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The truth about antipsychotics Are side-effects being ignored?

An LA production of 4.48 Psychosis. (Anne Cusack/Los Angeles Times via Getty Images)

An LA production of 4.48 Psychosis. (Anne Cusack/Los Angeles Times via Getty Images)


March 22, 2024   6 mins

The discovery of antipsychotics was an accidental revolution, the result not of systematic research, but of random observations. In the early Fifties, an obscure French naval surgeon was trying out chlorpromazine as a potential anaesthetic; he noticed that it calmed some of his patients. This inspired psychiatrists to try out the drug — there being virtually no constraints on pharmacological research in these years — and many reported that it functioned as a major tranquilliser. Before long, the company that owned the rights to the pill in North America had put it on the market. The dawn of psychopharmaceuticals had broken.

The psychiatric profession rapidly embraced the new pills, which more closely resembled the practices of mainstream medicine than the remedies that had previously been used to treat mental illness: insulin comas, shock treatments, lobotomies. Nobody really knew why the drugs worked. We still don’t, entirely. Serious mental illness is a source of profound suffering, and its ravages rapidly spill over to affect patients’ families, their immediate community, and society at large. This creates a desperation to do something — anything — to cope with its symptoms. Yet our understanding of the origins of psychosis remains strikingly primitive and feeble — and so, too, our understanding of its treatment.

Earlier this year, The Times reported that clozapine, a relative of chlorpromazine, is “Britain’s most dangerous prescription drug”. Prescribed in Britain to some 37,000 people suffering from schizophrenia each year, it has been associated, the story noted, with around 7,000 deaths since 1990: the equivalent of around 400 each year. There is a whiff of journalistic hyperbole at work here. A death rate of more than 1% of those taking the drug is certainly cause for concern, but there are far more dangerous drugs in the pharmacopoeia. Nevertheless, it is worth asking how clozapine ended up on the market, and why it continues to be prescribed.

The puzzles psychiatry wrestles with are so difficult to solve that when an intervention appears to work, enthusiasm tends to win out against any cautious restraint. So it was with the arrival of antipsychotics. Within 18 months of the first chlorpromazine pills being approved for the market, they were being prescribed to more than two million patients in the US. The now defunct pharmaceutical company Smith, Kline & French had bought the North American rights to the drug, but others were rushing to create their own copycat versions. In the words of an early advertisement for Thorazine: “Assaultive or destructive behaviour is rapidly controlled
 helping to dispel or modify delusions, hallucinations and confusion, while keeping the patient calm and approachable.”

The drugs did indeed work, to a degree. They didn’t cure psychosis, but for many patients they alleviated some of its most dramatic and disturbing symptoms: the hallucinations and delusions that plagued them. Sadly — and this took years to be acknowledged — these medications had little effect on other devastating symptoms: the intellectual deterioration, the apathy, the failure to connect with others, the loss of spontaneity.

Early on, there were troublesome signs that the drugs imposed a heavy burden on those taking them: side-effects that surfaced and often persisted even after the drugs were withdrawn. Patients became incurably restless. They developed Parkinson’s-like symptoms. Most disturbing of all was a condition labelled tardive dyskinesia. A so-called extrapyramidal disorder, it involves facial tics, grimacing, grunting, rapid jerking and spasmodic movements — all of which are ironically often mistaken by naĂŻve observers as symptoms of mental illness. It afflicts very many patients — estimates range as high as two-thirds of those taking the drugs — and is incurable, continuing even after people stop taking chlorpromazine.

“Most disturbing of all was a condition labelled tardive dyskinesia.”

For a decade and more, psychiatrists ignored this on-going iatrogenic disaster. Leading figures in the drugs revolution minimised its presence or significance. Nathan Kline, often called “the father of psychopharmacology” and once a serious candidate for a Nobel Prize in Medicine, insisted that tardive dyskinesia was “of no great clinical significance”. Daniel X. Freedman, the long-time editor of the Archives of Neurology and Psychiatry, claimed that the disorder was only found in a handful of patients, and was an “unavoidable price to be paid” for relief from delusions and hallucinations.

