What Would Better Treatment for Those with Psychosis Look Like?

Jill Littrell, PhD
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In the post on the debate between Allen Frances and Bob Whitaker, Frances argues that we should all advocate better treatment for those with psychosis.  I think that we all might embrace the goal of better, more empathic treatment.  However, we will differ on what “better treatment” might entail.  I would argue that a return to the state hospital systems of the 1960s would not constitute better treatment.

Frances laments the transfer of those with psychosis from the state mental hospitals to the state prisons.  During the 1960s, the level of humane treatment in the state prison system was about the same as in the state hospital.  When I worked men’s security in the Nebraska state hospital in the late 1960s, many of those people who worked as ward-aides would work a shift at the state hospital and then would go down the street to the prison to work a second shift in the prison.  (The pay was pretty low at the state hospital.)  There were bars on the cells in the prison.  At the state hospital, we had heavy metal doors on the individual rooms in men’s security, although there were big open dorms filled with beds in the rest of the hospital.  There was a lot of cruelty toward patients in the state hospital system.  In terms of how the obstreperous were handled, prisons had, and still have, solitary confinement.  State hospitals had quiet rooms.  The food was definitely better at the state prison than in the state mental hospital.  Ironically, in the 1960s, a prison term was finite whereas commitment to a hospital, before the change in commitment laws, was unlimited.

Presently, many unmedicated, psychotic individuals are living on the street.  They eat in soup kitchens run by churches.  They sleep under the bridges and, on cold nights, in shelters.  One of my students was employed by United Way to get these individuals in housing.  Similar to Steve Lopez’s account of Nathan in the Soloist, many refused her services, preferring the streets.  The housing options come with many rules and people don’t get to choose their roommates.  Having worked with the homeless, I tend to agree that the streets are better than some of the current housing options and definitely better than the state hospital.  Perhaps, we should be working to have more and better soup kitchens, more recreational options, and more options for housing into which people can choose to come and go.

The issue of whether medication with anti-dopamine is a component of better treatment should be debated.  Agreement is emerging in psychiatry that hypofunction of NMDA receptors are a major factor in hearing voices.  Studies employing drugs that target the NMDA receptors are proliferating in issues of JAMA Psychiatry and the American Journal of Psychiatry.  My questions are, “why do these studies always use the NMDA receptor targeting drugs as add-ons to the antipsychotics?”  “Why aren’t we testing N-acetylcysteine, sarcosine, anti-inflammatories, etc. as monotherapy in those with first episode psychosis?”  All of these drugs have better side-effect profiles than anti-psychotics.  Bonnie Kaplan, a blogger on this web-site, has successfully employed multivitamins to resolve psychosis.  Peet et al. have shown that omega-3s (fish oil) can be effective in treating first episode psychosis, although they may not be helpful in those who have been treated with antipsychotics for years.

Why aren’t we testing all these options in large clinical trials for those with first episodes? The mind-set in psychiatry seems to be that failure to employ a dopamine antagonist constitutes medical neglect.  Insisting on using an anti-dopaminergic drug to treat psychosis is analogous to using arsenic to treat syphilis.  Arsenic worked in the past, but now that we’ve got better approaches would we continue to incorporate arsenic into treatment regimens? My analogizing of antipsychotics with arsenic might seem hyperbolic.  However, antipsychotics do shrink the cortex, cause diabetes, are associated with worse long term outcomes, and can induce fatal cardiac arrhythmias.  I don’t think I’m exaggerating.

The society does have to deal with those who “dine and dash” and those who threaten strangers on the street for no apparent reason.  Currently these individuals go to jail even when they may not have the capacity to control their own behavior.  The late Thomas Szasz would argue that the criminal justice system is an appropriate response for those who commit felonies and misdemeanors regardless of mitigating circumstances.  Those who do not believe that hearing voices has a physical basis, I guess would say that individuals with psychosis who break laws should be treated like everyone else: go to jail.  What should we do with them?  Any ideas?

References:

Rodway, M., Vance, A., Watters, A., Lee, H., Bos, E., & Kaplan, B. J. (2012). Efficacy and cost of micronutrient treatment of childhood psychosis. BMJ Case Reports, 2012.

Peet, M. (2004). Nutrition and schizophrenia: beyond omega-3 fatty acids. Prostaglandins Leukotrieneand Essential Fatty Acids, 70(4), 417-422.

