Changing the balance of psychosis treatment

Summary

Antipsychotic medication is the primary form of treatment offered to people diagnosed with schizophrenia or psychosis, but it is associated with severe adverse effects, it is often experienced as unpleasant and its benefits may have been overstated. Therefore, it is important to evaluate research into approaches that aim to minimise the use of this medication. Existing studies suggest that such approaches can be successful and result in avoidance of antipsychotics in a high proportion of clients.

Since their introduction in the 1950s, antipsychotic drugs have been the mainstay of treatment for people diagnosed with psychosis and schizophrenia, rapidly replacing the sedatives and physical treatments, such as insulin coma and electroconvulsive therapy, that were previously used (Moncrieff 2008). Many have portrayed them as miraculous drugs that helped to empty the asylums, but it is commonly known that they produce severe adverse effects and many patients dislike taking them. Long-term use is associated with disabling and life-threatening effects such as tardive dyskinesia and metabolic syndrome. The drugs also increase the risk of premature death more than twofold (Joukamaa 2006) and brain imaging studies suggest that they may reduce brain volume after only a few weeks of treatment (Lieberman 2005). In addition to their physical effects, the use of antipsychotics may perpetuate chronicity by hindering people from developing other coping strategies that might enable them to better manage future episodes or exacerbations.

The negative effects of antipsychotics provide one reason for trying to avoid their use where possible, but a further reason is that their benefits may have been exaggerated. Long before the introduction of these drugs, it was known that a proportion of people who have a psychotic breakdown recover naturally. In addition, it is generally accepted that up to a third of patients derive little benefit from taking antipsychotics, but continue to manifest disabling symptoms.

Research on antipsychotics

It is commonly assumed that research has demonstrated that antipsychotics substantially reduce the risk of relapse, but this research has serious flaws. In particular, long-term studies in which patients are randomised to continuation of treatment or replacement of antipsychotics by a placebo have not taken into account the effects of drug withdrawal. The cessation of any psychoactive substance can produce withdrawal effects and therefore many of the episodes of ‘relapse’ recorded in patients on placebo may simply have been the manifestation of these effects. This is especially likely since withdrawal effects of antipsychotics include agitation and insomnia, which may be classified as relapse when relapse is defined, as it often is, by small increases in rating scale scores. Withdrawal may also occasionally produce withdrawal-related psychosis (Moncrieff 2006).

How drugs function

General assumptions about psychiatric drugs and how they act have obscured the nature of antipsychotics. The orthodox view is that psychiatric drugs work by reversing or improving an underlying neurochemical process that produces the symptoms of a particular mental disorder. Thus, antipsychotics are thought to act by helping to rectify the pathology that produces the symptoms of psychosis or schizophrenia. Elsewhere, I have argued that a more convincing explanation of how antipsychotics ‘improve’ psychosis is that they create an abnormal drug-induced state comprising sedation, slowed thought and flattened emotions (Moncrieff 2005). This state can help to reduce the intensity of psychotic symptoms by dampening down all mental activity. Although it is clear that such a state may be helpful at times, it is also likely to be unpleasant and disabling. In addition, viewing psychiatric drugs as drugs (as extrinsic substances that alter the way the body functions) highlights their capacity to produce adverse effects and changes the way that we evaluate them. Instead of assuming that they are beneficial because they correct an underlying abnormality, we should assume they are harmful unless we can prove otherwise.

Other approaches

Assessing Soteria

It is therefore imperative that we devise alternative strategies for helping people who suffer psychotic episodes. The article by Calton & Spandler (2009, this issue) is to be welcomed for focusing our attention on studies of treatment approaches that aim to minimise or avoid the use of antipsychotic medication. The largest of these, the US Soteria Project, was well designed with random or alternating allocation, but a limitation of the experiment was that people who were judged to be unmanageable in a Soteria setting were excluded from allocation and a number of other participants dropped out during the early stages of the experiment. The data certainly suggest that the Soteria Project was at least as good as treatment as usual in terms of 2-year outcomes (Bola 2003). However, the claim that residents of the Soteria communities had superior outcomes is more difficult to evaluate, since it is based on a complex statistical analysis involving numerous outcome measures, which might have resulted in false-positive results. The most important finding is that a high proportion of Soteria-treated participants in the US study avoided the use of antipsychotic drugs altogether (32% of the intention-to-treat sample).

The Finnish trial in perspective

The Finnish trial was also well designed and avoided the problem of exclusions because it was a cluster trial in which the minimal-drug approach was applied throughout the services of the chosen areas (Lehtinen 2000). The finding that 43% of participants in the experimental areas received no antipsychotic drugs throughout the study and had equal or superior outcomes provides clear evidence that a high proportion of people with a first episode of psychosis can be successfully cared for without the use of these drugs. The positive results are more remarkable for going against the current trend for the increasing use of antipsychotics (Alessi-Severini 2008). However, the replication of this trial in Sweden failed to achieve such high levels of avoidance of drug treatment, with only 19% of participants remaining drug-free (Cullberg 2002). This may be because of decreased efforts to avoid drug treatment and suggests a continuing need for reinforcement of the rationale of the minimal-drug approach.

Changing the balance of treatment

There are some people with severe psychosis for whom antipsychotic-induced effects may be helpful or necessary. However, there are many others who may be able to endure and survive their psychosis without the use of these often unpleasant and potentially harmful drugs. The Soteria and Scandinavian experiments suggest that psychosis may be managed successfully using lesser quantities of antipsychotic drugs than are currently used and avoiding them altogether in one-third or more of patients. Further research is needed to confirm their results. In particular, pragmatic studies in real-life settings are needed to assess the feasibility of minimal-medication approaches and help to identify factors that might predict who is most likely to benefit from avoiding antipsychotic medication. However, the onus should not be on minimal-medication approaches to prove their success, but on the standard drug-focused approach to prove its superiority and to demonstrate that this superiority adequately compensates for the recognised negative effects of antipsychotic treatment.

There is no reason why antipsychotics should be used universally and many reasons why they should be avoided if possible. Projects that attempt to minimise the use of antipsychotics should be supported because evidence suggests that use of these drugs is not always necessary and because, as Calton & Spandler highlight, many patients and carers want this choice.