People wanted to believe chlorpromazine was a silver bullet; when you are confronted by the distressing symptoms of mental illness, it is tempting to ignore the drawbacks of anything that might offer relief. The current vogue for poorly researched and dubious interventions for sufferers of depression — deep brain stimulation, psychedelics, ketamine infusions — is only the latest example of this tendency.

But eventually the medical establishment couldn’t keep ignoring the dangers of chlorpromazine. A 1973 paper by Maryland psychiatrist George Crane, which appeared in the august pages of Science, effectively ended the silence surrounding tardive dyskinesia. By 1980, two other prominent psychiatrists spoke of the profession’s attitude to the issue having moved “from curiosity and mild concern to panic”. But once the period of denial came to an end, the absence of alternative treatments was glaringly obvious. This is where clozapine enters the story.

Clozapine was actually not a new drug at all. First synthesised in 1958 by a small Swiss company later absorbed by Sandoz, it was brought to the European market in the early Seventies, despite concerns about its propensity to provoke seizures and low blood pressure. A significant number of patients developed a serious, often fatal condition called agranulocytosis, where a dramatic loss of white blood cells wrecks a patient’s immune system and leaves them overwhelmingly vulnerable to infections. Before clozapine entered the American market — then, as now, the most lucrative market for pharmaceuticals — it was abruptly withdrawn from sale in Europe. For nearly two decades, it vanished from the scene.

But as concern about chlorpromazine’s side effects mounted, it occurred to Sandoz that clozapine could be brought back to life. With the caveat that patients given the drug would need to have their white cell counts carefully monitored, regulatory approval was soon forthcoming. Now, clozapine is prescribed in cases where other antipsychotics have failed — why it works is a mystery, but the evidence that it often does is solid. Nevertheless, common side effects include agitation, constipation, dizziness and fatigue, seizures and tremors, and serious weight gain. It is an intervention that should be sanctioned only in desperate cases.

Just as chlorpromazine’s discovery prompted rival drug companies to create a host of copycat drugs, so the re-emergence of clozapine prompted the development of a raft of new potions in the Nineties. Collectively known as second-generation antipsychotics — though their chemical structures often have little in common — these drugs seem less likely to provoke tardive dyskinesia, although a large study funded by the United States’ National Institute of Mental Health, rather than the drug companies, raised some doubts about the strength of the evidence for that claim. But these drugs remain no more effective at relieving hallucinations and delusions than their predecessors, and just as inefficacious at treating other symptoms of schizophrenia: the social withdrawal, the lack of interest in life, the intellectual deterioration and loss of linguistic capacity. A careful 2008 review in Nature found that they were no more than moderately effective in 41% of those treated (versus the 24% who responded positively to placebo), and the response to treatment declined over time. Second-generation antipsychotics are therefore important for those who do respond, but very far from curative; the authors of this particular study concluded that “there is much room for more efficacious compounds”.

Some studies have been more critical. Over time, second-generation antipsychotics provoke massive weight gain (10 or 20kg is not uncommon), and they are associated with heart disease and disorders of the metabolic system. Many of those taking these pills develop diabetes. So it’s unsurprising that one authoritative 2015 review in the Journal of Psychopharmacology concluded that “the [adverse effects] profiles of the newer antipsychotics are as worrying as the older equivalents for the patient’s long-term physical health”.

The danger is that the inappropriate prescription of these drugs will give psychiatry a bad name. That sector of society with little empathy for the psychically troubled — groups like the Scientologists or the followers of the late psychiatrist Thomas Szasz, who proclaimed that mental illness is a myth — will discuss side-effects in order to dismiss psychiatry as toxic or, worse, an “industry of death”. Patients who fail to respond to antipsychotics (and there are many), or who experience only the negative consequences of taking these pills, in many instances echo some of the complaints of these critics. I understand their anger and dismay. As a historian who has researched the foibles and failings of psychiatry, and the manifold ways its interventions have often served to magnify rather than reduce suffering, I’m not blind to the profession’s deficiencies.

