Straterra: A Safer Desipramine?By now, the anti-psychiatry narrative has nearly become a cultural meme1, attracting a large cult following on the internet. The narrative, of course, is that (1) there is an “epidemic” of mental illness afflicting this country (i.e. an astonishing rise in the incidence of severe mental illness in the U.S)2; and (2) this epidemic has been fueled by (allegedly) harmful psychiatric medications such as antidepressants and antipsychotics.I have challenged this false narrative in two previous columns3,4 pointing out, for example, that rates of psychiatric disability determinations are an invalid indicator of disease incidence or prevalence and are subject to considerable manipulation and bias. At the risk of being repetitious and appearing a bit obsessed, I return to the issue now, in light of an important new study.

The recently-released (2016) National Survey on Drug Use and Health (NSDUH) is well-worth every psychiatrist’s attention5. The NSDUH is an annual survey of the civilian, non-institutionalized population of the United States aged 12 years old or older, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

On the one hand, the 2016 survey gives the lie to the “epidemic” narrative, showing that, for the most part, rates of serious psychiatric illness in adults (18 or older) have remained fairly stable over at least the past decade. On the other hand, it raises a red flag with respect to young adults, age 18-25.

Before presenting some of the data, it’s important to define two key terms. The survey defines “any mental illness” (AMI) as any mental, behavioral, or emotional disorder in the past year that met DSM-IV criteria (excluding developmental disorders and substance use disorders).

It defines “serious mental illness” (SMI) as any mental, behavioral or emotional disorder that substantially interfered with or limited one or more major life activities.

AMI and SMI are not mutually exclusive categories; adults with SMI are included in estimates of adults with AMI. (Co-occurring mental health issues and substance use disorders were evaluated separately and are not discussed here).

Key Findings

So,here are the key findings relevant to the bogus “epidemic” narrative:

  1. The percentage of adults with AMI in 2016 (18.3%) was similar to the percentage from 2008 to 2015; e.g., in 2008, the percentage was 17.7.  (Figures 55 and 57 in the report).
  2. The percentage of adults with SMI in 2016 (4.2%) was similar to the percentages from 2010 to 2015, though higher than the percentages in 2008 and 2009 (3.7% in both years, statistically significant at the .05 level).

If we go back to the NSDUH data from 2002, we find that 8.3% of adults in the U.S. were found to have serious mental illness during the 12 months prior to being interviewed.6 Thus, if anything, the rate of SMI in recent years appears to be lower than that from 15 years ago.

There is no signal from these data that the incidence or severity of mental illness is spiking to epidemic proportions. (Recall that the standard definition of “epidemic” is the occurrence in a community or region of cases of an illness or an outbreak with a frequency clearly in excess of normal expectancy).7

What about rates of major depressive episodes (MDE)? In 2016, 6.7 percent of adults aged 18 or older had at least one MDE in the past year, and 4.3 percent of adults had an MDE with severe impairment in the past year (Figure 51). These rates are largely unchanged, compared with (non-severe) MDE rates between 2005 and 2015; and with severe MDE rates between 2009 and 2016.

In the face of widespread and even increasing use of antidepressants during the past 20 years,8 we see no signs of an “epidemic” of MDE in the adult cohort as a whole. “With respect to suicidality, the percentage of adults aged 18 or older in 2016 who had serious thoughts of suicide was similar to the percentages in most years between 2008 and 2015. Similarly, the percentage of adults aged 18 or older who attempted suicide remained stable between 2008 and 2016. Thus, the notion that widespread antidepressant use is driving up rates of suicidal behavior is not supported for U.S. adults as a group, over the past decade.

Finally, inpatient status is a well-established proxy for severity of illness.9 If psychiatric treatment or medication were fueling an “epidemic of mental illness”or making patients “sicker”– we would reasonably expect an increase in inpatient psychiatric admissions, all other factors (insurance coverage, admission policies, etc.) being equal.

Yet the NSDUH data show that between 2002 and 2016, inpatient service use in adults 18 or older remained remarkably stable. Of course, unknown variables may be at work here, such as potential inpatient admissions being diverted to the prison system, now the largest de facto mental health treatment system in the country. But looking simply at the data over 14 years, we find no signal of an epidemic of severe mental illness requiring hospitalization.

What About Schizophrenia?

