How Effective are Neuroleptic Drugs?

Sandra Steingard, MD
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Jonah Lehrer wrote an intriguing article in The New Yorker magazine on “the decline effect.”   The article discussed a phenomenon of scientific inquiry in which early promising results tend not to hold up over time.  Although this occurs in an array of scientific disciplines, the article began with a discussion of neuroleptic drugs. The author described a 2007 meeting during which clinical researchers and representatives of the pharmaceutical companies discussed the fact that more recent studies were reporting less robust efficacy of these drugs than had been found in earlier studies.

“A recent study showed an effect that was less than half of that documented in the first trials, in the early nineteen-nineties. Many researchers began to argue that the expensive pharmaceuticals weren’t any better than first-generation antipsychotics, which have been in use since the fifties. ‘In fact, sometimes they now look even worse,’ John Davis, a professor of psychiatry at the University of Illinois at Chicago, told me. “

Researchers at the FDA published a report on this in The Journal of Clinical Psychiatry and a link to an article about this study was posted on this website a few weeks ago.  The researchers were trying to understand these declining results by comparing data from studies done from 1991 to 1998 with those done  between 1999 and 2008.  They also compared results from studies done in North America to those done elsewhere.

Indeed, the more recent studies show a smaller difference between active treatment  and placebo groups than the earlier ones. But, as I wrote in an earlier blog on a new antipsychotic lurasidone, what was most striking to me, is just how small the treatment effect was – even in the earlier studies.

The researchers focused on the results of the PANSS (Positive and Negative Symptom Scale). This is a 30 item questionnaire that measures symptoms such as voices and delusions (so called positive symptoms) as well as apathy (so called negative symptoms).  Each item is rated on a scale of 1-7 thus the score can be anywhere from 30 to 210 points.  At entry into the study, the average score was about 90 points.

For all of the studies, the average decline in the PANSS in the active treatment group was 15 points and in the placebo group 6.4.  The effect size is the difference between these numbers and that is about 8 points.

This is not a big difference.

The prevailing belief among psychiatrists is that these drugs are extremely effective.

This is a belief that needs to be reexamined.

37 COMMENTS

  1. Perhaps the time has come to subject the beliefs themselves to the rigors of scientific inquiry. What is the scientific evidence that supports the expectation that a neuroleptic will reduce or eliminate so-called, Positive and Negative symptoms of so-called, psychosis?

    Back to square one: There is no scientific evidence , or foundation for a belief that perturbing the function of neurotransmitter pathways in the brain will correct positive or negative symptoms of psychosis. There is no basis for the beliefs you are saying need to be reexamined!

    Then, there is the matter of denial, or avoidance of reality regarding the adverse effects of neuroleptics. Where a belief is sorely needed, there is none. The prescribers of neuroleptics do not believe in the damaging effects of these drugs, or they have concluded that the positive and negative symptoms of psychosis are worse than brain shrinkage, diabetes, cardiac events… In other words, someone other than the one who has to take the drug, and someone who can discount virtually every complaint offered by the one who has to take the drug, decides that the drug is better than the condition suffered by —someone whose impressions and beliefs are invalidated due to positive and negative symptoms of psychosis- determined by a psychiatrist…. who cannot cite scientific evidence to support the belief that the risks of taking the drug are less than the risks of the disorder diagnosed via arbitrary, subjective analysis of check off lists and evaluation scales.

    Sooner or later, we are going to have to grapple with the real problem here— No science + no medical condition = no need for psychiatric intervention (MD not applicable. MD presents greater risk than any other option)

  2. And then just think of all the “side effects”… and the fact that at least a million children in the U.S. are on them now. Neuroleptic drugs are being used for just about everything today. With the way they are being prescribed you would have to think that the doctors are either sociopaths are have somehow rationalized every single negative effect of the drugs. They are used for migraines, as sleep-aids, to break and prevent temper tantrums in children, for gastrointestinal problems, for vertigo and motion sickness, for restless leg syndrome (ironically now renamed “akathisia”), for depression, for anxiety (an irony considering the terrible, sometimes suicide inducing anxiety they can cause), to protect against brain damage (yep, believe it or not.), for drug and nicotine withdrawal, and who knows what else.

    Things just keep getting worse. Every single day.

