Southern Oregon physicians—from family practice specialists to psychiatrists—and nurse practitioners, social workers and other mental health professionals have been meeting for several months to review the issues raised in Robert Whitaker’s Anatomy of an Epidemic and held a forum with well over 100 in attendance to share lessons and observations from these earlier discussions.
One thing that seems clear is that something more systematic could emerge from these energizing experiences. I am proposing the following draft policies and practice protocols for all programs and practitioners to optimize not only the prescribing of psychiatric medications but the many other evidence-based practices that contribute to positive longer-term outcomes. For too long, we have accepted that psychiatric medications are effective in both acute and longer-term outcomes. The research literature, when studied objectively, seems to raise major questions about the role of medications in promoting recovery and resilience. The policies and practice protocols suggested here can be considered a much more comprehensive and sophisticated approach to “informed consent” compared to the narrower and more common approach of a simple listing of short-term side effects.
There are three relatively distinct (though sometimes overlapping) groups of people with mental health challenges who need somewhat different approaches from the programs and clinicians who serve them:
1. Young people (and others) with first episodes of psychosis, depression, bipolar, and anxiety disorders should receive specialized attention from programs designed specifically for these purposes such as the Early Assessment and Supports Alliance in Oregon, Open Dialog originating in Western Lapland Finland, the Australian approach created by Patrick McGorry, and other tailored approaches. These programs have differences but common factors include a) the careful rule-out of alcohol/drugs as sole causative factors, b) careful attention to family supports and therapy as indicated, c) an unwavering message of hope for recovery, and d) a cautious psychiatric medication practice that minimizes the use of antipsychotics both short-term and especially longer-term.
2. As new clients come into existing programs or practices with prior diagnoses of major mental health challenges, a different opportunity is created in which much more attention should be focused on the broader concept of informed consent. Client or patients new to the practitioner should be counseled on the findings of longer-term outcome research with medications and the likelihood of better outcomes for people who are able to rely less on psychiatric medications and even discontinue use over time. Again, similar to first episode clients, these individuals should be given a clear message of hope for recovery, increased or renewed attention to potential trauma or toxic factors in the person’s history or environment, caution about maintaining high dosages, multiple medications and prolonged exposure to psychiatric medications. These patients should not be encouraged to abruptly discontinue medications that may have been prescribed by previous providers but to begin a fresh and careful assessment of alternatives to medication approaches. These interventions include nutritional counseling, exercise, cognitive behavioral therapies to cope with symptoms, meditation, family and spiritual supports, peer supports, and psychiatric rehabilitation interventions such as Supported Employment, Supported Housing, Supported Education and other recovery-oriented approaches.
3. For those many patients who have been maintained long-term on psychiatric medications for, in some cases, decades, an even more carefully designed program of decreased reliance on these medications is required. The informed consent discussion must take place over many sessions and include far more detail about the potential risks and benefits of gradually simplifying and tapering medication regimens. This kind of discussion must take into account the length of time the person has been exposed to psychiatric medications and must assume that changes may need to take months and years, rather than weeks, of decreasing before total discontinuation. Plans must be established to manage the return of symptoms and this is likely to require the teaching and mastery of alternative approaches to maintaining sleep patterns, avoiding the use of alcohol and street drugs, increasing exercise and understanding the potential role of nutritional deficiencies, food allergies and other environmental toxins. Other skills are almost certainly needed in cognitive behavioral therapies, spiritual supports, and coping capacities for the re-emergence of prior trauma experiences. Decisions about how and when to involve family members and peer supports will also be crucial points for discussion.
As a former state mental health and addictions commissioner, as well as someone with several decades of experience in delivering and managing local programs, I am fully aware of how many competing and compelling issues demand attention from programs. The development of policies and practice protocols is never easy and always takes time for careful input and then even more, adoption and implementation in real world settings. I do believe it is time for us to ramp up the discussion of these issues so that we can assure ourselves, and more importantly, the people we serve that we are indeed, following the guidelines based on best evidence of short-term and longer-term outcomes.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.