Duration of Untreated Psychosis Revisited: Response to the Goff Paper


Earlier this year, the American Journal of Psychiatry published a paper, “The Long-Term Effects of Antipsychotic Medications on Clinical Course in Schizophrenia.” This was a response to the concerns that have been raised that these drugs negatively impact long-term outcome. The authors conclude, albeit in a somewhat lukewarm way, that overall, the “evidence for a negative long-term effect of initial or maintenance antipsychotic treatment is not compelling.” Robert Whitaker, and Joanna Moncrieff, whose work was cited by the authors, have written critiques of this paper.

Even if one accepts the paper’s conclusions at face value, there is little argument regarding some serious long-term risks such as movement disorders and weight gain. One of the most compelling reasons why these authors support long-term care is related to the relapse data: when one is started on these drugs, the relapse rate is higher when they are stopped than when they are continued (at least over the first two years). However, there is general consensus that there are some individuals who will recover and not need medications long-term. In fact, there is even consensus that some can recover without drugs; the dispute is over numbers.

For me, this raises an urgent question about initial treatment. Doesn’t it make sense to try to capture all of those individuals who might get through a psychosis without drugs? Doesn’t it make sense to invest heavily in interventions that do not rely on drugs as a first-line treatment? At least then we can protect that group — be it 20% or 80% — from the cycle of relapse that seems to begin once the drugs are introduced.

However, this approach has not been carefully evaluated within the mainstream of psychiatry. This is because of the hypothesis — almost elevated to accepted doctrine — that a delay in starting antipsychotic drugs increases the likelihood of a poor long-term outcome. This notion has been around for almost thirty years. If one is interested in offering approaches, such as Open Dialogue, that do not insist on early use of drugs, this is a pressing concern. I addressed the history of this concept — often referred to as Duration of Untreated Psychosis (DUP) — in an earlier blog and I concluded that while there is strong evidence that intervening early with people experiencing psychosis is helpful, the intervention did not have to include drugs. So I read with interest the section in the Goff paper on DUP and I review that here.

Goff and colleagues only devote one paragraph to this topic and cite three papers. They conclude, “The efficacy of antipsychotics for the initial treatment of psychosis is well established. Early initiation of antipsychotics may improve long-term course of the illness, although this has not been established by randomized trials.”

The first paper they cite by Pentilla and colleagues was a meta-analysis of studies that evaluated the association between DUP and long-term outcome. They found that the longer the time before the development of psychotic symptoms and the initiation of treatment, the worse the outcome. However, in this paper, treatment was not synonymous with drugs. Treatment was defined as “antipsychotic medications, psychosocial treatment, contact with treatment services or first hospital admission.” It seems, therefore, impossible to form any conclusion from this paper on the relative merits or drawbacks of the drugs.

The second paper studied was by Melle and colleagues. These authors assessed the impact of an early detection (ED) program designed to help identify and treat individuals who were experiencing psychosis. In this study, the program was effective in identifying individuals and connecting them with a treatment that included not only medication but also significant psychosocial supports. The group in the ED area were less ill at the outset, and, over time, they remained less impaired. There was no difference among the groups in exposure to antipsychotic drugs and there is no specific analysis comparing the duration between initial symptoms and initiation of drug. It seems that what one can conclude from this study is that if individuals are identified early, they tend to be less impaired and they remain so over time. It is hard to know if intervention of any kind had much effect. Again, this paper does not offer any specific information to inform us about impact — negative or otherwise — of the drugs.

The final paper is a thorough literature review of studies that analyzed the association between duration of untreated psychosis — and in this paper, treatment appears to be synonymous with initiation of drug — and various outcomes. They found that those started on drugs earlier had a more robust reduction of psychotic symptoms. They did not find conclusive evidence that the drugs had any impact on function or quality of life. They did not assess long-term outcomes.

It seems hard to support, based on these three studies, the assertion that “early initiation of antipsychotics may improve long-term course of the illness.”

This is not without import.

A frightened individual and his family comes in to my office. They want the best. In our current climate, there can be enormous pressure put on young people already in distress to try the drugs. They often do not like them and when they stop, well-meaning families may implore them to resume. This comes out of fear for the future. This can lead to alienation and a rupture between people who can be so critical to a person’s recovery.

We need to be honest with individuals and their families about what we do and do not know. It does not seem that there is adequate evidence to insist on the drugs as a way to improve long-term outcome and my own experienced suggests this insistence can do harm.

I will be discussing this in my lecture on the MIACE course on Psychiatric Drug Withdrawal.


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.


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  1. I wish you were my psychiatrist, Sandra. Mine’s mantra is drugs, drugs, drugs. In the past, I’ve gone for a decade with no treatment and no symptoms (1990 – 2000) so clearly I’m a good candidate for an alternative approach like you describe.

