On February 18, BBC World aired a 26-minute broadcast on “drug-free treatment” in Norway, and while it was encouraging to see that initiative get this attention, the broadcast, in the way it handled the story, was also a source of disappointment: couldn’t the media, I wondered, ever challenge the conventional wisdom regarding the merits of antipsychotics? Just once?
Then, two days later, I read the latest publication by Martin Harrow and Thomas Jobe on their findings from their long-term study of psychotic patients, which once more powerfully told of the negative long-term impact of antipsychotics, and I thought, couldn’t the mainstream media, just once, report on their study? Was that too much to ask?
First, the BBC report.
The opening eight minutes of the broadcast explored the political origins of the Norwegian effort and told of the drug-free unit in Tromsø, led by Magnus Hald. The final five minutes told of basal exposure therapy, a practice at a hospital near Oslo that has proven successful in helping chronic patients reduce their use of psychiatric medications, or withdraw altogether. Those two parts of the broadcast were fine, and well done.
However, in between those two segments, the BBC devoted 13 minutes to critics of the drug-free initiative, and this is where the broadcast, in terms of serving the public, failed miserably. The BBC gave air time to critics in the spirit of “let’s give both sides equal time,” but in the process they let the critics reframe the initiative for listeners as one that was likely to harm patients, without pushing back on the critics’ assertions.
Here is what the listeners heard during this 13-minute interlude:
- You can’t treat psychotic patients without drugs, and Kingsley Hall is proof of that.
First, Norwegian psychiatrist Jan Ivar Rossberg said there was no record in the research literature of any non-drug therapy that had ever proven effective for psychotic patients. He pointed to the Kingsley Hall experiment led by R.D. Laing in the 1960s as an example of that failure. In that instance, the BBC explained, “antipsychotics were out, LSD was in. Patients were encouraged to regress to childhood. They called this methodology antipsychiatry.”
The BBC reporter then concluded that “other attempts to tackle psychosis using talking therapies alone similarly failed.” For Rossberg, the BBC added, this “movement for drug-free treatment is based on an ideology rather than on the evidence.”
2) Antipsychotics are a life-saver for many people.
After informing listeners that non-drug therapies for psychotic patients had always failed, the BBC then reminded viewers that antipsychotics were a life-saver for many. The broadcast then featured an interview with a patient who, after trying to stay well without the drugs, had gone back on antipsychotics and now she was living a much better life.
3) People diagnosed with a psychotic disorder who won’t take antipsychotics are often homeless.
Norwegian psychiatrist Tor Larsen then told of the horrors of “untreated psychosis.” Fifty percent of the homeless population living under bridges were said to be suffering in this way because they didn’t take their antipsychotic medication. The homeless “actually have no food and no treatment for infections,” and so sometimes died, Larsen said.
4) And those who don’t take antipsychotics often commit crimes, including homicide.
Larsen told the BBC that perhaps 30% of those with “untreated psychosis” commit crimes, and on rare occasions, this leads to homicide. The broadcast then discussed why this threat to public safety was a reason that some patients needed to be forcibly treated, and spent time detailing the story of a psychotic man who had gone off his medication and killed a man with an axe.
Such was the criticism of Norway’s drug-free initiative. Rossberg and Larsen told a story that psychiatry, as an institution, regularly repeats to the media. Antipsychotics are an effective treatment for psychotic disorders, and people so diagnosed who don’t take these medications fare poorly and are a threat to public safety. With that framework from the critics, the BBC broadcast in essence presented this initiative, as well-meaning as it might be, as one that lacked scientific support, was likely to fail (if the past was any guide), and could lead to “untreated” patients who would become homeless and commit crimes.
And here was the frustrating part for me: I had spoken to the BBC reporter months earlier, and urged her to tell of the science that supported this initiative.
The Missing Pushback
The BBC journalist who narrated the broadcast, Lucy Proctor, had contacted me in November. She said that she had read the MIA Report that I had written on Norway’s drug-free initiative in 2017, and that BBC now was looking to do a story on it. We spoke via Skype, and in that call, among other things, I emphasized that the drug-free effort was an evidence-based initiative. I had made this same argument in the MIA Report that Proctor had read.
Although Rossberg may have told the BBC that there was no record of a therapeutic approach that had been successful in treating psychotic patients without the use of antipsychotics, the success of Open Dialogue, as it was practiced in Tornio, Finland for more than 20 years, provides such a record. As Jaakko Seikkula and colleagues have reported, newly diagnosed psychotic patients were not immediately put on antipsychotics in their Open Dialogue practice, and such medication was offered only if the patients failed to improve over the next few weeks. At the end of five years, 71% of their patients had never been exposed to the drugs, and only 20% used them regularly. And here were their outcomes: 82% of the patients were asymptomatic, and 86% were working or in school. Only 14% were on government disability. Their outcomes were far superior to the outcomes for first-episode patients treated conventionally with antipsychotics.
