Of FEP’s, DUP’s and BS

Wayne Munchel
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No, they are not lyrics to an obscure doo-wop song.  First episode psychosis (FEP) and duration of untreated psychosis (DUP) remain the foci of great numbers of early intervention programs in Western countries.  When youth and young adults experiencing severe emotional distress come into contact with these programs, they will likely encounter an overzealous biomedical approach.  “Untreated” in DUP-anese is considered synonymous with unmedicated, which often creates a sense of urgency and a myopic fixation on getting these youth started on anti-psychotics and keeping them on.

What is the impact of this medical model and its accompanying chemical imbalance narrative on these emerging adults?  How often does it set them on a course of regained functioning and restored hope, or does it serve as a gateway into a lifetime of disability and discouragement?  The stakes are very high for youth, their families and communities.

In Anatomy of an Epidemic, Whitaker cited a 2008 GAO report that identified one in sixteen young adults as seriously mentally ill.  Once on SSI or SSDI, few young adults seem to come off of it.  These youth and young adults deserve our best, most up-to-date care and compassion, without succumbing to the “soft bigotry of low expectations.”

Yet, despite the mounting and compelling evidence (Harrow and Wunderink) for a very selective and judicious use of neuroleptics – many of these youth will continue to be subjected to the sledgehammer of polypharmacy.  On her MIA blog Dr. Sandra Steingard has provided an excellent analysis of the “optimal use of neuroleptic drugs.”  In her overview, Steingard argues that:

  • “The impression of short term efficacy (of anti-psychotics) tends to be inflated.”
  • “The impression of long term risk tends to be minimized.”
  • “The impression about the risks of delaying treatment (Duration of Untreated Psychosis) with anti-psychotics is inflated.”
  • Although anti-psychotics are sometimes remarkably effective in reducing psychotic symptoms, this does not mean they are always required.”

What will be the time lag between research and practice?  Now that Thomas Insel, Director of NIMH, has seen the light and called for a change, how many more youth will be treated inappropriately and potentially harmed before the current standards of practice and pharmacentric approaches are replaced?  Studies from the translational research field postulate that it currently averages seventeen years for scientific evidence to migrate into clinical practice.  Can we hurry it up?  These are not abstract questions. If I had a family member seeking help for “distressing anomalous experiences”, I would want the best treatment for them now.

I modestly propose the following incremental steps while awaiting the revolution.

  • Consign the “get them on meds right away and maintain for life” standard to the dust-bin of mental health history, along with gay conversion therapy and pre-fontal lobotomies.
  • Replace the almighty DUP with the concept of Delay of Intensive Psychosocial Treatment (DIPT) forwarded by Haan et al in a 2003 study.  The sooner youth in severe emotional distress can be engaged in additional caring relationships with peer mentors and providers trained in Open Dialogue style services, the better.
  • Ensure that all early intervention programs are well versed in providing trauma informed care.  Evidence of the prominent role that trauma seems to play in the onset of psychosis is strong and growing.  Healing from trauma will not come from a prescription of Abilify.
  • Provide robust vocational interventions for youth and young adults.  Youth experiencing severe distress frequently lose contact with the protective factors of school, work and training opportunities.  Many providers work hard at getting youth onto SSI disability rolls – we need to work much harder at helping youth not need it.

12 COMMENTS

  1. Wayne,
    Having suffered through a two year first episode psychosis program that my son was enrolled in, I can only agree with your assessment of the way forward. The program purportedly had good intentions (to integrate the person back into the community), but it fell way short of the mark, and a lot of the blame falls on insistence on the medication mystique as the primary modality. Once medications become the focus, fear takes over and so does biomedical psychiatry. Talking about one’s voices was taboo, but I remember on one occasion, when the families and “loved ones” were all gathered, one of the young men told the group how he dealt with his voices, which was to listen to them and try to make sense of them. This got an immediate reaction from the psychiatrist, who told the group that acknowledging and trying to deal with one’s voices was not recommended, and voices are to be ignored.

  2. Seventeen years means that thousands of kids and young people will be zonked on the toxic drugs before the shift takes place. Thousands will most likely be shifted onto the rolls of SSI and SSDI, systems that are already trying to bleed out due to the large numbers of people drawing moneies to exist on.

    The general public needs to be better informed about what is going on but I don’t know how to go about combating the PR machine that the drug companies have set up. It’s really great that Insel came out in favor of a more judicious use of psychiatric drugs but the general public has no idea that he’s stated anything about this. The professional staff where I work know absolutely nothing about it. Ignorance is bliss I guess, at least for some people. How do we go about getting this out to a wider audience?

    • With regard to addressing the professional staff, bring in the Wunderink article along with McGorry’s editorial and Insel’s blog. These are hard to refute or just dismiss.
      As for the general public, I think this is harder. Most of us – when considering complex topics – need to decide which expert we will believe. We have no choice since it takes so much time to read the primary material and decide for ourselves. So moving for a shift in expert consensus opinion is very important. This i hard. I just leanred that Fuller torrey will be on 60 Minutes this Sunday. I am not sure he represents US psychiatry consensus opinion but he has the cloak of authority.

  3. It has been an interesting summer to be a psychosis patient to say the least. My providers have gone in under three months from trying to get everyone on medication ASAP and maintained indefinitely to trying to get the relatively stable ones to do a trial period of reduction or withdrawal. It seems Wunderink’s paper was the one that finally flipped them. And considering these are the “thought leaders” at Harvard Medical School — the rest of psychiatry is probably about to start turning soon too. -A