Critical Psychiatry Textbook, Chapter 7: Psychosis (Part One)

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Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Critical Psychiatry Textbook. In this blog, he discusses the lack of efficacy and poor evidence base for drugs used for psychosis. Each Monday, a new section of the book is published, and all chapters are archived here.

Psychosis drugs are the poster child of psychiatry and were highly praised in the textbooks. We are told that, before the advent of them, many patients needed to live the rest of their lives in hospitals and other institutions;16:222 the discovery of the pills in the 1950s meant that many psychotic patients clearly improved their quality of life, enabling their dismissal from the institutions and reintegration into society;20:416 patients who were previously tortured by their disease and were aggressive could now live alone or in protected housing;18:307 psychosis pills led to a decrease in hospital beds.16:616

We are told that chlorpromazine was a revolution in the treatment of psychotic disorders16:560 and it contributed in particular to emptying psychiatric hospitals;18:307 and—before chlorpromazine, lithium, depression pills, and benzodiazepines, the seriously ill patients spent most of their lives in isolated institutions, behind locked doors, with barred windows, and physical force was used—but the development of psychiatric drugs in the 1950s revolutionised the treatment.17:644

Photo of a pill bottle on a prescription padPsychiatrists propagate this narrative all over the world to gain support for their specialty but all the above is wrong.1,4-8 There were no references for the extravagant claims, but it has been documented that the pills had nothing to do with the emptying of the asylums.1:155,3:53,147,148 Furthermore, it is impossible for drugs that—according to the standard scale for evaluating the effect on the psychosis—do not have clinically relevant effects (see just below) to produce such dramatic outcomes.

Since the “emptying of the asylums” is the core argument for the claimed revolution in psychiatric drug treatment that started with chlorpromazine in 1954, I shall explain why it is wrong. The misconception stems in particular from flawed studies in New York.148 The authors noted that the populations in asylums fell after 1954 and ascribed this to drug treatment. Better studies were conducted in Michigan and California by other authors who compared treated and untreated patients. They found that the drugs did not increase discharge rates.

In 1985, a study debunked the myth totally.148 It covered all US states and compared two nine-year trends in discharge rates, 1946 to 1954 with 1955 to 1963. The mean percentage change in discharge rates was 172 before chlorpromazine, a little higher than with chlorpromazine, 164.

There are no supportive studies of the myth from other countries either. In England, inpatient populations began to decline before the drugs were introduced; in France, inpatient populations increased for 20 years after the drugs were introduced;148 and in Norway, inpatient numbers did not change with the introduction of the drugs.3:54

The Joint Commission on Mental Illness and Health, commissioned by the US Congress, wrote in 1961 that “Drugs have revolutionized the management of psychotic patients in American mental hospitals,” quoting the misleading New York studies and avoiding mentioning the better designed Michigan study even though it was available.148 It was politically expedient to dupe the population this way, painting a false picture of huge progress in psychiatry.

Psychosis pills don’t have clinically relevant effects on psychosis

One textbook noted that the strongest evidence in psychopharmacology is for the effect of psychosis pills in the acute phase of schizophrenia and for relapse prevention, as they markedly reduce the risk of relapse.16:560 It claimed that the pills improve prognosis and survival in most patients,16:222 and that it is essential to know which biological processes in the brain the pills influence in order to offer the most optimal medical treatment.16:216

All of this is wrong. Robert Whitaker once wrote to me that it requires extraordinary mental gymnastics by the psychiatrists to conclude that these drugs, which cause obesity, metabolic dysfunction, diabetes, tardive dyskinesia, lethal cardiac arrhythmias, and so on, protect against death. They don’t; they kill many people,7:307 which I shall explain below.

It is impossible to offer a better treatment by knowing more about biological brain processes when the drugs do not have clinically relevant effects on the psychosis apart from tranquillising the patients, which is an unspecific effect.

Virtually all placebo-controlled trials of psychosis drugs are seriously biased by cold turkey withdrawal effects in the placebo group, which occur when the psychosis drug the patient is already on gets withdrawn before randomisation. These iatrogenic harms are usually avoided in the actively treated group. The reason that Janssen could claim that its bestseller risperidone didn’t cause more extrapyramidal (muscular) harms than placebo was the abrupt withdrawal of the previous psychosis drug, which inflicted these effects on the placebo group to such an extent that one in six patients got them.1:276 The companies needed to show that their drugs reduced psychotic symptoms and they made some of the placebo patients psychotic by withdrawing their drug cold turkey.4:45,31,149

