Last week, as part of carrying out research into women’s mental health at Manchester University, a colleague and I visited a Medium Secure Unit for women in the North West for a meeting to discuss some training for mental health nurses on the sexual and reproductive health of women accessing psychiatric care.
Secure mental health services are defined as ‘specialist services providing treatment for adults with mental disorders including personality disorders that mean that they are at significant risk of harming themselves or others. In such services, patients are detained under the Mental Health Act 1983/2007 and many, but not all, will be convicted offenders.
In this context, ‘secure’ relates to the range of physical, relational and procedural measures put in place to ensure the provision of a safe and secure environment in which to deliver treatment. There are three levels of secure mental health care: High, Medium and Low.The purpose of security measures is to ensure the safety of patients and the public, to prevent escape and absconding and reduce the likelihood of patients failing to return from agreed periods of leave. Medium Secure Services cater for people who present a significant risk of harming themselves or others. Many patients will have a history of offending and some will have been transferred from prison or from the courts to receive inpatient treatment’ (http://webarchive.nationalarchives.gov.uk).
In light of the above definition, the Medium Secure Unit we visited provides mental health care to particularly vulnerable women. What struck me when we were approaching the Unit was the very tall and thick wired fence surrounding the main building (an old, rather grim looking building) and its small yards, which brought about in me a nauseous sense of approaching a prison -no doubt, the tall and thick wired fence was part of the physical security measures…I was rather surprised to see that the interior of the building was not as old and grim looking; it was certainly lighter, possibly refurbished, and I especially noticed the bright and colourful paintings that decorated the walls, beautiful paintings made by the women service users and apparently a number of them award winning. As we were taken to the room for our meeting, I could not help noticing that every single door was locked and was closing securely behind us – part of the physical security measures again, I thought. And before we could actually enter the Unit, at the reception, we were asked whether we had any of a long list of Contraband items on us, which we would have to hand in and collect on our way out. Chewing gum and blue tack were on the Contraband list together with mobile phones and sharp items – apparently the women service users could use the chewing gum and blue tack to create molds for making keys and escaping!
We met with a Nursing Manager and had a discussion with him for over an hour. He came across as a warm, gentle and caring guy, with a lot of experience in secure mental health services for women, and very keen to make our sexual and reproductive health training with his nursing staff happen. He also told us that he had 3 daughters, which may explain the fact that he was clearly sensitised to and comfortable with discussing issues bearing on the sexual and reproductive health needs of women.
When our meeting finished and on our way out, I noticed a big pile of booklets in a bookcase in a corner of the meeting room. Looking through the booklets (booklets for service users on how to contribute to their care plan, I think), I found a DVD entitled ‘A Journey into Light’. I immediately thought that it was one of those DVDs that talk about journeys of spiritual awakening and enlightenment through practices such as relaxation, meditation and yoga. I nearly pictured the women service users in the Unit benefiting from relaxation, meditation and yoga sessions. I also recalled seeing a painting by Peter Waddell, a historical painting of a Masonic Temple, with the same title, ie ‘Journey Into Light’…
My daydream was interrupted rather abruptly when I noticed the two labels and the logo on the top right corner of the DVD case:
My heart sank… What I naively took to be a DVD about a journey of spiritual awakening and enlightenment was a DVD that was sponsored and produced by Novartis, the pharmaceutical company, to ‘educate about’ and promote Closaril (clozapine), a psychiatric drug! In the British National Formulary (BNF), Closaril (clozapine) is referred to as ‘an anti-psychotic medication used for the treatment of schizophrenia in patients unresponsive to, or intolerant of, other (conventional) anti-psychotic drugs’ (www.medicinescomplete.com/mc/bnf).
