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I'm an MD who specializes in Psychiatry. Although much of this article is somewhere between a little and a lot inaccurate, the basic premise that an absurdly expensive antipsychotic is the most popular drug is alarming. It is a useful and effective medication with a clear role for a relatively small subset of the population. Why it is being prescribed so widely is a question worth asking.
If you read the article carefully, and/or click through, you'll find it's only #1 in dollar sales, it's still on patent until April or so.

I wouldn't be surprised if Ativan/lorazepam is still #1 in terms of prescriptions.

On a per prescription basis acetaminophen plus hydrocodone is the top selling drug.
These issues are sociologically complex and they are being addressed as if all mental health issues can be treated on an individual level. There should be regulation that prevents rate of expansion into new 'fuzzily defined' target markets that is scientifically regulated with scientific, precisely and pedantically defined, formalized language. This personally horrifies me, and I watched this happen over and over again in federally funded facilities:

> When someone's antidepressant didn't work, Pharma marketers began floating the idea that it wasn't that the drugs didn't work; it wasn't that the person wasn't depressed to begin with but had real life, job and family problems—it was "treatment-resistant depression."

Over-prescription in general seems to come from ill equipped / underfunded facilities. These are places that can't afford to give every person individual therapy. They are communal, so there is lots of personality clashing that goes on inside of the facilities that exacerbates disorders which stem from or are composed largely of adaptive socialization behaviors that become maladaptive in different environments. A person who grew up in poverty or from an abusive environment is going to be angry and depressed. Just because there is no one available to have an intelligent kind of compassion for that person, doesn't make them psychotic. People are afraid of what they don't understand in general. It's easier and cheaper to zonk someone out than actually have to think about or pay how to help them.

I really don't mean to come off so cynical, but some of these public facilities can be blackholes for many of the people they treat, with the possibility of re-traumatizing people on top of the problems they already have.

Oh, and on top of that, the humorous part (read with heavy sarcasm): people at these places are called "clients" and the facility stresses that that specific phrasing is used. No one is called a patient. They are a "client", a consumer.

What's wrong with calling someone a client, and separating their medical situation from their identity as a member of the social relationship?

A client is a more engaged partner in the activity of achieving and maintaining well-being; a patient is a more passive victim of their situation.

What do you think of the use of e.g. olanzapine as a sleeping aid in bipolar disorder? Is it justified, even when no (hypo)mania is present?
I'm not a doctor, but back when my doctor and thought I might have true bipolar disorder (vs. as it turns out "depression of a bipolar nature" that only goes manic when I take the wrong drugs), I studied up on the disorder.

What's prescribed for people with is are "mood stabilizers" (and all of them but the "gold standard" of lithium were originally developed for other indications like psychosis and convulsions). So people who have true bipolar disorder by definition have manic phases, and they need their mood stabilizer all the time to deal with both that and depression phases.

A few months ago I succumbed to a particularly drawn-out case of the hiccups. Two nights in, sleepless from constant hiccuping, I made it to the ER. The cause was heartburn, triggered by an earlier night of celebratory drinking, irritating my esophagus. The irritation was close enough to my diaphragm to stimulate it.

One dose of thorazine, given by the ER doctor, and the hiccoughs subsided. Thorazine dampens the vagus nerve. This was the intended effect. Less intended was my complete lack of motivation to do anything outside the confines of my apartment for the rest of the weekend. (I also took great interest in my neighbourhood parks, for once.)

Fascinating... and makes me wonder whether anyone has experienced hiccups as a side-effect of amphetamines or other dopamine agonists.
Yes, I have. Also, nictotine oral sprays are known to cause them as well, quite consistently.
I used to work in a pharmacological research lab, and while I'm frequently discomfited by the misalignment between commercial incentives and social good in the pharmacology industry, this statement isn't quite fair:

> Everyone has heard of "mission creep." In the pharmaceutical world, approval creep means getting the FDA to approve a drug for one thing and pushing a lot of other drug approvals through on the coattails of the first one.

