Archive for: David Cohen

When Psychiatric Medications Are Abruptly Discontinued, Withdrawal Symptoms May be Mistaken for Relapse UCLA research contributes to assessing the reliability of industry-funded drug trials

/0 Comments/in , , , , , , , , /by

By Stan Paul

Withdrawal symptoms following the practice of discontinuation, or abruptly “coming off,” of psychiatric drugs in randomized clinical trials may be mistaken for relapse and bolster the case for continued use of medication, according to two new studies by UCLA researchers published in the journal Psychotherapy and Psychosomatics.

Principal investigator David Cohen, professor of social welfare in the UCLA Luskin School of Public Affairs, said that clinical trials employing a drug discontinuation procedure had not previously been studied systematically.

“For years, observers have asked whether people getting more symptoms when they came off their medication was their disorder returning or the withdrawal effects from drugs that could be reduced by more gradual, patient-centered discontinuation,” Cohen said.

In light of the difficulties that people have in discontinuing psychiatric medications, Cohen sought to answer that question, joined by co-author Alexander Récalt, a doctoral student in social welfare at UCLA Luskin who is also pursuing a master’s degree at the UCLA Fielding School of Public Health.

They looked at how and why antidepressants, antipsychotics and stimulants were deliberately discontinued from trial subjects in more than 80 randomized controlled trials from 2000–2017. The study also included benzodiazepines, a class of drugs such as Valium, upon which long-term users may become dependent and experience withdrawal symptoms.

In the first study, the researchers found:

  • In 67 percent of studies, no justification was given for a particular discontinuation strategy, which was abrupt or lasted less than two weeks in most cases (60 percent).
  • In 44 percent of studies that related to antidepressants, stimulants and antipsychotics, researchers used mainly abrupt discontinuation to test whether the drugs prevented relapse. Yet, researchers in most studies did not indicate that misclassifying a withdrawal reaction could occur.
  • Most studies incorporating benzodiazepines used discontinuation differently. These studies recognized that withdrawal symptoms were common, and they employed longer drug-tapering periods (more than eight weeks in most cases) to help people successfully come off and stay off these drugs.

The pharmaceutical industry was involved in 70 percent of the 80 studies; in most of the relapse-prevention studies; but in few of the benzodiazepines studies with longer tapering periods, according to the researchers.

Cohen, who also serves as associate dean for research and faculty development at UCLA Luskin, observed across the 80 studies that, in addition to testing relapse prevention, drug discontinuation was employed to chart withdrawal effects and to compare different methods of managing older and frail residents in institutions, given the known damaging effects of drugs taken over the long term.

But only a single study out of the 80 actually employed the discontinuation procedure in order to distinguish clearly between “relapse” and “withdrawal symptoms,” the researchers noted.

“This suggests to us that sponsors or researchers of discontinuation studies are really uninterested in exploring this crucial question,” Cohen said.

“Distinguishing between them requires careful history taking, an open mindset from the clinician and a degree of suspicion that the discontinuation process itself may be contributing.”

In many first-person accounts, patients have complained that they were not warned about these effects or told how slowly they should come off, Cohen said. Instead, their prescriber told them that the effects confirmed that the patients were better off taking the medication and therefore should continue to take it.

“The disconnect continues to drive a wedge between patients and their prescribers and is increasingly discussed in the media, as about one in six adult Americans take — increasingly for years — psychiatric drugs,” Cohen said.

“Our findings, if confirmed by other researchers looking at this literature, contribute to helping decide whether industry-funded drug trials in psychiatry are — as critics have maintained for years — infomercials for drugs or credible scientific investigations,” he said.

In their second study, Cohen and Récalt focused on whether they could detect evidence in the relapse-prevention randomized control trials that an actual misclassification — a confound — of relapse with withdrawal was occurring.

