Developing Policies and Practices for Medication Optimization

Robert Nikkel, MSW
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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.

16 COMMENTS

  1. Bob.
    Thanks for all the thought,experience and time that you obviously put into your post.

    I particularly like the focus on gradual medicine reduction, especially for people that have been on them for years. Although everyone is an individual when it comes to this process, my experience in working with patients to reduce and discontinue medicines has shown me that too much of a hurry can backfire.

    Medicines change the neurochemical structure and function of the brain. Basically, the brain adapts to the chemicals present. Removing any medicine abruptly leaves the brain out of balance. It needs time to re-adapt.

    Small, gradual steps within the context of relationships with supportive trusted people is the safest and surest way to achieve goals of reducing and discontinuing psychiatric medicines.

    I’m glad to see there is so much energy and experience here through Mr. Whitaker’s website. I’m sure we can find our way forward together.

  2. Patrick McGorry in the same sentence as “cautious psychiatric medication practice that minimizes the use of antipsychotics both short-term and especially longer-term” right? McGorry as I’m sure you know has until recently advocated the prophylactic use of antipsychotics. His own evaluation of his early psychosis programmes (EPP)in comparison to treatment as usual showed five times the rate of suicide in the EPP group over a 5 year horizon. Perhaps including the voices and perspectives of those who have been harmed, and the families of those who have died, as a result of psychiatry’s use of psychoactive drugs would enhance the possibility that your policies and protocols would have real world application and impact.

      • Maria and Michael, thank you for raising the concern about prophylactic treatment with antipsychotics–that is definitely not what I am recommending we consider. I included Dr. McGorry only because his work has been cited as an influence on the Oregon EAST/EASA initiatives. These projects do not treat prophylactically; as I mentioned, we must be careful to rule out alcohol/drug influences in psychotic symptoms too and make sure that we are dealing with a bona fide first psychotic episode–not pre-psychotic. I don’t think we’re good at predicting that and the knowledge that I have of starting antipsychotics before we’re sure of what we’re doing with is not encouraging at all. So thank you for raising the question.

  3. Bob

    Often meds can do more harm than good.

    Here is what I just posted onto one of Dr Alice Keys’ postings, where she discussed meds and the position of psychiatry.

    Thank you to Dr Keys – Alice – for your honesty about the current position in psychiatry and the power of the drug companies.

    ‘I honestly have no idea what to do next.’

    I have skimmed through all the helpful posts – a mixture.
    I have read and met at conference Bob Whittaker.
    Brilliant expose of the situation and the power of the drug companies and the problems with meds as the only form of treatment.
    I take meds myself – bipolar diagnosis – but human being first and foremost.
    I believe in recovery without meds.
    I have learned various self help techniques and I have also availed myself of a useful 6 week 1 hour long session series with a psychologist on CBT.
    I have read a lot and I blog a lot and have ‘spoken’ on line and in person with various people in the mental health field.
    I speak to my GP who still believes in meds but who is listening to what I say, and I loaned her my book by psychiatrist Dr bob Johnson. Have you heard of him Alice?
    I have met him and been to conferences where he speaks and helps.
    He has two books I know – one about ‘Emotional Health’ and the other about drugs and how they are not the answer and in fact ‘do more harm than good’ I think is his quote.
    Dr Bob Johnson is based in London and he advocates a simple ‘Emotional Health’ model which as I understand it works well.

    I am no longer the child who was stuck/frozen in time emotionally when I was (whatever happened to me then), but now I am an independent adult etc and so the parentoid figure (usually the one responsible, for not protecting, if not the abuser), cannot hurt me anymore. I am therefore free and able to lead my own life.
    As simply as I understand this model, it does work and has been used effectively. To learn more google Dr Bob Johnson psychiatrist who is based in London and has hiw own website.

    My own GP listens to what I have to say about meds, and she listens to me, and she prescribes me reduced meds and supports me in gradually reducing. I told her the story about a stupid psychiatrist who once took me abruptly – just like that – off Effexor (venlafaxine – and the anxiety/suicidal feelings/worthlessness was awful to deal with. Silly psychiatrist, as it is well documented about how you need to taper off the Effexor gradually.

    I think Dr Bob Johnson’s website is Trust, Consent and is a foundation.

    Alice – please reply. Anne Brocklesby

    Could I ask you Bob to reply.

    • Anne, your reply is a great example of the kind of balanced approach to all this that I hope we learn so much more about through these discussions. I too have “lived experience” with reducing meds and probably going off too quickly. The caution about reducing gradually is very real and important. Thank you for sharing some of the approaches that have been helpful to you.