    At the moment, I’m an involuntary out-patient, being coercively drugged with a 400 mg Maintena injection every three weeks, rather than the recommended four. I’m also on 800 mg Seroquel, 30 mg Abilify and 2 mg clonazepam. It’s an insane maintenance drug regime and will continue indefinitely thanks to British Columbia’s draconian Mental Health Act.

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    • They’re afraid you’ll fall onto Frances Fuller’s patient list. She was Abram Hoffer’s secretary for decades, and got a doctorate in nutritional medicine while working for him. He turned all his patients over to her when he had to give up his practice, shortly before he died.

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    • That’s really insane. I’m not sure that you heart and your body organs will be ok with admission of 4 antipsychotics at the same time. You should do something about it. They are killing you. This is awful. Hope you’ll find a help.

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    • The discussion on patients that have not been treated is the following. In this report from 2012 the damaging effects of antipsychotics of the brain have been proven, see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476840/ . The report show shrinkage of the brain due to haldol and zyprexa, both in humans and in monkeys. This report how ever leaves room to the intepretation that the schizofrenia causes the shrinkage, and the antipsychotics used could be “preventing damage”.

      The article says:

      “The current study could have been strengthened by having control groups, eg, schizophrenia patients assigned to deferred or no antipsychotic treatment or healthy volunteers treated with antipsychotics for comparable periods.”


      “However, ethical standards in human subject research prohibit such comparison groups.”

      This last argument is bogus as plenty of patients fear these medicine and would love to have an alternative treatement without medicine. One should set up a research where patient with first episode psychosis get theere fMRI scan taken and after 2 years of not being treated with antipsychotics another fMRI scan can he taken to show the brain damage done by the schizofrenie it self.

      A test like this would definately prove that it is not the illness that is causes the brain shrinkage and the medicine do, as already show in the test done with monkeys.

      “After 17 to 27 months of treatment, both haloperidol- and olanzapine-treated monkeys had an equivalent and highly significant 8% to 11% decrease in fresh brain weight and volume when compared with the sham group.”

      Monkeys don’t have schizofrenia (we’ll perhaps they hear voices too) so these tests already show with high significance that these drugs do result in brain damage, but he the industry says it is the schizofrenia and not there “can’t do harm” pills.

      Maybe the Open Dialogue movement can give us patients that don’t want to receive medication but that are willing to participate in a research like this. Maybe a University could see the necessity of such a test and perform it, maybe a researcher who knows how to setup such a test could get rid of the last arguments that the industry has.

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    • @Francesca

      As an outsider and a non-westerner, I just want to ask you, just for information; let’s say you were rich. Like quite rich. Perhaps you had 10-15 million $. Would you be able to sue your way out of this torture?

      In fact, can really rich people get away from this nonsense by using their money? Or is even money not enough to get you out of the trap of psychiatry?

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          • Well, once you’re forced into treatment it means that you’re mixed up with the legal system and when you try to drop out of sight they send sheriff’s deputies to search for you and bring you in so you can be forced to spend time in an institution and given the drugs. It’s very difficult to get loose from the system once it has you in its clutches.

            People say that she could move to a different state but most people don’t realize that states have reciprocal agreements to send people back to the state that they ran away from. I think she’d probably have to go to another country to get away.

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          • In “3rd world” countries you could probably do something to escape.

            I suppose in the developed world, the structures have become shackles. Not so much if your life is great to begin with. But in cases like this, when a person has a history of forced treatment (or any history at all), you cannot outrun the law. You could try to defend yourself against the cops and sheriffs etc., but they’ll probably just physically assault you, perhaps even shoot you.

            I fear coming to the “developed” world. Perhaps I am better off in my “3rd world dump where people crap on the streets”.

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    • From the US drugs.com drug interaction site. The US apparently does not have Maintena, so that was not included in the drug interaction check.

      “Interactions between your selected drugs
      “quetiapine aripiprazole
      “Applies to: Seroquel (quetiapine), Abilify (aripiprazole)
      “MONITOR: Agents with anticholinergic properties (e.g., sedating antihistamines; antispasmodics; neuroleptics; phenothiazines; skeletal muscle relaxants; tricyclic antidepressants; disopyramide) may have additive effects when used in combination. Excessive parasympatholytic effects may result in paralytic ileus, hyperthermia, heat stroke, and the anticholinergic intoxication syndrome. Peripheral symptoms of intoxication commonly include mydriasis, blurred vision, flushed face, fever, dry skin and mucous membranes, tachycardia, urinary retention, and constipation. Central symptoms may include memory loss, disorientation, incoherence, hallucinations, psychosis, delirium, hyperactivity, twitching or jerking movements, stereotypy, and seizures. Central nervous system-depressant effects may also be additively or synergistically increased when these agents are combined, especially in elderly or debilitated patients. Use of neuroleptics in combination with other neuroleptics or anticholinergic agents may increase the risk of tardive dyskinesia. In addition, some neuroleptics and tricyclic antidepressants may cause prolongation of the QT interval and theoretically, concurrent use of two or more drugs that can cause QT interval prolongation may result in additive effects and increased risk of ventricular arrhythmias including torsade de pointes and sudden death.