  3. Major tranquilizers are effective in getting people to shut the (censored) up and sit down and not be any trouble.

    This is why they are violently forced into the bodies of the group of people who may be having at a given point in time, thoughts or beliefs that are labeled as ‘sick’, by ideologues who believe that thoughts and beliefs can be literally ‘sick’. Ideologues who don’t examine anybody’s brain but label said brains ‘diseased’ anyway.

    This is also why major tranquilizer drugs are forced into the bodies of troublesome demented old people in ‘care’ facilities, and also why they are given to unloved foster children.

    These drugs are only given to shut people up, people who society has decided the following for:

    1. Someone wants them to shut the (censored) up.

    2. That these someones want them to shut up is more important than their human right to own their own body.

    That is, enslavement, violation, human rights atrocities, disgusting maximally invasive rape of the neurochemistry of innocent human beings, is acceptable, when the ‘other’ is a powerless human being, and more powerful others have decided to shut them up with tranquilizer drugs.

    The more brain disabling the tranquilizer drug is, the more they shut people up. The new tranquilizer drug cited in the article above, obviously is not as brain disabling as the original chemical lobotomies.

    Maybe that’s good news that you’ve isolated an ineffective major tranquilizer drug in lurasidone.

    Maybe I can beg and plead with terror and fear on my face to my captors in the quiet room next time for them to rape my brain only with this new lurasidone drug. Sort of like a rape victim who begs her attacker to put on a condom. As they hold me down and pull my pants down maybe I can suggest lurasidone instead of thorazine, so that after they’ve had their way with me and my body, I can have some of my wits about me to instruct a lawyer and try and hopefully fight to get ownership of my body back from the gang rapists in psychiatry.

    The message from psychiatry has always been this:

    Don’t you dare think thoughts psychiatry considers to be ‘diseased thoughts’, and if you do, psychiatry will be off to get a court order to make sure psychiatry can take swift ownership of your body, load you full of tranquilizers, and then you’ll learn to shut up and be a good little government defined ‘mental patient’ drooling in your chair watching televangists on the common room tv not causing any trouble with your thoughts that were labeled ‘out of order’.

    We’re not waiting for studies or data, we are waiting for our basic human right to stay as far away from a brain rapist quack as humanly possible.

    Or in language I might have used if I wasn’t a brain rape survivor:

    ‘We seek the right to refuse consent today and forever, in a legally binding way’.

    Welcome back to the fray, Sandra. Ain’t it pleasant to interact with the wasteland of forever raped and traumatized victims of your profession?

    I maintain that the millions of brains psychiatry has entered and violated without consent represent a primal, visceral scream of the darkest side of humanity, a level of violence and violence and violation only revealed elsewhere in war, violent crime, and the holocaust.

    Actions by human beings, against other human beings.

    Not to be confused with nature’s violence, tsunamis and hurricanes, or cancer eating your bones.

    No, to be a survivor of psychiatry is to be a survivor of the violence of other misguided, overly legally empowered to rape your brain, human beings.

    • And if anyone thinks I’m engaging in hyperbole… they wouldn’t be called (neuroleptic) brain-seizing drugs if was wrong, would they?

      One day, psychiatry’s PR rebranding will bury the ‘neuroleptic’ tag just as deep as it buried the ‘major tranquilizer’ tag.

      You see, the Bush white house rebranding torture as ‘enhanced interrogation techniques’, just as psychiatry rebranded major tranquilizers/neuroleptics as ‘antipsychotics’, or electroshock as the relatively benign sounding acronym ‘ECT’.

      You’re being manipulated every time you utter the APA diktat phrase to describe any of psychiatry’s brain disabling arsenal of drugs or labels.

      You, as in anyone. Not directed at Sandra.

    • Survivor of Brain Rape. Thanks for this term. Drug Merchants colonized my brain. Just like any other rape, the intent is to kill the soul of the victim and render them amenable to exploitation. I was a zombie when I was ingesting these poisons. It was all “off-label”, it was all uniformed experimentation. It was all about making money.

      • I meant “uninformed” because the doctors randomly prescribed the behavior chemicals and learned from their mistakes on my disposable Medicaid-funded body. But “uniformed” is also apt, since the intent was to force me into uniform behavior, so that I would accept my oppression quietly. I was LUCKY to have been massively overprescribed Paxil, because the resulting toxic psychosis forced me to examine the lies. There was never anything “wrong” with me that fresh air, sunshine and human contact could not ameliorate. Instead of human care for the effects of the trauma I suffered as a rape victim, I was offered stigma and neurotoxins.