This is more accurately referred to as "drug repurposing," and it's hardly the unalloyed evil that it's characterized as here. It's true that drug companies love to repurpose existing FDA-approved drugs, both because it saves them money and because it typically permits them to patent the compound again in a new context, but there are nonetheless real benefits to the public at large when a drug whose side effects are comparatively well-characterized over the long term is put into service to treat a different malady.

The real problem isn't drug repurposing, but off-label promotion. If you want to take a drug through FDA approval for another set of indications, that's fine and dandy. What isn't cool is actively promoting the use of a drug without market approval - having reps drop subtle hints, funding third-party publication, paying doctors to speak at conferences about their off-label prescribing and so on.

Eli Lilly, Pfizer and AstraZeneca have collectively paid out more than $2.5bn in settlements over the off-label promotion of atypical antipsychotics. The drugs that they unlawfully promoted are now being used widely for the treatment of a variety of conditions for which there is little evidence of efficacy. Lilly were marketing Zyprexa for the treatment of dementia, in spite of having extensive unpublished research showing that it was ineffective.

Atypical antipsychotics are being used by far too many psychiatrists as a catch-all where other lines of treatment have failed - OCD, autism, PTSD, ADHD, anorexia, substance abuse, you name it. In most cases the evidence of efficacy is slim-to-none. That's not medicine, it's quackery. Frankly, I'd be happier if they were prescribing placebo; Nobody has ever died from the side effects of sugar pills.

But turning an off-label use into an on-label one to promote it has its own nasty consequences, even if the drug is proven to work for the new indication (or whatever).

Consider Lucentis vs Avastin. Ophthalmologists were using Avastin off-label for wet AMD. Genentech was making a huge multifaceted effort to discourage off-label use because they had sunk a bunch of effort/$ into the order-of-magnitude-more-expensive Lucentis for not much of an improvement. Similar situation and different ending with Lumigan (glaucoma/ocular hypertension eyedrops) vs Latisse (eyelash enhancer), where Latisse's patent (afaik) was thrown out because Allergan was trying to patent a known major side effect of Lumigan.

I'm not a fan of misleading promotions of off-label uses either, but I wish there was a middle ground still banning that that didn't also involve more patents and protection.

To take the atypical anti-psychotics as an example, it turns out they or at least some of them are good mood stabilizers, i.e. can be used to treat bipolar disorder (manic depression). And while they have their fair share of nasty side effects, there pretty much aren't any nasty side effect free mood stabilizers....
I was prescribed an atypical antipsychotic* originally for bipolar disorder in my late teens. At the time, it was an absolute lifesaver. I had almost completely lost my ability to function, and the treatment brought me back to an operating state sufficient to complete high school without completely sinking my GPA.

I had to stop using it because of unacceptable side effects (rapid weight gain and sexual dysfunction), and it took me a long time to find something else that worked as well. The medication that ended up working for me was originally developed as an anticonvulsant. My symptoms lessened over time in adulthood, but if I hadn't had the course correction provided by repurposed 'Big Pharma' medications I would be living a much harder life.

*: I'm not naming medications because I don't want to promote them. What worked for me isn't necessarily what will work for anyone else.

Sure, nobody denies that's a good thing. Viagra is a famous example of this.

But the article is clearly talking about its abuse.

It was a shock for me to have worked in the US for a few years, and slowly realize that I was in the distinct minority in my circle of friends in not taking any medications consistently (I'm in my thirties). Made me think of Brave New World.
I'm Dutch, but I grew up with many Americans around me. It always shocked to see the huge amount of pill-bottles in the bathrooms of my American friends, and how much part of daily life these things were.

Anti-bacterial wipes for everything, pills at the smallest sign of illness (even just the sniffles), copious use of sleeping aids, and so on.

In my upbringing (which was kind of 'typically' Dutch), we took medication as a last resort. Even painkillers were not something you took unless your headache was unusually bad.

I have no doubt that this is also changing in Holland, especially when it comes to prescription drugs for psychological issues, but in general it seems a bit healthier to me to allow the body to take care of itself when it can, rather than stuffing it with foreign bodies that often have all kinds of adverse side-effects.

This state of affairs often makes me think about how malleable societies really are, for both good and bad, and how much variation there is even within 'Western-European' nations.