I have only found two trials where none of the patients had received a psychosis drug before. One was from China and appeared to be fraudulent.150 It compared olanzapine with placebo in patients with first-episode schizophrenia.151 The patients needed to have a score on the Positive and Negative Syndrome Scale (PANSS) of at least 60 to be included. However, the score before treatment was only about 9, even though by definition it must be at least 30 (the lowest score is 1 and there are 30 items). The score increased to 71.3 in the olanzapine group and to 29.4 in the placebo group. The authors reported that olanzapine was effective although patients on placebo fared much better. Furthermore, a difference of 42 in PANSS is implausibly large. In the placebo-controlled trials in submissions to the US Food and Drug Administration (FDA) of newer psychosis drugs, including olanzapine, the difference was only 6.152

The only trial that doesn’t appear to be fraudulent and wasn’t flawed by withdrawal effects was published in 2020, 70 years after the discovery of the first psychosis drug, chlorpromazine.153 It randomised 90 patients with a first-episode psychosis (FEP) with a duration of untreated psychosis of less than six months to risperidone, paliperidone, or placebo.

However, even after 70 years, the psychiatrists weren’t yet ready to draw the obvious conclusions of their results. They wrote that the differences were “small and clinically trivial, indicating that treatment with placebo medication was no less effective than conventional antipsychotic treatment” (P = 0.95). They noted that “the immediate introduction of antipsychotic medication may not be required for all cases of first episode psychosis” with the reservation that “this finding can only be generalised to a very small proportion of FEP cases at this stage, and a larger trial is required to clarify whether antipsychotic-free treatment can be recommended for specific subgroups of those with FEP.”

What the authors should have written is something like this: “Our study was small, but it is unique because it only included patients who had not been treated with a psychosis drug before. We found that psychosis drugs are ineffective in patients with untreated psychosis. This is great progress for patients, as these drugs are highly toxic and make it difficult for them to come back to a normal life. Based on the totality of the evidence we have, the use of psychosis drugs in psychosis cannot be justified.”

The authors of a 2011 Cochrane review of psychosis pills for early episode schizophrenia pointed out that the available evidence doesn’t show that the drugs are effective.154 This is one of the few Cochrane reviews of psychiatric drugs that can be trusted. Apart from the cold turkey problem, Cochrane reviews in schizophrenia include trials in a meta-analysis where half of the data are missing.

This Cochrane review noted that twice as many patients on chlorpromazine than on placebo were rehospitalised within three years, risk ratio 2.3 (1.3 to 4.0). There were also fewer rehospitalisations in the placebo group at the one-year follow-up in the famous trial funded by the US National Institute of Mental Health (NIMH), which was published in 1964, but the difference wasn’t quantified, and the original data appear to have been lost.154 These data totally contradict the psychiatric narrative that psychosis pills emptied the asylums.

In trials supposed to be double-blind, but which are not blind in practice, investigators may report positive effects that only exist in their imagination. This occurred in the NIMH 1964 study, which is still highly cited as evidence that psychosis drugs are effective.

344 newly admitted patients with schizophrenia were randomised to phenothiazines such as chlorpromazine or to placebo.155 The investigators reported, without offering any numerical data, that the drugs reduced apathy and made movements less retarded, the exact opposite of what these drugs do to people, which the psychiatrists had admitted a decade earlier.5:49,5:61

The investigators claimed a huge benefit for social participation (effect size 1.02) and that the drugs make the patients less indifferent to the environment (effect size 0.50). The drugs do the opposite. The authors also claimed, with no data, that 75% versus 23% were markedly or moderately improved and suggested that the drugs should no longer be called tranquillisers but antischizophrenic drugs.

Their study contributed to shaping the erroneous beliefs that schizophrenia can be cured with drugs and that psychosis pills should be taken indefinitely.1

The truth is that psychosis pills do not have clinically relevant effects on psychosis. Despite the formidable biases—cold turkey, lack of blinding, and industry funding that often involves torturing the data till they confess6,7—the published outcomes have been very poor.4 The least clinically relevant effect corresponds to about 15 points on the PANSS scale156 commonly used in the trials. Yet, what was reported in the placebo-controlled trials of recent drugs submitted to the FDA was only 6 points, or 3% of the maximum score of 210 on this scale.152

A textbook claimed that the effects on the dopamine system can restore homeostasis in brain signal transmission.18:97 This assumes that there is a defect in the dopamine system to begin with, which has never been documented and is unlikely (see Chapter 4). We are also told that the treatment response is related to dopamine activity.16:220 This is not possible for drugs that don’t work.

There were case stories in one of the textbooks and they were always positive in relation to the drugs used, but most of them were misleading. Here are some examples.

A patient improved within a few weeks on a psychosis pill and no longer heard voices or experienced persecution.18:87 The pills do not have such effects.

