British Journal of Psychiatry Editorial Urges Rethinking the Use of Antipsychotics

Kermit Cole
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The August issue of the British Journal of Psychiatry offers an editorial stating that, as “mental health services appear to have overestimated the strength of the evidence base for antipsychotic medication, while underestimating the seriousness of the adverse effects, it seems sensible to re-evaluate the risk–benefit ratio of such drugs.” The authors cite Martin Harrow’s 20-year study of schizophrenia outcomes (among other research) in concluding that “It may be time to reappraise the assumption that anti-psychotics must always be the first line of treatment for people with psychosis; rather, this should be a collaborative decision that is balanced with provision of informed choices and the offer of evidence-based alternatives.”

Article → 

Morrison, A., Hutton, P., Shiers, D., Turkington, D; “Antipsychotics: is it time to introduce patient choice?” British Journal of Psychiatry. 2012 (201) 83-84

From the conclusion:

“Given that mental health services appear to have overestimated the strength of the evidence base for antipsychotic medication, while underestimating the seriousness of the adverse effects, it seems sensible to re-evaluate the risk–benefit ratio of such drugs. This risk–benefit profile may be a factor in the high rates of non-adherence and discontinuation of medication found in patients with psychosis; thus, some decisions to refuse or discontinue antipsychotic medication may represent a rational informed choice rather than an irrational decision due to lack of insight or symptoms such as suspiciousness. Given accurate and honest assessments of both risks and benefits, it should be possible to prescribe antipsychotics in a more thoughtful and collaborative way, and these considerations should involve explicit discussion of the possibility of not prescribing at all. Provision of such choices may help to engage people who might otherwise reject services; for example, patients with low levels of insight and/ or high levels of internalised stigma might resist medication but consider that talking to someone is acceptable.

“To facilitate informed choice and decision-making, we require a much better evidence base to help address questions such as how and when medication might be required, who is most likely to respond and what alternatives exist. There is some evidence for different trajectories of response, with a small proportion of patients demonstrating a rapid and dramatic favourable response to certain antipsychotics,11 but more research is clearly required to inform our ability to predict those most (and least) likely to respond to antipsychotics. Shorter duration of untreated psychosis has been shown to be a predictor of response to antipsychotics,12 which could be employed as an argument against offering no medication as a choice. However, any additional benefits of early treatment would still need to be evaluated against the long-term risks, and the traditional assumption that ‘untreated psychosis’ can only be treated by prescribing antipsychotics (and therefore not by psychosocial therapies) has yet to be comprehensively tested. It is relevant to this assumption that 20-year outcome data from the Chicago Follow-Up Study suggest that service users who decide not to take antipsychotics (often against medical advice) do relatively well, if not better, in comparison with service users who take such medication continuously.13

“In addition to research regarding predictors of response to antipsychotics, research is also required to inform evidence-based alternatives to antipsychotic medication, since the most likely candidates (such as psychosocial treatments including cognitive therapy and family interventions) have almost exclusively been evaluated as an adjunct to medication. There are a few exceptions, such as a recent trial of cognitive therapy for people who chose not to take antipsychotics;14 however, more clinical trials with greater methodological rigour are clearly needed.

“It may be time to reappraise the assumption that anti- psychotics must always be the first line of treatment for people with psychosis; rather, this should be a collaborative decision that is balanced with provision of informed choices and the offer of evidence-based alternatives. These decisions should be negotiated with service users on the basis of the likely positive and negative consequences and the prioritisation of their goals and values; such a collaborative approach might also result in better response for those who choose to take antipsychotics, since the quality of relationship with the prescribing clinician is associated with attitudes and adherence to medication.”

Note from Kermit Cole, “In the News” editor:
The authors of this editorial are encouraging readers to reply to it, saying “We (Tony Morrison, myself, David Shiers, Doug Turkington) are trying to start a debate around antipsychotic treatment and choice, drawing attention to what we perceive as a changing cost-benefit ratio … Whether you agree with our arguments or not, please do consider contributing to the debate: http://bjp.rcpsych.org/letters/submit/bjprcpsych;201/2/83.”

They add: “Service-user opinions will be particularly important here.”

