Two Alternative Viewpoints:  Psychotropic Drugs and Crises

A Response to Practical Questions Raised by this Web Site

I. The Use of Psychotropic Drugs:

The materials presented on this website make clear some of our views on the overuse and misuse of the psychotropic drugs, in particular the so called “neuroleptics” or “anti-psychotic” medications. These drugs, even the newer so-called “atypicals”, have serious adverse effects and toxicities associated with their use. Some of their toxicities are life threatening (neuroleptic malignant syndrome), while others, like tardive dyskinesia and tardive dementia are usually cosmetically disfiguring, irreversible and result in seriously diminished overall functioning. Numerous other toxicities, both physical and cognitive, are associated with their short and long term use. Hence, if possible, it seems prudent to avoid or minimize (short term, low dose) their use.

As experience has accumulated with the newer anti-depressants (Prozac is the best known one, but there are a number of others) several important facts have emerged:

  • They are only slightly more effective than placebos (“sugar pills”).
  • They cause, in a certain percentage of cases, a very disturbing form of agitation called “akathisia” that can produce violent behavior (suicidality or homicidality), especially when associated with another of their effects, “disinhibition” or emotional indifference.
  • These drugs may also cause psychosis and/or mania severe enough to result in psychiatric hospitalization.
  • They are all associated with withdrawal problems (see below) that are much more common and severe than has generally been acknowledged.

So, the high initial expectations of these “wonderful” anti-depressants (as widely heralded by their makers) are exaggerated. These problems with the anti-depressants should be taken in the context of the fact that there are numerous studies indicating that several types of psychotherapy are as, or more effective, and result in fewer relapses.

Unfortunately, many psychiatrists believe the myths that drugs are the only real treatment for “major mental illnesses” (they may give lip service to psychosocial interventions) and that they have improved the long-term outcomes of patients receiving them. Many studies show that these two beliefs are indeed myths. In fact, long term social, vocational and symptom outcomes for persons labeled as having “schizophrenia” are probably worse now than before the anti-psychotic drugs were introduced. However, since it does not fit the currently fashionable belief system this research is given little credence and is discouraged by funding sources and journal editors. Furthermore, 70-80% of persons taking anti-depressants report living unsatisfying lives. Suicide rates have not declined since the advent of these drugs.

Moreover, it is common (and in my opinion, questionable) practice these days to give many patients a “cocktail” of a combination of different types of drugs to try to treat the many different kinds of symptoms a single patient may present-independent of his/her actual problem(s). Hence, psychiatrist’s tend to “cover all the bases” with their medication regimes. This practice has never been subjected to clinical trials and no credible scientific evidence exists that such drug cocktails produce better results in the treatment of psychotic symptoms. Each additional drug has its own set of adverse effects, toxicities and interactions with other drugs that result in exposing patients to an ever larger number of possible medication related problems.

In addition to their short and long term unwanted effects all psychiatric drugs have withdrawal reactions because of changes they cause in the brain. These reactions vary in time of onset, severity and type of symptoms experienced. There is also great inter-individual variability about if, when and how withdrawal is experienced. As a rule of thumb the longer a drug has been taken and the higher the dose the more severe the withdrawal reaction will be.

Do not stop your drug(s) suddenly or reduce your dose quickly, as this usually increases the chances of developing severe withdrawal reactions. Dose reduction and discontinuation should always be done slowly while in a relationship with a thoughtful and competent physician — not necessarily a psychiatrist. You should be aware that it is generally considered to be malpractice for a physician to prescribe (this includes a withdrawal regime) for patients he has not seen. Hence, because I am not your doctor I am not able to give you specific advice about what to do about the drugs (if any) you are currently taking or being asked to consider.

I would counsel that you find a physician you like, trust and with whom you can form a collaborative relationship to discuss your concerns and wishes. It is the doctor’s responsibility to provide you with the information you need to make an informed decision. Be very careful of information derived from pharmaceutical manufacturers, especially about their newest “breakthrough” product(s).

A fairly complete list of potential withdrawal reactions from neuroleptics, as well as a prudent withdrawal program to be undertaken in conjunction with your physician, are discussed in “Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications,” by Peter Breggin & David Cohen (Perseus Books, 2000).

My own thinking about psychiatric drugs (especially the so-called “anti-psychotic”medications) is that they should be avoided if at all possible. My approach would be first to develop relationships with the persons involved and establish a safe and protective social context-preferably at a residence. Then I would take a relationship building therapeutic approach including the family if possible — based on developing a joint understanding of, and finding meaningfulness in, the situation presented. This is easy to say but hard to do in the context of managed care and mental health practitioners who often lack training in basic listening skills.

In addition, a lack of non-coercive in-residence mobile crisis teams, communities lacking safe residential places (like Soteria House) and viable, involved support networks — all of which can dedramatize crises — makes the process even more difficult. If for some reason psychotropic drugs are necessary, and agreed upon by all parties, I recommend starting with the lowest dosage possible of the least toxic drug for the shortest period of time needed to address a specific behavior.

