European Psychiatry Drug pollution and pharmacotherapy in

www.cambridge.org/epa
psychiatry: A “platypus” in the room
Unax Lertxundi1 , Rafael Hernández2, Juan Medrano3,4 and Gorka Orive5,6,7,8
1
Bioaraba Health Research Institute, Osakidetza Basque Health Service, Araba Mental Health Network, Araba Psychiatric
Viewpoint Hospital, Pharmacy Service, c/Alava 43, 01006 Vitoria-Gasteiz, Alava, Spain; 2Internal Medicine Service, Araba Psychiatric
Hospital, Araba Mental Health Network, c/Alava 43, 01006 Vitoria-Gasteiz, Alava, Spain; 3Psychiatry Service, Bizkaia
Cite this article: Lertxundi U, Hernández R,
Medrano J, Orive G (2020). Drug pollution and Mental Health Network, Vitoria-Gasteiz, Spain; 4Biocruces Bizkaia Health Research Institute, Mental Health Network
pharmacotherapy in psychiatry: A “platypus” Research Group, Osakidetza, Bizkaia, Spain; 5NanoBioCel Group, Laboratory of Pharmaceutics, School of Pharmacy,
in the room. European Psychiatry, 63(1), e33, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, Vitoria-Gasteiz 01006, Spain; 6Biomedical
1–2 https://doi.org/10.1192/j.eurpsy.2020.32 Research Networking Centre in Bioengineering, Biomaterials, and Nanomedicine (CIBER-BBN), Vitoria-Gasteiz, Spain;
7
University Institute for Regenerative Medicine and Oral Implantology—UIRMI (UPV/EHU-Fundación Eduardo
Received: 17 March 2020 Anitua), Vitoria, Spain and 8Singapore Eye Research Institute, The Academia, 20 College Road, Discovery Tower,
Accepted: 18 March 2020 Singapore, Singapore
Key words:
Drug therapy; environmental pollution;
psychiatry

Author for correspondence: Abstract

Unax Lertxundi, Preoccupation about potential deleterious effects of pharmaceuticals in the environment is
E-mail: unax.lertxundietxebarria@osakidetza.
growing fast. Psychiatric pharmaceuticals have received particular attention because of their
net
increasing use and their potential impacts on many living beings due to their effects on
phylogenetically highly conserved neuroendocrine systems. Recent studies that have shown
that many pharmaceuticals (including psychotropics) bioaccumulate through the web food have
raised this concern into new heights. As professionals working in the field of psychiatry and
academia, we believe we are about to enter a new era with regard to pharmacotherapy. We
estimate drug pollution will have a major impact on our daily practice in a way we are just
starting to imagine. So far, this problem has largely been ignored by healthcare professionals,
who are the ones prescribing and dispensing pharmaceuticals. We are convinced that increasing
awareness among these professionals will be a key element to effectively fight against drug
pollution.

Concern about potential deleterious effects of pharmaceuticals in the environment is rapidly

growing worldwide [1]. Drug pollution has been considered as a “wicked problem” by the Dutch
authorities: it is a complicated and diffuse problem that is characterized by scientific uncer-
tainties, a large number of interested parties with different values and interests, and institutional
complexity [2]. Once excreted by patient’s urine or feces, drugs, in the best of scenarios, are
transported to sewage treatment plants, where actual widespread technology does not guarantee
they are efficiently eliminated. Psychiatric pharmaceuticals have received particular attention
because of their increasing use and their potential impacts on many living beings due to their
effects on phylogenetically highly conserved neuroendocrine systems. Recent studies, however,
have raised this preoccupation into new heights. Richmond et al. showed that many pharma-
ceuticals (including psychotropics) bioaccumulate through the food web, estimating that platy-
puses in Australia receive as much as half of the human antidepressant dose daily [3].
Nowadays, despite concerns may arise in the environmental risk assessment (ERA) of the
drug presented to the European Medicines Agency (e.g., asenapine is believed to “have potential
endocrine disruption properties [4]” and vortioxetine “is expected to pose a risk for the
environment [5]”), environmental aspects are not considered in the global risk–benefit assess-
ment of drugs for human use. Besides, these ERAs only became mandatory in 2005, so abundant
knowledge gaps about many drugs which are extensively used in routine clinical practice still
exist.
© The Author(s) 2020. This is an Open Access
As professionals working in the field of psychiatry and academia, we believe we are about to
article, distributed under the terms of the
Creative Commons Attribution licence (http:// enter a new era with regard to pharmacotherapy. We estimate drug pollution will have a major
creativecommons.org/licenses/by/4.0/), which impact on our daily practice in a way we are just starting to imagine. Eco-sustainable or green
permits unrestricted re-use, distribution, and prescribing has already been proposed by some authors, although not pertaining to healthcare
reproduction in any medium, provided the [6]. For example, oxacepam, a drug that would be considered a wise choice for elderly people
original work is properly cited.
because the benign pharmacokinetic profile (it is eliminated via glucuronidation), persists
without biodegradation in the bottom of lakes for decades [7]. Another relevant consequence
may affect patients, in the way they may feel guilty about taking certain drugs. For instance, a
depressed patient could become even more depressed when he hears about potential conse-
quences of the drug he is excreting with his urine. Taking environmentally unfavorable
2 Unax Lertxundi et al.

medication could further add to the stigma of a mental illness. issues about drug pollution are nowadays generally ignored in
Additionally, psychiatric drugs are not popular even among people Pharmacy and Medicine faculties. In line with the recommenda-
who could benefit from them; therefore, the awareness that a drug tions given by the Strategic Approach of the European Commis-
can have a deleterious impact on the environment can increase sion, we are convinced that increasing awareness among these
some patient’s reluctance toward psychopharmacological reme- professionals will be a key element to effectively fight against drug
dies. On the other hand, ecotoxicological aspects of psychiatric pollution. We believe neglecting drug pollution aspects could con-
pharmaceuticals could transform into a potent argument for the tribute to the discredit of medicine, healthcare, and science in
antipsychiatry movement [8] and hospitals, could be banned or general. It is time to realize we have a platypus in the room.
restricted near ecosystem reserves, or may even become a “not-in-
my-backyard” institution. Conflict of Interest. The authors declare no conflicts of interest.
The unwanted effects of drugs on ecosystems are gaining
momentum, at a speed, that soon, pressure to include environmen-
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