The Journal Sentinel claims antidepressants and other psychiatric medications are over-prescribed. Are they right?

Jon Lehrmann has developed a healthy respect for post-traumatic stress disorder. As an expert in providing mental health care to military veterans, and an administrator at the sprawling Zablocki VA Medical Center, he’s come to know its paranoias, agitations and insomnias. And so Lehrmann, who chairs the psychiatry department at the Medical College of Wisconsin, also knows how difficult it can be to combat this illness with pharmaceuticals. “There’s not one medication that treats it all,” he says. Some patients “do really well” taking a battery of pills – five or so antidepressant, anti-anxiety, antipsychotic and mood stabilizer medications – and some don’t.

Lehrmann includes PTSD on his list of conditions that often require a handful of pharmaceuticals to treat effectively, alongside severe bipolar disorder, schizoaffective disorder and psychotic depression, conditions that combine mood and psychotic symptoms, or mania and depression. As with PTSD, some of these patients acclimate well to a range of medications, whereas others struggle to find an effective combination. “It’s not about the number” of drugs, he says. “It’s about watching for side effects and toxicity.”

A Watchdog project published by the Journal Sentinel this spring, the lead story of which was titled “Fighting the Fog of Mental Illness,” relied heavily on numbers, and as a result, ended up depicting much of the above treatment as something bordering on malpractice. The project’s distrust of modern pharmacological practice went further, writing off a class of psychotropic drugs as something “offered to the masses to simply numb the uncomfortableness of the human experience,” with no other perspective quoted. And a longer story all but blamed a woman’s years-long struggle with psychosis on the medication she was taking. For readers wanting a scientifically based investigation of overmedication – which remains a valid, if less sweeping, issue – this wasn’t it.

One of the key examples offered by the stories is of an unnamed Wisconsin person, identified through Medicaid records, who “held prescriptions for five or more different psychiatric medications for three months straight,” which is depicted as outrageous. For the rhetorical gasp, Steven Moffic, a retired psychiatrist and hospital administrator, is quoted as saying, “Any self-respecting doctor would faint if they saw a patient on that much medication.” To explain how this situation came about, the story states that doctors (including general practitioners) pile on medications one after the other, hoping to find “a good balance for the patient, but few consider the interaction[s] the drugs have.”

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In fact, there are surprisingly few no-go interactions between psychiatric drugs, with the most important warning generally being to not double up on two that work by the same mechanism, such as two antipsychotics or two SSRI antidepressants. For 2014, the Journal Sentinel found about 7,000 cases where Medicaid patients in Wisconsin had prescriptions for at least two antipsychotics at the same time. Lehrmann, who was interviewed for “Fighting the Fog” but not quoted, says that figure might be inflated by patients who are switching medications or who, in limited cases, are doubling up because they’re treatment resistant. Other possible scenarios include unused scrips: Due to side effects, an estimated half of patients don’t take antipsychotics as prescribed.

To illustrate the harm that psychiatric drugs allegedly cause, the story quotes a pastry chef from Waukesha who took benzodiazepine sedatives for several years – part of a chain of events that began with insomnia – and now blames them for “ringing in her ears and trouble focusing,” as well as some difficulties with balance. No FDA data, and no other perspective, is given. There’s no context provided, except for the woman’s comments that, “Basically, this drug is offered to the masses to simply numb the uncomfortableness of the human experience. It’s like playing Russian roulette with people’s souls.”

A much longer and more emotional story deals with a woman whose psychotic illness, over the years, has led to repeat hospitalizations and long periods where she was heavily medicated, perhaps to the point of overmedication. The story’s interactive graphic says that during one of the heaviest years, 2003, she was “in and out of psychiatric wards and heavily sedated with as many as six different medications,” but according to the same graphic, she took a total of six medications for only two days in 2003, and that cocktail included an asthma medication and painkiller. “She says she could barely think straight,” the story adds, pointing a finger at the medications, but such situations are complex. Which cognitive effects come from the medication, the disorder or both? In 2004, the woman is said to have regularly taken two different antipsychotics, but only one (Risperdal) is listed. The other regularly occurring medication that isn’t an antidepressant is Depakote, a mood stabilizer.

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When the woman was a teenager, a doctor prescribed her Geodon, a newer antipsychotic, and the story can be read as partly blaming it for causing her psychosis. While many different psychiatric medications carry a slim chance of triggering psychosis, those episodes are typically limited in duration and not lifelong.

Still the question remains, are doctors overmedicating their patients? Richard Friedman, a professor of psychiatry at Weill Cornell Medical College and writer, says he doesn’t see a large amount of bad “polypharmacy” (multiple meds) in his work at a university hospital. “Not really,” he says, “and I see really sick people. There’s a group of people that needs polypharmacy. Without it, they would suffer.”

Another well-known academic, Alexander Tsai, an assistant professor of psychiatry at Massachusetts General Hospital, says that while medications carry risks, there are also dangers associated with undermedicating patients as symptoms become so tortuous they harm themselves or others: “There are costs and benefits associated with every decision we make.” ◆

‘Down the Hatch’ appears in the July 2017 issue of Milwaukee Magazine.

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