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

The nation’s top psychiatrists are struggling with a daunting dilemma these days.

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.

The issue is being watched closely by personal injury lawyers fresh from the asbestos and tobacco wars and looking for their next lucrative lawsuit.

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 anti-psychotics 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 more favorable outcomes and fewer side effects.

But the benefits of the drugs have been obscured as personal injury lawyers seeking clients have begun buying newspaper ads and establishing websites that strongly suggest the new drugs are linked to increased incidences of diabetes.

When vulnerable schizophrenia patients learn of the lawyer-generated controversy, they may stop taking their medication, causing harm to themselves and possibly to others. Failure to take medications properly already is a huge barrier to schizophrenia treatment, and news about lawsuits only exacerbates the situation.

Of course, science is not conclusive; the link between depression and diabetes is nebulous at best. Long before the advent of anti-psychotic drugs, studies have found 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 schizophrenia itself somehow be causing diabetes — which is believed to be one of the most undiagnosed diseases today? Are changing lifestyle factors involved? Could genetic predispositions be the trigger? Or, as a few inconclusive studies now speculate, is the diabetes link related to medications?

These are tough questions that ought to be settled by scientists and doctors rather than lawyers in search of sympathetic juries and 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.

And, it’s not entirely clear whether patients who take the drugs and test positive for diabetes actually had diabetes before they ever began taking the medication. 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.

And, in the process, they struggle to sort through all the studies – from the inconclusive ones that show the drugs might be linked to diabetes to a recent study that suggests the drugs may actually have a protective effect against diabetes.

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 and loved ones. It must be treated as effectively as possible.

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