In my book The Bitterest Pills, I wrote of how many psychiatrists simply do not want to face up to the harms their treatments can produce. This is illustrated by the way the psychiatric establishment tried to avoid the implications of tardive dyskinesia, by suggesting it was a symptom of ‘schizophrenia’ and ignoring the evidence that tardive dyskinesia involves cognitive impairment. Similarly, when it became obvious that some of the second generation antipsychotics caused massive weight gain and metabolic disturbance, mainstream psychiatric journals published articles suggesting that diabetes was linked with schizophrenia as well.
The suggestion that antipsychotics reduce brain volume is not new. Psychiatrist Peter Breggin made this claim over thirty years ago1, but was dismissed as a crank. Over the last 10 years, however, the evidence has become irrefutable. Some leading members of the psychiatric establishment, like the UK’s Robin Murray, have even publicised their concern about it2.
Coupled with and possibly linked to this evidence of harm, doubts have started to mount that the benefits of long-term treatment with antipsychotics have not been as firmly established as is generally believed. The inadequacies of randomised trials of maintenance treatment have been highlighted, and the fact that there is little data on the overall impact of drug treatment when it is taken over the long periods of time that many patients are prescribed it for. Some evidence points towards the possibility that some people may do better if they stop or reduce their antipsychotic treatment, rather than continue on it long-term. These points have been raised by several mainstream psychiatrists3, as well as the usual suspects, including me4!
The paper by Donald Goff and seven other leading psychiatrists published in the American Journal of Psychiatry on May 5th is an attempt to rebut these concerns and re-establish the good reputation of antipsychotics5. I am shocked by how the article dismisses concerns about long-term treatment and evidence of brain impacts. It is riddled with distortion, ignores the most pressing criticisms, and is shot through with the unexamined presumption that the multitude of problems currently labelled as schizophrenia or psychosis will one day be revealed to be due to a specific brain abnormality that is targeted by antipsychotics.
While I would not dispute the usefulness of antipsychotics for the treatment of acute psychosis (in many, though not all situations), decades of research into early intervention has not demonstrated that early antipsychotic treatment improves long-term outcomes. Goff et al’s suggestion that the Norwegian Early Detection study (known as the TIPS study) showed improved long-term outcomes with earlier antipsychotic treatment is not borne out by the paper they cite6. Although the paper shows lower levels of negative symptoms, cognitive and depressive symptoms at the two year follow-up in people from the area with the Early Detection programme compared to those in areas without the programme, baseline data demonstrate that people in the Early Detection area had milder conditions, with fewer negative symptoms to begin with. In fact negative symptoms declined more in people from the area without the Early Detection programme! Moreover, the Early Detection group showed no benefit in terms of remission, relapse or positive symptoms.
Goff et al state that “the effectiveness of maintenance treatment for prevention of relapse has been well established,” but they do not acknowledge how there are no prospective randomised trials of maintenance treatment, only studies of maintenance treatment versus usually sudden withdrawal of maintenance treatment. Thus they completely fail to address concerns that effects of withdrawal of long-term treatment inevitably confound such studies. They also fail to mention the dearth of long-term data from randomised trials. Only 6 of the 65 trials in Leucht et al’s 2012 meta-analysis lasted longer than one year7.
They correctly point out that results of naturalistic studies, like Martin Harrow’s long-term follow-up of people from Chicago8, and the Finnish cohort study 9, are affected by the fact that patients who stop antipsychotics successfully are likely to have less severe conditions. However, they also claim that two other naturalistic studies found “improved outcomes in people with schizophrenia in people who continued antipsychotic treatment with those who did not.” Yet the papers cited refer to quite different sorts of studies, with neither presenting any data on global outcomes or social functioning, and only one involving the sort of follow-up periods of the Finnish and Chicago studies. One of the papers referred to looked at rehospitalisation rates within 3 years of antipsychotic discontinuation in a national database10, and the other looked at mortality rates11 (also see the extensive critique of this paper by De Hert et al, 2010). 12
The most worrying thing about the Goff et al paper, however, is the minimisation of the evidence that antipsychotics produce brain shrinkage. First the authors claim that shrinkage of brain grey matter has been shown to be part of schizophrenia. They trot out the old adage that brain differences were detected long before the introduction of antipsychotics. The paper they cite here is a post mortem study published in 1985, long after antipsychotics had been introduced13. The air encephalography studies that properly pre-date the introduction of antipsychotics involved long-term institutionalised patients who had been heavily treated with various sedative drugs along with physical treatments such as ECT and insulin coma therapy. Although these are commonly referred to as evidence that people with schizophrenia have smaller brains and larger brain ventricles, in fact the only two which had proper control groups showed no difference between brains of people with schizophrenia and brains of people without 14 15.
In any case, the presence of differences between the brains of people with schizophrenia and controls does not establish that there is progression of brain volume loss, which is what has been clearly demonstrated in people and animals taking antipsychotics. There are no studies that show progressive brain changes in people diagnosed with schizophrenia or psychosis in the absence of antipsychotic treatment. The authors cite one report from a group in Edinburgh suggesting progressive brain loss in people at ‘high risk of psychosis’ prior to receiving antipsychotic treatment16. However, this study finds subtle changes in some regions in a very small number of patients, not the cortex-wide loss of grey matter observed in people and animals taking antipsychotics.