      “MANAGEMENT: Caution is advised when agents with anticholinergic properties are combined, particularly in the elderly and those with underlying organic brain disease, who tend to be more sensitive to the central anticholinergic effects of these drugs and in whom toxicity symptoms may be easily overlooked. Patients should be advised to notify their physician promptly if they experience potential symptoms of anticholinergic intoxication such as abdominal pain, fever, heat intolerance, blurred vision, confusion, and/or hallucinations. Ambulatory patients should be counseled to avoid activities requiring mental alertness until they know how these agents affect them. A reduction in anticholinergic dosages may be necessary if excessive adverse effects develop.”

      Perhaps, you should give this to your doctor? Although, it will just piss him off. Good luck, God bless, Francesca.

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  2. Thank you for continuing the debate on the efficacy of the psychiatric drug “antipsychotics”.

    Myself I was tortured by psychiatry on my first admission to psychiatry with the use of “antipsychotics”. I endured the sensation of extreme thirst and did not have access to water or a bathroom. I was tied to a bed/gurney.

    Today thirty years later , I do not take psychiatric drugs and I am relatively stable . “Stable” meaning out of psychiatric hospital for several years. The relapses in “mental health” I have had , have reasons , not brain chemical imbalances ( to be corrected by a magical chemical-antipsychotic).

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  3. “Even if one accepts the paper’s conclusions at face value, there is little argument regarding some serious long-term risks such as movement disorders and weight gain.”

    Akathisia isn’t a movement disorder, it’s a crime against humanity.

    People who feel the need to do studies and write about the studies should just take a drug like Olanzapine for about two weeks – if you can hold out on it that long – and I promise you will fully realise it’s forced and coercive use is a crime, which has nothing to do with psychosis; it HAS to stop.

    Having studied the glutamate/GABA system in some depth, there is something important there. Anti-NMDA receptor encephalitis causing psychosis is significant. Aspects of the treatment in the use of chemo are terrible and in my view wrong. The question is: why are antibodies attaching to the sub-units of the N-methyl D-aspartate receptor ? If you do not know about NMDA receptor encephalitis watch this:


    The psychiatric part:


    And by the way, I’ve found that psychiatrists really do not like to be informed of this nor asked questions about it, they just ignore me or stop communicating.

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  4. Thanks for this post, Sandy. So glad you are addressing this important topic. The “Holy Grail” of the DUP drives such anxiety, such demands for compliance, such unquestioned certainty. It’s hard for anyone to withstand – let alone a vulnerable, overwhelmed youth & family. Keep up good work.

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  5. The disconnect between the data and mainstream practice is so profound, and it seems that logic and research make no dent in it. It seems obvious that if you could safe 20% of people, or even 10%, or 5%, from the long- and short-term consequences of antipsychotics, anyone who cared about their patients would want to know. I can only conclude that caring about patients is a secondary concern (at best) of our leading psychiatric “opinion leaders.”

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    • Empty billfolds and bank accounts are just not great incentives to get psychiatrists to actually care about the people forced into their so-called “care”. I know for a fact that many of the psychiatrists where I work know absolutely what the drugs do to people but they continue right on forcing people to take them. They just can’t face empty billfolds and bank accounts and having to drive smaller cars and not having their egos stroked for being real “doctors”. I’ve confronted psychiatrists privately and they admit that there are huge problems, but they won’t explain to me why they continue to make use of the drugs. They go silent on me and refuse to continue our conversation. I’ve given copies of studies that prove long-term outcomes are worse for people on the drugs and they refuse to discuss the studies and don’t want to read them.

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  6. The only way the evidence wouldn’t be compelling was if you didn’t take a look at it, if you ignored it, which is exactly what these psychiatrists are doing. Tardive dyskinesia, tardive akathesia, obesity, heart disease, diabetes, death–these are the results of long-term drugging.

    How can they study Duration of Untreated Psychosis without allowing some people to go untreated? The use of psych-drugs is pervasive. I see it everywhere. Resisting the impulse to drug, drug, drug? I don’t see that so much. In fact, deviation from standard practice (drug, drug, drug) can result in civil suits for the doctor doing the deviating.

    Great post! We really need to do something about this epidemic of chemically induced injury masquerading as health care we, if we deal with people in the mental health system, see all around us. It is not health care at all, it is disguised negligence.

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  7. I agree with Dr. Steingard’s analysis. There are enough confounding variables re introducing antipsychotic medication early as to make the study conclusions meaningless. I suggest that other confounding variables are the age of onset and the sex of the individual.