I have noticed that too. It's pretty much standard that people take at least some prescription drugs regularly. Also the children of some friends know all the ins and outs of different pills. I don't think I ever had had a headache pill when I was the same age.
That's pretty shocking indeed. So what do these people think of their own med use? When I was on antipsychotics I couldn't wait to get off of them, and my psych was very supportive regarding that.
"The standardized United States Product Insert says Abilify's method of action is "unknown" but it likely "balances" brain's neurotransmitters."

The whole neurotransmitter imbalance hypothesis is itself not proven for Abilify or any other anti-depression drug (like SSRIs). At best, it is a guess since there is no way to measure levels of neurotransmitters in live subjects. At worst it is a lie. Regardless, the method of action is irrelevant if medicines work, but considering the efficacy of such drugs (not very good) and their frequency of prescription (very high) it's not surprising that the medical industry would work so hard to push an unproven theory as fact simply to sell more drugs.

Not only is it not proven for <insert drug here>, it's not even a useful hypothesis in the scientific sense. No one has ever proposed a useful model of the "chemical balance" that is hypothesized to be "imbalanced", so the whole theory is a non-sequitur. It is proposed because the more accurate explanation of "this is a powerful drug that introduces long-term changes to the structure of your brain. A few cherry-picked studies funded by pharmaceutical companies seem to show that there might be some short term amelioration of your symptoms. We have no idea how it works, but that's not surprising, as we have no idea why you have your disorder, or what it is other than a particular constellation of symptoms. We won't find out in the near future, because there's really no money being invested in finding out the ultimate causes for mental illness or in studying the long term effects of these treatments." doesn't get you invited to the really nice pharma-sponsored conferences.
The title is misleading. Abilify is being prescribed for people who are already on SSRI's for depression because the combination helps accelerate recovery and not because these people need traditional anti-psychotic medicine. With this headline you give people a reason to be hesitant before asking for help.
Nevermind the fact that alcohol and coffee are way more popular drugs.
There's no proof of this. I think that's why the article is titled this way.
The insinuation of headlines like this is that antipsychotics are inherently hardcore drugs for people with severe, possibly dangerous mental illness. This delegitimizes depression by suggesting it is not or cannot be a serious mental illness; furthermore, it stigmatizes people who suffer from psychosis by suggesting that their symptom is beyond the pale of what a normal person might suffer.

That is: Antipsychotics are for people who experience psychosis, and people who experience psychosis are crazy lunatics, so it's absurd that so many normal people are being prescribed antipsychotics.

This point is sort of irrelevant to the article.

Read this, perhaps instead.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518694/

The issue is not that they are portrayed as too "hardcore", but rather in general things like depression are over-simplified and dumbed down to stoke consumer demand for narcotic remedies.

(Trivializing the subject is not a good thing.)

I have heard that people in post-acute care (think nursing homes) frequently end up taking Seroquel because it appears on their hospital discharge paperwork, despite never having any diagnosis of psychosis.

It turns out that certain hospital physicians find it a convenient sleep aide for use in the hospital, and the prescription unintentionally follows the patient, sometimes for months or years.

(Source: I sell software to long-term care facilities and their pharmacists.)

I have really bad insomnia, due to genetic anxiety and depression (apparently "of a bipolar nature", but only a drug can make me manic), and without a low dose of Seroquel before bed I'd only be getting ~4 hours of sleep a night (and my anxiety would be much worse). It's been pretty much a life saver.

Seroquel is ... interesting in that it hits a histamine receptor harder than anything else; for someone like me, who also suffers from bad allergies, this duel side effect is particularly advantageous.

As far as I know, all atypical anti-psychotics have been black boxed (major league warning) for treating the elderly with dementia, the side effects in them are worse than the benefit.

> apparently "of a bipolar nature", but only a drug can make me manic

Insomnia is, in my experience, symptom of low dopamine. You need to exert executive function to intentionally drop trains of thought that are keeping you awake—without enough dopamine to do so, you end up increasingly exhausted but unable to sleep. Vyvanse is the best thing that ever happened to my sleep schedule.

> As far as I know, all atypical anti-psychotics have been black boxed (major league warning) for treating the elderly with dementia, the side effects in them are worse than the benefit.