Goff et al also cite a paper which showed decreases in grey matter volume in eight people following antipsychotic discontinuation compared to eight people who continued taking antipsychotics. However, the changes were localised to the putamen and nucleus accumbens, components of the basal ganglia, which other studies have shown to be enlarged during treatment with antipsychotics. Far from concluding that the study is evidence “that volume changes reflect progression of illness” as Goff et al suggest (P 5), the authors of the discontinuation paper concluded that “discontinuation reverses effects of atypical medication”17.
When describing the animal studies that show antipsychotic induced brain volume reductions18 19, Goff et al suggest that “the relevance of findings in rodents and monkeys to the treatment of psychosis in humans is unclear, both because of species related differences, and because animals lack the pathophysiology of schizophrenia. It is possible that antipsychotics have deleterious effects on normal brain, but protective effects in the presence of schizophrenia-related neuropathology” (P 6). Anything is possible, but this is just a leap of faith, and one that is completely at odds with the Hippocratic oath to ‘first do no harm!’ Monkeys and rats were chosen for these studies because of their similarities to human biology. There is no good reason at present to assume that the effects demonstrated in these animals would not occur in a similar species, i.e. us! And there is no evidence that antipsychotics have different effects on the brains of people with and without schizophrenia — although of course such evidence would be very difficult to obtain. I agree with Goff et al that these changes have not been definitively linked with effects on actual mental functioning, and that we need further data on this, but as they correctly suggest, ‘most but not all’ current studies show that brain volume reductions are correlated with decreased intellectual performance.
I still think antipsychotics can be useful, and that the benefits of treatment can sometimes outweigh the disadvantages, even in the long-term for some people. However, it does no one any service to pretend that they are innocuous substances that somehow magically transform (hypothetically) abnormal schizophrenic brains back to normal. Psychiatrists need to be fully aware of the detrimental effects of antipsychotics on the brain and body. They also need to acknowledge the way these drugs make life so miserable for many people, even for some who might have been even more distressed were they to be without them, something that is well described in Miriam Larssen-Barr’s recent blog here on Mad in America. Psychiatrists need to support people to evaluate the pros and cons of antipsychotic treatment for themselves and to keep doing this as they progress through different stages of their problems. To do this they need to be able to acknowledge the real nature of these drugs, and not sweep inconvenient truths under the carpet!
- Breggin P. Hazards to the Brain. New York: Springer Publishing Company; 1983. ↩
- Murray RM, Quattrone D, Natesan S, van Os J, Nordentoft M, Howes O, et al. Should psychiatrists be more cautious about the long-term use of antipsychotics? British Journal of Psychiatry 2016;209:361-5. ↩
- Leucht S, Heres S, Hamann J, Kane JM. Methodological issues in current antipsychotic drug trials. Schizophr Bull 2008 Mar;34(2):275-85. ↩
- Moncrieff J. Antipsychotic Maintenance Treatment: Time to Rethink? PLoS Med 2015 Aug;12(8):e1001861. ↩
- Goff DC, Falkai P, Fleischhacker WW, Girgis RR, Kahn RM, Uchida H, et al. The long-term effects of antipsychotic medication on clinical course in schizophrenia. American Journal of Psychiatry 2017;ajp.psychiatryonline.org. ↩
- Melle I, Larsen TK, Haahr U. Prevention of negative symptom psychopathologies in first-episode schizophrenia. Arch Gen Psychiatry 2008;65:634-40. ↩
- Leucht S, Tardy M, Komossa K, Heres S, Kissling W, Davis JM. Maintenance treatment with antipsychotic drugs for schizophrenia. Cochrane Database Syst Rev 2012;5:CD008016. ↩
- Harrow M, Jobe TH, Faull RN. Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study. Psychol Med 2012 Oct;42(10):2145-55. ↩
- Moilanen JM, Haapea M, Jaaskelainen E, Veijola JM, Isohanni MK, Koponen HJ, et al. Long-term antipsychotic use and its association with outcomes in schizophrenia: the Northern Finland birth cohort 1966. Eur Psychiatry 2016;36:7-14. ↩
- Tiihonen J, Walhbeck K, Lonnqvist J, Klaukka T, Ioannidis JP, Volavka J, et al. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study. BMJ 2006 Jul 29;333(7561):224. ↩
- Tiihonen J, Lonnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009 Aug 22;374(9690):620-7. ↩
- De Hert M, Correll CU, Cohen D. Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study. Schizophr Res 2010 Mar;117(1):68-74. ↩
- Bogerts B, Meertz E, Schonfeldt-Bausch R. Basal ganglia and limbic system pathology in schizophrenia: a morphometric study of brain volume and shrinkage. Arch Gen Psychiatry 1985;42:784-91. ↩
- Storey PB. Lumbar air encephalography in chronic schizophrenia: a controlled experiment. Br J Psychiatry 1966 Feb;112(483):135-44. ↩
- Peltonen L. Pneumoencephalographic studies on the third ventricle of 644 neuropsychiatric patients. Acta Psychiatr Scand 1962;38:15-34. ↩
- McIntosh AM, Owens DC, Moorhead WJ, Whalley HC, Stanfield AC, Hall J, et al. Longitudinal volume reductions in people at high risk of schizophrenia as they develop psychosis. Biol Psychiatry 2011;69:953-8. ↩
- Boonstra G, van Haren NE, Schnack HG. Brain volume changes after withdrawal of atypical antipsychotics in patients with first episode schizophrenia. J Clinical Psychopharmacology 2011;31:146-53. ↩
- Dorph-Petersen KA, Pierri JN, Perel JM, Sun Z, Sampson AR, Lewis DA. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. Neuropsychopharmacology 2005 Sep;30(9):1649-61. ↩
- Vernon AC, Natesan S, Modo M, Kapur S. Effect of chronic antipsychotic treatment on brain structure: a serial magnetic resonance imaging study with ex vivo and postmortem confirmation. Biol Psychiatry 2011 May 15;69(10):936-44. ↩
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Re. diabetes. In their now out of print book, The Hallucinogens, Hoffer and Osmond suggested an inverse relationship between diabetes and schizophrenia, pointing out that schizophrenics have a much lower incidence of diabetes than the population at large- at the time the text was written there were 5 diabetics in a Saskatchewan mental hospital population of 3300.