    I am saddened that, knowing what we do know, that many people will not need to embark on this perilous journey in the first place, they are none-the-less continuing to be coerced into it by spurious studies. How quickly one journeys from “first episode psychosis” to being labelled “chronic.” It’s a preventable journey in theory only. Tragic.

    Of course, now that a former pharmaceutical exec (and lawyer!) has been appointed the new Health and Human Services secretary, there’s not a snowball’s chance in Hell that the system is going to change to accommodate those who want to avoid treatment with antipsychotics..

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  8. “We need to be honest with individuals and their families about what we do and do not know”.

    Yes indeed, but in the UK it would appear that mainstream psychiatry dismisses with arrogance and contempt the GMC demanded Duty of Candour.

    It is almost impossible to even complain about the cruelty, contempt and injury inflicted on those correctly – (and often incorrectly) labelled as “psychotic” by these drug-dependent pseudo-physicians.
    Injuries callously caused to those whom, once labelled, have in effect lost all human rights.
    For those labelled and detained for forced drugging, their human rights are lost for life, along with access to all life’s joys and rewards.
    Psychiatry can neither be questioned nor challenged. It most certainly cannot be criticised.
    To do so merely confirms their “correctness” and invites retribution.

    It is impossible to seek redress for the maiming neurological, endocrine, metabolic, genito-sexual, integumentary and disfigurement injuries.
    Not a hope of recognition of the emotional, relationship, financial destruction, nor of the lifelong devastation of self esteem.

    Dishonesty, arrogance, contempt for patients, contempt for families, ignorance and denial of agonising and irreversible ADRs, refusal to ever contemplate an apology to those so terribly injured by psychotropic prescription medications: – these are the characteristics of psychiatrists which I have observed with disbelief.

    There are gifted, courageous and persecuted exceptions who may wish to withhold antipsychotics, to be aware, and to be cautious with drugs and to prevent iatrogenic injury.
    These are the only ones who merit the title “doctor”.

    There are some who are not diagnostically astute enough to differentiate SSRI/SNRI induced toxic delusion from functional psychosis.
    I have seen this error and witnessed akathisia “treated” with enforced antipsychotics.

    It is essential that those who are responsible for such errors are called to account.
    Attitudes will never change whilst immunity to criticism and accountability predominates.
    Without accountability: –
    Dishonesty to, and deception of individuals and their families will remain the routine modus operandi.

    Thank you Doctor Steingard.

    TRM 123. Retired Consultant Physician.

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  9. at long last, an honest psychiatrist. this must be frustrating, for those in the mental health field who actually (gasp) want the best for those in their care.

    Not to sound (too, too) bitter, but my impression of Mental Health, Inc. is that dogma and self-serving lies rule the day. Social class and overall social standing seem to play a bigger role in “treatment” than one’s level of need or severity of distress.

    My last psychiatrist wrote a prescription for a reduced dosage of an “atypical” tranquilizer. I’m happy about that, of course, but I get the sense that his gesture was more about giving me an “attaboy” on his way out to private practice than anything else (it helps that I come from a “good family”).

    Dr.Steingard’s honest review of the literature gives me hope that there are at least a few “mental health professionals” who are trying to use their expertise (and status and authority…) to improve peoples’ lives. Of course, thanks to decades of low quality research and pseudoscientific dogma, it doesn’t seem the “professionals” who actually care have much to work with.

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  10. Most people on these drugs are mad all the time, anyway. I was on drugs for 4 years; what worked, was definitely not the drugs – it was straightforward psychotherapy.

    The psychotherapy might have been described as drug withdrawal psychotherapy but it still works today.

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  11. From a patients point of view RTCs only cover short time symptom reduction and maintenance (typical 12 month) but do not look at recovery (functioning in family and jobb) over many years. Open dialogue reports 80% recovery. Standard care with antipsychotics “(b)etween 8,1 and 20% of service users with FEP achieve clinical recovery (Jaaskelainen et al., 2013)” under the profession’s current protocols.

    Open dialogue tries to medicate as little as possible. i. e. many patients who would be medicated are never medicated in Open dialogue reducing the incidents of psychosis from 33 to 2 per 100 000 annually.

    Is it possible to give a rough guess on the long-term effect of antipsychotics on recovery?