Peet, M., Brind, J., Ramchand, C. N., Shah, S., & Vankar, G. K. (2001). Two double-blind placebo-controlled pilot studies of eicosapentaenoic acid in the treatment of schizophrenia. Schizophrenia Research, 49(3), 243-251.

Peet, M., & Horrobin, D. F. (2002). A dose-ranging exploratory study of the effects of ethyl-eicosapentaenoate in patients with persistent schizophrenic symptoms. Journal of  Psychiatric Research, 36(1), 7-18.

 

 

 

46 COMMENTS

  1. I found this piece very confusing and hard to follow; in fact, I’m not even sure I understand what the author is trying to say. Is she really advocating a return to solitary confinement, which research has shown is detrimental to physical, mental and emotional well-being, and which some of us equate with torture? And it is news to me that commitment to a psychiatric facility is no longer “unlimited.” Tell that to people who have spent the last 40 years in state hospitals and are still there.

    It seems obvious to me why many people who are homeless do not want to enter frightening unsafe shelters that impose all kinds of infantalizing rules on people in order to have a roof over their head.

    The author seems to accept Allen Frances’s terms of debate, but I do not accept DSM terminology (i.e., psychosis) related to the experience of extreme states. Why, in the face of all the evidence to date, must we assume that some kind of drug is the “answer” for people experiencing extreme states? The people I know who recovered from so-called “psychosis” did so after rejecting the drugs.

    I have no idea what is meant by “dine and dash.” In fact, my primary reaction to this piece is simply that I don’t understand its message.

    • I think that there’s an emphasis on things being a _huge deal_, that upheaval is needed, panic etc rather than a calm, rationalizing, ‘normalizing’ way of dealing with whatever.

      If something is episodic in nature, or perceived to be, then it will pass. Psychiatrists seem to fly off the handle, they see disordered thought and the instinct is freak out, bomb it out of existence with large doses of major tranquilizers, and afterwards ? Well keep taking them, the assumption being that they will prevent another ‘episode’, and if life sucks a bag of dicks inbetween … well at least that future episode is prevented right ? Sure, forget that there’s no proof of lasting physical harm from the ‘illness’ but there appears to be indisputable evidence that these drugs are ‘bad m’kay’.

  2. “… current treatments are barbaric and … demanding better options” is imperative, I agree. And I think it’s important the psychiatric practitioners be made aware of the fact that when a patient is wrongly put onto a neuroleptic, “anti dopamine” (for example, when the ADRs or withdrawal effects of an antidepressant are misdiagnosed as “bipolar”). The antipsychotics can and will CAUSE psychosis, in at least a percentage of people. And when one is weaned off these wrongly prescribed neuroleptics, they also cause a withdrawal induced super sensitivity manic psychosis. I know there is medical literature from as early as 1964 pointing out this reality, as well as more recent literature. But the psychiatric practitioners, in practice, seem completely unaware of these realities – yet no doubt, this is happening to millions of innocent children still to this day, particularly in the US.

    I found psychiatric commitment lasts only as long as one’s insurance chooses to pay, and is completely unrelated to one’s “mental health,” and the laws within one’s state of residence. My medical records and court documents show proof that patient’s signatures are forged, in order to delude judges into taking away rights of patients with good health insurance, who’d dealt with prior easily recognized, and complex, iatrogenesis. In my case, the doctor who admitted me, was arrested by the FBI for similar crimes against other patients, however. Hopefully, I just experienced the absolute bottom feeders of the medical community, but the white wall of silence does belittle the credibility of all doctors. And the experiences of other MiA readers seems to imply the crimes committed against me are “appropriate medical care” for all psychiatric practitioners.

    As to what to do with “voice hearers”? Since the “bipolar” cocktails can CAUSE “voices,” rethinking standard psychiatric care would be advisable. I’m not a criminal, my worst crimes are minor traffic violations. And I had no personal or family history of any mental health problems, until I was railroaded by doctors trying to cover up easily recognized iatrogenesis, so I’m not the best person to answer this question. But I will say I don’t believe convicting people for crimes they committed due to the horrific ADRs and withdrawal symptoms of today’s toxic psychiatric drugs is appropriate. And I think the psychiatric industry needs to learn that hearing “voices” is considered a “gift” in most indigenous cultures. Perhaps learning to respect other human beings, and their experiences, would be a wise move for the psychiatric industry some day soon?