The NSDUH data does not address rates of psychosis or schizophrenia, so it’s useful to take a brief look at that issue, based on other sources. It must first be said that determining rates of schizophrenia in various cultures, over vast periods of time, is far from simple and there are many confounds discussed in the voluminous literature. But a 1995 report by the World Health Organization10 found suggestive evidence from several countries that the incidence of schizophrenia between 1969 and 1988 actually declined. This finding is notable, since this period saw extensive use of antipsychotic agents in most industrialized nations.

More than two-thirds of the WHO studies cited found a decrease in the incidence (new cases) of schizophrenia since 1960.

To be clear: some of this apparent decrease may be explained by the shifting diagnostic criteria for schizophrenia, changes in the immigrant population, and many other factors.10 On the other hand, as the WHO report observed, “it is likely that the increased use of antipsychotic drugs has led to a greater number of patients being treated successfully by general practitioners and never referred to any type of psychiatric treatment agency or included in service-based statistics.” 10 (italics added)

The WHO report is consistent with a study11 from the United Kingdom, using the General Practice Research Database, which found that between 1996 and 2005, the incidence and prevalence of schizophrenia and psychoses in the U.K. were either stable or declining.

While these data are not definitive, they provide no evidence of an epidemic of schizophrenia, or any signal that antipsychotic medication is somehow worsening rates of the disease. Consistent with this conclusion, a recent review12 by a group of epidemiologists (Sohler et al) examined the effects of long-term antipsychotic treatment on psychotic disorders. Several outcome variables, such as remission, relapse and re-hospitalization were analyzed. Although flaws in the available studies did not permit a firm conclusion, the authors found that the data did not support the hypothesis that long-term treatment with antipsychotic medication causes harm.

The Red Flag

 While the above findings are reassuring, the NSDUH study highlights several disturbing trends in the subgroup of those aged 18-25. For reasons as yet unclear, younger adults have shown rising rates of psychiatric disorder in the past eight years or so. Specifically, the 2016 percentage of young adults with serious mental illness (5.9 %) was higher than the percentages in each year since 2008 (statistically significant at the .05 level); and the 2016 percentage of young adults with any mental illness (22.1 %) was higher than the percentages in 2008 to 2014 (statistically significant at the .05 level).  Furthermore, the percentage of young adults aged 18 to 25 with serious thoughts of suicide (8.8%) was higher in 2016 than in the period from 2008 to 2014.

Even more worrisome: other data show that between 1999 and 2014, the suicide rate among adolescents (age 10-14) nearly doubled, with most of the increase occurring after 2007, and with the sharpest rise occurring in girls.13

Many hypotheses have been put forth to explain these worrisome trends, but there is little or no evidence linking them to psychiatric medications. Specifically, a medication-related effect is not consistent with the comparatively lower rates of adolescent suicide between 1999 and 2007, during which period psychiatric medications were widely prescribed in this population.

Moreover, two independent analyses of antidepressants and suicide concluded that these medications have, overall, a “neutral” effect on suicide rates. Thus, Ghaemi14 concluded that serotonin reuptake inhibitors (SRIs) increase [completed] suicide risk in 1% of children, and lead to completed suicide in about 1 in 500, which is the same as their prevention rate. Their overall effect [on suicide] is probably neutral when benefits are weighed against harms.

Similarly, Carroll15 found evidence of equipoise between the therapeutic outcome of preventing suicide and any potential drug-related provocation of suicide among adolescents treated for [major depressive disorder] with fluoxetine. The notion that antidepressants increase adolescent suicide rates is rendered even less plausible by several epidemiological studies showing an inverse relationship between SRI prescription and rates of suicide in children and adolescents.16 For example, Gibbons et al16 found that after adjustment for sex, race, income, access to mental health care and county-to-county variability in suicide rates, higher SSRI prescription rates were associated with lower suicide rates in children and adolescents.

Therefore, we may need to consider a variety of societal and psychological factors to explain the spike in adolescent suicide, especially among girls,since 2007. Speculatively, causes may include the rise and influence of social media, cyber bullying and the potential infectious nature of suicide.

Conclusion

 Nothing I have related here calls for high fives within the profession of psychiatry. The justifiable (and long overdue) debunking of the “mental illness epidemic” narrative in no way means that mental illness in the U.S. is being successfully managed and treated. As several prominent critics within psychiatry18,19 have pointed out, untreated or inadequately treated mental illness remains an enormous societal problem. Indeed, less than one-half of adults who struggle with a mental illness receive needed treatment.20

This shortfall is particularly true of untreated psychosis, which increases the risk of harm to both self and others.18 And even when treated appropriately, many patients with schizophrenia, bipolar disorder and major depression respond only partially, or experience substantial side effects from medication.

