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Debate: Is the long term use of psychiatric drugs harmful?

The controversial topic will be discussed by leading experts at the Maudsley Debate, King's College London

BMJ

The benefits of psychiatric drugs have been exaggerated and the harms underplayed due to poor trial designs, argues one expert in The BMJ. But another expert and a patient contend that the evidence supports the use of these drugs.

More than half a million people aged above 65 years die from the use of psychiatric drugs every year in the Western world and the benefits would need to be "colossal" to justify these "immensely harmful" treatments, argues Peter Gøtzsche, professor and director of the Nordic Cochrane Centre, Denmark.

But benefits are "minimal", he explains, adding that these treatments should "almost exclusively be used in acute situations". New guidelines should support this change as well as widespread withdrawal clinics to help many patients gradually come off these medications.

Benefits have been overemphasised and harms understated, he says, because randomised controlled trials have been biased, not blinded appropriately, have not fully evaluated the effects of these drugs and deaths have gone under reported.

For example, the majority of studies have included patients already using a psychiatric drug and such patients may undergo abstinence and suffer from withdrawal symptoms. As a result, this study design exaggerates the benefits of treatment and increases the harms in the placebo group.

Industry funded trials have under reported deaths, he adds, estimating that there have probably been 15 times more suicides among people taking antidepressants than reported by the US Food and Drug Administration (FDA).

He calculates that deaths from three classes of drugs - antipsychotics, benzodiazepines and similar drugs, and antidepressants - were responsible for 3693 deaths every year in Denmark. This number corresponds to 539,000 deaths in the United States and European Union combined.

The beneficial effects of psychiatric drugs are so small, he says, that it would be possible to stop current use almost completely without causing harm. He recommends stopping the use of all antidepressant, ADHD and dementia drugs, and prescribing only a small fraction of currently used antipsychotics and benzodiazepines.

But Allan H Young, a professor of mood disorders at King's College London, and John Crace, a psychiatric patient, argue that research supports the use of psychiatric drugs which are just as beneficial and efficacious as treatments for other common, complex conditions.

These drugs are needed, they insist, to reduce the long term harms of psychiatric conditions, which are the fifth leading cause of disability worldwide. Most patients suffer from co-existing health conditions, they add, a primary cause of death among this group.

They explain that psychiatric drugs are rigorously examined for efficacy and safety and while the evidence base is "imperfect", research shows that psychiatric drugs are more beneficial than harmful.

Careful evaluation of these drugs is undertaken before and after regulatory approval, they explain, and that post surveillance after a drug is licensed can include safety of a medication in the general population, which unlike study populations, includes people with varied medical conditions.

Yet concerns persist and many are "overinflated", they add, and list recent studies supporting the use of lithium, once labelled a "toxic placebo", and antipsychotics, and treatments for mood disorders.

But as with any drug treatment, the harms and benefits need to be evaluated from group data in trials, and be applied to individual patients whose subjective experiences are important to consider, they argue.

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