Second, as I told Proctor, there is the research by Martin Harrow and Thomas Jobe to consider. They tracked the outcomes of patients diagnosed with schizophrenia and other psychotic disorders for more than two decades, and found that recovery rates for those off medication were significantly higher. The “medication compliant” patients who stayed on the drugs were much more likely to remain psychotic and to remain functionally impaired. (See here for an in-depth review of their research.)
Basal Exposure Therapy provides a third reason to support antipsychotic tapering efforts, which is part of the Norwegian initiative. Published research tells of how it helped chronic patients taper from their medications, or to get off the drugs altogether, and how this led to dramatically improved lives for many.
Now—and this is what I tried to emphasize when I spoke to Lucy Proctor in November—when you consider this body of research, the Norwegian initiative should be described as a much broader effort to “rethink” the use of antipsychotics. There is evidence that minimizing initial exposure to antipsychotics and limiting their long-term use will increase the likelihood that psychotic patients will recover and do fairly well over the long-term.
My hope was that armed with this information, Proctor would push back on Rossberg and Larsen when she interviewed them. I had tangled with Rossberg in a debate in Oslo, and I knew what his criticisms would be.
Yet, and this is what I found disheartening, that pushback is missing from the broadcast. Rossberg and Larsen, who were presented as prominent psychiatrists in Norway, put forward the usual spiel about antipsychotics and the horrors of “untreated” psychosis, and in that way claimed the mantle of science for BBC listeners. As such, the BBC broadcast, even as it reported on this radical “experiment—and did so with thoughtful interviews of Magnus Hald and several leaders of user groups—ultimately served to reinforce conventional societal beliefs.
This is something you see over and over again when mainstream media report on alternative approaches to treating patients diagnosed with a “serious mental illness.” Nearly always there comes a moment when the publication takes care to reassure readers that the drugs are mostly “helpful,” and neglects to mention research that would point to a different conclusion.
Harrow’s Latest Paper
I probably wouldn’t have been moved to write this blog if it weren’t for the fact that two days after the BBC broadcast, I read the latest published paper by Martin Harrow and Thomas Jobe. It was the juxtaposition of the two that so tells of media coverage that leaves the public misinformed and in the dark about the long-term effects of antipsychotics and other psychiatric drugs.
The research by Martin Harrow and Thomas Jobe is, I believe, the most important psychiatric research that has been conducted in the past 65 years. The reason is that it completely belies the conventional narrative that has animated psychiatric care since chlorpromazine, marketed as Thorazine, was introduced into asylum medicine in 1955. That drug, or so the narrative goes, made it possible to empty the asylums. Chlorpromazine is remembered as the first antipsychotic, a name that tells of how it was a specific antidote to psychosis, and it is said to have kicked off a “psychopharmacological revolution.” This is the very class of drugs that sits at the center of that narrative of progress.
Martin Harrow and Thomas Jobe began their study, which was funded by the National Institute of Mental Health, in the late 1970s. They enrolled 200 psychotic patients who had been treated conventionally in a mental hospital with antipsychotics and simply began periodically assessing how they were doing, and whether they were taking antipsychotic medication. In 2007, they reported that the long-term recovery rate for schizophrenia patients off antipsychotic medication was eight times higher than for those on the medication (40% versus 5%).
While this was a stunning finding, Harrow and Jobe offered an explanation for the divergence in outcomes that spared the drugs any blame. They wrote that it was those with a better initial prognosis who were more likely to stop taking their medication, and that could be the reason for the better outcomes for the off-med group.
However, since then, Harrow and Jobe have conducted further analyses of their data and regularly updated their findings, and as they have done so, that drug-saving excuse has gradually been put to rest. Specifically:
- They reported that in every subgroup of patients, outcomes were much better for those off medication. Schizophrenia patients with a “good prognosis” at baseline who stopped taking antipsychotic medication fared better over the long term than those with a good prognosis who stayed on the drugs. The same was true for schizophrenia patients with a “bad prognosis” at baseline; those who got off medication fared better over the long-term. And it was true for patients diagnosed with milder psychotic disorders—the off-med group had markedly better outcomes.
