Interesting article

[Attending1985]

---

Members don't see this ad.

https://www.consultant360.com/video/consultant360/examining-long-term-use-antidepressants

Wanted to share this piece with Dr. Raison that I really like. Makes you wonder about the future of depression treatment and what role antidepressants will play.

 

[Old&InTheWay]

Thanks for sharing, interesting read.
On the subject of the chronic use of psych meds, here's a recently published 20 year study looking at antipsychotics.

Twenty-year effects of antipsychotics in schizophrenia and affective psychotic disorders - PubMed

This study reports multiple findings that bring into question the use of continuous antipsychotic medications, regardless of diagnosis. Even when the confound by indication for prescribing antipsychotic medication is controlled for, participants with schizophrenia and affective psychosis do...

pubmed.ncbi.nlm.nih.gov

 

[Attending1985]

Thanks for sharing, interesting read.
On the subject of the chronic use of psych meds, here's a recently published 20 year study looking at antipsychotics.

Twenty-year effects of antipsychotics in schizophrenia and affective psychotic disorders - PubMed

This study reports multiple findings that bring into question the use of continuous antipsychotic medications, regardless of diagnosis. Even when the confound by indication for prescribing antipsychotic medication is controlled for, participants with schizophrenia and affective psychosis do...

pubmed.ncbi.nlm.nih.gov

So much data seems to be emerging regarding the negative consequences of psychotropic use especially in the long term. Really makes you wonder about the future of psychiatry.

 

[Old&InTheWay]

So much data seems to be emerging regarding the negative consequences of psychotropic use especially in the long term. Really makes you wonder about the future of psychiatry.

Well I certainly think there's a role for meds in the short term at least, and if so, our role will largely be helping patients decide when to taper and then providing monitoring during and after that process. Perhaps we continue to follow patients with regular visits even after they are off meds.

 

[brosa]

Thanks for sharing, interesting read.
On the subject of the chronic use of psych meds, here's a recently published 20 year study looking at antipsychotics.

Twenty-year effects of antipsychotics in schizophrenia and affective psychotic disorders - PubMed

This study reports multiple findings that bring into question the use of continuous antipsychotic medications, regardless of diagnosis. Even when the confound by indication for prescribing antipsychotic medication is controlled for, participants with schizophrenia and affective psychosis do...

pubmed.ncbi.nlm.nih.gov

Could you kindly post the article? I don't have access to it.

I read the abstract and I know this is completely empirical, but I simply cannot believe that not treating is a better idea than actually treating psychosis. I did my training in Brazil and it was common for people not to use their meds, and they would slowly get way worse. It always reminded me of the term "dementia precox", by Kraepelin. On the other hand, I did saw some mild cases with very supportive families who could stay years without meds and still do quite fine, however they were all milder cases to begin with, plus those were always families with better outcome.

I am very curious to read the full article and see if they adjusted for all that.

 

[Attending1985]

Well I certainly think there's a role for meds in the short term at least, and if so, our role will largely be helping patients decide when to taper and then providing monitoring during and after that process. Perhaps we continue to follow patients with regular visits even after they are off meds.

Makes me wonder if need for psychiatrists will decrease? If medications are prescribed more selectively and people get off of them faster seems the number of psychiatrists needed will go down.

 

[Old&InTheWay]

Could you kindly post the article? I don't have access to it.

I read the abstract and I know this is completely empirical, but I simply cannot believe that not treating is a better idea than actually treating psychosis. I did my training in Brazil and it was common for people not to use their meds, and they would slowly get way worse. It always reminded me of the term "dementia precox", by Kraepelin. On the other hand, I did saw some mild cases with very supportive families who could stay years without meds and still do quite fine, however they were all milder cases to begin with, plus those were always families with better outcome.

I am very curious to read the full article and see if they adjusted for all that.

I would love to share it, but I'm not sure SDN takes kindly to posting copyrighted material.

They did try to control for severity of illness by looking at premorbid characteristics that portend a worse clinical course. I agree with you though, in my limited clinical experience, I have seen many, many patients stop taking their antipsychotic med and become psychotic again.

 

[psychacad]

I would love to share it, but I'm not sure SDN takes kindly to posting copyrighted material.

They did try to control for severity of illness by looking at premorbid characteristics that portend a worse clinical course. I agree with you though, in my limited clinical experience, I have seen many, many patients stop taking their antipsychotic med and become psychotic again.

Yeah, but that in itself doesn't speak to the value of antipsychotics. It's possible that they decompensate once they stop their meds, but that they would do equally better if they weren't on meds in the first place (I think that's what the article about antidepressants was arguing). Another thing is that it's very possible that they stop their meds because they are decompensating. We don't really know which one comes first.

 

[PikminOC]

Makes me wonder if need for psychiatrists will decrease? If medications are prescribed more selectively and people get off of them faster seems the number of psychiatrists needed will go down.

Psychiatrists have much more talent than just meds.

 

[Attending1985]

Psychiatrists have much more talent than just meds.

How would you see the role of a psychiatrist without prescribing?

 

[Attending1985]

Yeah, but that in itself doesn't speak to the value of antipsychotics. It's possible that they decompensate once they stop their meds, but that they would do equally better if they weren't on meds in the first place (I think that's what the article about antidepressants was arguing). Another thing is that it's very possible that they stop their meds because they are decompensating. We don't really know which one comes first.