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected]

20 COMMENTS

  1. Hi!

    I just thought you should know your external link for the article is incorrect, pointing to an article on sanctions imposed on executives held responsible for failing to note the addictive potential of Oxycontin in their marketing programs…

    And this, BTW, is a fascinating article; thank you for sharing it.

    – bonzie anne

  2. “It is relevant to this assumption that 20-year outcome data from the Chicago Follow-Up Study suggest that service users who decide not to take antipsychotics (often against medical advice) do relatively well, if not better, in comparison with service users who take such medication continuously”

    Relatively well, if not better? I’ve seen the data and listened to Bob and others speak/write about Harrow’s outcomes and I have to say, the authors appear to be minimizing the dramatic differences between those off-meds vs. on-meds.

  3. I agree with your comment, but I still think it’s awesome to see a psych journal editorial with this thrust. Change is in the air…

    Point well taken regarding bipolar, however. We have to watch out for the change being simply changing targets!

    —- Steve

  4. I particularly liked the bit where he said that discontinuation of medication may be because the drugs are intolerable after all and not because the patient “lacks insight” or is “suspicious”.

    I read that and can’t help but wonder how many people rightly wanted to discontinue but were bullied or legally coerced into taking the medication. The fact that Doctors view any dissenting view by a patient as further evidence of their illness has to be one of the most toxic and dangerous ideas in all of psychiatry.

    • The following may be instructive in this context. The decision of the Supreme Court of Canada in Starson v. Swayze, [2003] 1 S.C.R. 722, 2003 SCC 32, (Patient refusing consent to proposed medical treatment for bipolar disorder…. Physicians finding patient not capable of making treatment decisions because of a psychiatric disorder that he acknowledged.) allows informed refusal of medications even by a patient with a diagnosed psychiatric disorder. The presiding judge stated “HCCA (Health Act) confronts the difficult problem of when a mentally ill person may refuse treatment. The problem is difficult because it sets in opposition fundamental values which we hold dear. The first is the value of autonomy — the ability of each person to control his or her body and consequently, to decide what medical treatment he or she will receive. The second value is effective medical treatment — that people who are ill should receive treatment and that illness itself should not deprive an individual of the ability to live a full and complete life. A third value — societal protection — comes into play in some cases of mental illness. Where the mentally ill person poses a threat of injury to other people or to him– or herself, it may be justified to impose hospitalization on the basis that this is necessary in the interests of public safety The right to refuse unwanted medical treatment is fundamental to a person’s dignity and autonomy. This right is equally important in the context of treatment for mental illness….Few medical procedures can be more intrusive than the forcible injection of powerful mind-altering drugs which are often accompanied by severe and sometimes irreversible adverse side effects……… As the reviewing judge observed, “[a] competent patient has the absolute entitlement to make decisions that any reasonable person would deem foolish”. This point was aptly stated by Quinn J. in Koch (Re) (1997), 33 O.R. (3d) 485 (Gen.Div.), at p. 521:The right knowingly to be foolish is not unimportant; the right to voluntarily assume risks is to be respected. The State has no business meddling with either. The dignity of the individual is at stake.
      In this case, the only issue before the Board was whether Professor Starson was capable of making a decision on the suggested medical treatment. The wisdom of his decision has no bearing on this determination…The Board must avoid the error of equating the presence of a mental disorder with incapacity. Here, the respondent did not forfeit his right to self-determination upon
      admission to the psychiatric facility…The reviewing judge properly held that the Board’s finding of incapacity was
      unreasonable, and that the Board misapplied the statutory test for capacity. There is no basis to find that either of the courts below erred on the evidentiary issues that were raised by the appellant. Accordingly, I would dismiss the appeal.
      The patient was granted the right to refuse medications and seek psychotherapy.

  5. I am so glad that more and more psychiatrists have started speaking out against antipsychotics and forced medication here in Britain. I am glad that they have started recognising the harm these antipsychotics cause. Only three years ago they were totally blind to it all. Trying to talk to them was like hitting your head against a wall.