Yes, there has been a major push by Medicare and others to reduce anti-psychotic use in the elderly.

I've had periods of insomnia. Personally, I liked https://en.wikipedia.org/wiki/Trazodone and it comes in generic. I've only ever needed to use it on a short-term basis.

Also, I think banning drug ads and the profession of pharmaceutical sales rep would go a long way toward fixing over-prescribing and medical costs. When the new Congress wants to reform Obamacare, someone should add this ban.

This is a great read for anybody with issues sleeping. The vast majority of sleep problems are in your head and after reading this I never had another issue. He debunks the utility of sleeping pills and give you lots of strategies for improving your sleep. http://www.amazon.com/Say-Good-Night-Insomnia-Drug-Free/dp/0...
I think you've got the wrong approach. Sleep is a waste of time! If you can't sleep count your blessings and do something productive.
I always find it interesting that these kind of articles points the fingers at Big Pharma and completely forget that there's a key element needed for prescription: Doctors. So, why not blame doctors as well, at least as much as Big Pharma? They share a huge part of responsibility in the situation.
> [Thorazine] was an antipsychotic given to mentally ill people, often in institutions, that was so sedating, it gave rise to the term "Thorazine shuffle."

I think the term "Thorazine shuffle," refers to the characteristic locked-knee shuffling gait that develops because Thorazine frequently causes tardive dyskinesia as a side effect.

Edit: ignore this, see below; though, the drug does induce discomfort and restlessness in the limbs that prompts patients to pace around.

It's tardive dyskinesia, and the term is typically used to denote the facial tics that are a sometimes permanent side effect of older antipsychotics. The "shuffle" is a separate effect, and calling it that is often regarded as pejorative.
Does anybody know of natural drugs against depression?

So far I have only found lavender oil, sardines and chocolate to work.

The endorphins from exercise work wonders against depression. Of course, getting the patient to "take their medicine" is non-trivial, but even a short walk can be helpful.
1. Traveling 2. Sunlight 3. Walking 4. Meeting new people (travel, couchsurfing meetings, classes)

Taking an herbal drug can be very helpful psychologically even if it is not proven medically effective (the placebo effect). Just do some research because natural drugs can have harmful side effects too.

Saint John's Wort in conjunction with therapy is one that comes to mind. All antidepressants should be combined with active, regular therapy. Often the cause of depression is not chemical imbalance, but an actual issue in the person's life.
S-ame (s-adenosylmethionine) is probably the most effective natural anti-depressant. I know it's widely used in Germany. There's extensive research on PubMed regarding it's effectiveness--if it weren't naturally occurring and therefore not subject to patent, it would likely be a blockbuster drug given that it outperforms most prescription drugs.

From my own personal experience, it reduces my anxiety within hours of taking it. And relieves depression in about a week. In the US, you can buy it off the shelf at any CVS/Walgreens. But it's certainly not cheap.

I hear B and D vitamins help. I also hear that doctors aren't really sure if vitamin supplements even work, so eat leafy greens and beans and get some sun.
The most common is Hypericum Perforatum (St. John's Wort). It's an (considerably strong) SSRI inhibitor and potent CYP450 inducer. Better not take it if you're regularly taking any other kind of drug. If you do ask your pharmacist/doctor, if you're already into any kind of anti-depressants also it's better to avoid it, excessive SSRI activity could lead to serotonin-syndrome.
I find meditation and strong exercise help quite a bit. I also took classes with a Tibetan Buddhist monk. He had pretty good insights into how the mind works. Not sure if that can be generalized though.
Check out the book Perfect Health Diet, a nutrition book written by an ex-Astrophysicist (Harvard, MIT, ... ) . Plural of anecdote etc., but I am a very satisfied customer.
Why do you want natural drugs only?

If you want natural, I would try tobacco (it can be snuff, no need to smoke, although smoking works faster). For synthesized, try moclobemide.

How would you describe your symptoms?

20 years ago, I dated a pharmacist and she said that two of the most prescribed drugs that she dispensed was ritalin and Prozac. It shocked me back then, so hearing that anti-psychotics are amongst the highest these days is no surprise, unfortunately.