The article actually says people do worse with antidepressants. They are more likely to relapse and they negate the protective effect of therapy. If more data like that comes out antidepressant prescribing will definitely change.

 

[Attending1985]

Yeah, but that in itself doesn't speak to the value of antipsychotics. It's possible that they decompensate once they stop their meds, but that they would do equally better if they weren't on meds in the first place (I think that's what the article about antidepressants was arguing). Another thing is that it's very possible that they stop their meds because they are decompensating. We don't really know which one comes first.

Also they’re proposing aidsp develops and worsens long term prognosis and rebound psychosis

 

[calvnandhobbs68]

Yeah, but that in itself doesn't speak to the value of antipsychotics. It's possible that they decompensate once they stop their meds, but that they would do equally better if they weren't on meds in the first place (I think that's what the article about antidepressants was arguing). Another thing is that it's very possible that they stop their meds because they are decompensating. We don't really know which one comes first.

So no, I have no idea what they're actually arguing in this article. And I quote:

"Most of these studies are six weeks in length or 8 weeks. At the end, they take you off whatever you are on, and we're going to ask this very simple question. Are you more likely to stay well if you respond to a placebo and it stopped, or if you respond to an antidepressant and it stopped?

The data were very clear that you do much better with a placebo. You're way, way more likely to crash again if you get an antidepressant. The more potent the antidepressant was at the serotonin reuptake site, the faster you crash. So, Paxil was especially heinous in that regard.

Then naturalistic data showing that if you look across these large cohort studies—and of course, causality is always more complex here—but being on antidepressants longer, it's actually associated with a worse outcome."

Those are completely different data sets saying completely different things and one doesn't necessarily have anything to do with each other. You're talking about very clean RCT populations in one sentence and wayyy messier population based cohort studies in the next sentence. The populations are barely even comparable (the population that gets put on a SSRI in an RCT trying to prove efficacy is vastly more rigorously selected and diagnosed than pulling info on cohorts of people who have been prescribed SSRIs vs not in a some population.

I don't even get what point he's trying to make about people "crashing" after having their SSRI stopped vs placebo stopped after a study. Uhhhh if it WAS a good maintenance medication than that's exactly what you'd expect?

 

[psychacad]

So no, I have no idea what they're actually arguing in this article. And I quote:

"Most of these studies are six weeks in length or 8 weeks. At the end, they take you off whatever you are on, and we're going to ask this very simple question. Are you more likely to stay well if you respond to a placebo and it stopped, or if you respond to an antidepressant and it stopped?

The data were very clear that you do much better with a placebo. You're way, way more likely to crash again if you get an antidepressant. The more potent the antidepressant was at the serotonin reuptake site, the faster you crash. So, Paxil was especially heinous in that regard.

Then naturalistic data showing that if you look across these large cohort studies—and of course, causality is always more complex here—but being on antidepressants longer, it's actually associated with a worse outcome."

Those are completely different data sets saying completely different things and one doesn't necessarily have anything to do with each other. You're talking about very clean RCT populations in one sentence and wayyy messier population based cohort studies in the next sentence. The populations are barely even comparable (the population that gets put on a SSRI in an RCT trying to prove efficacy is vastly more rigorously selected and diagnosed than pulling info on cohorts of people who have been prescribed SSRIs vs not in a some population.

I don't even get what point he's trying to make about people "crashing" after having their SSRI stopped vs placebo stopped after a study. Uhhhh if it WAS a good maintenance medication than that's exactly what you'd expect?

Not really. Why would you expect the placebo group to do better than the AD group after you remove the med/placebo? Presumably they have been randomized to each group so there is no difference in illness severity...etc. What this is arguing is that being on AD makes you more sensitive for decompensation once the med is stopped.

 

[calvnandhobbs68]

Not really. Why would you expect the placebo group to do better than the AD group after you remove the med/placebo? Presumably they have been randomized to each group so there is no difference in illness severity...etc. What this is arguing is that being on AD makes you more sensitive for decompensation once the med is stopped.

Sure but this is a bit disingenuous if you ask me and avoiding any other explanation for this. Here's another way to look at it. Unless it's Prozac which basically self tapers, most people can feel when they stop an SSRI. They're not gonna feel the same way stopping a placebo. So you've basically derandomized your groups as soon as this happens. So now your SSRI group pretty much knows they were on an SSRI and the placebo group might have an idea that they might have been on a placebo. This is important considering that essentially all diagnostic criteria for MDD are subjective, which may somewhat "prime" your SSRI group to recognize that they've lost this support of being on a real antidepressant medication and subjectively feel much worse when they start feeling depressed again and know they aren't on this medication which helped them before. Additionally, many studies show that SSRIs do have an effect over placebo, so you also have a larger proportion of patients in the SSRI groups who had an actual response to treatment (and then lost that when the SSRI was pulled).

 

[psychacad]

Sure but this is a bit disingenuous if you ask me and avoiding any other explanation for this. Here's another way to look at it. Unless it's Prozac which basically self tapers, most people can feel when they stop an SSRI. They're not gonna feel the same way stopping a placebo. So you've basically derandomized your groups as soon as this happens. So now your SSRI group pretty much knows they were on an SSRI and the placebo group might have an idea that they might have been on a placebo. This is important considering that essentially all diagnostic criteria for MDD are subjective, which may somewhat "prime" your SSRI group to recognize that they've lost this support of being on a real antidepressant medication and subjectively feel much worse when they start feeling depressed again and know they aren't on this medication which helped them before. Additionally, many studies show that SSRIs do have an effect over placebo, so you also have a larger proportion of patients in the SSRI groups who had an actual response to treatment (and then lost that when the SSRI was pulled).