  4. The theory of positive and negative symptoms of schizophrenia has always bothered me. I am not a psychiatrist and I have never been to medical school but I have had the experience of hearing two voices arguing in my head at the age of 19. I was at the time cramming for my exams, not sleeping enough, drinking much too much coffee, fighting with my parents and misbehaving at school. At the same time I felt terribly guilty about it all and felt abandoned by everyone. The big voice in my head was yelling to me what a bad person I was and a tiny little voice was trying to defend me.Eventually I collapsed and developed all the negative symptoms. It wasn’t surprising really: I had abused my body relentlessly for at least six months and something had to give. My parents didn’t seek medical help but they gave me space to rebuild my physical strength and they started talking to me about things that mattered to me and so I recovered without any antipsychotics. I took some valerian pills to sleep for a month or so: that is all I needed. What a lucky girl I was!

  5. Thank you Dr. Steingard for your post. I appreciate your calling it like it is—That some psychiatrists have a BELIEF that neuroleptics work, is not the same thing as having evidence the neuroleptics actually work. I would add that not only do psychiatrists and others who treat patients by giving them teratogenic drugs need to examine their Beliefs about the drugs as ‘necessary medical treatment,’ but, that —the rest of us need to decide whether it is moral to legally mandate people to take neuroletic drugs, when it does not appear that it doing so is based on ethical or even medical principles, but upon a BELIEF the drugs ‘work.’ Particularly, since it is a false belief. The empirical data clearly demonstrates that the neuroleptics are minimally efficacious for a small minority of people who experience symptoms of psychosis. The data pretty clearly demonstrates these drugs cause serious debilitating iatrogenic diseases and neurological impairments.

    Belief in something absent any empirical evidence supporting one’s belief, is all well and good in Religion. It has no place in Medicine. It certainly is not an ethical medical decision to use one’s belief as an excuse or a justification for abdicating one’s primary professional responsibility and ethical duty to the patient. First, foremost and always is the dictum to, “First, do no harm…” It seems that psychiatry and mental health professionals who practice ‘psycho’ pharmacology are not aware of, and don’t ‘BELIEVE in’ the Hippocratic Oath.

    Words matter. Calling neuroleptics ‘antipsychotics,’ when they are ‘anti’ psychotic for only a small percentage of people who experience psychosis; is misleading—I dare say it is dishonest… The word neurlopleptic at least is descriptive of what the drugs mechanism of action is.

    from my blog post, “The Failure to protect foster children and children on Medicaid”:
    “Ten years before there was any “approved” pediatric use for Johnson and Johnson’s ‘Risperdal,’ it was given to my son. It was prescribed “off label,” an innocuous term for “experimental use.” I believe the term off label is used because it sounds innocuous; it disguises the fact that Human Experimentation using teratogenic drugs is what is being done. Human Experimentation with psychiatric drugs is now embedded within Standard Clinical Practices. I also believe that is why the term neuroleptic has been replaced with the word, ‘antipsychotic.’ The word Neuroleptic is French, a combination of the word neuro, meaning nerve; and the Greek word ‘leptikos’ which means, ‘disposed to take’ equivalent to ‘lēp’ meaning ‘to seize.’ The word neuroleptic actually describes what this class of drug does to the human body. Neuroleptics act on the parasympathetic nervous system; which explains the myriad of negative effects they are known to have. It is why the drugs cause a wide variety of diseases and progressive cognitive and neurological impairments; and it is why they shorten people lives… But then, all substances that cause disease also cause a loss of life…”

    http://involuntarytransformation.blogspot.com/2011/03/is-medicaid-fraud-endorsed-by-federal.html

  6. I remember I was startled by this relative lack of even short-term efficacy when, in 1998, I used a Freedom of INformation Request to get the FDA reviews of the clinical trials for olanzapine and risperidone. The drugs’ advantage over placebo was small on these scales, and that was so even though the placebo group wasn’t a true placebo group at all, but rather patients who had been on neuroleptics and then were abruptly withdrawn from them.