Great article Dr Moncrieff! Balanced and fair
What’s the point of rehashing Moncrieff’s research over and over again? She’s right for blessed sake.
I was diagnosed early in life at 18 with the dreaded P. Schiz label. Indeed, I was depressed and anxious, that was taking it a stretch as I re-examine my life’s course. It was likely my Hashimotos and sensitive thyroid that may have brought on “symptoms” that the DSM categorizes as a “disease,” the “canary in the coal mine,” is our thyroid gland; sensitive to toxins and environmental stress.
I’ve played the devil’s advocate in my own behalf… I was on neuroleptics for almost 30 years and now off (through my own volition and efforts) for 16 months and still struggling. Enough of the academic arguments against these “drugs,” we need help and intervention, all know these drugs are poison, they know, we know they know, they lie. Joanna and others haven’t experiences what survivors like me have; a trauma that only compares to nothing that should ever be part of a “normal” human experience. I will likely not be of this earth soon, not because I take my own life, but because I am withering and suffering in my own stress torn body. A life that should have been filled with love, happiness, fulfillment, achievement, and growth.
I’ve seen everyone from Breggin to those who purport to follow his rational approach now. We need a voice and support from our neighbors, from the public, from former friends and companions who have been sold to psychiatry….
I want to live, others like me do too. Is this a hopeless situation? Are we going to re-hash the obvious time and time again? I want to go out and be me again
David BA, MS
I hear you David. Right now I feel like I can’t trust anyone where I live. I may be able to educate Dad on the hoax of psychiatry.
For some reason my Mom has lost her “edge” mentally. A bit worrisome. Not senile, just lazy–especially cognitively. Content to get all her “mental health” education from television programs and drug commercials. Being on Celexa doesn’t help her. 🙁
The evidence we have from John Read (Models of Madness) and others writing about trauma, poverty, neglect and so on shows that “psychosis” is most often not an “illness” one is “at risk of”, but the individual’s understandable responses of terror, rage, confusion and despair to adverse experiences and deprivations in life. It is these feelings, primarily, that generates the “symptoms” of psychosis and the resulting incapacity of social and work function. Thus giving tranquilizers – and that is what they are, not medications – to severely distressed persons cannot possibly address the life problems leading to such breakdowns over the long term, except to make a person progressively less able to feel their thoughts and feelings, and progressively less able to respond flexibly and adaptively to life’s challenges.
I think your article is great, except it uses a lot of medicalized language that is inappropriate to what is simply severe human suffering.
The Goff article can be viewed as a positive thing: It shows that Lieberman et al are sufficiently threatened by antipsychiatric and critical psychiatric criticism to have to start speaking out against it preemptively and aggressively. These authors sense that the cash train that is antipsychotic drug treatment – all 18 billion dollars a year of it – is going to become increasingly vulnerable to derailment as the evidence about how ineffective and nonmedical tranquilizers really are is revealed to a wider and wider swath of the public. Such changes in awareness, and the growing realization that profound distressed labeled “schizophrenia” does not constitute a lifelong, incurable brain disease- these also undermine the medical identity of these authors and their claim to be doctors treating diseases of the brain. Their incomes and status may greatly diminish if their most cherished “illness”, “schizophrenia”, and its supposed treatment, “antipsychotic treatment”, are revealed as what they really are. In this regard, “schizophrenia” and “antipsychotic medications” should become a prime target for antipsychiatrists and critical psychiatrists, being the Achilles heel of psychiatry as they are.
Your article make many great points, but it could go even further. Rather than saying, “Psychiatrists need to support people to evaluate the pros and cons of antipsychotic treatment for themselves and to keep doing this as they progress through the journey with their condition.” It could say many people do not need psychiatrists period; non-medical therapists and friends/family are more than enough for many psychotic people to get well, just as they are/were in poor countries today and in the past, as evidenced by the World Health Organization’s studies in Agra, Columbia, Mauritus, Nigeria etc.
Also Joanna, I’m wondering why you don’t write, “tranquilizers or neuroleptics can be useful, and the benefits of tranquilizing people can sometimes outweigt the disadvantages”
or, “While I would not dispute the usefulness of tranquilizing or numbing people for the treatment of acute distress”…
It doesn’t sound quite so medical or “good”, then, does it?