This is not different than when they are placed on meds. The SSRI will also know they were on an SSRI because they're getting side effects, so here you have it: some extra placebo effect. This is a common issue in all psych trials and people try to adjust for it various ways. I don't see how it's particular to the effect he's describing. I also don't think you'd expect the placebo group to do better once the intervention is stopped. Heck, if we are this sensitive to subjective information as you're presuming, then this already tells you something how effective AD are.

 

[calvnandhobbs68]

This is not different than when they are placed on meds. The SSRI will also know they were on an SSRI because they're getting side effects, so here you have it: some extra placebo effect. This is a common issue in all psych trials and people try to adjust for it various ways. I don't see how it's particular to the effect he's describing. I also don't think you'd expect the placebo group to do better once the intervention is stopped. Heck, if we are this sensitive to subjective information as you're presuming, then this already tells you something how effective AD are.

Do you not think subjective information plays an extremely important role in psychiatry? As it does in any area of medicine where you can't directly measure a blood level or image something directly.

So here's another example. Would we argue that toradol doesn't actually treat pain because your pain gets notably worse when you stop an toradol vs a patient who was taking a placebo and stopped that (substitute whatever other pain medications), keeping in mind that perceived pain is entirely subjective? Would we argue that beta blockers don't treat hypertension if the patients taking beta blockers got rebound hypertension while the placebo group didn't? I also don't get how arguing that a medication makes you more sensitized to suffering worsening symptoms when you stop the medication somehow supports an argument against continuing said medication (the name of the article is "Examining the Long Term Use of Antidepressants").

I'm not actually arguing that we should keep people on SSRIs forever but the logic here just doesn't make much sense to argue that SSRIs are somehow "worse" than placebo just because the SSRI group of these trials did worse after stopping the SSRI vs placebo.

 

[psychacad]

Do you not think subjective information plays an extremely important role in psychiatry? As it does in any area of medicine where you can't directly measure a blood level or image something directly.

So here's another example. Would we argue that toradol doesn't actually treat pain because your pain gets notably worse when you stop an toradol vs a patient who was taking a placebo and stopped that (substitute whatever other pain medications), keeping in mind that perceived pain is entirely subjective? Would we argue that beta blockers don't treat hypertension if the patients taking beta blockers got rebound hypertension while the placebo group didn't? I also don't get how arguing that a medication makes you more sensitized to suffering worsening symptoms when you stop the medication somehow supports an argument against continuing said medication (the name of the article is "Examining the Long Term Use of Antidepressants").

I'm not actually arguing that we should keep people on SSRIs forever but the logic here just doesn't make much sense to argue that SSRIs are somehow "worse" than placebo just because the SSRI group of these trials did worse after stopping the SSRI vs placebo.

Well, it's not as simple as this effect means we need to stop ADs. He's not making that argument. But he adds a couple of important observations:
1) The AD benefits stop after a year from large naturalistic studies.
2) Long term naturalistic studies show that people on long term ADs aren't doing very well.

Of course with 2) there are also a lot of confounds, but it already tells you something important that ADs aren't doing what they are supposed to do on the long term. This is not the case with the examples you're mentioning. All of this information means we have to rethink the cost/benefit analysis here. The effectivity of AD is problematic.

And yes, of course I think subjectivity plays a huge role in psychiatry, but if it's so strong that it can completely derail an intervention that does say something about the effectivity of said intervention.

 

[Attending1985]

Do you not think subjective information plays an extremely important role in psychiatry? As it does in any area of medicine where you can't directly measure a blood level or image something directly.

So here's another example. Would we argue that toradol doesn't actually treat pain because your pain gets notably worse when you stop an toradol vs a patient who was taking a placebo and stopped that (substitute whatever other pain medications), keeping in mind that perceived pain is entirely subjective? Would we argue that beta blockers don't treat hypertension if the patients taking beta blockers got rebound hypertension while the placebo group didn't? I also don't get how arguing that a medication makes you more sensitized to suffering worsening symptoms when you stop the medication somehow supports an argument against continuing said medication (the name of the article is "Examining the Long Term Use of Antidepressants").

I'm not actually arguing that we should keep people on SSRIs forever but the logic here just doesn't make much sense to argue that SSRIs are somehow "worse" than placebo just because the SSRI group of these trials did worse after stopping the SSRI vs placebo.

I’m not sure the point of the article was arguing if they work short term that’s been argued extensively elsewhere. The point of the article was to examine the long term effects of taking the medication which is important for risk benefit decisions for patients. I have patients ask me this a lot and unfortunately it’s not well studied.
I believe I found the article he’s referencing which shows at 3 month follow up those who recovered on placebo vs SSri the relapse rates were 21% and 43%. This may be due to withdrawal but that doesn’t make it any less clinically meaningful or important to patients. This is only one study and long term studies on antidepressants are really lacking and very needed.

 

[TexasPhysician]

It is incredibly hard to do good research with depression as there are many confounding variables. For ex:

40yo M that was a VP for oil/gas company making $750k/year is laid off. His marriage was already less than excellent, but now the wife files for divorce. She is seeking full custody. Now with SI.

