01 May 2003 Doctors, Not Lawyers, Should Treat Mental Illness

When the nation’s top psychiatrists gather May 17-22 in San Francisco for the annual meeting of the American Psychiatric Association, they will be struggling with a vexing dilemma.

They will also be closely watched by personal injury lawyers.

At issue: allegations that new drugs proving effective for schizophrenia might contribute to the risk of diabetes — and the desire of some lawyers to sue “deep-pockets” drug manufacturers without waiting until the facts are known.

Schizophrenia is a severe, often dangerously debilitating mental illness, probably the most difficult mental illness for sufferers and their families. Symptoms include hallucinations, delusions, disordered thinking and unusual behavior. Victims of the disease find it difficult to have careers and relationships, and often suffer acute social stigma.

The drugs at issue, atypical antipsychotics such as Eli Lilly’s Zyprexa and Janssen’s Risperdal, have been proven in many cases to be a more effective treatment than older drugs, with outcomes that are more favorable and fewer side effects.

However, as personal injury lawyers in search of plaintiffs have begun buying newspaper ads and establishing websites, the lawsuits, at best premature, are becoming better known than the facts.

When vulnerable schizophrenia patients read about the lawsuits, they can become prone to halting their medication, causing harm to themselves and possibly to others. Failure to take medications at all or regularly already is a huge barrier to schizophrenia treatment, and news about lawsuits doesn’t help.

Meanwhile, some cash-strapped state budget managers, seeking to cut Medicaid costs, are blocking access to the drugs. Private insurers are doing the same, insisting that patients “fail” on older, often less effective, medications first.

Irresponsible publicity is partly to blame for the danger that these drugs won’t be used to best advantage.

Newspaper ads and web sites essentially are implying what science itself does not yet know and may never conclude: that the drugs negligently increase a patient’s risk of developing diabetes.

For decades, long before the advent of antipsychotic drugs, science has recognized that people with schizophrenia are two to four times more likely to develop diabetes than the general population. What isn’t known is why.

Can the disease itself somehow be causing diabetes? Are lifestyle factors involved? Could genetic predispositions be the trigger? Or, as a few inconclusive studies now speculate, is the diabetes link related to medications?

Tough questions that should be settled by scientists and doctors, not by lawyers in search of big checks.

Schizophrenia patients are already among the most difficult patients to treat. Many struggle simply to survive, sometimes living on the margins of society or mired in homelessness.

The public debate so far has been dominated by inadequate science. None of the reports linking the drugs to diabetes stem from the gold standard of clinical science: double-blind, randomized, long-term research trials in large populations. Still, the results made headlines.

Psychiatry isn’t about leather couches and pipe-smoking. Today, the top doctors in the mental health profession must call on a host of divergent skills to tackle confounding issues that involve politics, ethics, economics and the law as much as medicine itself.

Psychiatry is far more nuanced than lawsuits can lead you to believe. While lawyers might claim that an effective treatment should instantly be tossed aside because of possible side effects, doctors seek to tailor the best solution for individual patients from competing alternatives.

While we wait for science to speak definitively about the diabetes link, a partial solution to the current dilemma is to make routine screening for diabetes a part of what’s called “standard of care” for schizophrenia. That means it would be an automatic part of the diagnosis and treatment regimen provided to all schizophrenia patients.

Another solution is a partnership between the medical establishment and the Food and Drug Administration to produce definitive, top-notch research to resolve where the diabetes link truly lies.

Other measures are right-before-your-eyes easy, such as providing warning labels with the medications. Patients, of course, read. Including patients in the framework of solutions is deceptively simple — and effective.

It is crucial that we keep these two terrible diseases in their proper perspective. Though it affects fewer people than diabetes, schizophrenia is a grave illness that can engulf the entire lives of not just patients, but family members. It must be treated as effectively as possible.

Going to court in the absence of solid science solves nothing, yet may hurt many.

Amy Ridenour is president of The National Center for Public Policy Research, a Washington, D.C. think tank.