    Another question that needs to be asked: When do neuroleptics show even this limited efficacy in these short-term trials? At two weeks, four weeks, or six weeks? I remember one report that studied this concluded that it all depended on the length of the short-term trial. If it was two weeks, then the researchers concluded that the efficacy showed up at that time. If it was four weeks, then there wasn’t much efficacy over placebo at two weeks, but there was at the trial endpoint (at four weeks.) And so on. At least in that report, the conclusion seemed to be this: When researchers running a drug trial wrapped up the study, and were making their endpoint observation, that was when they were most likely to see that the drug worked.

    Also, in these studies, the researchers of course can pretty easily tell who is on a neuroleptic and who isn’t, and so they aren’t really double-blind either.

    Finally, that was one of the key findings in Loren Mosher’s Soteria study. At the end of six weeks, psychotic symptoms had abated as much in his Soteria subjects, many of whom hadn’t been placed on neuroleptics, as those treated conventionally in the hospital with the drugs.

    • “The patient probably has a brain chemical imbalance” is what the psychiatrist believes. Without the belief of unbalance brain chemicals what is the psychiatrist doing to his patient? How can the psychiatrist help his patient?

      Feeling angry from the heat is probably a brain chemical imbalance.
      http://www.cbc.ca/news/health/story/2012/07/06/wdr-heat-wave-mental-health-suicide.html
      “Dr. Len Cortese said it’s common for psychiatric beds to fill up during heat waves.

      Right now the mental health unit at Windsor Regional Hospital is completely full.

      “Essentially, what’s occurring is that the neurotransmitters, the chemicals in the brain, are probably going off balance. When chemicals in the brain go off balance, it will cause difficulties in what the brain does,” he explained. “And what the brain does is, it helps us with our mood, so our mood is set off. The brain helps us keep our anxiety under control so [during heat] people have difficulties with anxiety.”

    • “Finally, that was one of the key findings in Loren Mosher’s Soteria study. At the end of six weeks, psychotic symptoms had abated as much in his Soteria subjects, many of whom hadn’t been placed on neuroleptics, as those treated conventionally in the hospital with the drugs.”

      A finding that tally’s with John Weir Perry’s understanding of psychosis;
      “Did Jung really see this as a healing process?

      He did indeed! He believed that “schizophrenia” is a self-healing process – one in which, specifically, the pathological complexes dissolve themselves. The whole
      schizophrenic turmoil is really a self-organising, healing experience. It’s like a molten state. Everything seems to be made of free energy, an inner free play of
      imagery through which the alienated psyche spontaneously re-organises itself – in such a way that the conscious ego is brought back into communication with the unconscious again.

      How long does the experience normally last?

      The acute hallucinatory phase, during which these contents go through the reordering process, usually lasts about six weeks. This, by the way, corresponds to the classical description of visionary experiences in various religious texts, such as the proverbial “forty days in the wilderness” often referred to in the Bible.
      Anyway, six weeks is roughly it.”

      From When The Dream Becomes Real: the inner Apocalypse in mythology, madness and the future. By Michael O’Callaghan http://www.global-vision.org/papers/JWP.pdf

      From my own experience, having been through it four times in the past five years, unrestrained, the last three times documented online. Six weeks is the timeline for a spontaneous energy phase which seems to seek a natural metamorphosis? Each of these episodes has enabled a more positive future outcome, as I gain more experience, and a less fearful & judgmental expectation?

      Yet in terms of real world significance, perhaps my experience is meaningless, because we do seem to prefer our wary, mind reading diagnosis, to sensing the reality of the living breathing creature before our eyes?

      I sometimes think the most unfortunate term in the history of psychology/psychiatry, is object-relations?

      So what does maintain the illusion that the drugs work? Will we find that answer in statistical analysis and intellectual discussion?

      • Thank you, David. Your generous offerings of the inner transformation -revelation experience reminded me of a quote that may resolve Sandra’s
        dilemma, which she articulated as :

        ” I do not know how to be fully aware of the multitude of ways in which I have been influenced.”

        H. Maudsley wrote: “Anomalies when rightly studied, yield rare instruction; they witness and attract attention to the operation of hidden laws or of known laws under new and unknown conditions; and so set the inquirer on new and fruitful paths of research.”

