook County County Commission to protect its mental health program. She later became a leader of county mental health directors.

    Nikkel found Whitaker’s book disturbing and inspiring. She and her husband, Bob Nikkel, Oregon’s former commissioner of mental health, invited the author to Oregon to talk with providers. That led to a conference in Portland last February of psychiatrists, providers, researchers, and activists from 13 states.

    Afterward, a smaller group of them founded the Foundation for Excellence in Mental Health. Its goal: to further discussion by funding unbiased research. Nikkel left her job to become its executive director. She’s gone from the mental health establishment to questioning it, but she says it’s not that big a change. The group is not anti-drug, Nikkel says, but “what is optimal for one person might not be for another.”

    Change rolls in

    Megan Caughey is part of a big change underway in Oregon’s mental health system: veterans of it will help others, providing supports other than medication. The idea dovetails with Whitaker’s points, and Caughey is fan – though she says her life serves as a counterpoint.

    Three decades ago, college classmates found Caughey standing barefoot in the snow. She was diagnosed with schizophrenia at 19, and began a nasty cycle: start a medication, stop due to side effects, be hospitalized, then a new drug.

    Caughey has been hospitalized more than 100 times — usually for psychotic breaks or suicide attempts; she’s undergone electroshock therapy, and for a time, tried a pharmaceutical-free “reparenting” group.

    Today, the 56-year-old takes medication, but when the rage or the darkness begins, she paints or writes to express herself, and meditates and exercises, too. In her Old Town apartment, Caughey hangs her art, including abstract murals using a Japanese black-ink technique.

    Caughey sat on the advisory group that helped write Oregon’s health care reform law this spring. Her influence is seen in calls for “peer wellness specialists” in medical and mental health organizations across the state.

    Cascadia Behavioral Health in Portland recently hired her to train peer specialists, which she previously did in Benton County. Peer support works to get people well with as little medication as possible.

    “I take medication and I see the role it plays in my life,” she says. “But those of us who do take medication, many of us would like to either not be taking medication or be taking less because of side effects.”

    For Caughey, it was Geodon, a medication that improved her life and allowed her to work fulltime for the first time, at age 51.