“Most publications do not raise the issue openly, so they do not provide the data to examine this issue directly,” said Cohen, explaining that an indirect method to test their hunch was used. Because withdrawal symptoms are known to begin to occur within an interval of time after drug discontinuation, the researchers focused on the timing of symptoms for drug-continued vs. drug-discontinued participants. They looked for evidence that end-of-study symptoms might already have been present during the study at set discontinuation times. A 50 percent rate of occurrence was chosen to indicate a substantial, non-trivial possible misclassification, Cohen said.

Few studies provided the data to actually test the hypothesis, even indirectly. Among the 14 studies that did provide the necessary data, about three-quarters showed evidence that withdrawal may be mistaken for relapse.

Relapse prevention trials that use psychiatric drug discontinuation commonly conclude that drugs work because they help prevent relapse, Cohen pointed out.

In line with a stream of previous warnings in the literature, the two studies show that more justifications are needed for why and how these discontinuation trials are conducted. Clinicians and consumers should not accept conventional interpretations of what is actually occurring to deliberately drug-discontinued participants in the trials, Cohen said, “and what this could mean for long-term use of psychiatric medications by ordinary people around the world.”

Cohen on Challenges of Tapering Off Antidepressants

/0 Comments/in /by

Social Welfare Professor David Cohen’s comments on the side effects of coming off antidepressants were featured in a recent article in TheBody. A 60% increase in long-term antidepressant use between 2010 and 2018 has prompted research on “discontinuation syndrome,” or the intense side effects that make it difficult for patients to taper off. According to Cohen, “Coming off anything that alters how your brain functions, even coffee or tea, will provoke some kind of reaction. The brain is no longer getting that feedback from the drug, and it reacts to the removal.” After patients of one study rated their withdrawal experience, Cohen explained that “those who rated [their withdrawal] as most severe were coming off the fastest.” Experts recommend careful planning for coming off antidepressants, including a tapering plan, flexibility and a strong support system. “Go slow, and stay in your comfort zone. Feel it out as you go,” Cohen recommended.

Read the article

UCLA Luskin Faculty Among Top 100 Social Work Scholars

/0 Comments/in , , /by

UCLA Luskin Professor David Cohen and Professors Emeritus Yeheskel “Zeke” Hasenfeld and Robert Schilling were recognized in the Journal of Social Service Research’s list of the “100 Most Influential Contemporary Social Work Faculty as Assessed by the H-Index.” The report uses a new method called the H-Index to measure the impact and influence of social work scholarship, taking into account not only the number of publications an individual has authored, but also the number of times that his or her work has been cited by others. “It feels great to be included in a list of highly cited scholars in my field — especially when some were my teachers,” said Cohen, who is also associate dean for research and faculty development at UCLA Luskin. “But creativity and quality mean more than citations — so I plan to keep on trucking, hoping that my best work is still ahead of me.” Cohen, whose research focuses on the effects of psychoactive drugs, treatment-induced harms and mental health trends, has authored and co-authored more than 100 book chapters and articles. Distinguished Research Professor Emeritus Hasenfeld, who passed away Feb. 28, 2019, was cited for his insightful investigation of the relationship between social welfare policies, the organizations that implement them and the people who use their services. Schilling’s research focuses on developmental disabilities, HIV risk and prevention, and substance abuse. Also on the list is Ron Avi Astor, who will join the UCLA Luskin faculty in the 2019-2020 school year. Astor is an internationally recognized expert on school safety. — Zoe Day

Read the report

New Study Examines Effects of Stopping Psychiatric Medication UCLA Luskin School professor co-authors report showing that more than half succeed in discontinuing usage of drugs

/0 Comments/in , /by

Despite numerous obstacles and severe withdrawal effects, long-term users of psychiatric drugs can stop taking them if they choose, and mental health care professionals could be more helpful to such individuals, according to a new study.

A new study shows that while long-term users of psychiatric drugs can stop taking them if they choose, mental health care professionals could be more helpful to such individuals dealing with problems like severe withdrawal effects.