  6. From the Editor’s desk by Peter Tyrer (free full text at http://bjp.rcpsych.org/content/201/2/168.full ) follows up with

    The end of the psychopharmacological revolution:

    “….it is time ‘to reappraise the assumption that antipsychotics must always be the first line of treatment for people with psychosis’. This is not a wild cry from the distant outback, but a considered opinion by influential researchers who help to formulate NICE guidelines. And the reasons for the change in view are not just, as some evidence suggests, a consequence of biased representation of drug treatment in the mass media,3 but an increasing body of evidence that the adverse effects of treatment are, to put it simply, not worth the candle. The combination of extrapyramidal symptoms, dangers of tardive dyskinesia and the neuromalignant syndrome,4 weight gain and the metabolic syndrome, sedation, postural hypotension, and interference in sexual function (but also note the important balancing paper by Reis Marques et al, pp. 131–136, that suggests drugs are not entirely to blame here), would need to be offset by massive symptomatic and social functioning improvement to make the benefit/risk ratio positive. Of course, it often is, at least in the short term, but for many the risks outweigh the benefits….”

  7. Thanks for that, read what I could and left my reply – yes of course we should have a choice what medication we take, yes, of course we can recover without medication (given luck, someone who loves us, someone who listens to us, someone who cares…more luck, some financial security, some therapy…anything except clumsy attempts to chemically change our brains which cannot and do not help to mend our fragile and frightened minds).

  8. In today’s Boston Globe on-line Dr. Steven E. Hyman is quoted as saying,”There has been enormous progress in making drugs safer and more tolerable. [But effectiveness has not improved substantially.] We’ve reached a fairly unsatisfactory place in the treatment of these devastating illnesses.” I wonder if the assertion that there has been enormous progress in making drugs safer and more tolerable can be supported empirically. (The conclusion of the BJP editorial refers to risk-benefit profile.)

    Interview in its entirety: http://bostonglobe.com/lifestyle/health-wellness/2012/08/05/understanding-drug-treatments-for-mental-disorders/TnsPNT9TUJtWdJjcNgNkRM/story.html

    • You and I both know the answer to your question. The so-called “new” or atypical antipsychotics are as damaging, if not more so, than the older drugs. But they continue to state their lies and spread their propoganda and people continue to believe it, like sheep led to the slaughter.

  9. Reading the conclusion, I have to imagine that the authors as mental health service providers believe that there are two sides of the fence on the issue. One of which is rational, measured, sane, and might only be faulted for expressing too liberal-minded a spirit on the issue. (Theirs. Cmon over, the water’s fine.) And one of which is irrational, unexamined, insane, and resultant from an ultimately false perspective of victimhood where no injury has resulted from either deliberate ignorance (turning the blind eye) or malice of forethought on the part of those who have caused them harm. (“Service-users.”) But, as many of us have learned in conflict-resolution, to fault intention obfuscates the issue(s). For that reason, I’ll try to stick with the logical inconsistencies in the conclusion.

    If it is the case that mental health service providers have “overestimated the strength of the evidence base for antipsychotic medication, while underestimating the seriousness of the adverse effects,” why indeed would we presume that “…Given accurate and honest assessments of both risks and benefits, it should be possible to prescribe antipsychotics in a more thoughtful and collaborative way?” The only way this ever works in favor of prescription is one in which psychosis (in some cases, not all subject to psychiatric evaluation?) is presumed to represent a far greater risk unmedicated.

    Here’s an equivalent statement:

    Our guess at the weight of that there ripe watermelon was clearly too high, we didn’t tare the scale properly. It’s not a ton at all! Our bad. Let’s weigh your grape again… Maybe that there ripe watermelon isn’t heavier.

    I’m not kidding, and I’m certainly not laughing.

    There was no mention of refusal of medication as ‘choice’ in the sense of a thing I as service-user (their term. not mine.) decide. Decision is by definition not collaborative. Either I decide or you do. This sounds like the old way in which if I decide ‘no,’ I’m subject to being overruled by default. The service-user’s suggested new choice, if I’ve understood it correctly is to take medication or be re-educated about medication until taking it (or convincingly healing alternatively somehow while being re-educated about medication. Note: healing *convincingly to the satisfaction of my service-provider may still require medication.) The apparently magnanimous gesture at first flush might very well look like this:

    Old Way:

    Meds by my choice?

    or

    Meds by their choice?