But that very familiarity with the barbarities that often preceded the psychopharmacological revolution prompts me to a somewhat less bleak assessment of the profession’s current state. Before totally denigrating psychiatry, it is necessary to face up to the suffering and disruption that follows in the wake of mental illness. It is vital, I think, not to resort to nihilism. There are substantial numbers of people for whom drugs provide considerable relief. These pills permit many to live some semblance of a normal life.

All medical interventions carry risks, and balancing risks and harms is a problem for medicine as a whole, not just for psychiatry. Caution is especially in order in the psychiatric realm, precisely because the stigma that attaches to mental illness may encourage some to clutch at straws, and because psychiatric conditions cannot usually be cured. But caution and scepticism should not become despair. We’re talking about some of the most profound forms of human suffering. If our treatments are imperfect, we should simply attempt to do better.


Andrew Scull is a sociologist and author, most recently, of Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness.


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Lewis Betty
Lewis Betty
3 months ago

Is the psychiatric community completely in the dark about the spirit hypothesis? No, it’s not. There are psychiatrists flying under the radar–a small, brave minority to be sure–who use spiritual techniques with great success. Babas in India and Daoist monks in China have long been resorted to by local populations with extraordinary success. At the very least, prayer and meditation can be helpful when directed by knowledgeable therapists.
You might wonder why antipsychotics have any effect at all. The reason is that dark spirits–those voices that their victims hear inside their heads–find those drugs unbearable and vacate the victim until the drug wears off, at which point they return and repossess the victim.
My article “The Growing Evidence for ‘Demonic Possession’: What Should Psychiatry’s Response Be?” in The Journal of Religion and Health has received over 25,000 views since I posted it ten years ago on Academia.edu.
I know how this comment will be disparaged. May the few of you who have followed current research on spirit possession and attachment be courageous enough to speak up. There is a growing literature in this unorthodox field. Jerry Marzinsky’s An Amazing Journey into the Psychotic Mind might be a good place to begin your investigation.

Skink
Skink
3 months ago
Reply to  Lewis Betty

Interesting stuff. I read Marzinsky. Worth keeping one’s mind open about.
My father, at 91, during a freak-out when he became violent, was given heavy antipsychotics. I requested opiates to calm him down instead. I was refused. They turned him into a zombie and he died in 3 months. He was a healthy man for his age, at the start of all this. A nasty way to go…

Miriam Cotton
Miriam Cotton
3 months ago
Reply to  Lewis Betty

I have to say this is the complete opposite experience I have had with my son. He is 27 and was diagnosed just before his 21st birthday. Although we didn’t know what it was at the time, one of the symptoms was that he set up a sort of altar in our sitting room with a cross and candles etc. and was full of talk about Jesus. I have to keep him as far away as possible from any/all spiritual/mystic ideation because they invariably trigger psychotic thinking and delusion. I would go to church on Sundays myself but am unable to because it would be dangerous for him. I can’t hide what I’m doing from him (his Dad has since died so its just me now). Holy Spirits, prayers to unseen Gods – there is no way to distinguish them from voices in his head that makes any sense to him so I never, ever discuss those things with him and have pretty much persuaded him that it’s all nonsense, for his own safety. Many relatives will tell you that their sibling/son/daughter is at their most dangerous/psychotic when they start talking about religion or are having religious inspired impulses about themselves or towards other people.

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0 0
3 months ago
Reply to  Lewis Betty

Yeah . Nice theory. Until your schizophrenic son stabs you up when the voices tell him his mother is the devil. Anyone actually working or living in this space knows that even with these side effects , these medications have given people their lives back and those of their loved ones. Theory is bunk in the face of reality.

R Wright
R Wright
3 months ago

Excellent article. Thankfully this is an area I have not needed to be exposed to in the past, but it is clearly of significance and I enjoyed the read.