When I realised what the ‘Journey into Light’ DVD was, I felt a surge of anger, frustration and cynicism coming up, and turning to the Nursing Manager, I asked (in a tone of voice that undoubtedly betrayed my feelings) whilst pointing to the DVD ‘What kind of Journey into Light is this, then?’ I think the Manager was taken aback by my question and he asked me whether I was against the use of psychiatric medication or something along those lines. I responded that I, too, was on very serious psychiatric medication, i.e. Lithium, a highly toxic drug. I guess I felt so angry and frustrated and cynical at the time that I was most probably incapable of expressing a coherent and balanced view on the complex and contested issue of psychiatric medication. Important to note here that in most occasions I am capable of doing so…
I recall that the Manager went on to tell me how he had seen ‘miraculous effects‘ of Clozaril (clozapine) on some women service users in his Unit. I responded that I did not doubt that some women would have benefited from Clozaril therapy. But I could also not help thinking that – sadly- even the Nursing Manager in question, an experienced mental health professional who spoke about the vulnerable women service users in his Unit with a great deal of care, consideration and sensitivity, appeared to have been seduced by Novartis’ ‘educational’ (i.e. marketing) material on Clozaril. My colleague then indicated that it was time to go. On the way to my colleague’s car I vented all my anger, frustration and cynicism about the ‘Journey into Light’ DVD. My colleague turned to me and said – jokingly- that perhaps ‘the Light’on the DVD title referred to the powerful white light that people are supposed to encounter and immerse in just before they die! In hindsight, my colleague’s observation, ironically, contained some truth. In 1974, 8 patients in Finland who were taking clozapine in conjunction with a variety of other drugs died as a result of agranulocytosis. Agranulocytocis is an acute condition involving a severe and dangerous lowered white blood cell count, representing a severe lack of one major class of infection-fighting white blood cells, so people with this condition are at very high risk of serious infections due to their suppressed immune system (http://en.wikipedia.org). The death of the 8 patients in Finland led to the withdrawal of clozapine in those countries where it was already marketed and the suspension of clinical trials elsewhere. However, following the publication of findings demonstrating clozapine’s efficacy in a significant proportion of ‘treatment-resistant’ patients with a diagnosis of schizophrenia in 1988, clozapine was remarketed in 1990 and progressively became part of common clinical practice.
Why did I feel this surge of anger, frustration and cynicism in relation to the Novartis-sponsored DVD ‘A Journey into Light’ concerning Clozaril (clozapine), then? What were these strong feelings about – especially considering that Clozaril can apparently have ‘miraculous effects’ on people with a diagnosis of schizopherenia who have been unresponsive to, or intolerant of, other anti-psychotic drugs? What were these strong feelings about when Clozaril seems to represent the very last chance, the very last resort for a number of very distressed and despairing people?
I read on www.clozaril.com that patients treated with Clozaril have reported positive effects and improvements including : i) improved ability to concentrate; ii) recovered ability to enjoy previous activity; iii) improved relationships; iv) improved ability to participate in counselling, vocational training, or other activities of daily life; v) improved ability to live independently; and vi) a decrease in suicidal behaviour. On the same website I read that ‘thanks to CLOZARIL, a great many people whose lives were once seriously affected by schizophrenia are now leading more independent and more productive lives’.
So, how come I felt so angry, frustrated and cynical in relation to material that promotes Clozaril- ie what seems to be a ‘wonder drug’ for a number of very distressed and despairing people? After all, I can relate very closely to the rather frightening notion of a psychiatric drug representing the very last chance, the very last resort, a ‘wonder drug’ for somebody acutely despairing…back in January 2010 I was prescribed Lithium for my ‘treatment-resistant’ severe and enduring depression having been unresponsive to a series of anti-depressants for one and a half years…the message I was given back then was that Lithium was essentially my very last chance, my very last resort following persistent but unsuccessful attempts to lift my mood, enhance my motivation and alleviate my desperation with different anti-depressants for so long…my very last chance, my very last resort before ECT, I guess… scary… and I suppose Lithium may have possibly proved ‘a wonder drug’ for me, as my GP put it once…since I started taking Lithium in January 2010, I saw dramatic positive changes in my mood, my level of motivation and interest in life, my ability to concentrate and use my cognitive skills, my ability to live independently and my ability to return to work…the beginnings of my recovery seemed to coincide -temporally at least- with being prescribed Lithium…of course I could not say for certain whether there is a causal relationship between being on Lithium and my recovery- given that the latter is a complex and multi-faceted process- but I suppose there must be some kind of association between the two…association that I am grateful for…grateful in spite of Lithium’s high toxicity and very serious side effects, which necessitate very regular monitoring through blood tests every 3 months…a high price to pay for having one’s desperation alleviated…
In light of my personal history of ‘last chance/last resort’ psychiatric medication, how could I feel so angry and cynical in relation to material promoting a psychiatric drug that seems to represent the very last chance, the very last resort for a number of very vulnerable, frightened and despairing ‘treatment -resistant’ people?