  4. For many years, my practice has been to try to reduce medication dosage to establish the minimally effective dose and to stop medications that do not appear to be effective. Many people come to me on medications that I am not convinced are needed. For the past year, I have tried to be more systematic about this and I have added into my discussions with my patients much of what I have learned from my readings of the primary literature that led to Whitaker’s conclusions. I have also changed in that I initiate this conversation more than I might have in the past, i.e., with some individuals are doing prety well and not asking to reduce or stop medications. We are also in the process of starting a crisis program that will be able to incorportate some of the principles of OD (although we will serve a much larger group of people so our resources will not be able to match what they have established in Western Finland). I hope to be able to report on this process in the next year.

  5. Bob, use of psych drugs is tied to diagnosis. We need to stop the misdiagnosis and recognize the trauma that is the cause of most “psychiatric behaviors.” Trauma should not be treated with drugs. Trauma asks, not what’s wrong with you but rather, what happened to you. Connecting with the person, hearing and understanding their story is what will lead to healing. Overcoming the use of the drugs is only part of the mess.

    • Pat,

      Thank you so much for this all too true, astute, critical observation so necessary for reform.

      One thing I know from much research is that trauma has been routinely covered up to blame the victims by giving them insulting, bogus, life destroying stigmas and toxic drugs to dismiss them and collude with their abusers and maintain the social injustice status quo perpetrated by the power elite. Psychiatry has a sordid history of sexism, racism, homophobia and other prejudices to target minority groups.

      Dr. Judith Herman, Psychiatrist, in her classic work, TRAUMA AND RECOVERY, exposes how the recently invented borderline personality disorder was used as an insult stigma to dismiss and discredit abuse/trauma victims. More recently, Dr. Carole Warshaw, Psychiatrist and domestic violence expert, and many others expose that such abuse/trauma victims, mostly women and children, are now routinely misdagnosed as bipolar, paranoid, psychotic, delusional and other stigmas to also discredit them to collude with abusive husbands and a society that condones such abuse.

      Dr. Warshaw points out that this very harmful practice is caused by the fact that psychiatrists are taught to focus only on outer symptoms with no attention whatever given to environmental causes when “diagnosing” people with the most harm done to women, children, blacks and other stimatized minorities.

      I noted with great horror and disgust in another article on this web site and others on the web that mainstream psychistry is now using bogus genetic and other false claims to justify putting those labelled borderline and PTSD under the vile bipolar fraud stigma, which to me is just another way to expand the market for the lucrative cocktail of toxic drugs pushed for this invented “disease” as exposed by many experts including Dr. David Healy in his book, MANIA. Dr. Fred Baughman, Neurologist, exposes that bipolar and all other psych stigmas are 100% FRAUD. This will exacerbate the blaming the victim demolition enterprise by mainstream psychiatry. I have also noted that by the time aritcles like this come out, it is merely describing what has been the latest practice since it is well known that trauma victims are routinely updiagnosed with bipolar. This is to exploit health insurance coverage/Medicaid/Medicare to justify lifelong “treatment” with lethal drugs ensuring permanent disability per Bob Whitaker as the real cost of using others’ trauma and suffering as profit centers which the tax payers must bear for BIG PHARMA profits as was equally true with the Wall Street meltdown orchestrated to make the 1% richer at the horrific expense of the 99%. A book called THE SHOCK DOCTRINE eplains this global power elite tactic well with the title being quite apt for mainstream psychiatry too.

      Dr. Herman claims that most mental health experts know that those they encounter have been abused in some way. Yet, she also exposes the all too human tendency to blame the victim due to the very invalid “just world theory” and the fact that is it is far easier to remain a bystander since taking a stand on behalf of the victims would take effort and may include some risk.

      This is in keeping with that famous quotation, “All it takes for evil to prevail is for “good men” to say and do nothing.”

      In spite of all this, I find this post very positive and hopeful and am very grateful for the people like you and the author of this post trying to change the status quo.

  6. I’ve been spending the last 10+ years working at the Urgent Walk In Clinic in Portland Oregon interviewing folks who come in or are brought in. Most of them are looking for pills although some are hoping I won’t reccomend pills. What a great majority share is a history of trauma and loss. For so many what they need more than pills is a person to talk with about their situation and what they might do about it. An aspect of my job that I find keeps me coming back is it is just fine with my employers if I don’t push pills. And also fine for me to sort out the folks already taking pills they believe are part of their strategy to stay out of trouble and send them along to the staff who write prescriptions. What many of these folks want but cant get is counseling–in particular counseling with others who have graceless the same road. Our “system” of public mental health services has shifted over the 30 some years I’ve been involved from one that thought what people need is wise conversation to one that believes what they need is an adjustment in thier personal biochemical state. From ” let’s talk” to “shut up and take your pills”

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