    New Way:

    Meds by my choice?

    or

    Other by my choice with the following proviso: if-and-only-if-other-demonstrated-to-be-greater-or-equally-safe-and-clinically-effective-to-the-satisfaction-of-my-provider-regarding-my-particular-case-of-soforth-etc.-as-demonstrated-by-etal.

    Did you see the fine print? OK, I didn’t notice choice in either way, but the second way makes a better optical illusion. Moving forward…

    Let us disregard for a moment the fundamental truth that the medical-model position is analagous to a virgin birth as far as the biological substrates of *any psychiatric illness. You’ve been so generous as to here concede that the pill itself is not for everyone in your care, clearly–you claim now to have appreciated a potential distinction in pill-candidacy. A new covenant perhaps? ‘We’ll promise to take science (and our Hippocratic oaths) seriously from here on in.’ Note this is not ‘we do promise.’ It balks at going even that far. This is ‘would such a promise satisfy? Let’s have a vote…’

    Incidentally, I seem not at all to have understood stigma correctly. Let me offer a suggestion I consider constructively critical: the definition of stigma is a bit too migratory (as is most psychiatric terminology,) and this particular inconsistency tends to inspire skepticism when used so flexibly. Is stigma what someone feels when they believe themselves sick in a way that society regards as antithetical to the presumed prerequisites for personal autonomy and humanity? Or only applies once treated for sickness, thus acknowledging sickness, and in so doing getting ‘well’? See, because the first one has to do with social and public perceptions the psychiatric and pharmaceutical alliance has wilfully and knowledgably manipulated. Psychiatry itself has done much to enhance, popularize, and enforce this sort of stigma. And the second has presumed identification with a disease category and drug-treatment model of wellness psychiatry and drugmakers support. Invoking ‘stigma’ in the second sense requires that psychiatry holds the answer to our (understandable though regrettable) denialism, and acceptance (to date, ‘take your pill’) is the correct answer, as it has always been, the answer of deference and humility. ‘The spirit willing though the body weak’ etc.. The second sense of ‘stigma’ necessitates psychiatric treatment in the form of medical interventionalism to absolve us of it.

    Your first step to mending trust, if this is what I am or anyone is supposed to take from your article’s conclusion, is woefully insufficient. The correct position to take, if patient trust is the goal (this trust is synonymous and inseperable from your interest in your patients’ wellness): would be one of sincere apology for the lies, intentional and ignorant, that have caused grievous bodily harm and emotional suffering, immediate cessation of all coercive treatment, abandonment of the current biomedical model of psychosocial illness, and the systematic labelling of each occurence in the public domain of all inaccurate and misleading scientific literature subsequently proven to be invalid as such, the active re-investigation of all psychiatric literature published with regard to all drugs currently prescribed including but not limited to your good faith appeals to relevant courts, justice departments, and legislative bodies for the immediate seizure of all documents and internal memoranda from all distributers, manufacturers, researchers and developers of CNS drugs for psychiatric use. You would be expected to accurately and honestly testify to the harm you have witnessed as practitioners. And you would demand to relevant regulatory agencies that the raw data from all clinical trials past, ongoing, and in the future be made publicly available. If your appeals to these agencies are unsuccessful, you would vow to surrender your medical licenses and refuse to practice as physicians as it would become undeniably clear in that case that there will be no means of public accountability for the deceit and bad science that have heretofore determined your harmful treatment-model, thus no possibility for evidence-based medicine, and thus no basis for the mantle of medical doctor which you and your colleagues have abused into outright extinction where the specialization of psychiatry is concerned.

    If those things once offered were rendered, I’d think a dialogue could begin. If I for a moment considered it likely or even possible that such things might be offered letalone rendered, I would despair that I’d developed delusional thinking. Nevertheless, I might be able to accept that the psychiatrists of this idealized, non-imminent, and regrettably all-but fictive future won’t always and only be profoundly dangerous people, capable of causing something other than harm in the course of standard practice.

    That the conclusion here represents the authors’ notion of ‘progress’ in any recognizable sense of the word is both surprising and offensive.