Non-psychopharm treatment for schizophrenia?

[biogirl215]

I was watching "A Beautiful Mind" a couple of weeks ago, and, geek that I am, decided to do some research on the actual story, upon which I learned John Nash hasn't taken any psychotropic medication since the 70's or so. Is there any empirical evidence for substantial effectiveness of non-psychpharm interventions with schizophrenia, beside social skills training? Any solid support for the theories that use of antipsychotics can worsen schizophrenia in the long run? Any thoughts on the matter? I'm curious...

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[chaos]

That's an interesting question because in terms of brain functioning, antipsychotic drug use among schizophrenics is correlated with fewer hospitalizations, self-report decrease of symptoms, physician-reported decrease of visible symptoms (disorganization, flat affect), better ventricular brain ratio (less cerebral atrophy)..etc.

However...

Antipsychotics are terrible for your health. Aside from the rare but irrevistible tardive dyskinesia, and the other extrapyramidal side effects and agranulocytosis with clozapine most antipsychotics cause significant weight gain, which is not good in a country that is mostly obese with a population that is not known for a healthy lifestyle. Elevated triglycerides, insulin insensitivity, general lethargy which contributes to further inactivity, and many other side-effects that can decrease quality of life. On the other hand, you have these terrifying symptoms that need to be treated, so it's really a no-win situation.

I've found that most psychiatrists vehemently dismiss any claims that the side-effects of the drug are worse that the disease they're treating. One even got really snappish when I tried to broach the subject, saying verbatim, "The side effects are just something that has to be dealt with. People with schizophrenia need to be on antipsychotics. Consistently and permanently. Period."

I'm not saying to ditch this class of drugs, because obviously they reduce positive symptoms unlike any other treatment, but it seems that some psychiatrists are uncomfortable talking about the truly destructive effects they can have on long-term health. Because they are the only treatment, it is uncomfortable to think that they are really not an acceptable or safe treatment at all, and that they can reduce quality of life nearly as much as they restore it. There is a reason for the astronomical non-compliance rates among people with schizophrenia, and it's not just because the patients are paranoid and start to think the drugs are poisoning them, etc. It's because in a sense, they ARE. The side-effects are torturous for many people and there is no way around it. Ask someone who has schizophrenia why they've stopped their medication so many times. Is it because they don't trust their prescriber, or don't want the symptoms to stop? No, it's because the medication makes them sleep 16 hours a day, or feel constantly restless, or gain 50 lbs, etc. I think every psychiatrist who prescribes these should have to take a low dose for a few weeks, just to see what they are prescribing (and the side-effects would be similar in sz and non sz subjects, I think, because sz is not a true deficiency model). This is especially important in a population like SZ where the doctors often feel the need to take a strong-arm approach because the patient is seen to, or in some cases does, lack basic competency and comprehension, and the choice to be medicated is often more a case of the physician telling the patient in no uncertain terms to take the medication. I'm not saying the physicians should stop prescribing it, but I think it might be helpful for everyone for them to know what they're dealing and not be so cavalier about it.

That being said, no...there is no other form of treatment that has reliably been shown to improve the symptoms of schizophrenia. Psychotherapy is sometimes used as an adjunct, but the results of clinical studies on this have been modest at best (partly due to the fact that the psychotherapies tests are mostly short-duration, highly scripted therapies, I'm sure). Some doctors still use ECT for schizophrenia which in my opinion is about the stupidest thing ever...but now is not the time nor place for my ECT rant. Transcranial magnetic stimulation seems to have some potential, but so far it only reduces auditory hallucinations, and only temporarily.

Regarding your question about John Nash, there is some evidence that symptoms tend to spontaneously decrease later in life...although the cause of this is not known.

 

[solumanculver]

That's an interesting question because in terms of brain functioning, antipsychotic drug use among schizophrenics is correlated with fewer hospitalizations, self-report decrease of symptoms, physician-reported decrease of visible symptoms (disorganization, flat affect), better ventricular brain ratio (less cerebral atrophy)..etc.

However...

Antipsychotics are terrible for your health. Aside from the rare but irrevistible tardive dyskinesia, and the other extrapyramidal side effects and agranulocytosis with clozapine most antipsychotics cause significant weight gain, which is not good in a country that is mostly obese with a population that is not known for a healthy lifestyle. Elevated triglycerides, insulin insensitivity, general lethargy which contributes to further inactivity, and many other side-effects that can decrease quality of life. On the other hand, you have these terrifying symptoms that need to be treated, so it's really a no-win situation.

I've found that most psychiatrists vehemently dismiss any claims that the side-effects of the drug are worse that the disease they're treating. One even got really snappish when I tried to broach the subject, saying verbatim, "The side effects are just something that has to be dealt with. People with schizophrenia need to be on antipsychotics. Consistently and permanently. Period."