    Antipsychotic medications are viewed as cornerstones for both the short-term and long-term treatment of schizophrenia. The evidence for symptom reduction will be critically reviewed. Are there benefits in terms of recovery?
    Leucht et al has 2009 found (How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials) the effect NNT(Number Need to Treat)=6 for short time treatment (1). However this was looking at 50% or more reduction of symptoms on the Positive and Negative Syndrome Scale (PANSS).
    Leucht et al 2012 looks at maintenance treatment with antipsychotic drugs. Between 7 to 12 month are covered. The results published are better but conclude that it is necessary to “clarify the long-term morbidity”.
    Bola et al. Cochrane.org 2011 (5) found just 5 studies with real placebo, i. e. RCT (Randomized controlled trial). One of them Rappaport et al 1978 found that umedicated patients managed better, e. g. readmission into hospital. NNH turned out to be 2.9 (NNH= number need to harm).
    The Council of Evidence-based Psychiatry exists to communicate evidence of the potentially harmful effects of psychiatric drugs to the people (3).
    Nancy Sohler et al. gives 2016 this summary: «For many years, this (…)clinicians’ belief in the need for long-term use of antipsychotic medications strong (Lehmann, 1966) that it has been impossible to design a sound observational study to address the question of efficacy or harm … (O)ur study also could not conclusively evaluate whether long-term antipsychotic medication treatment results in better outcomes on average. We believe the pervasive acceptance of this treatment modality has hindered rigorous scientific inquiry that is necessary to ensure evidence-based psychiatric care is being offered.»
    So I understand there are nearly no RCT controlled studies (avoiding «cold turkey» problems) answering my question on recovery.
    Real world outcomes and results

    However is it possible to use other studies to evaluate effects based on other studies and real world results?
    WHO Cross-Cultural Studies, 1970s/1980s found (Jablensky, A. 1992, Hopper, K. 2000): 16% of patients in the developing countries were regularly maintained on antipsychotics, versus 61% of the patients in rich countries. 63.7% of the patients in the poor countries were doing fairly well at the end of two years. In contrast, only 36.9% of the patients in the seven developed countries were doing fairly well at the end of two years. In the developing countries, 53% of schizophrenia patients were “never psychotic” anymore, and 73% were employed. In the rich countries, only 37 percent of the patients had good outcomes, and 59 percent had become chronically ill.
    Naturalistic studies of e. g. Harrow, M. & Jobe, T.H. (2012), Harrow et al 2014 (11), Wunderink (4,7) and Wils et al 2017 show that patients do better without long-time antipsychotic medication. Harrow, M. & Jobe, T.H. (2017) concludes in “A 20-Year multi-followup longitudinal study assessing whether antipsychotic medications contribute to work functioning in schizophrenia”:
    “Negative evidence on the long-term efficacy of antipsychotics have emerged from our own longitudinal studies and the longitudinal studies of Wunderink, of Moilanen, Jääskeläinena and colleagues using data from the Northern Finland Birth Cohort Study, by data from the Danish OPUS trials the study of Lincoln and Jung in Germany, and the studies of Bland in Canada,” (Bland R. C. and Orn H. (1978): 14-year outcome in early schizophrenia; Acta. Psychiatrica Scandinavica 58,327-338) the authors write. “These longitudinal studies have not shown positive effects for patients with schizophrenia prescribed antipsychotic for prolonged periods. In addition to the results indicating the rarity of periods of complete recovery for patients with schizophrenia prescribed antipsychotics for prolonged intervals, our research has indicated a significantly higher rate of periods of recovery for patients with schizophrenia who have gone off antipsychotics for prolonged intervals.”
    Jaakko Seikkula et al 2010 (Journal Psychosis Volume 3, 2011 – Issue 3) has reported on long-term outcome of first-episode psychotic patients treated with Open Dialogue Therapy in Western Lapland approx. 80% recovery (6). “Showing the benefit of using not much medication supported by psychosocial care.” 19% were on disability allowance or sick leave with 17% ongoing neuroleptics. Sveberg (2001) reported 62% on disability allowance or sick leave following standard care and 75% ongoing neuroleptics (11). Disability allowance or sick leave goes up more then 40%.
    The effect of cognitive therapy (8) and psychotherapy (9) is documented.
    Bjornestad, Jone et al. 2017 reported “Antipsychotic treatment: experiences of fully recovered service users”: “(b)etween 8,1 and 20% of service users with FEP achieve clinical recovery (Jaaskelainen et al., 2013)” under the profession’s current protocols.
    Approx. 60% or so of first-episode patients may recover without the use of antipsychotics (Whitaker 2017).
    In order to maintain the narrative of antipsychotis beeing “effective” schizophrenia is falsely declared chronic i. e. drug dependence is preferred over recovery.
    Now I know this guess is not exact science, but does it seem that approx. 40% of patients subject to regular medication (e. g. in Norway “National guideline for diagnosis, treatment and follow-up of individuals with psychotic disorders”) loose long-term recovery compared to non-medicated patients?
    Would this be a fair guess of the long-term effect of antipsycotics on recovery?
    Alternatives to medication

    Morrison et al. 2012 (8) concludes «A response rate analysis found that 35% and 50% of participants achieved at least a 50% reduction in PANSS total scores by end of (cognitive) therapy and follow-up respectively» i. e. NNT=2 for «follow-up» with cognitive therapy. Antipsychotic drugs perform NNT=6 according to Leucht et al. 2009. This shows Klingbergs conclusion (9): “In conclusion, psychosis psychotherapy does not have an evidence problem but an implementation problem.”