Euphemisms do have their place too, don’t they…
Be nice, it was her book The Myth Of the Chemical Cure that explained to me what a fraud psychiatry was the serotonin lies ect and set me on the path to recovery from the psychiatric nightmare.
I completely agree about the naming of drugs. The term ‘antipsychotic’ is euphemistic at best, and downright misleading or dishonest at worst! I have taken to using it because when I asked my medical students what neuroleptics were they didn’t know what I was talking about! The term antipsychotic seems to be more widely recognised now. I agree this situation is lamentable, but we need to communicate with people who don’t necessarily know as much about it all as we do.
On your other points, I guess I was aiming the piece partly at the authors of the Goff et al paper, and the sort of professionals who might be influenced by them. Hence I was trying to write in their terms, and to respond quite narrowly to the points they raise. I agree there is a much bigger battle to be fought about the nature of ‘mental disorder,’ how to help people and who should do this.
Good to hear back from you; I really like and support your incisive critical writing in general.
Language about distress is so powerful in shaping feelings and perceptions – we just had a discussion about this in ISPS. There is the necessity to use what may in some ways be euphemistic misleading terms in order to alert laypeople or others within one’s profession to one’s article, as you said. However, if it goes on too long and new ideas are not later introduced which question dogmatic assumptions based on euphemisms, it can lead to reinforcing misleading, stigmatizing terminology.
It’s a difficult conundrum. I also criticized Bob Whitaker for it at one time in the past, and he responded in a similar way to you. But I think he is also very aware of problems with the common use of terms like “schizophrenia”, “antipsychotic”, “medication”, “illness” etc, and uses them with increasing awareness and more lightly over time. To most psychiatrists, however, I think the use of these terms is not “light” at all, but a key identity piece and means of maintaining social control and perceived knowledge/authority in the eyes of consumers.
With me, it’s a bit more of a personal thing, because I don’t like to have my (past) experience and others’ experience of severe distress labeled as illness or disease when it is in fact uniquely personal, subjective, and transformable.
Anti psychotic is a convenient term because if a person takes this drug then “they are taking antipsychotics”.
“An international group of experts was convened…” – where? when? who funded this ‘convening of experts’? No information whatsoever. Traditionally such convening of psychiatric experts on a drug topic has been funded by drug manufacturers, under a ‘university cover’. The full article disclosures are below. I wonder if Dr Donald Goff [email protected] might answer the questions above regarding funding of this ‘expert consensus’ project. Others might enquire, i don’t have the time and energies.
“Full” disclosures from article (inverted commas as it appears bizarre that none are noted for Leiberman)
From the Nathan Kline Institute for Psychiatric Research and New York University Langone Medical Center, New York University School of Medicine, New York; the Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany; the Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry, Medical University Innsbruck, Innsbruck, Austria; the New York State Psychiatric Institute and New York Presbyterian Hospital-Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York; the Department of Psychiatry, Brain Center Rudolf Magnus, UMC Utrecht, Utrecht, The Netherlands; the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; and the Department of Psychiatry, Chinese National Clinical Research Center for Mental Disorders, Mental Health Institute, The Second Xiangya Hospital of Central South University, Changsha, Hunan, P.R. China.
Address correspondence to Dr. Goff ([email protected]).
Dr. Goff has received research support from Avanir Pharmaceuticals, NIMH, and the Stanley Medical Research Institute. Dr. Fleischhacker has received research support from Boehringer-Ingelheim, Janssen, Lundbeck, and Otsuka; he has received honoraria for serving as a consultant to and/or on advisory boards for Allergan, Dainippon Sumitomo, Gedeon Richter, Janssen, Lundbeck, Otsuka, Takeda, and Teva; and he has received speaker’s fees and travel support from AOP Orphan, Dainippon Sumitomo, Gedeon Richter, Janssen, Lundbeck, Pfizer, Otsuka, and Teva. Dr. Girgis receives research support from Allergan, BioAdvantex, Genentech, and Otsuka. Dr. Kahn has received consulting fees from Alkermes, Forrest, Forum, Gedeon-Richter, Janssen-Cilag, Minerva Neurosciences, and Sunovion and speaker’s fees from Janssen-Cilag and Lilly. Dr. Uchida has received grants from Astellas Pharmaceutical, Dainippon-Sumitomo Pharma, Eisai, Eli Lilly, Meiji-Seika Pharmaceutical, Mochida Pharmaceutical, Novartis, Otsuka Pharmaceutical, and Shionogi; speaker’s honoraria from Dainippon-Sumitomo Pharma, Eli Lilly, Janssen Pharmaceutical, Meiji-Seika Pharma, MSD, Otsuka Pharmaceutical, Pfizer, Shionogi, and Yoshitomi Yakuhin; and advisory panel payments from Dainippon-Sumitomo Pharma. All other authors report no financial relationships with commercial interests.
The authors thank Dr. Shitij Kapur, for his important contributions to the initial formulation of this project, and Dr. Lisa Dixon, for the invaluable perspective she provided as a consultant to the process.
I’m always concerned about mechanisms. A paper by Dominguez-Meijide et al. in Brain, Behavior, and Immunity in May 2017, explores the role of D2 receptors on the angiotensin system in the brain. Turns out that agonists on the D2 receptors on astrocytes decrease the level of angiotensinogen released and increases the anti-inflammatory angiotensin II receptors that counter the angiotensin I receptors. If D2 receptors are blocked (as occurs with all antipsychotics), there will be more brain inflammation. Thus, this might be one mechanism through which antipsychotics shrink the brain.