I think it was the very title of Novartis’ promotional DVD on Clozaril, ie ‘A Journey into Light’, that gave rise to my anger, frustration and cynicism. In this DVD the consumption of a pharmaceutical product (Clozaril) seems to represent a means of achieving an encounter with ‘the Light’, a promise of some dramatic transportation from the dark depths of schizophrenia to an enlightened, more independent and more productive, in other words transformed, life. The use of emotive language here, that is the reference to ‘Journey’ and ‘Light’ with their spiritual, almost transcendental connotations, is particularly seductive to the extent that one can easily forget that this is the perversely clever language of advertising that a pharmaceutial company is using for what I feel is the rather sinister manipulation of the hopes of very vulnerable and distressed people who are desperate for the alleviation of their tormenting ‘psychotic symptoms’...the language of the marketing of madness and of psychiatric drugs as its presumed ‘healing’ agents…
Seduced by emotive references to ‘Journeys’ and ‘Light’ with their spiritual, almost transcendental connotations, as in the case of Novartis’ DVD on Clozaril, one can easily forget the association that seems to exist currently between the ruthlessly competitive marketing of psychiatric drugs by the Big Pharma and what Joanna Moncrieff, a founding member of the UK Critical Psychiatry Network, refers to in her paper ‘Psychiatric drug promotion and the politics of neoliberalism’ as ‘the epidemic of psychotropic drug prescribing’ . To illustrate this ‘epidemic’ – 49 million Americans are reported as being on prescribed psychiatric drugs (www.cchrint.org/2012/07/18/with-49-million-americans-on-psychiatric-drugs-renowned-psychiatrist-issues-call-for-psychiatric-drug-withdrawal), whereas for the UK increasing rates of prescriptions for psychiatric drugs, especially antidepressants and antipsychotics, have been documented for the the period 1998-2010 . Seduced by the perversely clever language of marketing, one can easily forget that ‘psychiatric drugs are a big profit making business and the psychiatric/pharmaceutical industry is making a killing -$84 billion per year’ (www.cchrint.org/psychiatric-disorders).
Furthermore, ‘while the illicit use of drugs is universally frowned upon, and considered a bad way for people to deal with their problems, psychiatric drugs are made out to be “good” drugs, despite the fact that many are more addictive than cocaine or heroin, and have side effects that rival such hardcore street drugs as LSD, heroin and crack cocaine’ (www.cchrint.org/psychiatric-disorders). At a conference on medication back in 2011, I heard Richard Bentall, the author of ‘Doctoring the Mind: Why psychiatric treatments fail’, present a paper entitled ‘Antipsychotics: Too much given for too long to too many?’. He emphasised that ‘Antipsychotics are undoubtedly a powerful tool for rapidly reducing psychotic symptoms, but they may work for only a minority of patients (10-15%) and they have severe long-term side effects’.
In the case of Clozaril (clozapine) in particular, the British National Formulary (BNF) lists a range of very serious and even potentially fatal side effects: vomiting, anorexia; increased salivation that can lead to heavy drooling; tachycardia (palpitations), ECG (Electrocardiography) changes, hypertension; muscle stiffness, feeling restless or unable to sit still; increased weight gain; drowsiness, dizziness, speech problems, tremor, seizures, impaired temperature regulation leading to excessive sweating; urinary incontinence and retention; lowered white blood cell count; blurred vision; agranulocytosis  (see above); hepatitis, jaundice, pancreatitis; cardiological problems including potentially fatal myocarditis (inflammation of the heart muscle); agitation, confusion, delirium; pneumonia, anaemia; and intestinal obstruction – among others (www.medicinescomplete.com/mc/bnf).
I am wondering how the Novartis DVD on Clozaril deals -if at all- with the very serious and even potentially fatal side effects of the medication mentioned above…how these side effects, which can compromise the quality of people’s lives so gravely and even endanger life itself, are -if at all-reconciled with the apparent promised encounter with the ‘Light’, with what could be perceived as a promise of some dramatic transportation from the dark depths of schizophrenia to an enlightened, more independent and more productive, to a transformed life- as discussed above. What kind of ‘Journey into Light’ is this when the price to pay for embarking on the journey (through the consumption of Clozaril) is so high?
‘A Journey into Light’...an infuriatingly seductive title of an advertising tool produced by the Big Pharma as part of its campaign for the marketing of madness and the promotion of psychiatric drugs…a profit making campaign that capitalises heavily on the rather sinister manipulation of the hopes of very vulnerable and acutely distressed people who are desperate for the alleviation of their tormenting ‘psychiatric symptoms’.
 Moncrieff, J. (2006) ‘Psychiatric drug promotion and the politics of neoliberalism’, The British Journal of Psychiatry, 188:301-302
 Ilyas, S. and Moncrieff, J. (2012) ‘Trends in prescriptions and costs of drugs for mental disorders in England, 1998–2010’, The British Journal of Psychiatry, 200:393-398
 Potentially fatal agranulocytosis has been reported, which necessitates very regular monitoring of blood counts; in addition, patients on Clozaril should report immediately symptoms of infection, especially influenza-like illness (www.medicinescomplete.com/mc/bnf)