    • I very much support what you say regarding psychiatric drugs manufacturing mental illness. Peter Gotzsche identifies this phenomenon in his book “Deadly Medicines . . .” ; Robert Whitaker also describes this process graphically, in one of his videos.

      I have experienced rebound mood swings on withdrawal of lithium and desperate longterm anxiety on withdrawal from “anti psychotics”. My withdrawal syndrome has never disappeared, but I have developed coping skills.

  3. Jill,

    I’m for *equal* protection as guaranteed in the constitution.
    This would mean having an *attorney* and a jury of peers.

    In the event it can be *proven* in a real court (not a mental health court, of the kangaroo variety), that a person truly poses a threat to their community, then a *lawyer* (not a social worker) can legally provide advocacy on behalf of his/her client. He/she can ask for least restrictive, most therapeutic options available – *mitigate* if necessary, as he/she would for *any* client.

    Until people who have been diagnosed are given *full* constitutional rights, there will be no real, meaningful changes, Once constitutional rights are upheld, all kinds of options will begin to emerge; including more peer-run-respites, alternative treatments, etc.

    Duane

    • To clarify, IMO the *special* treatment (ie, mental health courts) have not made things better; they’ve made things worse.

      I’m not for *special* treatment for any citizen. *Equal* treatment is what’s needed. And mitigation is part of our legal system.

      In short, tossing someone in a psychiatric institution for misdemeanor crime is absurd. The US Supreme Court has ruled that forced psychiatric treatment is a “massive curtailment of liberty.” It seems obvious that the punishment often does not fit the crime.

      NAMI mommies and the Treatment Advocacy Center are involved in these cases…. Where are the lawyers?

      Duane

  4. My suggestion would be to avoid diagnosis, to avoid strong drugs – and to offer psychotherapy. When I came to the Maudsley Hospital South London in 1980, I asked for psychotherapy. But I was given an extreme diagnosis and drugged, and remained psychiatric for the next few years.

    I was diagnosed chronically in 1983, when I was hospitalised following an attempt to discontinue medication. I came off strong medication in 1984, moved to psychotherapy, and have been well since.

    My main problem was not the underlying problem, but the sabotaging effect of the “medical system”. I have no difficulty explaining how and why psychotherapy works.

  5. Psychotherapy would be a really cool alternative to medicines for psychosis, if it actually worked. The problem is it doesn’t work, except as an adjunct to medication, with major adaptations (that most psychotherapists have absolutely no knowledge of and make a right mess of) to accommodate the cognitive issues of psychotic disorders.

    Been to too many funerals of people who took the psychotherapy option. Everybody and his brother wants to get on that particular scam as it appears to be so lucrative. It’s great – except for the psychotic person. As usual, the psychotic person suffers for the sake of other peoples’ bizarre agendas.

    As for NMDA research, and why don’t we use NMDA medicines, it’s because the basic research has been incredibly disappointing. The author of the article doesn’t read the NMDA research with a balanced, disciplined approach so she has come completely to the wrong conclusion.

    ‘Anti-dopamine’ (sic, that’s a really severe error in conception of what these drugs do), medications need not be blockers. Partial agonists are far, far better as far as side effect profile. And even dopamine blockers in low doses are a useful option. Most side effects are dose related, but most doctors are already prescribing at a fraction of the doses used years ago.

    One of the things that happens in psychotic disorders is that a ‘branch’ grows between the excitatory and inhibitory nerve pathways to individual cells. Nerve cells have two ‘lines’ – excitatory and inhibitory. This is due to the illness itself, not medication.

    What happens due to the disease is that a branch forms between the two lines to the cell. When the cell is to be inhibited (rested) it is still also being excited. When it is being excited, it is also being inhibited.

    One of the most useful things that the ‘mean ole’ antipsychotic dopamine based action does, is cause those abnormal connections between excitatory and inhibitory lines, to go back to their original state – in other words, those abnormal connections fade out. This is one of the main things that helps to improve symptoms.

    Study, read, educate yourself, author. And stop promulgating such an incredibly one-sided and dangerous ‘treatment’.

    No, I am not a doctor. I am a nobody, but I have dealt with the homeless mentally ill for many decades, and I can read. A lot. I pay attention; you do not. I do feel sorry for you, but not enough sorry to ignore the harm you do to people i love.

    • It seems to me that you tend to make a lot of sweeping statements about a lot of things when you post your responses.

      I would never agree that all psychotherapists are great at helping people heal from their issues; there are really good ones and there are a lot of really bad ones and a ton of mediocre talk therapists who really don’t know any more about therapy than I do. I had one that I ended up doing therapy for!