I'm not saying to ditch this class of drugs, because obviously they reduce positive symptoms unlike any other treatment, but it seems that some psychiatrists are uncomfortable talking about the truly destructive effects they can have on long-term health. Because they are the only treatment, it is uncomfortable to think that they are really not an acceptable or safe treatment at all, and that they can reduce quality of life nearly as much as they restore it. There is a reason for the astronomical non-compliance rates among people with schizophrenia, and it's not just because the patients are paranoid and start to think the drugs are poisoning them, etc. It's because in a sense, they ARE. The side-effects are torturous for many people and there is no way around it. Ask someone who has schizophrenia why they've stopped their medication so many times. Is it because they don't trust their prescriber, or don't want the symptoms to stop? No, it's because the medication makes them sleep 16 hours a day, or feel constantly restless, or gain 50 lbs, etc. I think every psychiatrist who prescribes these should have to take a low dose for a few weeks, just to see what they are prescribing (and the side-effects would be similar in sz and non sz subjects, I think, because sz is not a true deficiency model). This is especially important in a population like SZ where the doctors often feel the need to take a strong-arm approach because the patient is seen to, or in some cases does, lack basic competency and comprehension, and the choice to be medicated is often more a case of the physician telling the patient in no uncertain terms to take the medication. I'm not saying the physicians should stop prescribing it, but I think it might be helpful for everyone for them to know what they're dealing and not be so cavalier about it.

That being said, no...there is no other form of treatment that has reliably been shown to improve the symptoms of schizophrenia. Psychotherapy is sometimes used as an adjunct, but the results of clinical studies on this have been modest at best (partly due to the fact that the psychotherapies tests are mostly short-duration, highly scripted therapies, I'm sure). Some doctors still use ECT for schizophrenia which in my opinion is about the stupidest thing ever...but now is not the time nor place for my ECT rant. Transcranial magnetic stimulation seems to have some potential, but so far it only reduces auditory hallucinations, and only temporarily.

Regarding your question about John Nash, there is some evidence that symptoms tend to spontaneously decrease later in life...although the cause of this is not known.

Hey Chaos, great post. I didn't know that rTMS had any effect on schizophrenia... It seems, though, that if rTMS works, ECT should probably work as well. Can you think of a reason why one would work and not the other?

 

[chaos]

Hmm, now that I think about it, when rTMS is used to induce seizure I guess it is functionally similar to ECT, so I'd take issue to both, although the short-term memory loss seems to be less in rTMS.

The fact that we really don't know the mechanism by which ECT alleviates depression or psychosis is troubling. I know, many medical treatments were originally intended for a completely different purpose and their therapeutic effects in a specific disorder were discovered accidentally, but still. I just can't agree with functionally and repetitively inducing seizures, because for some reason it sort of seems to work. And this falls within the realm of personal bias, but having been in close proximity with a number of people who were receiving ECT as well as those who had received it (for depression or bipolar disorder, not schizophrenia), I noticed subtle personality changes that perhaps were artifacts of an overactive imagination, but still...aside from profound memory loss after the fact, it seemed that there was a certain affective and cognitive dullness or apathy that persisted after the depression had abated. Like, the people said they didn't feel as depressed, but it sort of seemed like they didn't feel...anything. I'm not saying they seemed lobotomized, and you could argue they had these symptoms before, I guess. Really, I can't find much scientific evidence that ECT produces severe or long-lasting cognitive changes, but they may be of the sort that blunt clinical instruments don't detect. I can't help but think of what Hemingway wrote before he killed himself--- "It was a brilliant cure, but we lost the patient..."

I expect high-functioning patients with high metacognition would suffer most from these cognitive changes which are well-documented in the literature of personal experiences with ECT. But another consideration is that when you are dealing with a population like schizophrenia, which is already cognitively impaired, giving a treatment that has potential to increase the already significant cognitive deficits seen in SZ seems counter-intuitive. Also, I'm not a big fan of Breggin, but his hypothesis that ECT works primarily by inducing subtle brain damage that blunts affective metacognition rather than functionally 'fixing' depression on a neural level seems concordant with what I have seen of ECT patients myself.

Some people seem to react to it just fine, after the initial memory loss. Others claim their lives were destroyed by it. Journal articles are not known for reporting the subtleties of human experience, so I'd approach it with great reservation, myself.

Anyway, I apologize for taking this a little off-topic.

EDIT: Oh, and in response to your original question, I don't have enough background in neuroscience to explain how rTMS differs in its effects and side-effect profile..we only discussed it very briefly in my neuro seminar this semester, which is how I know about it.

 

[Therapist4Chnge]

Maybe with some very mild cases of schizophrenia, but medication really should be the first step (finding the RIGHT medication helps greatly of course).