Good point! I also worry about the narrow focus on dopamine though. Most antipsychotics affect a range of other receptors, which are also likely to be relevant to their effects.
I heard some specialist argue that SSRI’s should rightfully be called SRI’s or Serotonin Reuptake Inhibitors since there is nothing selective about the way they work.
Great article Joanna Moncrieff, thank you for the criticism of the May 5th paper by Donald Goff and others.
Good post, mostly. I have a problem though with a statement like the following:
“I still think antipsychotics can be useful, and that the benefits of treatment can sometimes outweigh the disadvantages. However, it does no one any service to pretend that they are innocuous substances that somehow magically transform (hypothetically) abnormal schizophrenic brains back to normal.”
Keyword, sometimes, the question is when.
I would hope that this conclusion, subjective or not, would not be used as a ruse to psych-drug a patient who objects to taking psych-drugs (i.e. a patient who does not ‘consent’ of his or her own volition), and who, for that reason, might also be accused of “going against medical advice”.
I have yet to see a circumstance in a clinical situation where patients are given a choice in the matter, and this, I think, ultimately disastrous; the supposition being found in a similar statement, without any qualms, that neuroleptics are “useful and the benefits of treatment outweigh the disadvantages.” Here we are put at risk for innumerable negative “effects”, among them, Tardive Dyskinesia, metabolic syndrome, “lowered brain mass”, etc., and we still don’t have any say in the matter. I’d say, in the overall scheme of things, the opposite statement is more true. Long-term, neuroleptics are not very useful, and the deficits of such treatment, by far, outweigh the advantages.
Listening to patients who have qualms about taking dangerous and potentially harmful neuroleptics, even short-term, the question becomes, is there a place for that in your “sometime beneficial usage”?
thank you for your comment. I understand your concerns, and how horrible it must be to have these drugs forced on you. I do see some people, however, who are really distressed and overwhelmed by psychotic experiences, tormented by paranoid feelings and voices and utterly engrossed in a bewildering and often frightening internal world. In this sort of state people are unable to connect with other people, so providing other sorts of help is difficult. Also, in a situation like this someone may not be able to make a proper choice. Sometimes antipsychotics can suppress the experiences enough to enable the individual to reconnect with reality and engage with people again, and then they have more chance of taking back control of their life, whether this ultimately involves taking medication or not.
first thank you for your thoughtful article.
I’d like to comment on your comment: “I do see some people, however, who are really distressed and overwhelmed by psychotic experiences, tormented by paranoid feelings and voices and utterly engrossed in a bewildering and often frightening internal world. In this sort of state people are unable to connect with other people, so providing other sorts of help is difficult.”
Respectfully, I took my wife thru d.i.d. and most of the symptoms you describe here are pretty much par for the course(we are in the end stages at this point). She didn’t need any drugs: I simply used attachment theory and it’s concepts of ‘safe haven’ and ‘affect regulation.” And at this point, I’m in the process or helping her reshape her ‘inner working model’ such that it reflects a more healthy one not based upon her early childhood trauma (her frightening inner world as you put it).
It can be done, but I understand that it’s way beyond what an expert is able to do simply because of lack of access and the time commitment that is required. That’s where I dream of the day when experts like you would team up with SO’s and family members like me. I had to learn all this by trial and error, but if my wife’s counselor had been willing to work with me and team up with me instead of protecting my wife’s privacy to the extreme, she could have facilitated the process instead of making me learn it on my own.
Again, thank you for this thoughtful article, but there are alternatives even in extreme cases; it’s the time commitment and attachment relationships that are key, though.
Hi Sam. Would you be able to write more in detail about the techniques you used to help your loved one? This could be of amazing help for me and a close relative. If so, please write to [email protected] and we can talk. Thank you very much and thanks a lot for sharing here.
I would be happy to correspond with you, and I would also direct you to my blog where I have tried to lay out many of the attachment theory principles and other things I have learned to help my wife. It is at samruck2.wordpress.com and if you have specific questions that aren’t on the blog, I can be reached at [email protected]. But I will also send this to the gmail account you listed in case you don’t see this reply.
Neuroleptic Eye Effects And the Doctoring of Patients Records + Eye Research.
I developed a serious eye condition a few years ago and attended two Top UK Eye Hospitals for investigation.
Since Neuroleptic medication had, had bad effects on my eyes I explained this to the eye doctors, as part of my history. I also explained that my neuroleptic consumption had been many many years ago and I had made good Longterm Recovery since (through Psychotherapy).
On applying and receiving my clinical notes I was taken aback to see that reported Historical Neuroleptic Eye Effects were missing – and that negative ‘Mental Health’ comments had been entered into the notes instead.
Both Top Eye hospitals had automatically engaged in this type of record doctoring.
This is all too common. My regular doctor rarely takes my concerns seriously because he considers me to be a non-compliant schizophrenic. He sees my issues as hallucinations. switching doctors does little because my medical record will forever have the words paranoid schizophrenia in it.
If I could go backin time and tell myself to keep my mouth shut around psychiatrists I would.
