Toward a Selective Use Model of Psychiatric Medication

In the United States the standard model of psychotropic treatment can be summarized as “first, frequent and forever” (FFF).  In other words, the general institutional consensus within the public mental health system is that people labeled with a mental illness diagnosis will (1) require medication as the first and primary treatment, and (2) will require consistent and frequent medication, and often a cocktail of mood stabilizers, benzodiazapines, anti-depressants and/or anti-psychotics and, (3) will need to remain on these medications forever.  Certainly this is the standard of care of persons labeled as having “severe persistent mental illness” diagnoses such as Schizophrenia or Schizoaffective Disorder.  But it is the general standard for most mental health diagnoses including Bipolar Disorders, Depressive Disorders, even Post-traumatic Stress Disorders.

For a discussion of how these “disorder” labels are largely unscientific metaphor rather than literal disease, please see “Mental Illness as Metaphor.”

Questioning the FFF Model

The trouble with the FFF model is that the empirical evidence to support its efficacy is profoundly lacking, and contradicting evidence is abundant.  In the case of the most powerful psychotropics that are euphemistically called “anitpsychotics,” the theory of how the drugs actually work lacks a clear and coherent body of evidence to demonstrate it to be true.  A great deal is said about the dopamine theory of psychosis and if one assumes that the premises are true, then there is an entire theoretical system of how the brain works and what anti-psychotics due in relation to the brain that gets discussed.

But there is the pesky little problem that we actually still have not been able to demonstrate the premises true at all.  In 2014, it remains unclear that excess dopamine is responsible for psychotic symptoms.  “Excess” dopamine is found both in persons with the label schizophrenia as well as in persons without such diganosis or corresponding symptoms. Excess dopamine is associated with a wide range of possible issues and the specifics of how excess or deficits of dopamine correlate to psychosis is not explicitly clear.  We think we know some things.  There seems to be something going on.

But we are not remotely close to an evidence based causal link or a coherent and robust evidence base.  Rather, we observe that when we introduce chemicals that impact dopamine reception, we notice one effect often being a suppression of “psychotic symptoms” as well as the general suppression of many other things including overall cognition.  That is why neuroleptics were historically identified (accurately) as major tranquilizers – their effect being to sedate major activities in the brain and thus achieve the side-effect of psychotic symptom masking.  One place where there is broad-based agreement, is that neuroleptics either reduce or suppress symptoms, they do not “treat” known root causes of any mental illness in any way that is presently understood by human beings.

When it comes to the most prominent category of “antidepressants,” Selective Serotonin Reuptake Inhibitors (SSRIs) the picture is even more problematic.  The so-called “chemical imbalance theory” of depression is widely discredited from within psychiatric and pharmaceutical institutions.  Some prominent representatives of the American Psychiatric Association have even gone as far as to deny that psychiatrists ever really believed in that theory at all.  The most robust body of research we have on so-called antidepressants shows that they are almost indistinguishable from placebo in their effect size.  We also know from both research and successful class-action lawsuits brought against the manufacturers that the serious side-effects of these medications have been minimized or in some cases deliberately hidden from regulators and the public.

Finally, we have a profound lack of studies which evaluate the safety and efficacy of long term treatment with psychotropic medications.  Most drugs are approved by the FDA on the basis for 6-8 week clinical trials.  The drug manufacturers are not required to turn over all of their research, but only the research which shows favorable outcomes.  Drugs are approved before any long term effect or problems can be evaluated.

Of the long term studies we do have, the findings are deeply troubling for the FFF model.  A 20-year outcome study done by Harrow and colleagues showed the following:

At 2 years, 74% of individuals of group 1 [those who stayed on drugs over the whole period] had psychotic symptoms, as did 60% of those in group 3 [the group that quit drugs by 2 years and stayed off].  Although these differences are not statistically significant, the lines diverge at 4.5 years and continue to diverge over the next 15 years. At 4.5 years, 86% of group 1 have psychotic symptoms compared with 21% of group 3. By year 20, the difference is 68% compared with 8%.

These are the exact opposite results we would expect if psychiatric drugs had long term efficacy for treatment of mental disorders (psychosis, in the case of this study.) This pairs with another study, a 2-year randomized clinical trial (RCT) with follow-up at 7 years.  The results of this study are as follows:

The DR [dose reduction/discontinuation] patients experienced twice the recovery rate of the MT [maintenance treatment] patients (40.4% vs. 17.6%). . . . Dose reduction/discontinuation of antipsychotics during the early stages of FEP [first episode psychosis] shows superior long-term recovery rates compared with the rates achieved with MT.

