1 Boring Old Man

Remember Arkansas? There’s a Janssen Risperdal Trial underway having completed its second week. Since I heard the plaintiff’s argument in the Texas Trial in January, I didn’t pay much attention except to notice that there was no news coming our way. Actually, the trial itself didn’t have a lot of appeal. No whistle-blower. No TMAP. Just Arkansas’ allegation that the people at Janssen are rotten people who sold them Risperdal under false pretenses. The only press coverage was in the Arkansas Democrat-Gazette which is subscription only. I found that I could buy a week’s worth of access for 99¢, so why not.

This was the week for the defense. I carefully cut and pasted the daily articles into a text file and read most of it. Here’s my summary: "It is not!" "It is too!" – daily haggling between lawyers. From what I can gather, the plaintiff’s arguments the week before had been similar to Texas, without the personae [Allen Jones, Stephen Shon, etc]. They must’ve done alright, because the defense was mostly about "It wasn’t that bad."  "Zyprexa is worse!"

I’ll spare you quotes as reporter John Lynch struggled to find something interesting to say about what sounded like rivals on an Elementary School playground – unsuccessfully, I might add [not his fault]. There are discussions going on about a settlement. Arkansas is more like South Carolina, West Virginia, Louisiana, and Pennsylvania. Janssen has prevailed twice – West Virginia and Pennsylvania – and has lost two – South Carolina and Louisiana – now being appealed. Only Texas has been definitively resolved. And Janssen’s problems with the Feds are still up in the air.

I was thinking about this whole Risperdal story. It’s the only Atypical Antipsychotic I’ve personally ever used. Once, in a Chronic Schizophrenic woman who could not tolerate the extrapyramidal side effects of Haldol, and in a couple of psychotic children. In both, they had been put on it in a hospital and I’m following the cases as outpatients. It’s a legitimate antipsychotic, not dramatically different from the drugs I used when I was a resident nearly forty years ago. I’ve taken many more people off of it that put on it, and nothing was lost by doing that – "off label" uses. I wish I lived in a world where the question of to give or not to give Risperdal never came up, but I don’t. I worry about each of these patients – whether they are on Risperdal, or are on Haldol, or are on no medications at all. It’s easy to talk about flagrant psychosis in the abstract. It’s a different matter up close and personal. Each case is a double bind and deserves its own individual struggle. At least that’s what I think.

These court cases are not about the drug itself. Risperdal has its assets and its liabilities. What’s on trial is that Janssen lied about both, hid the truth on purpose. They gave the impression that Risperdal could be used without the caution and guidelines we’d learned to exercise with the older antipsychotics. While the dangers were different, they were no less problematic, and for some, worse. The specter of Tardive Dyskinesia is still in the picture, but there’s the added chance for a metabolic syndrome that is only now as apparent as it needed to be on the day the drug was released.

In psychiatry, we don’t have casual medications. The anti-anxiety medications [Benzodiazepines] are addicting – effective but for short-term use only. The tricyclic anti-depressants are effective, but dangerous in overdose – a real possibility in depressed people. The SSRI/SNRI drugs are effective sometimes, but have the up-front problem of akisthisia and the possibility of a prolonged withdrawal syndromes. The anti-psychotics can cause irreversable neurological and/or metabolic illnesses. Stimulants can cause psychosis in overdose. Each class of medications can be useful, but there’s always a trade-off and each bears close scrutiny in practice. None of these medications are headed for OTC status; none should be blockbusters [yet they are]; none should be advertised direct to consumer [yet they are].