I would suggest that you add the provisions of the Harrow study, which found that patients with BETTER prognoses did worse on neuroleptics than patients with WORSE prognoses off neuroleptics. This really undercuts the idea that only the “less ill” do better off drugs. I don’t think you should concede that point at all.
Otherwise, great data, well argued. Thanks for keeping up the fight!
I do not understand why the most obvious answer is never considered: atrophy of nervous tissue causes brain shrinkage in “diagnosed people” from depression and especially from sedation reducing brain activity.
Simple. It might cut into the profit margins of Pharma-psychiatry. Hence Goff and all the other quacks have declared a War on Truth.
In the 20 years from 1975 – 1995, I saw several psychiatrists and was prescribed literally dozens of different psych drugs. I had 2 State hospitalizations, and several minor, shorter stays in local hospital psych wards. I was told repeatedly that I would need the drugs “for the rest of my life”. I read Dr. Peter Breggin’s “Toxic Psychiatry” in the early 1990’s, and found it to agree with what I’d already figured out on my own. Psychiatrists *LIE*!.
Now, I’ve been 20+years FREE of both psychiatry b& psych drugs, and I’m more whole, healthy, and happy than ever. Psychiatry is a pseudoscience, a drug racket, and a means of social control. It’s nothing more than 21st Century Phrenology, with potent neuro-toxins. Sometimes, some people do seem to do better, for some short length of time, on some psych drugs. But, long-term use of polypharmacy almost always results in worse outcomes. Thank-you, Dr. Joanna Moncrieff.
That is the biggest awakening when I finally realized that they were lying to me! When I finally realized that they did not have my best interests in mind, and that they did not care if the meds damaged me more than the psychosis ever does.
Some people never come to this realization. It is almost like the beginning of the movie called The Matrix when he suddenly realizes what is really going on.
I realize that Joanna has done a lot of great work, and that Mad in America is generally doing great work. But allow me to respond briefly to the following statement:
“I still think antipsychotics can be useful, and that the benefits of treatment can sometimes outweigh the disadvantages, even in the long-term for some people.”
This is simply not true. I could say that the benefits of running full tilt into a brick wall can sometime outweigh the disadvantages, even in the long-term for some people, but those people – who are real people by the way – would be people other than myself. How easy it is to see the benefits of people smashing into a brick wall from the outside.
I agree with Slaying–below. I would suggest though, Slaying,.. that you substitute the analogy of undergoing a frontal lobotomy.
Let me just add one thing. If we were to conduct an experiment, if every Mad in America pundit, writer, commentator, and reader would start his or her own daily regimen of psychotropic drugging in order to understand what is truly at stake, I submit to you that the whole tenor of this organization would change. What becomes abundantly clear as I read these articles is that there is an complete disconnect between reality on the one hand, and the detached, academic, sophisticated approach to understanding so-called “mental illness” and psychiatry on the other. The suffering inflicted by psychiatry is massive and real. The cost of human life and suffering is real. We are talking about real people, with real lives, with real hopes and dreams. Please do not try the experiment, because if you do, you could end up in a variety of places (the morgue, the psychiatric prison system, the streets, etc.), and you would not be able to do the work of exposing psychiatry for what it is… an insidious hoax of colossal proportions. If, after ingesting a portion of so-called “anti-psychotics” (which, by the way, Breggin and others have clearly indicated is a misnomer), one was still able to write articles, he or she would advocate the abolition of psychiatry.
No thanks, even though I’d only be awake 9 hours a day, so I wouldn’t notice getting fat or the tremor that’s likely to become permanent.
Neuroleptics, Serotonin Reuptake Inhibitors, and Benzodiazepines reduce the chances of recovering from madness. Without using these poisons you have a 70% chance of getting better. With them you have 0%. Psychiatric professionals like those odds–because they’re good for business. I do not.
Thank you for challenging the orthodox ideology that establishment psychiatry attempts to present as science. Their behaviour is a classic demonstration of Thomas Kuhn’s paradigm theory. He pointed out that established thinking in any scientific discipline will doggedly hang on to old ideas until anomalies and inconsistencies build up to an almost ludicrous degree.
Then – often forced by some new and apparently incontrovertible piece of evidence – the establishment will undergo a “revolution : a sea change, after which trend setting scientists will start believing ideas that, sometimes only months before, they had been contemptuously deriding.
As you have previously noted with your rejected attempts to inform the British Royal College of Psychiatrist’s annual meeting of this new evidence, the establishment don’t want to hear the evidence.
Joanna, Excellent article but there is a fly in the ointment. I appreciate your immense contribution to the “counter-narrative” as Robert Whitaker calls it. As you make clear, contrary to the conventional narrative the evidence undermines the claim that “schizophrenia” is a progressive brain disease, and confirms the proposition that anti-psychotics cause brain damage. This would be no surprise to the psychiatrists who promoted these drugs in the 1950s, often praising Thorazine as a “chemical lobotomy.” Nor would be a surprise to Peter Breggin MD who argued in the early 1980s that the “therapeutic effect” of neuroleptics was a product of brain damage.
However I must strongly object as have others have here to your statements in your last paragraph, “I still think antipsychotics can be useful, and that the benefits of treatment can sometimes outweigh the disadvantages, even in the long-term for some people.. Psychiatrists need to support people to evaluate the pros and cons of antipsychotic treatment for themselves and to keep doing this as they progress through different stages of their problems.” I also objected to Dr Larssen-Barr’s similar statement, but in her response to me (online, here) she back-pedaled and said she did not recommend long term use of of anti-psychotics.