While 1 in 6 Americans take a psychiatric medication for serious mental illness, there is little research on people’s experiences coming off the drugs. In the first large-scale study in the United States on this subject, Live & Learn, Inc., in partnership with researchers at the UCLA Luskin School of Public Affairs, UC San Francisco and New York University, began to fill this knowledge gap. Study findings are now available online in Psychiatric Services, a journal published by the American Psychiatric Association.

Surveying 250 long-term users of psychiatric medications who had a diagnosis of serious mental illness and chose to discontinue use, the study found that more than half succeeded in discontinuing usage, despite having little professional support while experiencing severe withdrawal symptoms including insomnia, crying and diarrhea. The majority of survey respondents cited the main reason they attempted to quit centered on health risks of long-term use and side effects.

Of the study’s respondents, 54 percent managed to stay off psychiatric medication for at least one year, with few reporting relapse or re-hospitalization. Eighty-two percent of those who discontinued use reported being “satisfied” with their choice.

“People stop taking their psychiatric medications whether or not they find the drugs helpful, and they do so at all stages of the medication experience — days, weeks, months, or years after taking them,” said David Cohen, professor in Social Welfare at UCLA Luskin and a co-author of the study.  “This study is novel because it asks questions about stopping to take medications from the consumer’s point of view.”

Many industry-funded studies have asked patients why they stop taking their medications, but typically with a view to increase compliance, according to Cohen. By contrast, this study asks consumers what they experienced while coming off drugs, who helped them make and carry out their decision, and whether they were satisfied with their attempted or completed discontinuation.

“Over 70 percent of our study sample had taken medication for more than a decade; however, these individuals reported having little to rely on when discontinuing except the internet and social support in order to endure withdrawal. Limiting access to care through cuts to health and psychosocial services can only make that situation worse,” says principal investigator Laysha Ostrow, founder and CEO of Live & Learn, a California-based social enterprise that provides research, technical assistance and knowledge translation services to behavioral health systems. “Most were working with a provider at the time but did not find them helpful in the process. However, even though it was often complicated and difficult, the majority who were able to come off medication completely were satisfied with their decision to do so.”

Cohen said that there are still plenty of challenges for researchers who are examining this topic.

“There’s a lot of work to do to understand how people come off medications and how to help them do so safely, especially when they’re taking several psychiatric medications simultaneously,” he said. “This study didn’t use a probability sample. Though it very carefully selected the 250 respondents, most with over 10 years’ history of taking medications, it should be a priority to confirm or modify these findings with a probability sample.”

The study was funded through a grant by the Foundation for Excellence in Mental Health Care.

David Cohen Offers Policy Suggestions for Protecting Foster Youth Social Welfare professor explains how to stem the tide of psychotropic drug prescriptions to children in foster care.

/0 Comments/in , , , /by

image_0

In November, UCLA Luskin Professor David Cohen was quoted in an ongoing investigative series by the San Jose Mercury News and Bay Area News Group on psychiatric drugs and foster youth.

In the third reported piece in the investigation titled “The Rx Alliance That Drugs Our Kids,” the San Jose Mercury News reveals that nearly 1 of every 4 adolescents in California’s foster care system are prescribed psychiatric drugs to control their behavior. That is more than three times the rate for adolescents nationwide. Often, the drugs that are prescribed are untested or not approved for children.

The investigation also showcased the relationship between the foster care prescribers and pharmaceutical companies. Pharmaceutical companies are spending millions of dollars to influence physicians who prescribe psychiatric medications to California children in foster care. The article explains that foster care prescribers earn nearly twice as much than the typical California doctor, with the highest paid doctors ranging from child psychiatrists to researchers at universities. The bulk of the payments fund drug company-sponsored research.

Professor Cohen noted that this incentive from pharmaceutical companies may be a motivating factor for some doctors.