Ethniciodo Rodenydo
Ethniciodo Rodenydo
3 months ago
Reply to  R Wright

Unfortunately, I have been exposed to this area, probably more so than many who work in the field. It is bad situation and there are no good solutions only less worse ones.
My younger brother developed schizophrenia when we were in our mid-teens and he has been on anti-psychotics for his whole life. It took a couple of years for him to be diagnosed and in the intervening period, and also after the diagnosis, there was a lot of violence before he got proper treatment. He has been on clozapine for some years.
My ex-wife and her sister developed schizophrenia in their mid to late 30s. Both were sectioned at least 3 times and both have, as far as I know, been on anti-psychotics effectively ever since.
As the author says anti-psychotics are not a cure, but then there is not better option out there. Compared to the alternative they are a God send. Even if early death is a likely consequence the alternative is worse. As my ex-wife psychiatrist explained it schizophrenia is like a fire and longer it is allowed to burn the more of the person it destroys.
The author says the anti-psychotics alleviated some of its most dramatic and disturbing symptoms such as the hallucinations and delusions, which is not quite right. The hallucinations and delusions are still there but the anti-psychotics help keep a lid on them, in much the same way as the sufferer is able suppress the hallucinations and delusions before, as they say, the illness first becomes florid. The remarkable thing is that sufferer will be absolutely convinced by their delusions but will not do anything more than hint about their existence to family and friends until there is a complete breakdown
Then, even while on anti-psychotics, I have had many a conversation with my brother and my ex-wife that have started off seemingly normal before you realize you are being drawn into their delusion. Sufferers are highly manipulative
The author says the anti-psychotics have little effect on other devastating symptoms: the intellectual deterioration, the apathy, the failure to connect with others, the loss of spontaneity. I do not know to what extent this is true or whether the anti-psychotic are to blame. Certainly all the patients I have come into contact with blame the medication for the symptoms referring to it as “a mental cosh”. I suspect that the author is probably right and that it is the schizophrenia, the illness itself, that wants them off the drugs which are suppressing it. There may not be any such thing as demonic possession but Schizophrenia looks very like it. When my wife was sectioned for the second time the psychiatrist commented “why was she ever allowed to come off the medication”.
One of the other issues with Schizophrenia that is remarkable is that very few sufferers have any genuine insight into their condition. My brother is a rare exception. He manages his own medication and stockpiles what he does not use because he terrified of running out. When I asked him how manged his medication he said he increased the dosage “when it starts to get a little bit noisy up there”. Having said this, the nature of the illness means that even though he has insight the voices can still trick him. As far as I know, my ex-wife and here sister never developed any insight.
On memory sticks out. I had to have doctors out at about 10pm on the night my ex-wife was first sectioned. It took them about half an hour to persuade her to go with them to the hospital. As they were leaving one of the doctors turned and said to me “I do feel so dreadfully sorry for you” as though he had just told me I terminal cancer. I had no idea. It was another 3 or 4 weeks before I was told the diagnosis.
Another memory is that my wife and her sister always hated each other and my wife loathed her mother. I suspect this is telling and that it was because the recognised something in each other.
There are many lessons I could impart, but these would be the key ones:
Do not trust the medical professionals. They are there to treat the patient and not you. If your partner or child has schizophrenia, their interests will not be the same as your own and the medical professionals will always work counter to your interests. Their main objective is to stabilise the patient and then get them home and make you responsible for their care.If you want to take on responsibility for caring for someone with a serious mental illness that is you prerogative. If you have children it is not a decision you have the right to make and you should get yourself and the children the f**k out of there. My children (4 and 6) at the time my ex-wife was first sectioned, have been permanently damaged. Your first duty is to you children and I had no right. In all honesty the decision to accept responsibility to care for my wife was down to guilt, pressure from the medical professional and hubris. Every fibre of my being was telling me to get out.You will find that you do not have many friend and that even family will cut ties. My family were absolutely great but my wife’s family, including her mother, were shocking. What was worse was that some of the parents of my children’s school friends tried to stop their children associating with mine. Cancer is a good heart warming family tale where everyone can bask in their own virtue signalling. Mental illness is the stuff of horror films. There is no support out there for the families of people suffering from serious mental illness, which is probably not a surprise. I got a letter every year from the assigned social worker asking me to contact her if I needed support. So I would phone and ask what support was available. I never got an answer to this questionThere is no happy endings. Things cannot go back to the way they were and they do not improve there are just ups and down

Helen Nevitt
Helen Nevitt
3 months ago

This is honest and moving, thank you. I care for someone who has had a stroke. He is physically but thankfully not mentally disabled and able to do his own basic care. It’s a doddle compared with what you’re describing.
However, what resonated with me is the medical professions attitude to the carer. The treatment he had at the time was brilliant, as was the package on leaving hospital. I, the carer, didn’t matter.
The only concern about me was that I wouldn’t injure my back and make myself useless.