Without paying good attention to the history, this gentleman meets criteria for severe MDD. Maybe he is just so down that he doesn’t focus on what has gone wrong. Maybe he doesn’t want to talk about how great he had it for fear you will pity him.

Placed on placebo. He had been on unemployment prior to the study, but now he has been applying for jobs and the economy in oil is improving. He lands a job after a few weeks and entertains dating. The divorce still sucks, but it’s less intense than imagined.

Life situations change. Med or placebo may have made no difference in his care. Either way, he skews the results of his arm. Without knowing the extent of the history, we may have no idea why.

Add in some opposite patients that have terrible life events that are worsening. Anti-depressants aren’t going to make the death of my parents vanish.

So these studies will involve patients that improve and worsen to a degree regardless of intervention used. In a large enough study, we hope that each arm is equal, but is it? How well are we analyzing the effects of confounding variables?

Studies in children on antidepressants and psychotherapy show improvement faster and more pronounced that therapy alone. Is it different in children vs adults? Are adults that have more side effects in a study more likely to not try as hard in counseling if they believe they avoided the placebo arm?

The questions are extensive in our field. I see nothing changing in the near future. We have too much to work out.

 

[hamstergang]

Not really. Why would you expect the placebo group to do better than the AD group after you remove the med/placebo? Presumably they have been randomized to each group so there is no difference in illness severity...etc. What this is arguing is that being on AD makes you more sensitive for decompensation once the med is stopped.

I didn't read the original article so tell me if I'm interpreting these posts incorrectly. If you take those that improved on the antidepressant and those that improved on placebo and then look at only them to see how they do when the medication/placebo is removed, this is really misleading. Those that improved while taking the placebo, along with some of those who improved while on the medication, would be expected to be more likely to stay well since there was no active ingredient helping them improve in the first place. Those that improved directly from the medication would be expected to do worse when the medication is then taken away.

It's quite a stretch to say that the medication itself caused the patients to be more likely to become depressed when it was taken away instead of concluding that the medication was actively helping and that taking a placebo isn't all that different from not.

 

[Attending1985]

I didn't read the original article so tell me if I'm interpreting these posts incorrectly. If you take those that improved on the antidepressant and those that improved on placebo and then look at only them to see how they do when the medication/placebo is removed, this is really misleading. Those that improved while taking the placebo, along with some of those who improved while on the medication, would be expected to be more likely to stay well since there was no active ingredient helping them improve in the first place. Those that improved directly from the medication would be expected to do worse when the medication is then taken away.

It's quite a stretch to say that the medication itself caused the patients to be more likely to become depressed when it was taken away instead of concluding that the medication was actively helping and that taking a placebo isn't all that different from not.

If you use this reasoning you’re assuming that MDD is a chronic disorder that requires maintenance treatment. MDD is defined as an acute disorder that can recurr. Like if you experienced an infection and while the placebo arm got better and stayed better the treatment arm led to recurrent infection after the treatment was stopped.

 

[Attending1985]

It is incredibly hard to do good research with depression as there are many confounding variables. For ex:

40yo M that was a VP for oil/gas company making $750k/year is laid off. His marriage was already less than excellent, but now the wife files for divorce. She is seeking full custody. Now with SI.

Without paying good attention to the history, this gentleman meets criteria for severe MDD. Maybe he is just so down that he doesn’t focus on what has gone wrong. Maybe he doesn’t want to talk about how great he had it for fear you will pity him.

Placed on placebo. He had been on unemployment prior to the study, but now he has been applying for jobs and the economy in oil is improving. He lands a job after a few weeks and entertains dating. The divorce still sucks, but it’s less intense than imagined.

Life situations change. Med or placebo may have made no difference in his care. Either way, he skews the results of his arm. Without knowing the extent of the history, we may have no idea why.

Add in some opposite patients that have terrible life events that are worsening. Anti-depressants aren’t going to make the death of my parents vanish.

So these studies will involve patients that improve and worsen to a degree regardless of intervention used. In a large enough study, we hope that each arm is equal, but is it? How well are we analyzing the effects of confounding variables?

Studies in children on antidepressants and psychotherapy show improvement faster and more pronounced that therapy alone. Is it different in children vs adults? Are adults that have more side effects in a study more likely to not try as hard in counseling if they believe they avoided the placebo arm?

The questions are extensive in our field. I see nothing changing in the near future. We have too much to work out.

“Now, if you want to get into stuff that's strange, though, there was a recently published paper where they looked at whether adding psychotherapy to an antidepressant would enhance the short‑term effect. No doubt, it did.

This is a group of people where half of them just had an antidepressant, half of them an antidepressant and psychotherapy. Then they basically randomized people, they took all the people that went into remission and they randomized them, but either stayed on the antidepressant or go off the antidepressant. Remember, there's data showing that if you just get psychotherapy without an antidepressant, you get this prolonged benefit where you're less likely to relapse.

In the study where the antidepressant was paired with the psychotherapy, nothing. The psychotherapy showed no protection at all. Which to me raises this interesting question about, medicines tend to dull down everything, whereas psychotherapy often works when people feel their problems and deal with them.”
I wonder if this occurs in kids as well?

 

[psychacad]

I didn't read the original article so tell me if I'm interpreting these posts incorrectly. If you take those that improved on the antidepressant and those that improved on placebo and then look at only them to see how they do when the medication/placebo is removed, this is really misleading. Those that improved while taking the placebo, along with some of those who improved while on the medication, would be expected to be more likely to stay well since there was no active ingredient helping them improve in the first place. Those that improved directly from the medication would be expected to do worse when the medication is then taken away.