All of the SE issues posted above are correct, but it is a 'damned if you do, damned if you don't' situation.

-t

 

[socialcog]

I think every psychiatrist who prescribes these should have to take a low dose for a few weeks, just to see what they are prescribing (and the side-effects would be similar in sz and non sz subjects, I think, because sz is not a true deficiency model). This is especially important in a population like SZ where the doctors often feel the need to take a strong-arm approach because the patient is seen to, or in some cases does, lack basic competency and comprehension, and the choice to be medicated is often more a case of the physician telling the patient in no uncertain terms to take the medication.

Thank you for your post, Chaos.

Interesting that you bring up this notion. I have never heard of a psychiatrist testing out meds on himself, however I have worked with a somewhat radical and passionate psych nurse in a hospital setting who has done this with most meds, so he says. (I believe him). He claims that by doing this, it has enabled him to truly empathize with the patients from a unique perspective. Moreover, he uses these experiences to subtly convey to the MDs that are more, shall we say, liberal in prescribing meds to these patients--helping the MDs think carefully about the doses and the coctails they put their patients on.

Pretty interesting. The culture on the units is such that the MDs are infallible and are venerated. This nurse was truly unique.

 

[chaos]

Mmm this reminds me of a conversation I had with a psychiatrist... I do love to grill them whenever possible, haha. He specialized in treating schizophrenia and had ordered ECT for many patients (generally for affective sx, but as he put it, the treatment often had the 'nice bonus' of reducing psychosis in BDI and SZa patients in many cases. And then I was talking about the subjective loss of cognition and creativity...a mental fog that patients report lasting to last for years after treatment, although clinical measures of working memory, executive function return close to baseline after several months. And he said that was an issue, and he was more reserved with the use of ECT for very 'high-functioning' (read: intelligent and of greater value to society) than 'low-functioning patients.' I'll leave the implications of that to you.

And later I asked, so if you were severely depressed, and medications weren't helping, would you do an ECT course? And he tried to weasel out of it by saying how he wasn't severely depressed, and depressed thought patterns are different, and he really didn't know what he would do... and I was like, come on, yeah you do, nd finally he admitted that no, he would investigate other options like DBS or vagus nerve stimulation first. Options that he did not offer his patients.

Anyway, I thought it was a rather illuminating conversation, if a little appalling.

 

[biogirl215]

Very, very interesting posts! Thank you very much.

Interestingly enough, I've heard something similar from a friend of mine who works with a lot of schizophrenics--that you almost wonder if giving them anti-psychotics is the right thing to do because many times the drugs fail to even be that effective at symptom-reduction but still produce Gd awful sid effects, so you end up doing a lot of harm. She still advocates the use of those medications, especially for severe cases, but said that once you see it "in action," so to speak, it's not nearly as easy or as clear-cut a decision as people tend to think.

To branch off of the topic a bit, what about psychotherapies designed not to decrease the symptoms themselves but to increase relative functionality? For example, someone at my university is currently putting toghether a study on mindfulness training as a way to reduce reactive distress in sz and therefore increase functionality. At least, that's the hypothesis the experimenter seesm to working under (I only know the barebones, "here's a summary of my current research," part of it); who knows if it will be supported by the evidence. Is there much/any evidence for that kind of intervention?

Sorry to pick you guys' brains so much...

 

[Therapist4Chnge]

It is more than just giving meds or not...it is also which types, dosing, etc. I think anti-psychotics get a bad reputation because sometimes they aren't a good fit, and sometimes the dosing isn't effective, etc. Prescribing is as much about science as it is about art, as there isn't a standard dosing that works for everyone.

Though to balance that, there was an interesting discussion in the psychiatry forum about which anti-psychotic you would take if you had to.

Surprisingly at least one person voted for Clozeril, though it could have been a pity vote.



-t

 

[chaos]

Very, very interesting posts! Thank you very much.

Interestingly enough, I've heard something similar from a friend of mine who works with a lot of schizophrenics--that you almost wonder if giving them anti-psychotics is the right thing to do because many times the drugs fail to even be that effective at symptom-reduction but still produce Gd awful sid effects, so you end up doing a lot of harm. She still advocates the use of those medications, especially for severe cases, but said that once you see it "in action," so to speak, it's not nearly as easy or as clear-cut a decision as people tend to think.

To branch off of the topic a bit, what about psychotherapies designed not to decrease the symptoms themselves but to increase relative functionality? For example, someone at my university is currently putting toghether a study on mindfulness training as a way to reduce reactive distress in sz and therefore increase functionality. At least, that's the hypothesis the experimenter seesm to working under (I only know the barebones, "here's a summary of my current research," part of it); who knows if it will be supported by the evidence. Is there much/any evidence for that kind of intervention?

Sorry to pick you guys' brains so much...

