Recently, I corresponded with Dr. Kurt Grady to ask some questions regarding psychotropic drugs.
Dr. Kurt Grady is a practicing clinical pharmacist in the St. Louis, Missouri area. He holds a Doctor of Pharmacy degree, a Master’s degree in Business Administration, and a Doctor of Biblical Studies degree in Biblical Counseling. Kurt is certified by the International Association of Biblical Counselors. He serves on the board of directors of Overseas Instruction in Counseling and Christian Education Enterprises, Inc. He is a faculty member at Gateway Biblical Counseling and Training Center, Master’s International School of Divinity and an associate teacher in international graduate degree programs with Overseas Instruction in Counseling. With Dr. David Tyler, he is the co-author of Deceptive Diagnosis: When Sin is Called Sickness and ADHD: Deceptive Diagnosis both by Focus Publishing. Kurt lectures on biblical counseling topics at both domestic and international conferences. He and Lesley have been married over twenty years and they have three teenage sons.
What percentage of your customers are purchasing psychotropic drugs?
My current position is in long-term care pharmacy so I take care of nursing home patients primarily. National data as of March 2013 show that approximately 63% of people in nursing homes receive at least one psychoactive medication. These include antipsychotics (24%), antidepressants (47%), antianxiety medications (22%) and sleeping medications (7%). Outside of nursing homes, in 2010, 1 in 5 adults in the USA took at least one psychoactive medication…that’s about 60 million people.
What are currently the most popular psychotropic drugs?
By volume, there were over 43.5 million prescriptions filled for two antidepressants (escitalopram (Lexapro) and trazodone (Desyrel) in 2011. Both of these drugs rank in the top 20 of all prescriptions dispensed in the United States that year. Other psychoactive drugs in the top 200 prescriptions by volume dispensed include: Cymbalta, sertraline (Zoloft), alprazolam (Xanax), Seroquel, clonazepam (Klonopin), fluoxetine (Prozac), citalopram (Celexa), lorazepam (Ativan), venlafaxine (Effexor), Abilify, Vyvanse, zolpidem (Ambien), diazepam (Valium), amitriptyline (Elavil), paroxetine (Paxil), amphetamine (Adderall), risperidone (Risperdal), and Zyprexa. Some of these drugs appear multiple times in the top 200 as the generics are often made by different companies. Alprazolam, for example, holds 5 spots in the top 200.
Considering the most popular, what are its purpose, actions, and side effects?
The top two psychoactive drugs by volume are escitalopram and trazodone. Both are classified as antidepressants and each carries a boxed warning of increased suicide rates in people up to 24 years of age taking the medications. While suicide rates are increased in people with depression, the FDA believed there was a more profound effect in younger people taking the drugs and thus added the black box warning. Each drug is associated with nausea, vomiting, constipation, decreased sexual performance and sex drive in general, dizziness, dry mouth, increased appetite and others. Trazodone is known to be profoundly sedating so much so that it is often used for sedation and sleep. In addition, both are sometimes used for treating anxiety.
What emotional problems do escitalopram and trazodone likely indicate?
This is a difficult question in that there is so much experimentation that goes on in mental health drug treatments. These drugs can be used for various anxiety disorders, depression, headaches, treatment of pain, bipolar disorder, aggression, obsessive-compulsive disorder, post-traumatic stress disorder and premenstrual dysphoric disorder and undoubtedly others.
By experimentation, are you referring to the trying of one drug and then another to see what works? If so, how many drugs to people commonly try before they settle on one?
I have seen patients taking up to a half-dozen psychotropic medications in an effort to find just the right cocktail. Rarely does a patient start on one drug and stay on that drug alone for a lengthy period of time. There is a high discontinuation rate.
What makes these two drugs so popular as opposed to other drugs?
Trazodone is a drug that has been on the market for decades so most are familiar with it. As noted, it is profoundly sedating so it is used more as a sleep aid than as an antidepressant. It is also used as a sedative for people with anxiety, bipolar disorder and other disorders. It’s also quite inexpensive. Escitalopram is newer and is thought to have fewer side effects than the other SSRI’s [selective serotonin reuptake inhibitors]. It is the generic for Lexapro, which was widely prescribed and was one of the last SSRI’s to lose its brand status. As such, it is the drug that has most recently been highly promoted for depression by a pharmaceutical company. If more people were taking the brand name agent due to heavy promotion, this would lead to more generic prescriptions once they are available. It really comes down to prescribing habits and familiarity.
If depression leads to suicide, and a particular antidepressant increases the risk of suicide, how can it be called an antidepressant? It seems like prescription of such an antidepressant is like dripping lighter fluid onto the fire. What benefit did research show that would convince a psychiatrist to prescribe it for depression?
The theories would have us think of it like this: severely depressed people may think of and even plan suicide, however, they do not have the “energy” or motivation to carry even this act to fruition because they are so profoundly depressed. When these drugs are given, as they begin to lift mood, this gives the depressed person enough energy to actually carry out suicide.
Another factor may have to do with people abruptly discontinuing their medications. While this is also theoretical, the thought is that a rapid discontinuation of the SSRI medications, for example, may lead to a “chemical storm” in the brain as the organ seeks to begin producing various neurotransmitters that it has not been producing because of the presence of the medications. This process of restarting the production of dormant neurotransmitter production takes time. So, if the drugs are removed before the brain can produce its own chemistry again, the results are all kinds of horrors from suicides to murder (including school shootings, theatre shootings, mass murders, etc.). The fact that the boxed warnings target a younger population could be supported by the fact that younger people are less likely to be adherent to drug therapy due to various side effects.
Finally, we do know that these people have problems. They are depressed. The incidence of suicide is higher in depressed people. Perhaps drugs are not the cause at all? Perhaps there are other factors involved….
Is there any danger if a person takes himself off the drug? For example, perhaps he has side effects that are so uncomfortable that he wants to quit the drug?
See above. The SSRI’s, for the most part, need to be tapered slowly. In working with counselees and physicians, my experience has taught me that the length of time it takes for a person to safely and successful come off one of these medications is related to how long they have been taking it. It is also possible that a person may not be able to completely discontinue one of the medications. It may be, in people who have taken multiple medications or who have taken them for a lengthy period of time, that real organic changes have taken place in the brain that do not allow complete medication discontinuation. However, our goal as biblical counselors is not to manage medications or suggest that people stop taking them. Our goal is to glorify God. Restoring the counselee (discipleship) to a place of obedience and usefulness in the Kingdom is our aim, regardless of whether or not they are still taking medications.
This interview continues in the next post with a question about current trends in psychiatry and then a series on chemical imbalance.