    Patients have a right to know in advance to decide with informed consent the benefit of actual symptom reduction in the beginning at the price of long-term reduction of recovery. Where there is a risk there has to be a choice.
    I would appreciate your answer based on your knowledge of studies. Thank you in advance.

    1)Leucht S, Arbter D, Engel RR et al. How effective are second-generation antipsychotic drugs?
    A meta-analysis of placebo-controlled trials. Mol Psychiatry 2009; 14: 429–447
    2)Leucht S, Tardy M, Komossa K, Heres S, Kissling W, Davis JM.2012 May 16;(5):CD008016. doi: 10.1002/14651858.CD008016.pub2.
    Maintenance treatment with antipsychotic drugs for schizophrenia.
    3)Council of Evidence-based Psychiatry
    Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment StrategyLong-term Follow-up of a 2-Year Randomized Clinical Trial.
    JAMA Psychiatry. 2013;70(9):913-920. doi:10.1001/jamapsychiatry.2013.19
    4)Bola JR, Kao D, Soydan H, Adams CE. Antipsychotic medication for early episode schizophrenia. 15 June 2011. http://www.cochrane.org/CD006374/SCHIZ_antipsychotic-medication-early-episode-schizophrenia
    5)Robert Whitaker. Harrow + Wunderink + Open Dialogue = An Evidence-based Mandate for A New Standard of Care:
    6)Dr. Lex Wunderink, MD, PHD of the University of Gronigen (Netherlands) speaks about his findings for long-terms use of antipsychotic drugs at the 2015 Yale Symposium: New Data and New Hopes Call for New Practices in Clinical Psychiatry. https://www.youtube.com/watch?v=RKeBjLG-ueY
    7)Morrison AP, Hutton P, Wardle M et al. Psychological Medicine. Volume 42, Issue 5 May 2012, pp. 1049-1056. Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial. Psychol Med 2012; 42: 1049 – 56
    8)Klingberg S, Wittorf A. Evidence­based psychotherapy for schizophrenic psychosis. Nervenarzt 2012; 83: 907-918.
    9)Harrow M, Jobe TH, Faull RN. Psychol Med. 2014 Oct;44(14):3007-16. doi: 10.1017/S0033291714000610. Epub 2014 Mar 24.
    Does treatment of schizophrenia with antipsychotic medications eliminate or reduce psychosis? A 20-year multi-follow-up study. https://www.ncbi.nlm.nih.gov/pubmed/25066792
    10)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
    11)Open letter to the Directorate of Health, Knowledge Centre, Public Health, Medicines Agency, Patient Safety Program, Norment, Experience Expertise 12. February 2017:
    Knowledge- and research-based liquidation of current harmful psychiatric medication in favour of evidence-based practice to promote recovery http://home.broadpark.no/~wkeim/files/open_letter_knowledge.html

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  12. It’s clear that research on non-drug approaches to the treatment of psychoses is sorely needed. I don’t think it would be hard to find volunteers for such a study. The limiting factor seems to be funding, and access to these drug-naive patients that tend to get diagnosed in hospitals under the control of small groups of psychiatrists.

    From my own experience, I know that recovery is possible without the use of anti-psychotics. When I was first hospitalized, I was on another planet, figuratively speaking, for almost two weeks. I refused drugs, and managed to avoid any “emergency” doses. At a certain point, I simply snapped out of it. My delusions dissipated, logic and reason returned, and my immense fear gave way to relaxation. It was at this point that I agreed to take an anti-psychotic. I was ignorant that this would be a “life sentence”, and was under the impression it was an acute treatment.

    Since then I’ve tried to get off anti-psychotics twice, once tapering slowly and another time cold-turkey. Each time I ended up involuntarily committed and repeated the same pattern of strong psychosis for almost two weeks, spontaneous recovery, and agreement to take anti-psychotics again. While I’ve managed to avoid getting forced treatment, I’ve realized my situation is untenable for detoxing because I’m dependent on and controlled by my family who insists I be medicated and won’t hear any alternatives. One day it’ll happen, I just hope it’s before it’s too late. .

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  13. Maybe I did not understand the study, but it seems to me there is an obvious selection bias, because the study does not take into account spontaneous recovery and spontaneous improvements.

    Suppose a group of 300 people including 100 slightly psychotic, 100 moderately psychotic, and 100 seriously psychotic.

    Neither these 300 people nor their relatives are seeking psychiatric services. It should be clear that only the severely psychotic and the people who are degrading will eventually be hospitalized. People who improve greatly or recover fully will never come into contact with psychiatric services.

    As a result, people who are slow to contact psychiatric services will appear to be more affected than those who contact them immediately, even though the rate of recovery of those avoiding psychiatry is higher than those seeking their services.

    Could you give me your opinion on this bias?