No, not at all, it's a great discussion. Yeah there seem to be some starry-eyed notions among clinicians (oddly enough, even those who treat a LOT of schizophrenic patients) about exactly how well these drugs reduce symptoms. Having had extensive contact with patients in an outpatient day/residential treatment program for SZ, these drugs do not eliminate hallucinations/delusions altogether for most patients, although in many cases they help significantly. In order to really knock out psychosis altogether, they need to be on such high doses that the patients are practically comatose, and even then you wonder if they're just too sedated to report symptoms. What they seem to be best at doing in my experience (please keep in mind that I'm only a student so I was only interacting with these patients, not treating them) is reducing thought disorder and disorganized speech. So because the patient is able to communicate more clearly, it seems to the clinician like there is a huge improvement, when subjectively the patient doesn't feel all that much better. And again, some people with SZ really do benefit from the medications and are able to function much better because of them, but in some patients they seem to cause so much trouble for a relatively minor reduction in symptoms that you wonder if it's worth it. Again I just think it's so unfortunate that there is this extremely anxiety provoking approach-avoidance gradient these patients have to deal with on these medications. It's like...you can be tortured by voices telling you to kill yourself, or you can sleep 14 hours a day and gain 50 lbs.


Anyway, regarding psychosocial interventions, I think they're good for improving quality-of-life...people with SZ are often so isolated and socially inhibited that a structured chance to interact is very beneficial. On the other hand, it all depends on the quality of the program. At the program I was involved with, I really think it could have been structured better. There was way too much time where the pts were just sitting around, some of the 'group exercises' were frankly patronizing to the higher-functioning members ('let's learn how to go shopping...find these items on the table' . Yeah I bet that was really helpful for the 26 yr old grad student dropout with the 130 IQ. Granted someone of that ability is an anomaly, but the groups really should have been subdivided according to ability, instead of seemingly randomly). Overall the vaguely patronizing attitude of the staff there grated on my nerves, and don't think the patients didn't notice they were being treated like 5 yrs olds. "I'm schizophrenic, not ****ing ******ed" was a common sentiment.

The program also had a cognitive remediation researcher, so the patients spent about an hour a day doing computer exercises designed to improve working memory, reaction time, attention, etc. Again I think this is potentially beneficial, but I have the same complaint: the exercises were kind of sterile and boring and didn't hold the patients' attention. I tried them out and they didn't hold my attention very well, either. If they found a way to make this type of game a little snappier...maybe in a simple RPG format with characters and a storyline, I think patients would become more interested and thus learn more.

Anyway I have rambled enough for the moment, hehe.

 

[chaos]

It is more than just giving meds or not...it is also which types, dosing, etc. I think anti-psychotics get a bad reputation because sometimes they aren't a good fit, and sometimes the dosing isn't effective, etc. Prescribing is as much about science as it is about art, as there isn't a standard dosing that works for everyone.

Though to balance that, there was an interesting discussion in the psychiatry forum about which anti-psychotic you would take if you had to.

Surprisingly at least one person voted for Clozeril, though it could have been a pity vote.



-t

True...but most of the drugs have a similar side-effect profile, so you tend to get the paradoxical sedation/akathesia combination with many of the patients of all of the drugs. All of them are pretty bad in terms of weight gain, too, although aripiprazole probably less so. Chemically it seems most promising since it's a partial agonist, partial antagonist, so it seems like it should balance things out rather than globally sucker-punching one or more DA receptor types. Unfortunately it doesn't actually seem to be more effective or well-tolerated than most of the other antipsychotics.

But yeah, the antipsychotics can have wildly different efficacies and tolerability for different pts, so persistence may be rewarded in the end.

BTW what do you think of polypharmacy for sz? Like, some patients are on 3 antipsychotics plus a mood stabilizer plus an antidepressant plus an anxiolytic. Maybe that's more of a question for the psychiatry crowd, though.

 

[Therapist4Chnge]

Chemically it seems most promising since it's a partial agonist, partial antagonist, so it seems like it should balance things out rather than globally sucker-punching one or more DA receptor types. Unfortunately it doesn't actually seem to be more effective or well-tolerated than most of the other antipsychotics.

I think if there are any more AP's developed they'll probably go down the route of the partials, hoping they can still get a therapeutic effect without some of the nasty side effects. I think some of the older APs (1st gen) get a bad reputation and get lost in the marketing shuffle, since they are pennies on the dollar of a name brand still under patent med, but I think people are too quick to not even consider them, and instead go to a 'wonder' drug.

BTW what do you think of polypharmacy for sz? Like, some patients are on 3 antipsychotics plus a mood stabilizer plus an antidepressant plus an anxiolytic. Maybe that's more of a question for the psychiatry crowd, though.