Oliver Heyes
Oliver Heyes
3 months ago

My other half had a period of psychosis.

You’re right about about the professionals, I’m not sure they even act in the interests of the patients long term stability, just the immediate, and as soon as the crisis abates enough they turf you out, and they never read the notes so every professional, and you never see the same one twice, forces their patient to begin from day 1 describing the most traumatic thing that happened in their life. Losing their mind and being forcefully medicated. It’s almost as though there’s some sadistic motive there.

We are now 7 years clear without relapse, but at the time I was told it would never end.

The drugs were needed for 2 years, then my partner took 4 years slowly decreasing doses. Coming off cold turkey was not an option because after 24hrs there were appalling withdrawal symptoms. The prescription for the smallest dose by tablet was ended by accidentally missing an appointment, and the mental health team cut support immediately, renewing a prescription would take a month or more. My partner then had 3 months of tingling, stabbing pains, twitching, difficulty sleeping, nausea, and other issues. We were told that getting back on was the only option.
She suffered through, but occasionally pains re occur, the NHS can’t work out why, there’s no recording of them, the follow up checks that used to happen have yearly have stopped, but every 6 months or so she has severe pain and tingling. It might be permanent, and correlates strongly with symptoms of nerve damage.

The deranged thought patterns and behaviours are hopefully gone for good, but the withdrawal symptoms are something else.

I agree with the “I’m dreadfully sorry for you” sentiment. I wouldn’t wish it on my worst enemy. Frankly, sudden bereavements are easier to deal with. I had nightmares, flashbacks, serious issues with intimacy, and other issues. My partner remembers very little of it, but I stuck with her for my sins and because of sickness and health. It would have been easy to find a way to leave, however, now we have a good life together and I’m glad we do. Every day we make choices in how we live that puts us further from those days.

I doubt your children are actually “damaged”, different, but they will have learned something that others have not. They will gain a capacity to assist people who others cannot, people who are at their lowest ebb.

I fully understand every word you say. It’s horrific. I took a mental health first aid course at work a few years back. I couldn’t help but think that it completely and utterly failed to describe how hard it really is. That when you have to spend a week or so on watch, with someone talking at you all day and all night swinging between modes. That it takes so much work to get someone sectioned and prevent them actually harming themselves or someone else on the way. It’s laughable that they tell you about all these “services” but they actually are useless when you’re at the sharp end. I came to the conclusion that actually preparing for the reality of it might be so horrific that nobody would take the course, but I think they should do it.

The only person I know who actually understands is a police officer who has seen it all on the beat, and informs me that often the ambulance refuses to deal with the incident, and waits until the police force the arrest. My experience mirrors this. Shockingly the best care our services provide is found in handcuffs, kicking and screaming.