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    • I am not sure to which study you refer. There is a general consensus that the longer the time between the appearance of the problem labeled psychotic and entering into some form of treatment, the worse the outcome. This could be for many reasons and may not be related to the kind of treatment but to the differences in groups. You raise the point that there are some folks who never come into contact because their problems may just resolve. The the study of early detection, they found that with community advertisement, they were able to identify a less ill cohort who continued to be less ill over time.
      My point is that there is insufficient data to conclude that delaying the use of drugs will worsen outcome. I was suggesting that early connection to some form of help appears to be helpful. What you are suggesting is that because we are not including the group who never had any contact with the system and may have gotten better on our own, that we can’t make any conclusions and that is a valid point. But for those who seek help, I still think we can avoid telling them it is optimal to start drugs immediately for the sake of their long-term outcome

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  14. Dear Sandra

    You mentioned movement disorders in the beginning of the article. “there is little argument regarding some serious long-term risks such as movement disorders and weight gain.” I myself had psychoses and suffer from rhythmic movement disorder. This is the first time I found psychosis and movement disorder can be related. Is this true? what is the relationship between movement disorder and psychosis? is movement disorder “curable” like healing is possible for psychoses? This is the biggest problems of my life I go into crisis occasionally by just thinking about my movement disorder/ urge to shake feet constantly an rock before falling a sleep, its biggest problem of my life im 20 and it drives me crazy. Thank you.
    Best George

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  15. I find it truly bizarre that in the article and in the discussion there is NO mention of marijuana. A large portion of the young adult population is experimenting or using marijuana. What would a review the literature show on outcomes of first episode psychoses in marijuana using patients who are given a truly supportive environment, real help in being marijuana/substance free ( like mandatory rehab . aimed at eliminating pot long term? (since active psychosis would sort of impair the young person’s ability to recognize that pot may be the root of his psychosis, more than addiction may alone would cloud one’s thinking).)

    Is it because it is impossible to keep marijuana away from these young adults that we just throw up our hands.. ‘can’t be done.. I won’t address it..I’ll just keep doing talk therapy/ motivational interviewing’ while the kid keeps dumping more and more marijuana on his brain?

    I find this extremely troubling.. VT is in a mental health crisis. We realize that antipsychotics have major problems and are at least sometimes not helpful/harmful. We also all know that there are now literally hundreds of studies contributing to the literature and creating a consensus that marijuana can cause and worsen psychosis.. WHY is not there a truly drug, marijuana, free area in northern Vermont for these young adults? Do they deserve what so many of us were given, took for granted? Why isn’t there even one truly drug free high school? What would their recovery rate be then? And why is n’t this even discussed? In Minneapolis I understand the state supports at least one truly drug free high school.. it is not an entirely unheard of concept.

    What would outcomes look like if the VT education department and Vermont Mental Health Department were truly serious about providing at least one drug/pot free environment for these vulnerable folks? Isn’t it at least conceivable that this is a disability which requires that the state address it? If your kid has an allergy to nuts the school must provide a nut free environment.

    On a public health and systems level if just the Vermont Department of Mental Health and mental health providers were to publicly recognize the value of establishing a truly pot free high school (and university for that matter) wouldn’t this loud public recognition alone send a message to the state and Vermonters, who are now quite confused about the role of marijuana in mental illness? If mental health providers were to lobby for the establishment of just one truly marijuana free high school ( not in name only) would this send the state and Vermonters a message? (Even if the idea is hopeless because there is no money for it? ).. The mere public acknowledgement by leaders in psychiatry and mental health providers of the value, for prevention and treatment of mental illness, of a real marijuana rehab, paid by BCBS and VT Health Connect, and a real marijuana free high school, would carry a lot of weight and would be helpful in educating and in sending a new clear message to lay Vermonters about the reality and danger of marijuana in causing psychosis, contributing to suicide and severe mental illness.

    I wonder what effect a real enforcement program of this type ( with pee tests) would have on our Church Street homeless psychotic individuals and on the associated violence issues? .. I hear the protest that it would be too difficult and too expensive.. but what if it were actually cost effective.. ? what is happening now is pretty expensive for Burlington.

    Many psychotic people can not grasp that they need to stop smoking pot long enough to recover. Our environment in Vermont sabotages them before they even start. In this case, almost by definition, withdrawing their marijuana must be very often involuntary?

    Motivational interviewing (and dialogue) in the face of cheap available pot and a blossoming addiction must be pretty tough to conduct. I wonder if there is data that motivational interviewing works on actively psychotic patients with active developing marijuana dependence? I wonder how many psychologists recognize marijuana as an addictive drug, a treatable addiction? Does BCBSVT insurance and medicaid approve payment for this treatment now?