The most common reason I have found it necessary to use medications has been when it has not been possible to assemble enough caregivers to assure everyone’s safety. Unfortunately, my views are not widely shared by my fellow psychiatrists or the drug companies.

There is an extensive discussion of why drugs should be avoided if possible and how they should be given when necessary in chapter 5, “Is Psychotropic Drug Dependence Really Necessary?” of Mosher and Burti’s “Community Mental Health: A Practical Guide” NY. Norton, 1994. Norton’s phone order number is 800-233-4830.

II. Dealing with Crises without Medicalizing Them

Remember, what follows are generic clinical guidelines about what to do in case of a severe personal/family emotional crisis (however defined). I cannot prescribe what to do because I am neither your doctor nor do I know you or the resources and options available in your area. In addition, such plans should be developed collaboratively with everyone involved. Prescription, by definition, is not usually a collaborative process. There are several generic principles that might be useful in your decision making:

1. Try to remain in as normal an environment as possible — one that includes your usual relationships — at home, at a friend’s house, or at a residential setting that is home like — even if staffed by paid caregivers. Try to engage natural resources like family, friends, clerics etc. to help by providing support, understanding and common sense advice within the context of their relationships with those involved.

If professional intervention is needed they should come to where you are. If possible use non-psychiatric mental health professionals, as they are more likely to address the situation from a psychosocial (rather than medical) perspective.

Emotional/psychological crises are very perplexing, frightening and distressing. Never-the-less try, at all costs, to avoid medicalization of whatever the “problem” is. Remember that crises are not life threatening “illnesses” — people don’t ordinarily die as a result.

If violence is a part of the crisis it can usually be managed by sheer force of numbers of persons present. Also, even though you may not know exactly what to do — do not let mental health professionals take away your power to control your own life by the use of coercion. The use of coercion usually means that the professionals don’t want to take the time to understand the problem and its context. They then provide a pseudosolution with the use of force that has serious long-term consequences: institutionalization, labeling, discrimination and marginalization.

Once you have been diagnosed, it will be impossible to remove a diagnosis from your medical records, regardless of the haste with which it was applied, or regardless of whether the diagnosis may be even remotely considered “correct.”

What I am saying — try to stay away from emergency rooms and hospitals unless it is clear to someone that the problem probably has a physical origin. It should be possible to determine this by a call to your primary care doctor.

A well organized, assertive family and support network can control professional involvement — both the timing and quantity — if it remains in its own residential context. This should be the goal.

2. Most crises arise in a family and its historical context. Hence, the focus of the relationally oriented intervention usually should be the family.

Given this conceptualization it becomes very difficult to decide whom, if anyone, should be medicated. I would not object personally to a sedative medication being given to all those who have been sleep deprived as a result of the crisis. The drug of choice for such situations is Benadryl, available without a prescription. Other sedatives would need to be prescribed by your physician. Sedatives have been shown to be as helpful as the anti-psychotic drugs in the de-escalation of severe (“psychotic”) crises and have fewer short term adverse effects.

Restoration of the sleep-wake cycle and “tincture of time” (with the passage of time a much clearer perspective often emerges and what had appeared to be a very difficult problem is self-healing or not really so difficult after all). These are two important clinical concepts that are too often overlooked. Unfortunately, psychiatry and hospitals are under too much economic pressure to allow the operation of tincture of time’s natural curative potential. These pressures are not present if “treatment” takes place in a residence with plenty of concerned and involved persons present.

3. Within the context of a relationship interventions should focus on the life events that are temporally related to the beginning of the crisis — e.g. loss of a job, breakup of a relationship, a death, failure at school, leaving home etc., etc.

Each situation is unique so there is no one answer to what went wrong and how it might be best dealt with. However, it is good to remember that the more normally people are treated the more normally they will behave. In addition, crises offer opportunities for growth and change in a positive direction and are usually self-limited if not dealt with in a way that prevents their resolution.

A major objection to the use of the anti-psychotic drugs in acute crisis situations is that because they are such powerful central nervous system suppressants they may well have the effect of preventing crisis resolution. They are powerful enough to abort a psychological process, which if supported and understood, would resolve itself in the context of a relationship.

It may not be easy to follow the generic principles outlined above. They should be regarded as guidelines that will likely have to be compromised. But remember — it is your (or a loved one’s) psychological life — that needs a very thoughtful, careful, unhurried and empathic approach.

Guard against unquestioning acceptance of authority — especially medical — even when you are nervous, perplexed and the situation feels chaotic and out of control. Psychiatry’s track record in providing non-harmful answers to serious psychological crises has not been admirable. The adverse consequences of institutionalization — its customary response — have been detailed in #1 above.

Soteria Associates
Loren R. Mosher M.D.- Psychiatrist, Director

Dr. Mosher died July 10th, 2004.

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