Ethniciodo Rodenydo
Ethniciodo Rodenydo
3 months ago
Reply to  Oliver Heyes

Thank you.
I mostly agree with what you say about the professionals, but they are driven by a shortage of beds. They have to clear patients out to make room for cases. I remember on one occasion a psychiatrist tried to bump by wife off the high dependency unit (one on one 24/7 supervision) to make room for another patient, who must have been very seriously ill, and the nursing staff refused to let him do it.
I agree about the police. The second time my wife had a complete psychotic breakdown, I phoned my the GP. She said I can’t do anything now it is 5:30 I have to go home. I had to call the police who came about midnight. My wife was absolutely raving. It was a couple of young police officers. When I told them about my conversation they were fuming. It was by no means the first time they had experience the medical professionals washing their hands and leaving the police to pick up the pieces. They handcuffed her and put her in the cells overnight, she proceeded to take of her cloths and stuff them down the toilet, before she was seen by the police surgeon in the morning and sectioned.
As to my sons they have most certainly been damaged. They will not have anything to do with women. Neither of them have ever had a girlfriend, they will never have a relationship and will never have children. My eldest son was the most seriously harmed. His mother rejected him when she was first released from hospital (my own mother watching was in tears), and it seems that over the net 10 years she took out her enmity towards me on him but always when I was not there. He also had to take the heat for and protect his younger brother. He has had a very large amount of psychotherapy over the last 10 years. The assessment of the longest serving psychotherapist was that at a very young age he had developed strategies to protect himself that no longer worked for him and prevented him from forming relationships as an adult.
that is why I say that if you have children you do not have the right to take responsibility for your partner an you need to get you and your children out.

Mangle Tangle
Mangle Tangle
3 months ago
Reply to  Oliver Heyes

Doctors act in their own, career preserving, interests. If there’s no conflict with the needs of the patient, then fine. Otherwise


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0 0
3 months ago
Reply to  Mangle Tangle

Yeah nah 

The NHS is a laughing stock of the developed world. But then the US & Aus are not far behind in the dreadful failure of mental health services. There are NO doctors who get into mental health for the money in these countries. Pays nothing. The only ones who do are the ones that at least once cared, and overseas qualified docs who will take any job ( psych and GP typically) as underpaid , short staffed and no native grad with a hope of anything better will go there. The anti psychotic meds developed in the 50-60’s were a godsend. People used to literally die of psychosis / exhaustion. They are not perfect, but the alternative is awfull.
Anyone who has kids with someone with a serious mental health lllness needs to get them & themselves out and supported. Harsh but true.

Paul Monahan
Paul Monahan
3 months ago

sending you love and wishing you peace – hopefully your kids will be able to process their experience with time –

chris sullivan
chris sullivan
3 months ago

excellent analysis thankyou – I worked in Mental health for many years in a 24/7 rehab facility that worked as well as anything could – it was closed down around 2005 because ‘the authorities’ decided that a residential programme was detrimental to the clients interest !!!!!!!!!!!! It was the only facility i knew of that managed to make any real gains – and also ran supported housing for those who would never cope in ‘open society,’. those to were closed down as ‘ghettos’. NZ is in a mental health crisis right now because of all this past ‘wisdom’ – and it is far too late to even attempt to recreate those types of facilities (we are all retired!). My nephew aged 44 is coping reasonably well at his parents home and is managing a part time job ( he has chronic schizophrenia). He could not cope in the ‘community’ and when his parenst are too old to cope it is unknown what will become of him unless another family member is willing to ‘take him on”. My advice to would- be parents considering parenthood is that if you have a history on mental illness in your family – do not procrate unless you have a LOT of money if things go bad – plus i think there is far more stress on young people today than say 30 years ago – and therefore a higher likelihood of that stress sparking a psychotic break. And if that should happen get on meds IMMEDIATELY – because the burning fire metaphor is a good one – go directly to a private psychiatrist and get the pills – dont wait for the public health system – O and get some XANAX for yourself – you will need it……………

AJ Mac
AJ Mac
3 months ago

Thank you for this account. Harrowing to read. Though I have some first-hand experience of psychosis–fortunately well in the past (knock on wood)–and exposure to the madness of others in my extended family, I can only begin to imagine what it has been like to live through this.
It does end up being close enough to demonic possession to earn that name. May God have mercy on all of us.

R Wright
R Wright
3 months ago

What a dreadful tale. My sympathies.

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0 0
3 months ago

Serious mental illness in our modern society has been thrown into the too hard basket. But the modern antipsychotics may still save the sufferers life and those of their close loved ones. You think talk therapy and some anti establishment BS will be a cross against the devil voices telling your loved one to do all sorts of awful things – well , you’re kidding yourself and depriving them of some kind of life. And yes, any kind of mental illness from bipolar, depression, autism, etc, you could not possibly believe the level of ignorance and paranoia from family, friends, society
 be prepared

Ethniciodo Rodenydo
Ethniciodo Rodenydo
3 months ago
Reply to  0 0

Did you read my comment?