“These figures suggest these doctors are not looking out primarily for the kids’ interests…but are looking out for their financial interests, and we should all be wary,” he said.

“The experimentation, the drug cocktails, the first-line drugging typically starts with the group that’s the least protected — and foster kids are at the bottom of the ladder in our society and so it’s easier to do this to them.”

Last week, as a follow-up to this article, Cohen offered some policy suggestions in California Healthline, for how to deal with the situation.

His policy proposals are:

1. The Department of Social Services should publish every quarter the percentage of children in foster care and other residential settings under state care who receive one or more prescriptions for psychotropic drugs. This publicly funded aggregated data has obvious public health relevance and no confidentiality concerns exist.

2. Any payment to a physician from a drug company is a payment for good services rendered (i.e., increasing a company’s revenues by enticing physicians to write prescriptions to foster children publicly reimbursed through Medicaid). Consumer bureaus should develop lists of physicians who do not accept funding of any kind from pharmaceutical companies. The medical licensing board should require physicians to display prominent signs in their waiting rooms informing patients about their drug industry funding.

 3. Alaska attorney Jim Gottstein has argued that cocktails of antipsychotics for behavior problems of children are prescriptions for non-medically indicated reasons and thus constitute false claims for Medicaid reimbursement according its own rules. If so, California Medi-Cal might just wish to obey federal law: screen those prescriptions properly and refuse to reimburse them (and kindly notify prescribers that they are breaking the law).

4. The executives of pharmaceutical companies found to have engaged in illegal marketing of their products should be held criminally responsible rather than their companies just paying fines as the cost of doing business (like $10.4 billion in 74 court judgments and settlements between 2010 and 2012).

5. Child welfare workers and juvenile court judges have an ethical duty to inform themselves responsibly about the drugs they encourage and sometimes compel non-consenting children to take. The drug industry floods the market with studies purporting to show short-term improvement in symptoms while it studiously under-documents harms and long-term consequences. Perhaps these officials should be held responsible when things go wrong, not just given a free pass because they don’t prescribe.

6. A stable foster placement matters for a child’s well-being, thus child welfare workers may understandably refer a child for a medication evaluation in order to avoid interrupting the placement. But psychological and behavioral instabilities shown by maltreated or neglected children are normal reactions to adversity, not mental illnesses to medicalize. A severe or delayed reaction to maltreatment does not automatically justify a prescription; it requires even more personal, individual attention given to a child.

 

Two Faculty Books receive Honorable Mention for “Outstanding Social Work Book”

/0 Comments/in , , , , /by

Two separate books by Social Welfare faculty members have been honored in the competition for the Society for Social Work and Research’s inaugural “Outstanding Social Work Book Award.”

Dr. Stuart A. Kirk, distinguished professor emeritus of Social Welfare, Dr. David Cohen, Professor of Social Welfare, Marjorie Crump and Dr. Tomi Gomory, Florida State University, received Honorable Mention for their book Mad Science: Psychiatric Coercion, Diagnosis, and Drugs.

Mad Science argues that much of modern American psychiatry’s claims are not based on convincing research, and provides a scientific and social critique of current mental health practices.

Dr. Laura S. Abrams, associate professor of Social Welfare and chair of the doctoral program, was recognized for her book Compassionate Confinement: A Year in the Life of Unit C, co-authored with Dr. Ben Anderson-Nathe of Portland State University,

Their book focuses on juvenile corrections, using narratives, observations and case examples from a year of fieldwork at a boy’s residential facility to highlight the system’s tensions and show unexpected pathways to behavior change.

Both works provide critical examinations of the history, institutions, and discourses involved in shaping institutional responses to some of the most pressing social problems.

SSWR is the leading academic and research organization in the field of social welfare. In conferring the award, the organization recognizes the “outstanding scholarly contributions that advance social work knowledge,” SSWR President Eddie Uehara said.

The awards will be formally presented at the SSWR annual meeting in New Orleans this January.