As previously stated, we lack numerous studies on the efficacy of long term psychiatric medication. However, of the studies that exist, there is not a single one that shows the efficacy of psychotropic medication over the long term.  In contrast we have an overwhelming amount of empirical data conclusively demonstrating the severely debilitating (and sometimes fatal) neurological and  metabolic effects of long term psychotropic drug use, as well as many other physical side effects, sexual dysfunction, pain and discomfort, lose of clear cognition, etc.

In other words, (1) there is no evidence that long term use of psychotripics helps psychaitric symptoms (2) there is some evidence that long term use of psychotropics does not help psychiatric symptoms and (3) we know for certain that long term use of psychiatric medications is extremely harmful to the body.

One has to question why, in light of this evidence, the FFF model is still the standard of care in the United States.  And one cannot seriously question this without suspecting that institutional politics and institutional power motives play a large and tragic role.

Alternatives to the FFF Model

I wish to avoid a false dichotomy between an FFF model of psychiatric medication and an argument that no one should ever receive psychotropic medications under any circumstances.

Psychiatric medications can, in some instances, be a helpful tool to provide relief from acute distress. When they are prescribed selectively for a limited duration, they may be one part of a larger healing process. When the minimal benefits are not overstated and the substantial risks are not minimized, medications may be understood by the individual as useful in temporarily alleviating acute distress. When prescribing choices are made in collaboration with the individual and when the individual is free to choose the approach that feels right for them (including the legitimate choice to take no medications,) then the relationship between individual and prescriber can be fruitful.

This philosophy and disposition toward psychiatric prescribing can be termed a “Selective Use” (SU) model.  A core value of this model could be phrased as, “the least amount of medication beneficial, in the lowest does necessary, for the briefest amount of time possible.”  An SU model would require a reorientation of attitudes and assumptions among psychiatric prescribers.  Psychiatric medication would come to be viewed as a short term last resort in periods of acute psychiatric crisis with the goal of immediate relief from the most severe symptoms.  Starting a psychiatric medication should be specified for a quantifiable brief period of time, not an indefinite period of time and not with the assumption of permanence.

Longer-term support would need to be expanded and reoriented to include peer based recovery resources (for which there is continually growing empirical evidence.)  This should be paired with community-based support in meeting basic needs including stable housing, health care, nutrition and opportunities for meaningful work (volunteer or employment.)  Finally, the option to partner with a counselor/therapist to explore emotional issues and their impact should not be overlooked, but also not elevated to some mythical level of importance.  I am not ashamed to be a counselor/therapist, but I also understand my role to be one of service, not authority.

Within this paradigm, psychiatric medication may continue to serve a complimentary role, in select situations, for limited duration, and with the ultimate goal of discontinuing use whenever possible, due to the extremely serious health consequences of the drugs and their limited demonstrated efficacy in the long term.  The decision about the role of psychiatric medication in services should be made in collaboration with the individual who will be putting these chemicals into their body and living with any positive and negative effects.

Moving toward an SU model will not be an easy task.  Our public mental health system is not designed to accommodate a lengthy and more holistic recovery process, especially one that may include episodes of chronic distress along the way.  There are few programs that emphasize safe psychiatric respite with strong relational supports that are not coercive and focused on chemical treatment for the long term.  There remain certain situations in which a person is a clear and immediate danger to themselves or other people in the community where coercive intervention is presently unavoidable. But that is a tragic offense against humanity, and I believe vigorous pursuit of system change to be our moral obligation.

If we are to take seriously the lack of empirical evidence supporting  chemical imbalance theories of “mental illness,” the lack of empirical evidence supporting the safety and efficacy of long term psychotropic medication treatment, the existence of strong empirical data showing the severely debilitating and dangerous effects of psychotropic medications on the body, and the existence of empirical evidence suggesting the long term use of psychotropics may be contraindicated – then we simply must begin the task of changing our treatment paradigm.

For further consideration of movement toward an SU model, please see “Full Disclosure: Toward a Participatory and Risk-Limiting Approach to Neuroleptic Drugs” published in 2007 in the Journal of Ethical Human Psychology and Psychiatry.