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?
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.