There are a lot of problems with this agnostic, seemingly libertarian, position. But let me ask you first: Where do you draw the line? I am sure there are patients in the 1950s who would have told you they benefited from lobotomies. Did the benefits of lobotomies outweigh the disadvantages FOR SOME PEOPLE? Should dissidents professionals have taken a wait-and see approach?(Virtually no one opposed lobotomies) Of course LONG TERM use of neuroleptics–the topic in dispute– like lobotomies produce irreversible effects.
Although you post on the blog started by Robert Whitaker you seem to be unfamiliar with his essays on anti-psychotics. First of all, I think Bob shows there is far more evidence than you indicate about the effects of “anti-psychotics” and the advantages of avoiding long term use. He discusses that evidence and its cumulative weight in many of his articles. You repeat the same canard about the Harrow study made by Frances, Pies, Torrey et al and others which Whitaker has repeatedly refuted, along with the charge that he doesn’t understand “science.”
It demonstrates more than a correlation. Patients who got off the drugs did so not because
their symptoms were less severe (they were not) and thus they decided with their psychiatrists to get off the drugs (as Pies claimed) but because they were “non-compliant patients.” But the Harrow study is one of many indicating–along with Bachoven, WHO, Wunderink,Open Dialogue, to mentioin a few– that patients in general do far better without neuroleptics. https://www.madinamerica.com/mia-manual/antipsychoticsschizophrenia
This led Whitaker to finally courageously conclude:
“I think the scientific literature argues for using antipsychotic medications in a selective manner that seeks to minimize their long-term use….But if psychiatry is going to be “evidence-based” in its practices, and if it is going to put the interests of its patients first, then I believe it has a duty to develop selective-use protocols, which seek to minimize long-term use of antipsychotics (and other psychiatric medications). I also believe that our society should provide the resources to enable this rethinking of the drugs.”
The moral obligation of the mental health professions to seek to minimize
the long term use of anti-psychotics has become a meme repeated throughout Whitaker’s writings. I think it is because Bob takes this position, particularly courageous for an outsider–he is a journalist, not a mental health professional nor an MD— that he is such an irritant to people like Jeffrey Lieberman, former APA President, who called him a “menace to society.” I think all dissidents professionals should follow Whitaker in taking up this position. This puts the responsibility where it should lie–not on patients, but on psychiatrists and on society.
Your wait and see approach is problematic for a number of reasons. I presume you agree that on the whole the costs of neuroleptics outweigh the benefits. You imply there is a small group for whom the reverse is true. These poor souls are so bad off –so severely afflicted by so called “schizophrenia ” –that the suffering the effects of brain damage (high likelihood, with varying effects) and/or tardive dyskinesia(very high incidence), diabetes,metabolic disorders,impotence, obesity, 15-20 years decrease in life span etc etc are outweighed by the benefits. That is, you claim that without neuroleptics these persons would be far worse–the same claim psychiatry makes when they are honest about the adverse effects of the drugs.
But we have no way of knowing in advance, Joanna how to identify these alleged benefitters. (It is not true that they are the ones with most severe symptoms initially). Thus in order to minimize harm we have to discourage long term use. Of course even if there were a number of psychiatrists who discouraged long term use (there are practically none in the US) there would still be patients who would take the drugs. (I am noit advocating making them illegal.)
I don’t believe these drugs are beneficial for anyone.There are certainly patients who claim they are benefitting, but how can you exclude the placebo effect? How can you exclude the nocebo effect–these poor patients have been terrified by doctors and authorities and parents and the media and NAMI into believing that “the meds” are their only life line to sanity, their only protection against a life time of torment by “mental illness,” by all the most horrific specters of their imagination. And they have been told by the doctors they trust–unlike the persons who read subversive blogs like this, the average person trusts her doctor– that if they take their medication they can hang on to sanity, avoid rehospitalization, quiet the demons in their mind. And everyone they know says “Take your meds.” If you think I exaggerate, re-read Kate Millett’s The Loony Bin Trip to see how her radical lesbian feminist artist friends handled Kate’s “mental illness.”
Please read the story told by Jan Carol in response to Dr Larrsen-Barr https://www.madinamerica.com/2017/05/responding-to-claims-that-the-benefits-of-antipsychotics-outweigh-the-risks/#comment-108165
I am going to quote the first few paragraphs. But let me say in closing some more positive words(qualified by the awareness that hope itself sadly can only be offered by the few dissidents since the psychiatric-pharmaceutical complex is unassailable)– the placebo effect is so powerful, and the therapeutic effects of social support are so potent, that I do not think it would be difficult to help patients cope without long term use of neuroleptics, unless they are already addicted. But it is professionals’ responsibility to give patients the reassurance they need that they can cope without neuroleptics (the worst of any of the drugs available, and thus in a class by themselves)–and not create more generations addicted to brain-disabling “anti-psychotics.”
Jan Carol writes:
” I have a dear friend who is being killed by the drugs. She has metabolic disorder, her endocrine is shutting down (Hashimotos, adrenal fatigue), has been diagnosed with TBI, suffers huge cognitive deficits, and her opportunities and options are cascading into collapse. She has been on Seroquel for at least 20 years, and various cocktails. Her current cocktail includes 5 drugs.
