Monday, May 17, 2010

Twenty, Twenty, Twenty-Four Hours a Day, I Wanna Be Sedated

The Ramones sang those lines quite a while back. Without knowing it, they were singing about how anti-psychotic and anti-convulsive medications really work on folks who carry the pseudo-diagnoses of bipolar II or childhood bipolar disorder but who really have personality disorders, anxiety disorders, and/or a family relationships environment that is more like a war zone than the refuge that a home and family should provide.

So why do patients and the parents of patients keep coming back for refills, and why do the doctors keep prescribing them? Well, they kind of "work." What happens is they calm the person down somewhat, because almost all of them are sedating and function like a tranquilizer. This is a side effect of the medication, not the main effect, however.

After a while, the tranquilizing effects of these drugs tend to diminish, and the drugs seem to "stop working." The doctor then will switch them to another drug or add a drug from a different class. This is why many patients come to me after having been on a wide variety of different drugs at different times, or on crazy combinations of drugs. Uppers in the morning, downers in the evening, sugar at suppertime.

I see this happen a lot in my patients with borderline personality disorder (bpd), who have severe and incapacitating agitation very frequently. Just about any half-way sedating thing that you put them on "works" for a month or two to diminish their agitation somewhat, although if they get upset enough, it breaks through. After that, most medications (except, ironically, benzodiazepines- actual tranquilizers like Klonopin) no longer have much of this effect.

Not surprisingly, most drug company-sponsored drug trials in patients who have borderline personality disorder do not follow the subjects very long, and the companies purposely try to leave the impression that any beneficial effects are not just side effects, and that they will go on as long as the patient stays on the medication.

A few years ago the old anti-psychotic drug Haldol was touted for use in bpd. The chairman of the psychiatry department at UAB at the time was one of the people doing the touting. Finally a longer-term study was published in the American Journal of Psychiatry which showed that indeed the drug seemed to stop "working" after a couple of months. Of course, the guy at UAB did not mention this study when I saw him speak.

The pharmaceutical companies know they are mixing up the side effects of their drugs with the therapeutic effects, and will almost never compare their drugs in a study to an actual tranquilizer like a benzodiazepine (the Valium- or Klonopin-like drugs). In the past, sedating drugs were at least advertised as what they are - sedatives.

Below is an advertisement first published in February, 1959 in the Post Graduate Medical Journal. It is an ad for the sedative Equanil, or Meprobamate, which was also called Miltown. It is a serious downer with much of the same properties as major barbiturates like Secanol or Nembutol ("Reds" and "Yellows" on the street way back when), drugs highly addictive and potentially fatal in overdose. Drugs like these have been replaced by the much safer benzodiazepines.

What strikes me about this ad is that the drug is being advertised as a treatment for temper tantrums, which according to the quacks and snake-oil salesmen selling the concept of pediatric bipolar disorder, are often a symptom of mania. If Equanil worked, it must therefore be a mood stabilizer? Well, maybe if you are not bipolar.


  1. As a former child bipolar patient diagnosed by a psychiatrist on staff at MGH, and having had to suffer through his tremendously inadequate and negligent care and it's never ending consequences -- I frankly think that a large proportion of mothers have Munchausen's Syndrome by proxy.

    My mother had it and does it to herself now. Some of these mothers are just doctor addicts.

  2. Great comment!

    "I frankly think that a large proportion of mothers have Munchausen's Syndrome by proxy."

  3. When you hold the prescription pad it's hard to tell a patient (or parent) the solution is not in the bottle. There's an almost endless number of drugs to try, and when you run out of monotherapies, you can start on the combinations.

    Don't just do something. Sit there.