        Under the influence of psychiatric training, which is mostly indoctrination, the psychiatrist seeks little from a “patient” other than validation of the schooling he/she received. Rather than studying and investigating WITH “the patient”, the doctor assumes the role of authoritative guide. Rather than share the suffering- even out of curiosity- the doctor begins to focus on eliminating IT. There is no opportunity for discovery of the actual phenomena, much less it’s potential value. Worse, this unbalanced relationship breeds dependence( desired or resisted, either way), which increases anxiety, heightens fear and manifests as a “pattern of disharmony” – a “disorder”… a “patient” who has lost the wholeness of being human—is now a fragmented part of something that does not fit —anywhere.

        Forget the influences of your training, Sandra… and educate yourself with the assistance of someone who trusts that you are an equal partner—become a keen listener, observer, and safe haven AND, then you will begin to understand … what cannot be taught — only experienced.

    • One of the issues I am aware of is the rush to diagnose a person with schizophrenia absent actually excluding conditions which can be the cause of the symptoms.

      In my son’s case, Left Temporal Lobe Epilepsy was excluded by taking it off his Medical Chart—obviously, is not ethical–in fact, it is illegal.

      My eldest son was diagnosed with schizophrenia, was given neuroleptics—which he was told were to help him sleep. Three things bought about the dx. 1. His younger brother had been dx. 2. he talked about his interest in Neurolinguistic programming(which the diagnostician believed was an entrenched delusion, since they had never heard of it) 3. At the time, he worked for Earthlink and was getting training–this was reported as he thought he was getting Earthling training…

      The thing is, he was diagnosed and lied to about the diagnosis and the reason neuroletic drugs were prescribed. I can’t help but wonder how common is it for a person to be diagnosed with schizophrenia–a diagnosis of exclusion–so carelessly and unethically as my both of my son’s were?

      Altering a Medical Record is a crime, like every other crime committed in the ‘treatment’ of my traumatized son; I reported it. And, also like every other crime, it was never investigated.

      There is a carelessness about the manner in which a diagnosis is applied, and treatment provided. Most troubling is the failure of professionals to consider the context of a persons distress, particularly after a diagnosis is attached. Which to me is a failure to exercise critical thinking skills.

      In my youngest son’s case, he had been on a neuroleptic drug for five years as a child prior to being diagnosed with schizophrenia; then he was used in drug trials—It doesn’t take a genius to figure out that Left Temporal Lobe Epilepsy is not ‘excluded’ by removing it from a person’s medical record; or that a child who has taken a teratogenic drug known to cause psychosis for five years will have some serious issues if the drug is withdrawn too quickly…reckless and careless are the terms which best describe the mental health care system as my family has, and continue to experience it.

      • There is a completely false assumption in the “educated” psychiatrist about what “knowing” really is?

        The diagnosis in the anxiety of that actual moment, is a reaction, not reason! An expectation of what is, rather than a true perception of the reality before the psychiatrist eyes?

        This is how we all judge reality in the anxiety of the lived moment, 80% reaction, 20% reason? The way we think. is NOT the way we actually function and we all collude in this mass-deception about reality, because we fear an unleashing of the chaos of our innate animal instincts.

        The collusion is seen in black & white, right here, as we prefer to intellectual bullshit, to speaking about reality? The focus on the BAD nature of “them” is instinct NOT insight, and we deceive ourselves in the false belief that something other than an “acting out” of unconscious arousal needs, is happening here?

        All the above statements & comments have been expressed thousands of times, and nothing really changes, because we collude in a mass-deception, we label civilization? Like the conservative need for civility, that actually covers-up realty over and over again, in an effort to maintain an established homeostasis (comfort-zone).

        Neither Robert or Kermit responded to my challenge for open transparency, which they will “rationalize” as intelligent reasoning? In reality, they fear exposure, of a lack of depth in their “intellectualism” about the true nature of LIFE.

        There is no “insight” in stating the blindingly obvious and pretending this is insight or real critique, just because we have “rank & status.”

        There are two year old’s dying now, because we refuse to get REAL about WHAT we are? AN ANIMAL. Supremely gifted & stupid, at the same time?

        As the heightened energy and sensory awareness of my recent six week psychosis experience wanes, have I undergone a natural metamorphosis? Time will tell?

        “All we have learned of psychotherapy suggests that it is at the precise time when the individual feels as if his whole life is crashing down around him, that he is most likely to achieve an inner reorganisation constituting a quantum leap in his growth toward maturity. Our hope, our belief, is that it is precisely when society’s future seems so beleaguered – when its problems seem almost staggering in complexity, when so many individuals seem alienated, and so many values seem to have deteriorated – that it is most likely to achieve a metamorphosis in society’s growth toward maturity, toward more truly enhancing and fulfilling the human spirit than ever before. Thus we envision the possibility of an evolutionary leap to a trans-industrial society that not only has know-how, but also a deep inner knowledge of what is worth doing.” _Willis Harman.