I'm pretty sure there isn't solid peer-reviewed research that supports that polypharmacy, in regard to treating SZ, is more effective than using one agent. I always look to the research first, and short of that, then I'd look at case studies.

Where I question polypharmacy isn't at its general idea, but more about how it is applied. There are cases out there that have a delicate balance of meds that allow the patient to manage their conditions and do well. These cases often take years for the right combination of meds (this is the part of psychiatry I consider more art and less science), though my problem with polypharmacy is when people start off on multiple agents from the get go, when using less may have the same therapeutic effect. Since we do not know and cannot definitively say that Med XYZ with its action on 5HT will lower this person's depression, while Med ABC will address their anxiety problems....I find the use of polypharmacy before single agents are used to be problematic. So I'd have a problem with polypharmacy from the get-go, but once other agents are used with a partial response and wanting to try something different, I'm okay with it.

-t

 

[Ollie123]

Grrr. Had a lengthy reply typed out that the board just ate because of the damn "log you out if you don't finish your reply fast enough" policy.

Abbreviated version since I don't feel like typing it out again:
Me = in the middle. Side effects = bad. Schizophrenia = bad. Concern for side effects = good. Scaring people who might be helped by meds/ect = bad. Crazy feminist group that thinks ECT is society's means of oppressing women = stupid.

Overall, just depends on the patient. Overmedicating is bad, but undermedicating is not any better. Thus I'm hesitant to frame things in a pro or anti-medication way (which most people here seem to be being careful about, but is still something to keep in mind). Instead, I think it just needs to be framed in a "Treat the person, not just the disorder" way. Long as we are doing that, I think a good practitioner will make the right decision, its when people become so focused on the disorder as a separate entity that these problems arise.

 

[biogirl215]

Side effects = bad. Schizophrenia = bad

And that seems to be the problem in a nutshell....

 

[biogirl215]

I'm bumping this thread up in light of this study I came across today--it seemed relevent to the discussion:
http://sswr.confex.com/sswr/2007/techprogram/P5210.HTM

 

[psychwanabe]

Bertram Karon has published a lot about working with schizophrenics using psychotherapy. I believe he has done some research on these cases as well. A quick search on google scholar brought up a couple of books and articles written by him. These might be of interest if you're curious about other methods of treatment.

I believe he is on the fringe when it comes to treating schizophrenia, as meds are generally the treatment of preference. There are some pretty strong opinions of his work out there if I am not mistaken. Regardless, it's sure to be interesting reading if you have the time.

Here's a citation for one of his articles:
Karon, B. P. (2003). The tragedy of schizophrenia without psychotherapy. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry, 31(1), 89-119.

 

[doctoroxygen]

I know of one paper that found evidence for the effectiveness of ACT in the treatment of schizophrenia (helped to deal with positive symptoms, IIRC).

 

[cara susanna]

I've read a lot on ACT being effective for schizophrenia, but I'm not sure how it would be without medication.

 

[doctoroxygen]

Something about accepting the positive symptoms as present but "not real", even in the absence of medication, I think.

 

[Cosmo75]

Something about accepting the positive symptoms as present but "not real", even in the absence of medication, I think.

Sounds like what John Nash does.

The research suggests that the most effective treatment is a combination of meds, "skills training," and reducing expressed emotion in the home. I agree with much of what's been said. I'd love to see a non-pharm way to manage schizophrenia, but I doubt it's possible in most cases. So as a compromise I'd love to see a reduction in the amount of meds used. I feel like they're just piled on to alleviate all symptoms, that maybe some of the therapies (like ACT for example) could alleviate.

 

[glasscandie]

There's some emerging evidence that nutritional supplementation can have a positive effect on schizophrenic symptoms, particularly negative symptoms. Definitely at the moment not enough evidence to nix anti psychotics, if ever, but maybe at least can decrease the amount of medication needed. That's actually part of a research project I'm involved in right now. It's fascinating.

 

[cara susanna]

I learned in my counseling class that schizophrenia has to be medicated before you can even begin therapy (if the person is psychotic, that is). I'm not sure how I feel about telling people to understand that the voices etc aren't real, because there's something in the brains of schizophrenics that make them think that they are. It's great that some people, like John Nash, can do that, but I'm not sure if all schizophrenics could.

 

[Ollie123]

I learned in my counseling class that schizophrenia has to be medicated before you can even begin therapy (if the person is psychotic, that is).