Alan Hughes
Alan Hughes
3 months ago

It is an awful situation. The few treatments available are of very modest efficacy (but much better than sham or no treatment) and run the risk of adverse effects. The latter need to be recognized or there is no possibility of the patient and doctor making an honest risk:beneft appraisal. Even when this is done people will often be left with the unpalatable truth that life is only tolerable with these medications and their problems. It is far from a unique situation in medicine a very similar calculus is done in oncology with chemotherapy or in later stages of Parkinson’s for example.
A well written and helpful article

Steve Jolly
Steve Jolly
3 months ago

A couple of decades ago when I was first prescribed anti-depressants (yes it’s been that long), I was told frankly by the doctor that they didn’t really know why the drugs alleviated symptoms. They knew is that the drugs affected neurotransmitter levels in the brain and there was a mountain of clinical experience already by that point to suggest their effectiveness, but he couldn’t tell me how exactly the neurotransmitter levels alleviated my intolerable anxiety and constant melancholy. The known side effects didn’t seem all that bad. I was bad off enough that it sounded like a pretty reasonable risk. A couple of decades later, I have no regrets. I still don’t know what effect the use of antidepressants might have over the long term. There could be dire consequences somewhere down the road, but it remains a risk I’m willing to take, because I know how miserable I was before and I know how I get when I’m not on the drugs. I’m somewhat functional with them. I’m basically a useless frazzled anxiety ridden mess without them.

This is the dilemma faced by patients suffering from mental illness or any illness and the doctors who treat them. Weighing the risks of treatment versus the risks of non-treatment is a serious dilemma in the medical profession. It’s a specific form of the more general dilemma of balancing the risks of action against the risks of inaction, which most of us have faced at one time or another. Trying a treatment is a choice but so is doing nothing. Mental illness, or any illness, can cause suffering. Medicine can sometimes alleviate that suffering, but not always, and it may have harmful side effects in either case.

The issues raised in this article are both important and difficult. Reasonable people can have disagreements about such uncertain and challenging dilemmas. Both the drug and the condition it’s treating come with serious risks, and since every situation is different, it ultimately falls upon patients and the doctors who treat them to assess the case in front of them and decide what is the best course of action. The matter is further complicated by the fact that many sufferers of psychotic disorders are not competent to make such choices and often legally proscribed from doing so, increasing the ethical burden on the doctors. However, the risk of non-treatment is also very high. The debilitating nature of psychotic disorders and the danger sufferers often pose to themselves and others justifies a significant amount of risk. Ultimately, until and unless better drugs are developed, it’s hard to fault doctors for being willing to take high levels of risk to alleviate symptoms and avoid significant suffering, nor can I fault patients for refusing the same drugs. This is one of those open-ended questions that medical science can’t really ever resolve in a satisfactory way.

AJ Mac
AJ Mac
3 months ago
Reply to  Steve Jolly

Very well said. I applaud your honesty, and willingness to lead an examined life.

Michael Miller
Michael Miller
3 months ago

A very helpful article in reminding us all how devastating and prevalent serious mental disturbances can be and that drug interventions , whilst undoubtedly helpful, come with a price. As worrying as the prescription of anti-psychotics is in relation to both side-effects and discontinuation effects, the same worry applies to the exponential rise in the use of anti-depressants. Whilst undoubtedly useful in helping people function, the discontinuation effects should give people cause
to question the long term usage. Having seen both the benefits and serious downsides to psychiatric medication over a 40 year period working in the NHS, two points are worth considering .Firstly psychiatrists should resist the temptation to explaining some forms of psychiatric disturbance as a deficiency or excess of brain chemicals which, mysteriously, are rebalanced by these medications. This easily leads to the notion that these drugs should be taken for life.Whilst arguably this maybe the case for the schizophrenias, manic-depression and ‘endogenous’ depression, it is harder to justify
In the milder forms of anxiety and depression. What is needed is a more nuanced attitude to psychiatric medication: for a lot of people in an acute life crisis such medication is utterly helpful and relieving but only for relatively short periods of time( before the side-effects become crippling ; the initial efficacy of the drug wanes and the potential for discontinuation effects dig in). Obviously this is a rather tall order given that our psychiatric services reflect cultural expectations but a lot could be achieved by reclaiming a notion of asylum for those who find themselves in choppy waters and incorporating the myriad ways that people can be helped above and beyond taking a pill.