No, there is no generalized epidemic of mental illness in the U.S. Nor is there credible evidence that psychiatric medication is driving up rates or severity of mental illness. But without a doubt, there is an urgent need for more accessible, affordable and effective treatment of psychiatric disorders.

Acknowledgment: I wish to thank Bernard J. Carroll, MBBS, Ph.D for his helpful comments on an earlier draft of this piece.

References

  1. Dr. Marcia Angell: “It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it.” Angell M: The Epidemic of Mental Illness: Why? The New York Review of Books. June 23, 2011.
  2. Whitaker R. Psychiatric drugs and the astonishing rise of mental illness in America. Ethical Human Psychology and Psychiatry, Volume 7, Number I, Spring 2005
  3. Pies RW. The Bogus  Epidemic of Mental Illness in the U.S. Psychiatric Times. June 18. 2015
  4. Pies RW. The Astonishing Non-Epidemic of Mental Illness. Psychiatry Times. Nov. 1, 2016.
  5. Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm
  6. Epstein J, Barker P, Vorburger M, Murtha C: Serious Mental Illness and Its Co-Occurrence with Substance Use Disorders, 2002. http://www.ce-credit.com/articles/100995/CoD.pdf
  7. UCLA School of Public Health. Accessed at: http://www.ph.ucla.edu/epi/bioter/anthapha_def_a.html
  8. Pratt LA, Brody DJ, Gu Q:Antidepressant Use in Persons Aged 12 and Over: United States, 2005-2008. https://www.cdc.gov/nchs/data/databriefs/db76.pdf
  9. 9.     Pope GC, Ellis RP, Ingber MJ: Principal Inpatient Diagnostic Cost Group Model for Medicare Risk Adjustment. Health Care Financ Rev. 2000 Spring; 21(3): 93-18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194677/#!po=1.02041
  1. Warner R, de Girolamo G.  World Health Organization, 1995. https://pdfs.semanticscholar.org/1c6a/e11922188a5c0d155862965e803b90154e61.pdf
  2. Frisher M, Crome I, Martino O, et al. Assessing the impact of cannabis use on trends in diagnosed schizophrenia in the United Kingdom from 1996 to 2005. Schizophr Res. 2009 Sep;113(2-3):123-8.
  3. Sohler N, Adams BG, Barnes DM, et al. Weighing the evidence for harm from long-term treatment with antipsychotic medications: A systematic review. Am J Orthopsychiatry. 2016;86(5):477-85.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907881/
  4. https://www.nytimes.com/2016/11/04/health/suicide-adolescents-traffic-deaths.html.
  5. Ghaemi SN. Classic study of the month. The FDA analysis of antidepressants and suicide. The Psychiatry Letter. April, 2015. Accessed at: psychiatryletter.org
  6. Carroll BJ. Adolescents with depression. JAMA. 2004;292:2578.
  7. Gibbons RD, Hur K, Bhaumik DK, Mann JJ. The relationship between antidepressant prescription rates and rate of early adolescent suicide. Am J Psychiatry. 2006 Nov;163(11):1898-904.
  8. http://www.healthline.com/health-news/us-suicide-rate-increases-highest-among-young-girls#1
  9. Torrey F. American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. Oxford University Press, 2013.
  10. Frances, A.J. (16 February 2016).  Setting the record straight on antipsychotics. Psychology Today.  https://www.psychologytoday.com/blog/saving-normal/201602/setting-the-record-straight-antipsychotics
  11. Kim et al: Patterns of Utilization and Outcomes of Inpatient Psychiatric Treatment in Asian Americans,  Am J Psychol. 2014 Mar 1; 5(1): 35-43. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430852

For Further Reading:

Goff DC, Falkai P, Fleischhacker WW, et al.  The Long-Term Effects of Antipsychotic Medication on Clinical Course in Schizophrenia. Am J Psychiatry. 2017 Sep 1;174(9):840-849. doi: 10.1176/appi.ajp.2017.16091016. Epub 2017 May 5.


 

This article originally appeared in:

Psychiatric Times

It is reprinted here with permission.