I would guess this depends on the severity of symptoms since like all disorders, schizophrenia exists on a pretty wide spectrum of severity. In the most severe forms of many disorders, I'd say medication or ECT is necessary prior to therapy. I imagine there are some schizophrenic individuals who could benefit from therapy even off medication, but frankly, if someone is completely incomprehensible, paranoid to the point of being unwilling to communicate, or catatonic, you can do as much therapy as you want but you probably won't get anywhere😉

Where they fall on the spectrum probably determines whether or not medication would be an absolute necessity for therapy - that being said, I'd guess that in nearly all cases, medicating first is probably the better option just because it can make therapy much more productive. Schizophrenia is one of the few disorders I'll say that for😉

 

[psychwanabe]

I agree. I have done some case management work with patients with schizophrenia and I know that I could not communicate with them in any coherent way when they were off their meds. Granted, I'm (very) new at this, so perhaps a more experienced clinician would have better luck, but from my limited exposure to this population I don't see how any therapy is possible without at least some meds to start. Even once they are on the meds it takes quite a long time before their thoughts become more organized and the hallucinations abate somewhat.

 

[FrdLcnKln]

Based on what some other clinicians have told me, the variant of schizophrenia as well as the ratio of positive to negative symptoms makes a big difference. Someone with paranoid type schizophrenia and few negative symptoms is a lot easier to treat than someone disorganized or catatonic.

Also, Karon cites a 1988 study by Harding who showed that all patients who made full recovery were in among the 50% of patients who had stopped taking their medication. Of course, there are many ways to read this finding (as Karon acknowledges), but I think it should make us think harder about the role medication plays in the trajectory of this disorder.

 

[toby jones]

Some psychiatrists have tried treating people with schizophrenia by providing them with some respite and some sympathetic people to talk to.

The studies don't tend to be done because it is 'common knowledge' that medication is necessary and that it would be unethical (even) to withold medications from people with a diagnosis of schizophrenia. This isn't something that has been seriously questioned. And it also isn't something that has been seriously studied.

The WHO did three studies and found that the rates of recovery from schizophrenia were significantly higher in developing nations than in developed nations (the samples were matched for severity). This has led to a bit of speculation that having less access to psychiatrists and medications and having more access to family and social supports might be the best treatment of all.

Even though those studies are clearly significant they aren't discussed very much. Common knowledge (promoted by the pharmaceutical industry that makes more money off psychiatric medications than medications for non-mental disorders) is that medication is a must.

There is a lot of worrying stuff about psychiatric medications... In particular, that side effects tend to take about 10-15 years before they become widely dessimated enough to impact on prescribing practices. Tends to take until AFTER the patient runs out and the pharma companies aren't so interested in defending that med anymore - they are on to the wonderdrug of now that is still under patient.

Newer medications aren't more effective. They are marketed as having less side effects (which take time to develop).

I think that it is a great shame that people aren't doing more work with non-medication treatment for mental disorders. Respite and caring and sympathetic people to talk to, in particular. Anti-psychotics were hailed as a 'chemical lobotomy' upon their discovery. It was meant to be a significant virtue of them that they provided all the benefits of a lobotomy with the added perk of being reversible. Subsequent research has shown that they aren't so reversible, however, with the development of tardive dyskinesias and dementias. The latter might be more likely with medications that target the frontal lobes instead of the basal ganglia.

The Nazi scientists dissected many a schizophrenic brain and had microscopes and as such they would have noticed gross neurological abnormalities. The joke was 'it is easy to spot the brain of the schizophrenics - they are the ones that look normal'. Now (AFTER the developments of anti-psychotics) we are finding gross neurological abnormalities in a number of subjects (e.g., enlarged ventricles). Why won't somebody do a long term medication vs control group in order to assess whether the degeneration is a part of the illness or a part of the medication for the illness? How many years do we need to wait? Till the drug is out of patient by any chance?

 

[psychwanabe]

Some psychiatrists have tried treating people with schizophrenia by providing them with some respite and some sympathetic people to talk to.

The studies don't tend to be done because it is 'common knowledge' that medication is necessary and that it would be unethical (even) to withold medications from people with a diagnosis of schizophrenia. This isn't something that has been seriously questioned. And it also isn't something that has been seriously studied.

The WHO did three studies and found that the rates of recovery from schizophrenia were significantly higher in developing nations than in developed nations (the samples were matched for severity). This has led to a bit of speculation that having less access to psychiatrists and medications and having more access to family and social supports might be the best treatment of all.

I wonder what (if any) role cultural factors have in these findings. When you think about mental illness as a social construct, it may be that if family and friends do not treat a person with schizophrenia as though they are "crazy," and if they provide the support that is needed, recovery without meds is possible.

Even though those studies are clearly significant they aren't discussed very much. Common knowledge (promoted by the pharmaceutical industry that makes more money off psychiatric medications than medications for non-mental disorders) is that medication is a must.

...Why won't somebody do a long term medication vs control group in order to assess whether the degeneration is a part of the illness or a part of the medication for the illness? How many years do we need to wait? Till the drug is out of patient by any chance?