Keith Dudleston
Keith Dudleston
3 months ago

I am nearly seventy years old and have worked in and around the mental health services in the UK as a student and medical practitioner since about 1977. In some capacity or another I still visit such hospitals most weeks.
I witnessed the anti-psychiatry movement of the 1970s, the hospital closure program of the 1980s, the inquiries into serious incidents in 1990s, the service re-configurations of the 2000s and the privatisation of a significant proportion of our inpatient provision in 2010s. Each decade has witnessed significant bed closures.
According to “Statista” there were about 90,000 such beds in 1975, 55,000 in 2000, and 25,000 in 2020. About 80% (20,000) of these beds are now used by a person detained under the Mental Health Act (compared to less than 15% when I began my career). About half of these beds (10,000) are now owned by the private sector. The cost of this private care is about ÂŁ2bn a year, about 15% of the NHS mental health budget.
In 1975 I was told that community care would improve the lives of the seriously mentally ill. I believed it. Now I am not so sure. The budget is now focused on the detention and treatment of people (without their consent) at significant cost to the economy.
This inpatient treatment nearly always involves second generation anti-psychotic drugs which have the benefits and risks you so clearly describe. All this change has benefited private sector providers and big pharma (and their shareholders) but has it really benefited patients?
https://www.statista.com/statistics/473278/number-of-psychiatric-care-beds-in-the-united-kingdom-uk/#:~:text=In%20total%2C%20the%20number%20of,students%20who%20graduated%20as%20midwives.

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3 months ago

Patients (or “clients”) are able to live on the street and be denied any reasonable care. Big pharma makes next to nothing on antipsychotics so no good deals there. Except that it’s way cheaper to let the seriously mentally ill live on the street or in crappy accommodation predated upon rather than help them. It’s less expensive letting undertreated people decompensate in the community, despite your assertion that detaining people once they are a danger to themselves & others is more so.

Keith Dudleston
Keith Dudleston
3 months ago
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I agree with you that neglecting the seriously mentally ill and allowing them to live in degrading conditions is unacceptable. My concern is that such patients risk relapse, detention and then treatment without consent. I believe proper aftercare or voluntary inpatient care can prevent relapse and so make repeated detention unnecessary.
Such voluntary treatment used to be available in a significant proportion of the 90,000 beds that were available in the UK in 1975. There are now only 25,000 beds; and most are reserved for the detained.
Many believed “de-institutionalised” care would save resources and improve lives but on balance I’m not sure this has turned out to be true. Some people who relapse are now detained in expensive private institutions many miles from home, sometimes in custodial conditions. In the past they were voluntary patients housed in unlocked units near their families and friends. Probably a better arrangement.

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3 months ago

This article is written by someone who has no idea or experience with the horrible reality of schizophrenia. The side affects of antipsychotic medications have been well appreciated since their invention, but the alternative of their absence is to exist 100 years ago with permanent institutionalisation.

Julie Curwin
Julie Curwin
2 months ago

As a psychiatrist, I am the first to admit that my profession is far from perfect and that, in general, psychiatric drugs are massively over-prescribed. But I’m pretty sure the scientologists (and others who deny that psychiatric illness even exists) have never had to strap down the arms of a young man trying to gouge his own eyes out with a pencil in the midst of a psychotic episode. Clozapine is an horrific drug, but also a miraculous one. I’ve seen people get their lives back on it–and I’ve also seen people die because of its side effects. All things considered, if I had a son or daughter with schizophrenia I’d want them to give it a go. There are no easy answers for people with severe mental illness, unfortunately.