A patient improved a lot on a psychosis pill and had relapses when he did not want to continue with the drug.18:89 It is highly likely that the psychiatrists confused withdrawal symptoms with relapse. And there is no reliable evidence that the pills can prevent relapse (see below).

A patient got a small dose of a psychosis pills and support, and improved.18:89 It was more likely the support that helped the patient, or the patient would have improved anyway, without treatment or support.

An increased dose of a psychosis pill affected the time to relapse.18:105 These pills do not have increased effect with increased dosage.157

It would be an eye-opener if the psychiatrists tried a psychosis pill on themselves. Two physicians have described how a single dose of haloperidol knocked them down.158 They experienced a marked slowing of thinking and movement, profound inner restlessness, a paralysis of volition and a lack of physical and psychic energy, being unable to read or work.

David Healy found the same in 20 staff from his hospital who received droperidol.4:116 Everyone felt anxious, restless, disengaged, and demotivated to do anything; a volunteer found it too complicated just to obtain a sandwich from a sandwich machine. Some felt irritable and belligerent and many were unable to recognise the altered mental state they were in and to judge their own behaviour. Peter Breggin calls this “medication spellbinding.”135,159

The predominant subjective effects reported by patients on the Internet when they take psychosis drugs are sedation, cognitive impairment, and emotional flattening or indifference.160 We also know from telephone help lines that what medicated persons miss the most are themselves.1:179

Psychosis pills were hailed as a great advance, but this was because they kept the patients docile and quiet, which was very popular with the staff in psychiatric wards.148 It was a huge conflict of interest that the same staff evaluated whether patients had improved or not, and this conflict of interest clouds psychiatric practice and research even today.

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7 COMMENTS

  1. This series is like an early Christmas. Usually people use too soft words to accurately describe the horrors of antipsychotics.

    Those treating psychosis have a really well trained way to describe big improvements when they see patients becoming incapable of speaking and thinking and unable to clean themself.

    Can one really trust anything anyone in a higher position says about those ones under his care? Is it a universal rule that making work easier means more than a truth? Do official vocabularies have a tendency to form words that do not describe reality, but justify their deeds and prevent criticism?

    It could be helpful if there was permission for authority handled people to write competing entries and criticism into the same data systems that are currently reserved for establishing one sided stories using well formed official languages that are in conflict with the real observations.

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  2. Brilliant chapter, Peter.

    In some very poor countries destitute hungry people sell themselves and even their children into trafficking in the hopes that at least some food coins will be made available. Faced with a condition of starvation and death, the desperate clutch at dusty straws. They barely care what they have to do to make it through just one more day. An NGO may enter their lives and rescue them from wicked traffickers. Stopping such harms is utterly vital. It is not ending the destitution or famine that preceeded the peoples journey towards trafficking as a quick fix. I am using a metaphor of people seeking help by treading towards trafficking, a metaphor here for turning towards psychosis pills, as it too is a simplistic risky answer to hellish problems that are already in situ. What I mean is that to mend the problem of why so many people willingly take psychosis pills there ought to be a greater sympathy with the state of desperation they feel a moment before making that choice, desperation at being driven to the brink of extinction through hallucinations, delusions and so on. Desperation that wants something of a (dubious) life saving cure right away, no matter the ultimate price. Some people have no option in life but to live for today. They have no resources to make it through to tomorrow or consider long term future impacts of desperate decisions. They may think they have no choice but to sell their possessions, sell their kidney, sell street drugs, sell their own kids.
    It is easy enough for those of us not going hungry tonight to be appalled at people who turn to traffickers to solve their abject misery. And of course it is easy to be appalled at traffickers. But would any of us be any different if we just could not find any scraps of food to fill our or our childrens aching hollow dying stomachs? If we or they were just dying of hunger or total torment?
    It is easy to think that by scrapping hideous trafficking or hideous psychosis pills all will be well. Job done!
    I am afraid that mental torment pushes people over the edge hourly, where desperation makes them clutch at such straws in the first place.

    I applaud necessary impressive diligent brave work that throws a light on the harms of psychosis piĺls. It is so very much needed. Does it start and stop with rescuing the violated from further harm from Big Pharma or does it also involve taking a look at WHY people come to the point of despair enough to want psychosis pills?

    I see parallels with alcoholism in the cohort of people desperate enough to obliterate themselves on Big Pharma psychosis pills intoxication. Is it enough to say that the intoxicants are damaging or risky and so nobody should imbibe them, without also respecting that nobody “chooses” to go on that godforsaken journey if they are not already over the edge of godforsaken anguish. Nobody “chooses” to traffick themselves, or drink alcohol to oblivion, or seek the comforting nullifying of torment that psychosis pills pretend to offer.