It's quite a stretch to say that the medication itself caused the patients to be more likely to become depressed when it was taken away instead of concluding that the medication was actively helping and that taking a placebo isn't all that different from not.

That's a good thought, but I think it can be addressed by looking at the baseline characteristics of the two groups (improved on placebo vs improved on med). Presumably they aren't different, so the assumption is that you're looking at fairly similar populations. I haven't read the article, so I don't know the extent to which they addressed all these confounds. You also took away the placebo effect, so I don't agree that "those that improved while taking the placebo would be expected to be more likely to stay well".

 

[Merovinge]

You also took away the placebo effect, so I don't agree that "those that improved while taking the placebo would be expected to be more likely to stay well".

Unless they know it was a placebo, then realize that they improved on their own, and this reinforces their improvement. Placebo is very powerful and even more powerful is to improve with it and then know one did it on "their own".

 

[Marasmus1]

I am not understanding the argument. There are many studies that showed patients who responded to placebo in RCT have relatively mild illness severity whereas the ones responded to an antidepressant tend to have more severe symptoms. So it would make sense that if you follow these folks long term, the placebo group would likely have a better outcome without intervention.

I am wondering if there is any long term cohort where they followed the placebo non responders longitudinally on antidepressants vs no intervention.

 

[TexasPhysician]

“Now, if you want to get into stuff that's strange, though, there was a recently published paper where they looked at whether adding psychotherapy to an antidepressant would enhance the short‑term effect. No doubt, it did.

This is a group of people where half of them just had an antidepressant, half of them an antidepressant and psychotherapy. Then they basically randomized people, they took all the people that went into remission and they randomized them, but either stayed on the antidepressant or go off the antidepressant. Remember, there's data showing that if you just get psychotherapy without an antidepressant, you get this prolonged benefit where you're less likely to relapse.

In the study where the antidepressant was paired with the psychotherapy, nothing. The psychotherapy showed no protection at all. Which to me raises this interesting question about, medicines tend to dull down everything, whereas psychotherapy often works when people feel their problems and deal with them.”
I wonder if this occurs in kids as well?

This really makes no sense for many types of counseling. CBT is academic in nature. You learn and practice strategies not unlike learning Algebra. If you pull away the antidepressant, are patients forgetting/not learning Algebra? No. I can understand if the trials used set doses and sedated some patients then they probably wouldn’t retain anything.

 

[Attending1985]

This really makes no sense for many types of counseling. CBT is academic in nature. You learn and practice strategies not unlike learning Algebra. If you pull away the antidepressant, are patients forgetting/not learning Algebra? No. I can understand if the trials used set doses and sedated some patients then they probably wouldn’t retain anything.

The author hypotheses that the emotional numbing from the medications renders the therapy less effective

 

[Mad Jack]

Well, it's not as simple as this effect means we need to stop ADs. He's not making that argument. But he adds a couple of important observations:
1) The AD benefits stop after a year from large naturalistic studies.
2) Long term naturalistic studies show that people on long term ADs aren't doing very well.

Of course with 2) there are also a lot of confounds, but it already tells you something important that ADs aren't doing what they are supposed to do on the long term. This is not the case with the examples you're mentioning. All of this information means we have to rethink the cost/benefit analysis here. The effectivity of AD is problematic.

And yes, of course I think subjectivity plays a huge role in psychiatry, but if it's so strong that it can completely derail an intervention that does say something about the effectivity of said intervention.

Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China - PMC

Background The long-term outcome of never-treated patients with schizophrenia is unclear. Aims To compare the 14-year outcomes of never-treated and treated patients with schizophrenia and to establish predictors for never being treated. Method All ...

www.ncbi.nlm.nih.gov

Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care - PubMed

Findings highlight the importance of adherence with antipsychotic medication in the long-term treatment of schizophrenia and its potential beneficial impact on the mental health and criminal justice delivery systems.

pubmed.ncbi.nlm.nih.gov

Psychiatry Online

ajp.psychiatryonline.org

I could keep going, but the gist is this: it is well-established that for most patients with schizophrenia, both nonadherence and lack of treatment correlate with poorer functional outcomes and increased risk of premature death and significant morbidity. There is a subset of patients, around 20%, that would benefit from not being on medication long-term, as they will enter a largely uninterrupted remission. Identifying these patients successfully and early would be a desirable priority, however we don't have a reliable way to do so at this time so it is more of a trial and error sort of thing

 

[Mad Jack]

Yeah, but that in itself doesn't speak to the value of antipsychotics. It's possible that they decompensate once they stop their meds, but that they would do equally better if they weren't on meds in the first place (I think that's what the article about antidepressants was arguing). Another thing is that it's very possible that they stop their meds because they are decompensating. We don't really know which one comes first.

I don't think you've spent much time working with severely mentally ill patients. Long-acting injectable antipsychotics show substantially improved outcomes versus oral antipsychotics in most studies, which shows that adherence further improves outcomes when compared to nonadherence. If consistent use of antipsychotic medication made outcomes worse, as you posit, their outcomes would deteriorate with improved adherence.