If you talk to her, she will express gratitude that she does not have intrusive delusions, that her behaviour is under control, and she is thankful for the benzo that can put her anxiety on hold for awhile, and grateful for the Z drug that helps her sleep.
But if you get to know her, and see the 30 point IQ loss, the chronic motor dysfunctions (shaking, jerks), the thyroid difficulties, the inability to address her situation or her problems with anything more than “whatever,” and see the constant drive to suicide, self harm – you will think: this is not a well person.
BUT HER DOCTORS AREN’T GOING THERE. They just treat her, “business as usual.”….
That’s the difference between knowing and understanding. She hears me talk about the harm of the drugs – but is so terrified (and conditioned to be so by the drugs) and has suffered akathisia, TD and cognitive decline for at least 20 years. How could she possibly go through this to a life of freedom from the drugs?
Where are the people to help her do this while she is worried about having enough food to eat, or how to pay her bills? This is clearly the result of long term neuroleptic and benzo use – but – how do you save her from what is killing her, when she believes so firmly that she “needs” it?…
The drugs cause more harm than good. Especially when you take the long term view into the equation.”
Here’s a question. Why are neuroleptics needed at all? Even short-term use to help a patient sleep or calm down to ease hallucinations seems unnecessary. All neuroleptics called antipsychotics are good for is tranquilizing someone. Aren’t there already tranquilizers that could be used? Many may even have been on the market for 60+ years–twice as long as most neuroleptics commonly used today. This would give a patient more information about the drawbacks to using the drug.
By the way, Joanna, if you read my comment and have the time I would really be grateful for an answer. You know more than I do about this.
Could ordinary tranquilizers be substituted for neuroleptics in long-term psychosis that gives little hope of improvement? If not, why not?
I suspect I’m not the only person here who wonders this.
Perhaps as a companion piece to this article, Mad in America might publish a list from the F.D.A. of all the various kinds of harm the worst of this class of drugs, Zyprexa, has done to countless Americans. I doubt if the F.D.A. records contain the number killed of people killed by it, but they number in the many thousands. Or, perhaps, an interview from a family member who lost a loved one….the article is fine in and of itself, but this sort of cold water slap of reality might bring the point home. Adults and children continue to be killed and maimed by these drugs.
When I went on Zyprexa my hair fell out! Almost as bad as chemo in that regard.
The Norwegian Early Detection study (known as the TIPS study) has been subject to a critical analysis:
– At 10 year follow-up, all the clinical and functional measures of the original study are not significantly different (and one measure is worse for the treatment group). Despite this, the authors claim in the abstract to have demonstrated that earlier detection of psychosis has reduced deficits and improved function. They base this conclusion on a completely new measure called “recovery”, which was not considered at baseline, 1 year, or 5-year follow-up, and which appears to be a proxy for vocational outcome, itself not significantly different at five-year follow-up.
– They do not examine the original hypothesis, that longer DUP causes a worse outcome, despite reporting a logistic regression which demonstrates no association between DUP and outcomes.
– They do not consider the alternative hypothesis, which emerged spontaneously before it was presented, that the intense effort to identify patients with psychosis might also sample selectively and recruit a less affected group of people.
– They do not report hospitalisation, despite this measure being significantly worse for ED patients at five-year follow-up (suggesting early detection actually caused a worse outcome)
They discuss only the putatively better outcome of recovery in the ED group, without discussing the relatively worse outcome in independent living for the ED group
– They suggest that the non-significant results may be due to the selective attrition of relatively higher-functioning patients from the ED group, but do not discuss the fact that there was a selective attrition of patients with longer DUP from the ED group, and not from the no-ED group. If longer DUP is a causal mechanism, this would improve the measured outcomes of the ED patients.
25 September 2017 from Google cache:
Long-term Follow-up of the TIPS early detection in psychosis study: Effects on 10-year outcome – facilitated by Dr Andrew Amos
WHAT is “DUP”? I can’t figure it out from the context. And is “ED” “early detection”?….
Walter, I think the gist of your comment is that long-term outcomes are worse, overall, with psych drugs and “standard” psych “treatment”, but that mainstream psychs falsely claim otherwise. Is that about correct?
Yes ED is “early detection” and DUP is “Duration of untreated psychosis”.
I tried to give numbers and I estimated that with “standard” psych “treatment” (e. g. in Norway “National guideline for diagnosis, treatment and follow-up of individuals with psychotic disorders”) approx. 40% of patients loose long-term recovery compared to non-medicated patients. Disability allowance or sick leave goes up more then 40%.: http://home.broadpark.no/~wkeim/files/question-recovery.html
In the Norwegian Early Detection study (known as the TIPS study) both groups where subject to the standard protocoll of medication with antipsychotics. The author claims that the Early Detection group showed better recovery results i. e. approx one third. However Open dialogue using minimal medication reported 80% recovery.
See Scientific Symposium. Pharmaceuticals – risks and alternatives. The 15th of October 2016 in Gothenburg, Sweden. Jaakko Seikkula, Professor of Psychotherapy, Clinical Psychologist, Finland. Naturalistic study designs for developing the system to reduced medication
Jaakko Seikkulas contribution: http://extendedroom.org/wp-content/uploads/2016/10/Open-Dialogueresearchgothenburg102016.ppt