      Actually, the person in therapy is the one who is supposed to do the actual work and not the therapist. The therapist asks articulate and pinpointing questions to help the person in therapy see new ways of looking at or dealing with things. A therapist who knows how to ask the right questions at the right time is worth their weight in gold. I’ve had two great therapists who truly encouraged me to do my Work and they were really helpful for me, and I’ve had some really mediocre therapists.

      I’ve never, ever once been helped by psychiatrists or other medical doctors who wanted to fill me to the gills with destructive and toxic drugs and chemicals. Why do you keep supporting what doesn’t work for the majority of people? It would be helpful if you didn’t make what I feel are sweeping statements. It seems that it’s either all good or all bad, either white or black when the reality is that there are myriad shades of gray all over the place in between the two extremes. I’ve never experienced life to be extremes. And, by the way, there are psychotherapists who have helped people recover from what you want to refer to as psychosis, therapists like Dr. Caron and Daniel Dorman and Loren Mosher, and tons of others that you seem to ignore. When you support the chemical imbalance theory you seem to also be promulgating an incredibly one-sided and dangerous “treatment”.

    • Tusu
      It worked for me. The longterm recovery rates of people that get a chance to engage in useful psychotherapy are very high, at 80% +. Years ago in 1983, when I was in hospital a psychologist told me that All “patients” could make full recovery through non drug means.

      I’m talking about practical psychotherapy, nothing expensive or complicated.

    • There is clear emerging evidence that psychotherapy does, in fact, work for psychosis, at least initially when not complicated with brain damage caused by psych drugs.

      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525111/

      There is also plenty of evidence at this point that antipsychotics, far from helping people become more functional, end up creating increasing numbers of disabled persons over time, as you’d know if you read Whitaker or were even up on the latest research from Harrow and Wunderlink, among others.

      Tusu, you’re going to have to do better than repeating platitudes to convince anyone that your views are anything more than a stance you’ve chosen to adopt. You make these claims but provide absolutely no basis for them in research. It’s kind of an “everybody knows” sort of an approach, and it is frankly a bit insulting to those of us here who’ve spent a lot of time reading the actual research. If you have studies in mind, please provide us names and links if available. Otherwise, I don’t think anyone here is going to take you seriously.

      —- Steve

  6. See a Szaszian who keeps the issues straight, maybe that helps.

    http://www.ncbi.nlm.nih.gov/pubmed/23722099

    The topic side tracks because the notion of dangerous behavior is utterly generalized and wedded to the concepts of compliance, restraint, and incompetence. Hannah Pickard always maintains that we are responsible for our actions. And of course Thomas Szasz’s idea isn’t that there are not any physical factors involved in problems in living. They contribute to mental health issues as they do to lovesickness, homesickness…. But you live these problems and they do not exist as an entity that you can excoriate or purge, physically. Psychiatry just is not and cannot be genuinely medically employed.

    • Jill, I looked back here to see what I thought after reading this great article that I can’t believe you’d want to miss. The same author as I linked to, but printed in a legal journal:

      http://www.ojls.oxfordjournals.org/content/33/1/full.pdf

      For the mental health side, the authors focus on “disorders of agency” and specify that “Core diagnostic symptoms of such disorders include actions and omissions that are criminally or morally wrong. But evidence-based treatment for these conditions typically depends on clinicians adopting a stance towards patients of ‘responsibility without blame’.” They talk over the (old and revamped) justice model and evaluate it alongside discussion of the (not totally gone) rehabilitation model that envisioned character change as the purpose of everything up to and beyond sentencing. Those are authors Nicola Lacey and Hannah Pickard working in U.K. But the discussion is in the most general terms and applies to issues of criminal responsibility and theories of punishment for any system of law and government that works from record to result in light of a constitution, I’m sure. Aside from that type of concern, and what Duane says, I would strongly suggest that the most relevant part of Szasz’z argument to this problem is that psychiatry doesn’t have to earn its customer base in a competitive environment, that most of behavioral healthcare relies directly on entitlement to the legal right to detain, and that almost all of it relies indirectly on the hospitals being places that stand in for “holding the disorderly people” and absolutely really and truly they involve themselves in wholly illegal pre-emptive detentions. These are just too numerous and too favored by communities and relatives of inmates to be protested effectively, much less challenged in court on a regular basis. It’s a joke.