Systematic review of long-acting injectables versus oral atypical antipsychotics on hospitalization in schizophrenia - PubMed

The primary results of this meta-analysis, including studies with both interventional and non-interventional designs and using meta-regressions, suggest that LAIs are associated with higher reductions in hospitalization rates for schizophrenia patients compared to OAs.

pubmed.ncbi.nlm.nih.gov

 

[psychacad]

Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China - PMC

Background The long-term outcome of never-treated patients with schizophrenia is unclear. Aims To compare the 14-year outcomes of never-treated and treated patients with schizophrenia and to establish predictors for never being treated. Method All ...

www.ncbi.nlm.nih.gov

Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care - PubMed

Findings highlight the importance of adherence with antipsychotic medication in the long-term treatment of schizophrenia and its potential beneficial impact on the mental health and criminal justice delivery systems.

pubmed.ncbi.nlm.nih.gov

Psychiatry Online

ajp.psychiatryonline.org

I could keep going, but the gist is this: it is well-established that for most patients with schizophrenia, both nonadherence and lack of treatment correlate with poorer functional outcomes and increased risk of premature death and significant morbidity. There is a subset of patients, around 20%, that would benefit from not being on medication long-term, as they will enter a largely uninterrupted remission. Identifying these patients successfully and early would be a desirable priority, however we don't have a reliable way to do so at this time so it is more of a trial and error sort of thing

I'm familiar with this study. There are problems with it. I disagree that it is 'well established' that long term treatment with antipsychotics is beneficial. We have good data for the first 2-3 years of treatment, not after.

Long‐term antipsychotic treatment of schizophrenia: does it help or hurt over a 20‐year period? - PMC

www.ncbi.nlm.nih.gov

"Unfortunately, views about the long‐term efficacy of antipsychotics are often based on the results from short‐term (0‐2 years) evaluations. As we have highlighted, there are at least eight major studies which fail to find better outcomes for schizophrenia patients treated on a long‐term basis with antipsychotics. These negative results from multiple large well‐documented long‐term studies are a clear warning sign."

 

[calvnandhobbs68]

I don't think you've spent much time working with severely mentally ill patients. Long-acting injectable antipsychotics show substantially improved outcomes versus oral antipsychotics in most studies, which shows that adherence further improves outcomes when compared to nonadherence. If consistent use of antipsychotic medication made outcomes worse, as you posit, their outcomes would deteriorate with improved adherence.

Systematic review of long-acting injectables versus oral atypical antipsychotics on hospitalization in schizophrenia - PubMed

The primary results of this meta-analysis, including studies with both interventional and non-interventional designs and using meta-regressions, suggest that LAIs are associated with higher reductions in hospitalization rates for schizophrenia patients compared to OAs.

pubmed.ncbi.nlm.nih.gov

Right I mean the simplest way to look at this is through history. Before the advent of antipsychotics, basically all people with severe mental illness were doomed to spend their lives in a psychiatric hospital. Antipsychotics were a true game changer for the entire field. To argue that somehow patients would do better whether they were on an antipsychotic or not is to ignore this entire history.

 

[clausewitz2]

I'm familiar with this study. There are problems with it. I disagree that it is 'well established' that long term treatment with antipsychotics is beneficial. We have good data for the first 2-3 years of treatment, not after.

Long‐term antipsychotic treatment of schizophrenia: does it help or hurt over a 20‐year period? - PMC

www.ncbi.nlm.nih.gov

"Unfortunately, views about the long‐term efficacy of antipsychotics are often based on the results from short‐term (0‐2 years) evaluations. As we have highlighted, there are at least eight major studies which fail to find better outcomes for schizophrenia patients treated on a long‐term basis with antipsychotics. These negative results from multiple large well‐documented long‐term studies are a clear warning sign."

These are the same authors that argue that because there are no solid RCTs, there is no reason to believe that ECT works for anyone. This paper does not inspire confidence when one of the major studies they cite as failing to support the use of antipsychotics (Harrison et al. specifically) . . . did not measure, correlate, correct for, or even report anything about pharmacological treatment or adherence in their samples. Citing as evidence against a proposition a study that failed to support it by virtue of being irrelevant is flim-flammery.

It would be nice if we had a set of mechanical logical decision rules that we could just apply to a base of evidence and spit out the correct answer without incorporating other sources of information. Then reasoning would just consist of knowing the rules well and applying them correctly and no other contextual knowledge would be necessary. It would be nice, like a kind of applied math. Unfortunately, Rudolf Carnap died in 1970 and this model of how we do scientific reasoning is of a similar vintage. Were it was otherwise.

 

[Mad Jack]

I'm familiar with this study. There are problems with it. I disagree that it is 'well established' that long term treatment with antipsychotics is beneficial. We have good data for the first 2-3 years of treatment, not after.

Long‐term antipsychotic treatment of schizophrenia: does it help or hurt over a 20‐year period? - PMC

www.ncbi.nlm.nih.gov

"Unfortunately, views about the long‐term efficacy of antipsychotics are often based on the results from short‐term (0‐2 years) evaluations. As we have highlighted, there are at least eight major studies which fail to find better outcomes for schizophrenia patients treated on a long‐term basis with antipsychotics. These negative results from multiple large well‐documented long‐term studies are a clear warning sign."

If you actually read any of what I posted, examples are presented of studies with durations of 1, 3, 5, 10, and 14 years

 

[psychacad]

If you actually read any of what I posted, examples are presented of studies with durations of 1, 3, 5, 10, and 14 years

OK, but as mentioned there are also 8 different ones that looked for long term outcomes and didn't find a beneficial effect. You can go back and forth if you want, but it is not well established that antipsychotics are beneficial over the long term.