One word: money. The pharmaceutical companies make kabillions of dollars off of those meds, the HMOs don't want to pay for more than a quick visit to the psychiatrist for a new Rx. What we are discussing here would likely be years of psychotherapy, and no insurance company is going to pay for that. Additionally, the current zeitgeist is that mental illness is bio-based, therefore the money should be put into biological solutions...MEDS.

 

[toby jones]

> What we are discussing here would likely be years of psychotherapy...

Not at all. We were discussing that ordinary everyday members of the community (such as families) or sympathetic others (whether trained or not) could provide the social supports. I didn't see anything about how training as a psychotherapist meant that one was more likely to be able to listen empathetically.

And now this approach has gone and isolated itself from the clinical psychologists and the social workers etc etc etc. It basically isolates itself by way of seeing not only the MEDICALIZATION but also the PROFESSIONALIZATION as being of dubious utility.

 

[psychwanabe]

> What we are discussing here would likely be years of psychotherapy...

Not at all. We were discussing that ordinary everyday members of the community (such as families) or sympathetic others (whether trained or not) could provide the social supports. I didn't see anything about how training as a psychotherapist meant that one was more likely to be able to listen empathetically.

And now this approach has gone and isolated itself from the clinical psychologists and the social workers etc etc etc. It basically isolates itself by way of seeing not only the MEDICALIZATION but also the PROFESSIONALIZATION as being of dubious utility.

Well, I should have said "what I am discussing..." because I was referring to treatment by a professional as opposed to the social support of which you speak. This was in reference to my earlier post of the work done by Bert Karon regarding the treatment of schizophrenia via psychotherapy. I should have been more specific. I would have to disagree however, and state that training as a psychotherapist does make one more likely to be able to listen emphathetically...that's the whole point of the training.

 

[toby jones]

Ah. Yeah, of course people are throwing up different ideas, I think I see what you mean now.

One thing I'm kinda interested in... Is how in the beginning (so to speak) psychoanalysis wasn't thought to be suitable for people who had a tendency to become psychotic. Since then less confrontational techniques have been developed, however. Thinking about some of the humanist developments, and thinking about the empathetic stance developed by Kohut in particular. It might well be that that style of therapy could be suitable for people who have a tendency to become psychotic.

> training as a psychotherapist does make one more likely to be able to listen emphathetically...that's the whole point of the training.

Well... That is one theory of the point of the training.

Here is a divergent theory of the point of the training:

There are certain techniques like flooding and systematic desensitisation and cognitive restructuring that have been found to work (to a certain extent) if the client engages in them. The therapists job is the educational one of getting the client to use these techniques.

Clinical psychologists are experts in the sense that they study human behaviour and they read up on the findings in order to employ the most effective techniques for behavioural change.

It is often said 'if you want a sympathetic ear then go find a councellor'. The thought being... ANYBODY can provide a sympathetic ear (though finding one can be harder than is commonly supposed) whereas it takes EXPERT KNOWLEDGE to get people modifying their behaviour...

 

[Ollie123]

The WHO did three studies and found that the rates of recovery from schizophrenia were significantly higher in developing nations than in developed nations (the samples were matched for severity). This has led to a bit of speculation that having less access to psychiatrists and medications and having more access to family and social supports might be the best treatment of all.

I may have to track down these studies. I don't doubt the accuracy of the finding, but that seems like quite a heroic superman-like leap of faith to conclude that medications are responsible. Life in a developing country is so vastly different in many ways beyond health care, I'm really not sure how one could make a very convincing argument that the actual medication is at fault for that difference. Could be activitiy, could be diet, could be....exposure to car exhaust. Who knows?

Its an interesting finding, but it doesn't sound like those studies are even approaching on reasonable evidence that social support is a better approach than medication.

 

[KellienComplex]

A Fight To Be by Ronald Bassman

 

[psychwanabe]

> training as a psychotherapist does make one more likely to be able to listen emphathetically...that's the whole point of the training.

Well... That is one theory of the point of the training.

Here is a divergent theory of the point of the training:

There are certain techniques like flooding and systematic desensitisation and cognitive restructuring that have been found to work (to a certain extent) if the client engages in them. The therapists job is the educational one of getting the client to use these techniques.

Clinical psychologists are experts in the sense that they study human behaviour and they read up on the findings in order to employ the most effective techniques for behavioural change.

It is often said 'if you want a sympathetic ear then go find a councellor'. The thought being... ANYBODY can provide a sympathetic ear (though finding one can be harder than is commonly supposed) whereas it takes EXPERT KNOWLEDGE to get people modifying their behaviour...

Well you are talking about CBTs, which a traditional psychotherapist may not use in practice. What I am talking about is the orientation of a psychotherapist, who would spend sessions attempting to enter the patient's phenomenological world as a therapeutic technique. This sort of session (to my understanding, based on what I have learned so far about psychotherapy) is completely geared around talk. Some of the theories that I have heard is that schizophrenia is a fear-based disorder. If a therapist can enter the client's world, and understand the fear, they can assist the client to come out of that disorder. This is a rudimentary description of what I have learned so far about this method of working with patients with schizophrenia, but again I don't think it would involve any CBT.