        It really is time to turn the SUPERIOR Frenchman on his head, and let go our crazy making heads? There is no reality in BIG MIND conceptualizing, no insight until we honor the reality of evolution within.

        The bulk of our sense of “objectivity” is an instinctual judgement, and not healthy perceiving, in tune with our innate capacity?

  7. I am skeptical about intuition that is influenced by the training psychiatrists receive. There is, unfortunately, a predisposition to base assessments and evaluations on psychiatry’s body of knowledge, taught as factual criteria for labeling symptoms. In addition to many gross errors regarding the etiology of these symptoms, there is virtually no aspect of the education and training that a psychiatrist receives that describes these symptoms in the context of a meaningful, non-pathological, non-medical human experience. The result of training and education that is NOT based on a thorough understanding of the experience and the process of “psychosis” is a treatment and intervention model that is experimental, at best, and potentially damaging, at worst.

    Question: Is it ethical, moral and representative of the sound judgement the public expects from doctors to conduct experiments on a vulnerable group of people?

    Holding accountable all professionals, para-professionals and business- minded stake holders in the mental health system to the long held beliefs of the public; that sound knowledge, grounded in thorough study and born out in clinical practice is the foundation for medical practice, is proving a most difficult task. Yet, this is exactly what needs to be pushed into the forefront of every issue raised by people who have begun to publicize the evidence that psychiatric treatment is far more likely to cause harm than benefit.

    IF, starting today, the acceptable guidelines for administering chemical agents to human being were enforced – there would be no first -line neuroleptic interventions. The only acceptable first line interventions would be anxiety reducing and rest promoting measures that common sense dictates involve remediation of the environment NOT the “patient”. The environment begins with the professional who meets the “patient”.

    Question: What attitudes and behaviors of a psychiatrist are more likely to increase, rather than reduce the anxiety of a person who is experiencing “psychosis” ?

    Then we fall back to square one: What training and education does a psychiatrist receive that increases the likelihood that he/she will be capable of achieving perhaps the most crucial first line intervention— gaining trust and establishing a relationship that enhances meaningful communication with a person struggling through a “psychotic episode”?

    Anything short of that crucial human connection IS the gateway for the body of knowledge that is currently the basis for training and education that psychiatrist’s receive, or rather, biased misperceptions that pathologize, frighten, torture and even kill—“patients”.

    • The violence starts with defining a person against their will as a “patient”. They don’t want to be anybody’s “patient”, yet here they are, described and defined by the more powerful one in the equation as a “patient”.

      People have the natural right to not be made anybody’s slave or “patient” by force. Psychiatry spits in the face of human dignity millions of times a year.

      • Sometime around 1880 something the term “psychiatrist” meant: doctor of the soul (psych is Greek for soul)– Literally speaking, there are NO psychiatrists in this neck of the woods—so , ergo, NO psychiatric patients either.

        So, whaddaya think, Anonymous? Should we correct the misnomers?

        How ’bout; “wardens” and “prisoners”?, or “thought police” and” thought criminals”? or,” Predators” and easy “prey”?

        I’m trying to tap into the brilliance PHARMA has displayed with regard to marketing for the hard sell…

        xo,
        Sinead

  8. The belief that psychiatrists have in the drugs they prescribe is a proxy for the belief that they themselves perform miracles and are therefore important to medicine.

    The drugs are talismans for power and prestige. The belief is wholly irrational and self-deluding.

  9. If I were the doctor I would judge effectiveness of the drugs by one standard only – is the patient able to resume a normal life on the drugs? But the issue is actually more complex, because mainstream psychiatry doesn’t believe that a “disease” like schizophrenia is curable, so anyone expecting they or their relative to get better and be fully recovered would be considered “delusional.” If the drugs really are effective, then the person should be back at school, dating, working – whatever- in no time. We don’t hear that outcome very often.

    • Exactly. Although I would be careful with the concept of “normality”. Lots of people live not-so-“normal” lives, but they still have a great quality of life. Especially among those who’ve experienced crisis, and have escaped the psychiatric system, there are quite a few whose crisis has taught them that “normal” actually doesn’t necessarily equal a good quality of life.