    Do we need a systems, societal solution to this problem… or is each isolated family left to treat marijuana addiction alone in an out patient near vacuum as pathetically as they can in a sea of cheap, cool pot? The addiction unrecognized really as a disease by most people, the treatment unpaid for by the insurance companies who gladly pay for unbelievably expensive antipsychotics, and marijuana generally unrecognized by families and friends, even some therapists, as a significant cause of severe mental illness made more expensive to treat by continuing to use..not recognizing on a societal level at all that the main solution may be removing pot…. A solution which it is nearly impossible to implement in the midst of a statewide race to more, cheap, available, and more socially acceptable marijuana.. driven by a powerful corporate, profit hungry, predatory, and destructive industry.

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    • It is so significant, what you’re saying, because warning kids not to use marijuana is the best defense against avoiding psychotic symptoms in the first place. Unfortunately, our youth is not told this truth. If they knew the truth, many (perhaps not all who use) would never try it in the first place.

      As different states mull over this issue, some state psychiatric associations are silent. They know if a state legalizes it will be good for the business of psychiatry. Again this makes psychiatrists look very unethical, as if they just want more clients. They know that psychiatry is criticized a great deal, but that the legalization of marijuana will create a greater need for more psychiatric treatments, even if they don’t know what they’re doing.

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  16. I am sorry that you find this discussion of the article to be bizarre but this was a paper that analyzed data on outcomes related to antipsychotic drug use. It is a long paper and I chose to focus on the section that addressed duration of untreated psychosis, specifically the impact of delaying use of antipsychotics.
    You raise interesting points and suggest proposed policies regarding impact and regulation of cannabis but that was not the topic of the paper under review.

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    • Very relevant, because there was a paper out of Great Britain that showed anti-psychotics are not effective on those who use marijuana. So whether or not the patient uses pot, quits pot or never used has to be taken into consideration.

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      • Could you please share a reference to that study? While I am not pro-cannabis (I do have questions about how effective prohibition policies are, who they help, and who they hurt), my clinical experience is that cannabis seems to have variable impacts on people who experience psychosis. In fact, it is the variability that can make it hard to convince people there are harms.

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        • I could not find it, have not looked hard (I am not an MD or even a psychologist, just an interested party). I believe it came from University of Manchester. From some reason that university sticks in my head. If you still can’t find I will ask my friend the pharmacologist to find it. I agree with you that there is great variability, but the pot advocates are less mellow than they claim. Here is the latest article connecting marijuana users to violence. https://blog.frontiersin.org/2017/10/11/cannabis-drug-use-violence-frontiers-in-psychiatry/

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        • Sandra, Thank you for your excellent review of this article and I have long been a fan of attempting to treat all mental illness symptoms with approaches that don’t involve medications if at all possible. However, I also agree with the two previous comments that the use of marijuana absolutely needs to be taken into consideration when dealing with any psychotic symptoms. We in Colorado are experiencing a significant rise in psychosis and violence with psychosis in emergency rooms and mental health programs/substance abuse treatment programs directly correlating with the increase in THC potency in the marijuana available. In the state hospital where I work a large majority of the folks I have been asked to do substance abuse assessments on were using marijuana either alone or in addition to other drugs at the time of their incident offense and they were so actively psychotic and violent they ended up on a lot of medications in order to keep them from harming themselves or others. I try to convince their medical providers to attempt to get them off meds once they are stable but this is a hard sell because they were so violent before. When we have had similar patients go through our 90 day inpatient dual diagnosis program in the same hospital, I have been successful in getting some off meds and in others significantly reducing their medications with good outcomes which to me indicates marijuana was playing a big role in their psychotic symptoms. Also we frequently discover the person doesn’t really have schizophrenia or schizoaffective disorder but more likely severe PTSD they have been attempting to “treat” with marijuana. In my experience PTSD psychosis does not respond to antipsychotic medication at all and therefore find EMDR and similar treatments most effective once the person is no longer using marijuana. I believe the study that jewelsfs was taking about is: Patel R et al. Association of cannabis use with
          hospital admission and antipsychotic treatment failure in first episode
          psychosis: an observational study. BMJ Open 2016;6:e009888.
          A large observational study of over 2000 participants showing that cannabis was associated with substantially worse clinical outcomes resulting in the use of multiple antipsychotics. I hope this is helpful.

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          • I am not objecting to the issue that cannabis use can impact psychosis. I was responding to the critique of my failure to address that in my post. This was not the focus of the particular paper and, therefore, it was not a focus of this particular blog.
            Thank you for the reference!

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  17. Perhaps there are more compelling papers than which Goff et al. chose to cite and I hope these too can be comprehensively deconstructed and critiqued as expertly done here.

    Unfortunately, so much has already been invested in early intervention and prophylactic medication (in the UK at least) off the back of ‘Duration of Untreated Psychosis’ as an established medical term. I suspect this of particular harm to young adults and adolescents whose brains we know are still developing.

    Alternatively, there is something to be said for the use of Omega 3 Fatty Acid supplements, which have an incredibly safe profile!

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