Last Saturday, Seattle-based journalist and Furious Seasons blogger Philip Dawdy was interviewed on Australian Radio National's All in the Mind program along with Sandy Jeffs, a writer, performer and poet who lives with schizophrenia and David Grainger, the Director of Corporate Affairs and Health Economics for Eli Lilly Australia. The subject under discussion was, of course, Zyprexa, in particular its side-effects of weight gain and Type 1 diabetes, and to what extent Eli Lilly is guilty of downplaying the risk of these, given their potentially life-threatening complications. Further information and documentation about this issue is available at Furious Seasons.
Here we observe the conjunction of two of psychopharmacology's main defense mechanisms: blaming the victim, and the maintenance of the myth of 'the bad old days' when anti-psychotic medications were chemical straitjackets rendering dayrooms a drool-fest of toe-tapping and tongue-poking and long, blank stares. Not that this is a myth, but the idea that it is a thing of the past certainly is. "We don't have to put up with that kind of thing any more," my psychiatrist emphatically reassured me just this morning. "Things have moved on, Ruth, it's not like it was ten years ago when you were in hospital." Right.
Psychiatrists can be downright 'borderline' about drugs. Where I live, the consensus in the psychiatric community with respect to benzodiazepines can be summarised as follows: Xanax = BAD and Klonopin = GOOD, as if being a slower-release drug didn't make the latter any less addictive. Likewise, the first generation of anti-psychotic medications, in use from the 1950's to the 1990's (and still in use here and there), the ones that we were told were lifesavers, that we absolutely must take for the rest of our lives, etc, etc, are now spoken of and written about as if they were the cruel product of some bizarre medieval superstition about the causes of madness. Are we merely (somewhat precipitously) celebrating scientific progress here, or are there other motives behind this anxious disavowal of chlorpromazine and friends? One of the much-vaunted advantages of the second generation drugs are their allegedly superior side-effect profiles, particularly with respect to sedation and tardive dyskinesia. But studies presented to demonstrate this have attracted some criticism - for example, that the reduced risks of tardive dyskinesia can only be inferred by comparing the new drugs with the nastiest of the old ones, e.g. Haldol or Prolixin/Modecate. And don't even try and convince me that Seroquel or Risperdal aren't sedative. The 'bad old days' is a time-honoured form of mythologising designed to obscure the reality of the 'bad new days' in which, as my shrink smugly observed, "we are busier than ever", and patients continue to flush their medication down the toilet. As Kirk and Kutchins put it in Making Us Crazy, their critique of DSM and its constant revisions, "The cycle of denigration, enthusiasm, and denigration makes an old system appear antiquated and a new system necessary, a marketing strategy pioneered by the automobile industry."
Blaming the victim is one of the grand old traditions of psychiatry - think Freud and his abandonment of the seduction hypothesis, which has percolated down the ages into the profound indifference many mental health professionals exhibit towards the familial and social contexts of their patients' problems. In the current biogenetic-oriented climate, the tradition manifests itself in claims that the poor physical health of patients is being misattributed to side-effects of the new drugs. Now, they will rarely come out and put it so bluntly, saying it's all in your head (or or your heart or your pancreas). It's quite enough, and quite skillful use of the media, to just introduce an element of uncertainty, to just say maybe, to get people to deny what's right under their noses. (Those opposing the climate change /greenhouse effect hypotheses have utilised a similar technique, with potentially devastating consequences.)
David Grainger, the Australian Eli Lilly spokesman, exemplified this approach very well:
Natasha Mitchell: In 2002 Eli Lilly Australia distributed a letter to Australian doctors informing them of the association between Zyprexa and hyperglycaemia -- or elevated blood sugar levels, just to explain -- and certainly other metabolic conditions related to diabetes. What was the basis, David, of sending that letter to the medical community in Australia?
David Grainger: Quite a complex little background to that, Natasha, you can appreciate people with serious mental illness, particularly schizophrenia, often have concurrent physical health problems. Things like disturbances to blood sugar levels are not uncommon but it also became apparent that they're perhaps slightly more common in people taking antipsychotic medications.
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But Philip Dawdy, Sandy Jeffs and host Natasha Mitchell are on to it:
Natasha Mitchell: David Grainger from Eli Lilly. The company does fund a Mind Body Life Initiative in clinics around Australia to help people with mental illness deal with issues of wellbeing, weight and exercise. The website has plenty of pictures of smiling folk, cartwheeling in the sunshine, but does this once again put the onus solely on patients rather than on the side effects of the company's drug?
Philip Dawdy: I mean I'm just sorry they haven't a clue how the average schizophrenic or severely mentally ill person lives -- you know they are covering their butts with this one. Unfortunately a schizophrenic who's on 15, 20, 30 milligrams a day of Zyprexa is going to be zonked out for 12 to 15 hours a day and when they're awake they are going to be so foggy that you know they are not going to be out in the front yard doing push-ups.
Sandy Jeffs: I think the problem is though that people with psychotic illnesses aren't in the mind space where they can do that sort of stuff. But there is a tendency to blame people and not see that it's the drugs fault. People's lives don't often have the space for good food, and good hygiene, and good stuff you know. I mean again it's blame the victim, blame the victim.
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David Grainger: The other point that you raise there is in relation to diabetes, and because this is known that there is an increased association of diabetes in people with serious mental illness regardless of any treatment, this has been the subject of a great deal of study as well. There is certainly no association or no direct causality been established between Zyprexa and diabetes.
Natasha Mitchell: There are concerns though that elevated weight gain or rapid weight gain is linked to diabetes, so is there any effort on behalf of Eli Lilly to investigate that in relation to Zyprexa and the weight gain associated with Zyprexa?
David Grainger: Absolutely, this whole topic of what's going on in terms of glucose metabolism and people with serious mental illness and what role does their often lack of physical exercise or less than ideal diet -- what role do those things play and what role does medication play...
Natasha Mitchell: But more importantly what role does their medication play?
David Grainger: Exactly, that's also been a subject of a great deal of research, and in spite of all that body of research there is no clear answer and there is no direct association between the antipsychotic medication and development of diabetes.
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As the bumper sticker goes: 'Give Me Ambiguity or Give Me Something Else'.
The full transcript of the program is available here.
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