This is about neuroleptics. It is about psychosis or madness or whatever term one prefers. It is about people 18 years and older.
I take Robert Whitaker's and others' criticisms of psychiatry seriously. As noted in previous blogs, I am most interested in the antipsychotic drugs and I have reviewed much of the primary literature from the chapter on this topic in his book, Anatomy of an Epidemic. I believe that we need to be cautious when recommending these drugs and it makes sense to try to avoid using them. I am studying Soteria and Open Dialogue and I am involved with some initiatives to bring them to my state. I work in a clinic where we offer an array of services. I believe that we need to talk about a multitude of ways to improve health - eating well, exercising, getting adequate sleep. Cannabis, alcohol, and other drugs can be destructive to a person's well being; we encourage abstinence and we try to give a person the tools to remain abstinent. Various forms of psychotherapy are often helpful and they are recommended and encouraged. We have an evidenced-based vocational program and expanding peer recovery involvement. We help people who are homeless get off the street and into safe housing. It has always been clear to me that my role as the person who prescribes medications is and should remain a small part of a person's treatment and recovery.
However, I still prescribe neuroleptics.
In a previous blog, I discussed my approach to my patients who have been on these medications for a number of years. This blog is about someone who has not been on these medications in the past or has been started on them only recently.
Most of the people who come to my office reporting that they are hearing voices or experiencing other psychotic symptoms do not come in with a specific request or agenda about treatment. They are often scared and looking for guidance. I have changed my approach in the past year. I have known for many years that it was important to use the lowest dose of neuroleptic possible. I do not believe I ever told someone in this situation that she would need to be on medications forever. However, prior to reading Anatomy of an Epidemic, I would not have held off on recommending an antipsychotic.
These days, I try to wait.
When I first meet a person who is, for example, hearing voices, I try to explain the varying options for treatment. I describe what I call the "mainstream" approach which is that the medications are considered first line treatment. I explain that I question that approach and have learned that some people feel better over time without medications.
Some but not all choose to try the medications. This is usually because they are extremely uncomfortable or frightened and they want to feel better quickly. I try to keep the dose low. Many of them are interested in stopping their medications after they feel better and then we begin to reduce the dose with a goal to stopping them.
For those who decline medications, we offer them all of the other services I mentioned above. If over time, their psychotic experiences persist, we again discuss the pros and cons of medications.
In contrast to the active discussions about the short-term efficacy of antidepressants, there is less attention on this website and elsewhere directed towards re-evaluating the short term benefits of antipsychotics. The firmly held opinion of my psychiatric colleagues is that they are highly effective in improving symptoms of psychosis. I invite readers and fellow bloggers to address this with me. Some of you have expertise in statistical analysis that I do not have. My initial review leads me to several conclusions. First of all, the current data do support their modest efficacy in the short term at reducing psychotic symptoms (Cochrane review on haloperidol). Secondly, the improvement comes with a high cost of side effects. The drop out rate from many studies is high. Thirdly, studies do no include an active placebo. Bola et al looked at treatment studies of first episode psychosis and concluded that we do not yet have enough high quality studies data to form conclusions about efficacy.
I certainly have observed instances in which the drugs appeared to be extremely helpful but I am mindful of the drawbacks of anecdote in forming conclusions. My best guess is that, as with many other treatments, there is a variability of response that reflects the variability of what we are treating. It is important is to be open to stopping these drugs when they have not offered much benefit or when the side effects outweigh whatever benefit the person has experienced. There is often a tendency to assume the person will be worse off without the drugs and that is something that needs to be actively questioned.
In Open Dialogue, my understanding from Daniel Mackler's documentary and my discussion with people who have trained in this method, is that they try to avoid using neuroleptic medications but they will suggest them in some instances. There is a small group of people who take them for a longer period of time. It is hard for me to know how my current practice matches what they are doing in Finland, although I understand as a rule they will not start antipsychotics right away.
There are some people for whom the psychosis is not only scary but also dangerous. I have had patients who have done extremely risky things while psychotic. In these situations, someone else has usually started the drug because the person has ended up in the hospital or even jail but it is hard for me to criticize that decision. I have read with great interest the descriptions of treatment in places where neuroleptics are not used and I have mixed feelings about the level of risk to which some people were exposed. What if the person had actually jumped out of the window? What if the person had left inadequately dressed and ran into a frozen lake in the winter? What if the person had driven off at a dangerously high speed?
I believe there are some fundamental disagreements that can not be resolved. It is a risk benefit equation. I rate the risks of certain forms of psychosis as higher than the risk of taking drugs in the short run. I have no doubt that there are many people who come to this site who evaluate this differently. For me, these are complex and difficult questions about personal autonomy. I do not pretend to have the one true answer and in each situation I try to make the best decision I can.
Anatomy of a Psychiatrist: Dr. Steingard chronicles how she is integrating information from Anatomy of an Epidemic into her community mental health practice. She also discusses changes in Vermont's mental health system and the influence of pharmaceutical advertising on clinical practice.