      The research focusses on “symptom reduction”, and equals it with increased quality of life. To me it is incomprehensible how a reduction of life, or aliveness, ever could produce an increased quality of life. Obviously, if somebody’s aliveness is a problem to themselves and/or others, reducing it might solve the problem, though only if death is regarded the desired outcome: the operation was a success, (but) the patient died…

    • I agree – the most fundamental problem is the standard. If you’re looking for a reduction in symptoms according to some checklist created by clinicians with no input from the recipients of the “treatment” about what is important to them, you can delude yourself into thinking you’re being successful, because the person is temporarily “less depressed” or “less psychotic” than they were. The fact that the person is physiologically, psychologically or spiritually suffering, has a shaking hand, can’t sit still, wants to vomit, still hears aggressive voices but just less loudly than before, can’t hold down a job, is unable to engage in meaningful relationships – not one of those factors I mentioned is even vaguely considered important by the “symptom management” approach.

      We need to start by resetting the goal – it can’t be about “symptoms”, it must be about improving life outcomes as defined BY THE PERSON SEEKING TREATMENT! And that includes accepting that the person may not seek treatment and be OK having his/her symptoms and working out a plan on his/her own to manage. Until we look at the person’s own intentions and values as the ultimate goal for intervention, arguing about whether a 5- or 10-point reduction on Dr. X’s scale of anxiety/depression/ psychosis will continue to waste everyone’s time.

      Thanks to Dr. Steingard for acknowledging the realities of the situation. As for the intuition question, I agree that intuition is part of any problem-solving approach, and leaving it out is part of the problem. However, it’s also very easy to mistake bias for intuition. The way to counteract that is to check out each and every intuition ruthlessly against both an internal bias checklist and by external measures and values that are effective in questioning your basic assumptions. A real scientist is always skeptical, and the more skeptical the more certain they feel they are right. Intuition only becomes effective when you’re brutally honest with yourself about your own biases, something psychiatry has not even begun to entertain as a profession.

      My intuition says, don’t trust anyone who says they can fix your mental problems with a pill. I think most people’s intuition would agree, including a lot of doctors, but we’ve been systematically instructed to ignore that basic knowledge. If that intuition is allowed to surface, most of the field of psychiatry would quickly dissolve out of existence, because it is based on fundamentally flawed logic that the average elementary age child finds offensive. (If you doubt me, you should ask a few non-brainwashed 8-year-olds about it.) I am not hopeful that psychiatry will ever be able to examine itself in that way.

      —- Steve

  10. Thanks for the pointer to Jonah Lehrer article. There is a refreshing contrast on how well-documented and researched this article is (about “the decline effect”), and the cautiousness in its conclusion “This suggests that the decline effect is actually a decline of illusion.”.

    I am not a statistician, but I still have enough training and credentials in mathematics to question how one aspect of the significance of results is presented in many research papers I read:
    – too many research papers put forefront in summary/abstract the “P” factor that justify their research result (often very low), like if it was a marketing argument, while hiding well the effect-size or numbers-needed-to-treat.
    – in justifying their result, most writers don’t seem aware that the “P” factor is only meaningful when making the assumption that there is no noise and no bias in the data collection process itself, and no errors in the methodology (good methodology with P=0.1, and good effect-size is much more credible than poor standards with P=0.001 and small effect-size). Maybe one day, somebody will propose to systematically use some extra statistical balancing measure, that would give a numerical assessment of the upper bound of unknown potential noise or bias that would still make P<0.05 (the current base value of P is irrelevant to measure that "robustness" to bias/noise). Maybe then the "decline effect" can be nipped in the bud, as some illusions might be detected more early.

  11. another thing that can affect what people believe is what people need to believe (to protect themselves).

    i think all psychiatrists need to be asking themselves what they will lose if they don’t believe neuroleptics are effective. and if they are willing to lose these things.

  12. This is an interesting post. One thing makes me wonder, though. I remember reading the Jonah Lehrer article when it was published in the New Yorker. Now that his work as a whole has been called into serious question by his history of plagiarism and fabrication, I have to wonder about the validity of anything he says.On the other hand, nothing in Lehrer’s weaknesses does anything to undermine the report in J. Clin. Psych.