Minimal – no, minimise – yes

Summary

This commentary questions evidence put forward in support of minimal-medication approaches to the treatment of schizophrenia. Psychiatrists should indeed seek to minimise the amount of medication that they use in order to reduce the incidence of side-effects. However, there is strong evidence that antipsychotic medications do help people with psychosis towards recovery. In practice, psychiatrists do not rigidly follow guidelines recommending medication, but rather work with and support individuals in a broad-based way to make informed choices about their mental healthcare.

The thought-provoking article by Calton & Spandler (2009, this issue) is most welcome. I would particularly like to pay tribute to Dr Calton for his courageous account of his own experiences of psychosis. I am glad that he could recover in a supportive environment, without antipsychotic medication, as was his informed choice.

However, there is incontestable evidence that antipsychotic medication assists recovery from acute psychosis. A search of the Cochrane Library on 1 November 2008 revealed more than 20 published Cochrane reviews of individual antipsychotic medications versus placebo in the treatment of people diagnosed with schizophrenia. They all essentially conclude the same thing: that antipsychotics are efficacious in reducing the symptoms of psychosis, improving functioning and preventing relapse, but are also imperfect medications with significant side-effects. The strength of this evidence has been contested with arguments such as that antipsychotics themselves cause relapses of psychosis, that the positive results recorded in trials do not translate into real life and that the ill-effects of these medications outweigh the positives (Joukaama 2006; Moncrieff 2006).

Although I accept the merits of these arguments, I still believe the evidence clearly demonstrates that antipsychotic medications do assist recovery. These medications are far from perfect and psychiatrists need to work to minimise doses, limit side-effects and use medications only as part of a holistic, individualised management plan. I could devote this entire commentary to specific evidence supporting the efficacy of antipsychotic medication, while at the same time questioning the evidence in support of other approaches. However, I prefer to focus on what clinical psychiatrists do in practice to help individuals to recover from psychosis.

The bigger picture

Calton & Spandler are correct in their assertion that there is too great an emphasis on medication in the NICE guidelines for treating psychosis. However, they are wrong to suggest that psychiatrists ‘rely almost entirely on the (sometimes involuntary) use of antipsychotic medication’ in their treatment of people diagnosed with schizophrenia. Medication approaches are highly amenable to empirical analysis. Hence, evidence-based guidelines are heavily skewed towards medication and other more measurable treatments, such as cognitive–behavioural therapy. Other, more holistic treatment approaches, such as those supported by Calton & Spandler, cannot for practical and economic reasons be subjected to the same kind of rigorous testing and are thus excluded from such guidelines.

Calton & Spandler suggest that the evidence in favour of community-based minimal-medication approaches is strong. However, if you were to apply the same critical rigour to the methodologies of the trials that they cite, as has been used to criticise the evidence for medication (Moncrieff 2003), one would find that they come up very short. These trials invariably were small, were not masked, were not randomly controlled and the participants were not representative (Rappaport 1978; Ciompi 1992; Lehtinen 2000; Bola 2003). Hence it is difficult to draw any conclusions based on their results.

It seems to me that Calton & Spandler have made the fundamental error of equating research publications with clinical practice. Research journals are indeed full of reductionist biomedical studies of psychosis, but it does not follow that psychiatrists apply only reductionist biomedical models when it comes to treating individuals. Psychiatrists are fully aware of the limitations of clinical trials and that the people who participate in them are far from representative of the complex individuals they work with in clinical practice. To be effective in assisting people with psychosis towards recovery, it is critical that psychiatrists work with them holistically towards making informed choices about managing their mental healthcare. Knowledge of the myriad factors that will influence that individual's recovery, and an ability to look beyond guidelines, are critical to this.

Clinical realities

A useful starting point is evidence-based guidelines, but psychiatrists in clinical practice are aware that many of the individuals they treat have moved beyond them long ago, requiring a breadth of care that far exceeds their narrow recommendations. Far from relentlessly driving people to take more and more medication, psychiatrists work continuously with service users who have made informed choices to take, or not to take, medication. Psychiatrists work with individuals on a daily basis in all kinds of non-evidence-based ways to maximise their recovery. Clinical psychiatrists spend most of their time listening to and counselling distressed individuals, exploring meaning with them, discussing lifestyle changes, helping to modify their environments, working with families and carers, contributing to multidisciplinary care, liaising with a huge variety of other professionals and agencies, advocating, agitating and much more.

Many people who have experienced psychotic episodes succeed in taking little or no antipsychotic medication, at least for periods of time. However, there are many others who cannot recover without medication or who cannot stop taking medication, as to do so causes significant worsening of their symptoms, along with distress and disruption of everyday functioning. For Calton & Spandler to say to such individuals that antipsychotic medications are ‘chemical sanitation’ and to suggest that medication-free recovery is somehow morally superior is to doubly stigmatise them. Antipsychotic medications are evidence-based and individuals who make an informed choice to take them as part of their treatment should be respected. There should indeed be more resources available to help people who would wish to recover from psychosis, as Dr Calton did, without recourse to medication, and psychiatrists do need to continue to agitate for these. However, psychiatrists need also to stand up to the misinformed assertion that they almost exclusively recommend medication-based approaches.

What is it about the idea of taking medication for mental health problems that so upsets some people? The Soteria Network, of which Calton and Spandler are trustees, is firmly part of the anti-psychiatry tradition. Their founder figure, Loren Mosher, denied evidence supporting the role of genetics and neurological abnormalities in disorders of the mind. He believed that medications are merely palliative and that they hinder true recovery, which can only be achieved through a true understanding of symptoms, most of which have their basis in society. Mosher mocked research demonstrating the role of the brain in disorders of the mind, regarding this as a mere epiphenomenon, and believed that psychiatrists are incapable of appreciating and responding to the broad basis of human distress, are agents of the state charged with corralling non-conformist behaviour, and are in an unholy alliance with the pharmaceutical industry in promoting medication-based solutions (Mosher 2005). These extreme and rigidly held beliefs are far removed from reality and it seems that no amount of contrary evidence can shift them.

The brain is a part of the whole

The optimal management of all health problems requires that the whole person be considered, along with their entire life history and social circumstances. Nowhere is this more important than in psychiatry. Nonetheless, it is quite clear that dysfunction of the brain makes an important contribution to conditions such as psychosis, and thus there is every reason to expect that medication will continue to form a vital part of the treatment. Available medications may be crude and have some unpleasant side-effects, but their effectiveness in treating the positive symptoms of psychosis is beyond dispute. Psychiatrists work with individuals holistically to help them to make informed choices about their mental healthcare and do not, as Calton & Spandler assert, pursue an exclusively medication-based ‘one-size-fits-all approach’.