- The better outcomes for the off-med patients emerged after patients went off their antipsychotic medication. At the two-year follow-up, there was little difference between those who were medication compliant and those who had stopped taking the drugs. However, over the next 2.5 years their outcomes dramatically diverged. The off-med group notably improved over that period, while the medicated group failed to do so. It wasn’t that patients in the “unmedicated” group had gotten better on the drugs and then stayed well after coming off; it was that they didn’t improve until they stopped taking the medication.
- The difference in outcomes that appeared at the 4.5-year follow-up remained throughout the study. At every subsequent follow-up, those using antipsychotic medication, on the whole, were more likely to be actively psychotic, anxious and functionally impaired.
- Given these results, Harrow and Jobe began writing about why the drugs might worsen long-term outcomes. One possible reason, they wrote, was that antipsychotics could induce a dopamine supersensitivity that made patients more biologically vulnerable to psychosis than they otherwise would be in the natural course of the illness.
These findings, from the best long-term study of psychotic patients that has been conducted since the arrival of chlorpromazine in asylum medicine, set the conventional narrative on its head. Antipsychotics, rather than serve as an antidote to psychosis, may worsen those symptoms over the long term, and, more broadly, worsen the long-term course of schizophrenia and other psychotic disorders.
In their recently published paper in Psychological Medicine, Harrow and Jobe did a careful analysis of any confounding factors that could account for the divergence in outcomes for the medicated and unmedicated patients. By doing so, they were focusing squarely on the usual excuse still given by defenders of psychiatry that those who went off their medication were less ill from the start. Here’s what they concluded:
“Our current study here shows that regardless of diagnosis (schizophrenia and affective psychosis), participants not prescribed antipsychotic medication are more likely to experience more episodes of recovery, increased GAF scores [which measure functioning], and are less likely to be rehospitalized. Further, participants not on antipsychotic medication were approximately six times more likely to recover than participants on medication, regardless of diagnosis status, prognostic index, race, sex, age, education, and other factors.”
In short, they isolated medication use as the variable that accounted for the poor long-term outcomes for those who stayed on the drugs. They also discussed six other studies published in the past decade that lend support to their findings. Here are the studies they cited and their description of the results:
- Wunderink (2013): At the end of seven years, patients randomized to a dose reduction/discontinuation treatment plan, compared to antipsychotic treatment as usual, were “significantly better in terms of social functioning, vocational functioning, self-care, relationships with others, and over all community integration.”
- Molainen (2013): In a 10-year follow-up of psychotic patients who were born in 1966, 63% of those who were not prescribed antipsychotic medication were in remission compared to 20% of those who were prescribed the drugs.
- Morgan (2014): In the AESOP-10 study in the UK, remission rates remained higher in the last two years of the study for those off medication compared to those who stayed on the drugs.
- Kotov (2017): in this large, “well-documented longitudinal study,” antipsychotic use was associated “with lower overall functioning as measured by a decrease in GAF scores, inexpressivity ratings, and apathy-asociality ratings overall.”
- Wils (2017): The Danish Opus trial found that “a larger percentage of patients on antipsychotic medication were doing poorly compared to participants not on antipsychotics. Approximately 75% of the 120 participants off meds at the 10-year follower up were doing well and in remission.
This, of course, is information that the public would like to know. It should be part of any informed consent process for prescribing the drugs, and one might think that major newspapers and magazines would be eager to report results from a long-term study, one funded by the NIMH and the best of its kind ever done, that so completely belies the conventional narrative and hints of harm done on a grand scale.
Yet, if you search for “Martin Harrow” in the search function of the New York Times, here is what you will discover: In 1967, he “won first prize” in the New England Open chess tournament in Boston. Dig at little more into this aspect of his life, and you will find that he twice drew with Bobby Fischer in chess tournaments.
And here is what you won’t find: any mention of his and Thomas Jobe’s research.
After I finished reading Harrow’s latest paper, I had this thought: if the public wants to know why there is an “antipsychiatry” movement, they could review the BBC broadcast and the findings in Harrow’s latest paper. Rossberg knew of Harrow’s research. He knew of the Opus trial. He knew of the superior outcomes in northern Finland with Open Dialogue practices that minimized use of psychiatric drugs. Yet he chose to tell the world via the BBC that there was no evidence that psychotic patients could be treated without drugs.
And then the public could turn to Harrow’s study and see what they weren’t being told. They would learn that, over the long-term, psychotic patients off antipsychotic medication were six times more likely to recover than those who were medication compliant, and that a number of other studies had produced similar results of better outcomes for unmedicated patients.
Six times more likely to recover.
Those were the words that would stick, and for many, they would be words that would break their hearts.
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.