 

[Mad Jack]

OK, but as mentioned there are also 8 different ones that looked for long term outcomes and didn't find a beneficial effect. You can go back and forth if you want, but it is not well established that antipsychotics are beneficial over the long term.

The studies you cite have quite poor methodology, unlike the ones I have presented

 

[FlowRate]

For some additional reading on related therapeutic approaches, his discussion of suffering and approaching emotions reminds me of the chapter in Mark Stark's Working with Resistance on "Resistance as a Failure to Grieve."

I see the Acceptance in ACT as not being dissimilar in concept, broadly.

 

[splik]

So much data seems to be emerging regarding the negative consequences of psychotropic use especially in the long term. Really makes you wonder about the future of psychiatry.

None of this is new. We knew that antipsychotics worsened the course of psychotic illness and that withdrawal caused supersensitivity psychosis back in the 70s and 80s with the work of Guy Chouinard and others. In Rethinking Psychiatry, written in the 80s, Arthur Kleinman, doyen of cross-cultural psychiatry, said these findings would send reverberations across the field and prove a reckoning for the ascendant field of psychopharmacology. Ha! These findings were largely suppressed and psychiatry continues its pace of diagnosing and drugging everything that moved. In the early 2000s, with psychiatry's unholy alliance with the pharmaceutical industry exposed, corrupt department chairs deposed, a congressional investigation, the flimsy evidence for antidepressants laid bare, and drug companies closing down psychiatric research pipelines due to increasing fruitlessness of psychiatric drug development, it was claimed that psychiatry would have to redefine itself or face annihilation. Today, the demand for psychiatric drugs to medicate misery is as strong as ever.

 

[Attending1985]

None of this is new. We knew that antipsychotics worsened the course of psychotic illness and that withdrawal caused supersensitivity psychosis back in the 70s and 80s with the work of Guy Chouinard and others. In Rethinking Psychiatry, written in the 80s, Arthur Kleinman, doyen of cross-cultural psychiatry, said these findings would send reverberations across the field and prove a reckoning for the ascendant field of psychopharmacology. Ha! These findings were largely suppressed and psychiatry continues its pace of diagnosing and drugging everything that moved. In the early 2000s, with psychiatry's unholy alliance with the pharmaceutical industry exposed, corrupt department chairs deposed, a congressional investigation, the flimsy evidence for antidepressants laid bare, and drug companies closing down psychiatric research pipelines due to increasing fruitlessness of psychiatric drug development, it was claimed that psychiatry would have to redefine itself or face annihilation. Today, the demand for psychiatric drugs to medicate misery is as strong as ever.

That’s demoralizing good read and makes me seriously consider switching fields

 

[Attending1985]

None of this is new. We knew that antipsychotics worsened the course of psychotic illness and that withdrawal caused supersensitivity psychosis back in the 70s and 80s with the work of Guy Chouinard and others. In Rethinking Psychiatry, written in the 80s, Arthur Kleinman, doyen of cross-cultural psychiatry, said these findings would send reverberations across the field and prove a reckoning for the ascendant field of psychopharmacology. Ha! These findings were largely suppressed and psychiatry continues its pace of diagnosing and drugging everything that moved. In the early 2000s, with psychiatry's unholy alliance with the pharmaceutical industry exposed, corrupt department chairs deposed, a congressional investigation, the flimsy evidence for antidepressants laid bare, and drug companies closing down psychiatric research pipelines due to increasing fruitlessness of psychiatric drug development, it was claimed that psychiatry would have to redefine itself or face annihilation. Today, the demand for psychiatric drugs to medicate misery is as strong as ever.

Did you know this going into psychiatry or did you discover it along the way? I’m guessing the latter or you wouldn’t have entered the field.

 

[clausewitz2]

None of this is new. We knew that antipsychotics worsened the course of psychotic illness and that withdrawal caused supersensitivity psychosis back in the 70s and 80s with the work of Guy Chouinard and others. In Rethinking Psychiatry, written in the 80s, Arthur Kleinman, doyen of cross-cultural psychiatry, said these findings would send reverberations across the field and prove a reckoning for the ascendant field of psychopharmacology. Ha! These findings were largely suppressed and psychiatry continues its pace of diagnosing and drugging everything that moved. In the early 2000s, with psychiatry's unholy alliance with the pharmaceutical industry exposed, corrupt department chairs deposed, a congressional investigation, the flimsy evidence for antidepressants laid bare, and drug companies closing down psychiatric research pipelines due to increasing fruitlessness of psychiatric drug development, it was claimed that psychiatry would have to redefine itself or face annihilation. Today, the demand for psychiatric drugs to medicate misery is as strong as ever.

I take the concern about SP psychosis very seriously and it's a reason I tend to try as hard as possible to keep anyone I prescribe neuroleptics to on the smallest needed dose for the shortest period of time but even Chouinard doesn't suggest that it is a universal phenomenon or even applicable to a majority of people put on neuroleptics. Here's some of his more recent thoughts on the matter:

Antipsychotic-Induced Dopamine Supersensitivity Psychosis: Pharmacology, Criteria, and Therapy

Abstract. The first-line treatment for psychotic disorders remains antipsychotic drugs with receptor antagonist properties at D2-like dopamine receptors. However, long-term administration of antipsychotics can upregulate D2 receptors and produce receptor supersensitivity manifested by behavioral...

www.karger.com

That paper estimates that this idea applies to about 30% of people with schizophrenia and perhaps 70% of people with "treatment-resistant" schizophrenia. Since the later also generally have totally unremarkable dopamine receptors and dopaminergic tone it's not surprising that D2 blockers are more harmful than helpful a lot of the time. I think it's criminal that people don't look more to non-dopaminergic approaches to treating people with psychosis who don't respond to adequate trials of neuroleptics. I don't think it's fair to say though that there is good reason to believe that they are everywhere and always harmful to people diagnosed with schizophrenia.