P.S. Just an afterthought: I was referring to psychdynamic psychotherapy...my post wasn't clear on that.

 

[eforest]

You're right- doctors do downplay side effects thinking this will make patients more compliant, or they just have no idea how detrimental the side effects can be. I see both sides- I'm in medical school and although I'm not schizophrenic, I'm bipolar and take some of these sorts of medications.

Acknowledgement of the side effects of antipsychotic meds is really important because they need to be addressed. For instance- lots of these meds dry out your mouth. This then makes you susceptible to cavities. I had a doctor dismiss me when I mentioned seroquel leading to cavities. Sure- I understand, I need to take my meds. But, doctors need to take into account side effects so that when a med causes dry mouth- they can stress the importance of dental check ups to the patient. Better than pretending its not a big deal or that it doesn't exist.

Weight gain is a big one! I had to make sure I watched what I ate when I first switched to seroquel. This way, I avoided an explosive weight gain right after going on the drug. I acclimated and didn't have to be so compulsive about my diet. Telling a patient that the drug might cause weight gain, and to make SURE he/she watches his/her diet during the beginning of the regimen.

Cognitive dulling is another reality. Sure, it gets better (I'm at a top ten school), but I need to write everything down now. So, acknowledging this and helping the patient to find new strategies is good.

I agree with a lot of the sentiments in this post. There is a cost benefit to medicating patients. And doctors need to be aware of the costs.

That's an interesting question because in terms of brain functioning, antipsychotic drug use among schizophrenics is correlated with fewer hospitalizations, self-report decrease of symptoms, physician-reported decrease of visible symptoms (disorganization, flat affect), better ventricular brain ratio (less cerebral atrophy)..etc.

However...

Antipsychotics are terrible for your health. Aside from the rare but irrevistible tardive dyskinesia, and the other extrapyramidal side effects and agranulocytosis with clozapine most antipsychotics cause significant weight gain, which is not good in a country that is mostly obese with a population that is not known for a healthy lifestyle. Elevated triglycerides, insulin insensitivity, general lethargy which contributes to further inactivity, and many other side-effects that can decrease quality of life. On the other hand, you have these terrifying symptoms that need to be treated, so it's really a no-win situation.

I've found that most psychiatrists vehemently dismiss any claims that the side-effects of the drug are worse that the disease they're treating. One even got really snappish when I tried to broach the subject, saying verbatim, "The side effects are just something that has to be dealt with. People with schizophrenia need to be on antipsychotics. Consistently and permanently. Period."

I'm not saying to ditch this class of drugs, because obviously they reduce positive symptoms unlike any other treatment, but it seems that some psychiatrists are uncomfortable talking about the truly destructive effects they can have on long-term health. Because they are the only treatment, it is uncomfortable to think that they are really not an acceptable or safe treatment at all, and that they can reduce quality of life nearly as much as they restore it. There is a reason for the astronomical non-compliance rates among people with schizophrenia, and it's not just because the patients are paranoid and start to think the drugs are poisoning them, etc. It's because in a sense, they ARE. The side-effects are torturous for many people and there is no way around it. Ask someone who has schizophrenia why they've stopped their medication so many times. Is it because they don't trust their prescriber, or don't want the symptoms to stop? No, it's because the medication makes them sleep 16 hours a day, or feel constantly restless, or gain 50 lbs, etc. I think every psychiatrist who prescribes these should have to take a low dose for a few weeks, just to see what they are prescribing (and the side-effects would be similar in sz and non sz subjects, I think, because sz is not a true deficiency model). This is especially important in a population like SZ where the doctors often feel the need to take a strong-arm approach because the patient is seen to, or in some cases does, lack basic competency and comprehension, and the choice to be medicated is often more a case of the physician telling the patient in no uncertain terms to take the medication. I'm not saying the physicians should stop prescribing it, but I think it might be helpful for everyone for them to know what they're dealing and not be so cavalier about it.

That being said, no...there is no other form of treatment that has reliably been shown to improve the symptoms of schizophrenia. Psychotherapy is sometimes used as an adjunct, but the results of clinical studies on this have been modest at best (partly due to the fact that the psychotherapies tests are mostly short-duration, highly scripted therapies, I'm sure). Some doctors still use ECT for schizophrenia which in my opinion is about the stupidest thing ever...but now is not the time nor place for my ECT rant. Transcranial magnetic stimulation seems to have some potential, but so far it only reduces auditory hallucinations, and only temporarily.

Regarding your question about John Nash, there is some evidence that symptoms tend to spontaneously decrease later in life...although the cause of this is not known.