      • Also, while here, I want to comment on your article. I actually did not do that in my original comment, which is why it might have seemed unjustly glib. But in point of fact, although the article impressed my with its friendly tone, and I didn’t give a second thought to its uncertain focus until you and the first couple of respondents hashed it out in the thread, I was overwhelmed by the range of considerations that come into play for so much as approaching the issue and getting the questions right in rough outline. My action was to go to this Szaszian who I personally feel safe in relying on. I should have said “the topic is prone to sidetrack”, because in fact I was thinking of the wider public debate in making that remark, and not your discussion exactly. Those thoughts in that paragraph just are the simple touchstones I call to mind when deciding to decide much of anything about this failure to provide good, cautious, well-explained services for mental health. That said, I believe that my point about why it sidetracks bears on your presentation, while what it doesn’t do is describe it.

        Additionally, whatever underlying brain processes there are, most people alive will never get medically diagnosed and medically treated for medically identifiable disorders, and even the designer drugs won’t prove to do that unless by magic they correct some underlying condition and restore functional capacity. But there’s no way, not in the brain. And it’s a fact that mental illness is a myth before getting to such points in a discussion as involves neurotransitters, anyway. The criteria have to remain linguistic and behavioral, and first and foremost experiential.

        Also, please watch out for the slippery slope with the free will debate. This is a medical model fantasy and huge marketing gimmick to pretend that psychiatrists know what someone has intended when they typically haven’t investigated the situation: their favorite mode of influence is to rule by decree. There is a world of difference between “responsibility without blame” and the hokey justifications of the insanity defense, since it is used, like every other measure in doctors’ control, to shore up their entitlement and publicize their authority in legislating good sense, certainly more often than it is needed to excuse an innocent person. Szasz is right, here, too–he was just a bad writer…

        http://www.szasz.com/1senseless.pdf

  7. Jill
    When you talk about better treatment for psychosis are you talking about people diagnosed with say ‘Schizophrenia’ and ‘Bi Polar’ or are you talking about the proportion of the most disadvantaged people with ‘diagnosis’?

    20% of Americans (I believe take psychotropics), but the impression I took from Allen Francis was that the ‘Schizophrenics’ and ‘Bipolars’ in general ‘needed medicating’ and the rest should probably quit. The title of your blog is broad but you seem to be mostly focused on ‘diagnosis and homelesness’, or the most disadvantaged.

    Homelessness itself is a social problem and unless it’s seen as the ‘governments’ responsibility (as it is in Western Europe) then the problem is likely to continue.

    • I agree with that – that homelessness should be seen as the government’s problem, or maybe societies problem and the government being the agency that takes on the responsiblity to deal with it.

      I also think that if Allan Frances really thinks ‘Schizophrenics’ and ‘Bipolars’ in general ‘needed medicating’ and the rest should probably quit then his vision is extremely limited. I wonder if he has almost no psycho-social information on the causes of mental distress or the power of drug companies or poverty or racism or anything else really?

      • I’m not certain what France’s beliefs on just whom does and does not need medicating. However, since the evidence shows that the most common variable amongst schizophrenics is that they had dealt with adverse childhood experiences, and there are no genetic markers for schizophrenia, and it’s now known the antipsychotics CAUSE the atrophy of the brain formerly thought to be proof that “schizophrenia” was a “real” illness. I don’t see definitive evidence that “schizophrenics” should be medicated, since tranquillizing a person does not actually help a person address and mentally cope with adverse childhood circumstances / real life injustices.

        As to “bipolar” patients needing the “bipolar” drug cocktails, “bipolar” is known to be a “partially or wholly iatrogenic illness.” And, in as much as massive major drug interaction laden drug cocktails can be used to cover up iatrogenesis, they won’t actually cure anyone of bad reactions to antidepressants, ADHD drugs, stimulants, or any other ADRs, drug withdrawal symptoms, or forms of iatrogenesis.

        My point is, I see no medical evidence of long run benefits to psychotropic drugging – even for the so called “schizophrenics” and “bipolar.”

        • Someone Else
          I agree with you about the ‘iatrogenic’, and I don’t believe there is any such thing as “schizophrenia”.

          The bio chemical (or brain damage) model is a theoretical position, and there is no recovery in this approach, only long term disability. But full recovery through psychotherapy and careful drug taper can be substantiated as fact. My own records reflect this.

          The starting point to non drug recovery would be that “schizophrenia” does not exist as an illness.