What are the odds that the response to a treatment is going to be homogenous across all members of a very heterogenous category that only exists for historical reasons?

 

[psychacad]

That’s demoralizing good read and makes me seriously consider switching fields

I mean, frankly most of us did not enter psychiatry so that we see pts for 15 min, prescribe meds and send them on their way. I presume many are interested in narrative, context and life history. That was the draw for me, and still is.

I recently made peace with the fact that the field as 'advertised' by the leadership is almost entirely unscientific. There will always be a place for meds and neuro-interventions but you don't have to practice exclusively this way, and I very much doubt any decent quality care would ever be practiced this way.

 

[Attending1985]

I mean, frankly most of us did not enter psychiatry so that we see pts for 15 min, prescribe meds and send them on their way. I presume many are interested in narrative, context and life history. That was the draw for me, and still is.

I recently made peace with the fact that the field as 'advertised' by the leadership is almost entirely unscientific. There will always be a place for meds and neuro-interventions but you don't have to practice exclusively this way, and I very much doubt any decent quality care would ever be practiced this way.

I completely agree with you. At the same time I don’t see psychiatrists practicing this way often. It seems like most aren’t interested in quality of care or changing the field most are interested in making the most money possible. If only we could financially incentivize good care.

 

[clausewitz2]

I mean, frankly most of us did not enter psychiatry so that we see pts for 15 min, prescribe meds and send them on their way. I presume many are interested in narrative, context and life history. That was the draw for me, and still is.

I recently made peace with the fact that the field as 'advertised' by the leadership is almost entirely unscientific. There will always be a place for meds and neuro-interventions but you don't have to practice exclusively this way, and I very much doubt any decent quality care would ever be practiced this way.

I actually can't disagree with any of that.

 

[Attending1985]

The corruption in our field is what really gets me. Honestly I’m embarrassed to say I’m a psychiatrist and it has nothing to do with mental health stigma.

 

[Mad Jack]

I mean, frankly most of us did not enter psychiatry so that we see pts for 15 min, prescribe meds and send them on their way. I presume many are interested in narrative, context and life history. That was the draw for me, and still is.

I recently made peace with the fact that the field as 'advertised' by the leadership is almost entirely unscientific. There will always be a place for meds and neuro-interventions but you don't have to practice exclusively this way, and I very much doubt any decent quality care would ever be practiced this way.

Providing comprehensive treatment with both pharmalogical and non-pharmacological interventions should be our role. Some patients need one or the other, some neither, some both. I have to tell at least a couple of patients a week that no pill will fix what they're describing and they need to make life changes along with engaging in therapy. The field is what you make of it, honestly

 

[calvnandhobbs68]

The corruption in our field is what really gets me. Honestly I’m embarrassed to say I’m a psychiatrist and it has nothing to do with mental health stigma.

What drama. If you’re so embarrassed to say you’re a psychiatrist nothings stopping you from becoming a barista and talking philosophy with the customers.

Or you could just try to be not “corrupt” on an individual level, do the best to help improve people’s suffering in day to day practice and get involved in psychiatry leadership to decrease the amount of corruption you’re so distressed by.

 

[Merovinge]

The corruption in our field is what really gets me. Honestly I’m embarrassed to say I’m a psychiatrist and it has nothing to do with mental health stigma.

What drama. If you’re so embarrassed to say you’re a psychiatrist nothings stopping you from becoming a barista and talking philosophy with the customers.

Or you could just try to be not “corrupt” on an individual level, do the best to help improve people’s suffering in day to day practice and get involved in psychiatry leadership to decrease the amount of corruption you’re so distressed by.

C&H, absolutely and clearly the overwhelming majority of psychiatrists go to work every day to help the marginalized, the sick, the downtrodden, in a way that until recently came with near zero prestige for the better part of 2 decades. Were it not for the pharmacologists we would not have medications like Abilify which has improved countless lives of the children I care for (with ASD and/or ID) or Latuda which I have seen transform bipolar depression in adolescents without the terrible metabolic side-effects of Seroquel or Vyvanse being a game-changer in binge eating kids with ADHD (I could go on and on). I see parents cry on a near-weekly basis over the improvements in their children's lives from this "corruption".

 

[WisNeuro]

What drama. If you’re so embarrassed to say you’re a psychiatrist nothings stopping you from becoming a barista and talking philosophy with the customers.

Or you could just try to be not “corrupt” on an individual level, do the best to help improve people’s suffering in day to day practice and get involved in psychiatry leadership to decrease the amount of corruption you’re so distressed by.

No one wants to sit down and talk with baristas. They just want their coffee and to mooch off free internet. You have to become a bartender to wax philosophical with the patrons.

 

[calvnandhobbs68]

No one wants to sit down and talk with baristas. They just want their coffee and to mooch off free internet. You have to become a bartender to wax philosophical with the patrons.

Can't argue with that.