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"The problem of prescription overdose in the military has its parallel in civilian life. The tragic overdose victims in both spheres represent canaries in the coal mine--only the most obvious victims of what has become our national orgy of over using psychotropic drugs." Allen Frances MD
Dr. Allen Frances, psychiatry professor emeritus and former chairman of psychiatry, Duke University who chaired the DSM-IV Task Force revision --i.e., psychiatry's diagnositic / practice manual--has emerged as one of the most outspoken, thought provoking critics of psychiatry and its diagnostic and prescribing practices.
Dr. Frances recognizes what few US doctors--and hardly any psychiatrists--do:
The "Hippocratic injunction of "FIRST DO NO
HARM" evolved in ancient Greece specifically to discourage
practitioners from being overly aggressive in using dangerous treatments for
conditions that are not responding (and may not respond well) to existing
interventions. It is important to recognize that sometimes the treatment
becomes worse than the disease."
Indeed, psychiatrists' overprescribing psychotropic drugs have worsened the disease or mental disorder they are presumed to be suffering from. Presumed, because as Dr. Frances--who chaired the Task Force of the DSM-IV revision-- has acknowledged, the concepts that define mental disorders in the DSM are just concepts lacking scientific authenticity:
“there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it....these
concepts are virtually impossible to define precisely with bright lines
at the boundaries.”
Below, Dr. Frances identifies the problems that have led to increased deaths among US troops--and he offers corrective steps to stem the tide of treatment-related deaths.
Vera Hassner Sharav
PSYCHOLOGY TODAY / PSYCHIATRIC TIMES
By Allen Frances, MD | February 13, 2011 / March 9, 2011
The
New York Times of February 14 carries the disturbing news of an
alarming increase in deaths from accidental overdose among our active duty
military personnel and our war veterans. The usual scenario is a diagnosis of
PTSD (often accompanied by a pain syndrome) unsuccessfully treated with a wide
array of psychotropic drugs, which in their aggregate wind up killing the
patient-- often at a very young age. Autopsy reveals significant blood levels
of prescribed medication reflecting the heavy drug cocktail and no other
apparent cause of death.
PTSD/pain patients are often prescribed a combination of psychotropics that may
include--one antidepressant, one antipsychotic, one antianxiety, one sleep, and
one pain medicine. Sometimes, the enormous medication burden is worsened even
further--either by the simultaneous prescription of more than one drug from a
given class or the additional self medication effected by the sharing of pills
among patients.
Individual psychotropic drugs can have serious side effects--in excessive
combination they sometimes threaten respiratory and cardiac function in a
potentially lethal way. And the whole is even more dangerous than the sum of
its parts since the medications can interact to increase each other's blood
levels. Prescription drugs are overtaking illegal drugs as the primary cause of
accidental overdose and death.
To its credit, the military is catching on and beginning to initiate
procedures to restrict and review heedless and excessive polypharmacy. But this
is a tough problem with no ready solutions. Some of the factors involved are:
1. The over prescription of multiple drugs that is also rampant in civilian
life. There is no research literature to guide and restrain
polypharmacy--so it becomes subject to individual physician whim, often under
patient pressure for relief.
2. PTSD has no effective medication treatment, encouraging the
potentially dangerous scatter shot approach of treating the individual
symptoms each individually with its own medication.
3.The recent ubiquity and carelessness of prescription of dangerous pain
medications that resulted as an over-compensation by the military
after it was previously criticized for being too sparing in their use.
4. Because they are legal, accessible, and cheap, pain medications are now an
attractive alternative to illegal recreational drug use--but with dangerous
consequences given their interaction with other psychotropic drugs.
5.The tendency to always add and never sunset medications leads to the
continued use of drugs that have not been effective, but will add on to the
cumulative and interacting side effects.
6. Chasing the side effects of one drug by adding another to deal with them--eg
if an antidepressant causes anxiety or insomnia it is usually a mistake to add
yet another potentially harmful pill to deal with these side effects rather
than reducing the dose or trying another antidepressant.
7. A shortage of mental health personnel that results in pill pushing rather
than the easy access to the one treatment with clear efficacy for PTSD- cognitive
behavior therapy.
8. Forgetting, the Hippocratic injunction of "FIRST DO NO HARM."
This evolved in ancient Greece specifically to discourage practitioners from
being overly aggressive in using dangerous treatments for conditions that are
not responding (and may not respond well) to existing interventions. It is
important to recognize that sometimes the treatment becomes worse than the
disease.
This is exactly our modern dilemma with some cases of PTSD where restraint is
safer and saner than unreasonable treatment perfectionism and optimism-- which
can be costly and sometimes even lethal.
None of these problems will be easy to solve, but some immediate
corrective steps seem obvious:
1. Greatly enhance the availability of CBT. If it is too expensive or difficult
to recruit trained mental health professionals, train the needed cohort of
medics and paraprofessionals. CBT is readily teachable to those with limited
previous training.
2. Educate doctors on the risks and limitations of polypharmacy for both
PTSD and for pain syndromes, and especially the combination of both.
3. Require special explanations from physicians whenever they prescribe more
than three psychotropic medications, or prescribe higher than standard dosages,
or prescribe drugs that have significant interactions, or prescribe
simultaneously two drugs from the same class.
4. Require automatic, thorough quality assurance auditing to ensure
there are adequate reasons for exceptions.
5. Pharmacies should routinely use available drug interaction algorithms to
spot dangerous doses and drug combinations and to alert clinicians.
6. Readily available detoxification and rehabilitation should be provided for
those who have become addicted to prescription medications and/or other
addictive substances.
This problem of prescription overdose in the military has its parallel in
civilian life. The tragic overdose victims in both spheres represent
canaries in the coal mine--only the most obvious victims of what has become our
national orgy of over using psychotropic drugs.
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