    I would just like to see in antipsychiatry circles more sympathy for those with very real desperation due to unending daily, hourly, horrendous hallucinations.

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  3. “Psychosis pills don’t have clinically relevant effects on psychosis.” I’m pretty certain that’s untrue.

    Since in well insured patients who are misdiagnosed with “psychosis,” the antipsychotics can create “psychosis,” via anticholinergic toxidrome poisoning.

    https://en.wikipedia.org/wiki/Toxidrome

    Not to mention, the neuroleptics can also create the “negative symptoms of schizophrenia,” via neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    Which likely means the “psychosis drugs” / “neuroleptics” / “antipsychotics” – which can create both the positive and negative symptoms of “schizophrenia” – should be outlawed. Especially since the so called “experts,” the psychiatrists, still claim ignorance of these facts.

    Thank you, again, Dr. Peter, for all that you do.

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  4. I slept a night after reading this and after waking up, a question just did not leave me. What are the major barriers for making a proper trial with a long time follow up period for the first episode of psychosis?

    If research with an unmedicated control group is almost non existent it is not easy to convince anyone.

    I believe that if done properly that research should also contain freely available video material without precuts to prevent scams with the current usage of words. Differences between the well-being of medicated and unmedicated people would likely be seen clearly without any training.

    Trained psychiatrists cannot be trusted to make objective observations, because the language they have learned to use is not fit for neutrality, but condemning and telling scary stories. For example if a patient is hungry and is not getting their attention and raises a voice and tries more to make a contact or mocks the psychiatrist for not doing his job for that then a professional can “observe” that patient is aggressive and delusional and shouts and talks all the time without the ability to stop.

    Then if medication makes a patient lose ability to express himself it can be wrongly described as remission. Those kinds of situations can be observed from raw videos, but cannot be observed later on from when staff has written that the patient is aggressive and completely psychotic and manic. Those videos would also give the ability to compare how patients change after medication.

    Still even old school research without video material, but with proper unmedicated control groups and describing harms and benefits honestly, would be a lot.

    Also one kind of research I have never yet seen is studying how psychiatrists describe patients and is it accurate. Currently everything written by a professional is taken as an objective fact, but instead of focusing on patients there should be more critical research focusing on observing an observer and how their observations differ from reality and why. There should be an easy pattern like turning personal feelings as a symptom of a patient to make personal life easier.

    In that kind of research there would be situations written by a third observer with neutral terms including all parties and their behavior would be seen as a reaction to what others say and do.

    Then there would be the very same situations written by professionals with non neutral terms focusing only on the patient and what they think is “sick” with him.

    Finally there would be a third written text focusing on observation errors of observers and how they are born.

    That last study would not be easy to make, because there is no school for making neutral notes. We humans have a tendency to use non neutral words for achieving our goals so natural language is filled with words that do not accurately describe what is seen, but individual words contain opinions and stand points for what is wrong and what is right.

    There was a case when I saw a video of a programmer named Terry. Almost every written comment in Youtube was describing how psychotic he was and how terrible his state was and how ill he was. That was not really seen on video. He spoke how he was the best programmer in the world and was very proud of the operating system he wrote using a programming language he had created. His voice was harsh like voice is when people force themselves too much without enough rest and it was clear that he wanted to be praised and adored for what he had done. Sometimes he was so tired and stressed that there were long stops before he spoke again. He spent a lot of time trying to comprehend the will of God from an app producing random colorful lines on screen. The way others talked about him must have felt awful and was likely a major cause of his stress.

    Therefore that observing group should not be excluded from the observation. If someone had been making a list of his “symptoms” that would have been twisting the reality and forgetting the context and mixing personal moral values into observation.

    Transforming observations from morally judging language to what is actually seen has to be trained, because typically we are just like radio repeaters repeating the words what we hear associated with what we see. In every situation everyone speaks to express their personal needs so the language we use is not neutral before it is cleaned from morality that hides in individual words and inside their taxonomic classifications.

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  5. Additions to misconceptions about the history of psychiatry

    > Neuroleptics have made it possible to empty psychiatric hospitals

    No, it’s retirement homes and antibiotics (among other things) – medico-social developments. Before 1945, the majority of people admitted to psychiatry suffered from organic psychoses, in particular senility, cerebral atherosclerosis and syphilis. Antibiotics almost completely eradicated syphilis, while the elderly were gradually admitted to nursing homes. Another psychosis that has diminished without neuroleptics having anything to do with it is alcoholic psychosis.

    > With neuroleptics, the discharge rate was higher than the admission rate

    No, it was not until 1970 that the number of discharges exceeded the number of admissions, 15 years after the introduction of neuroleptics. From 1955 to 1970, American psychiatric hospitals were emptied due to a very high mortality rate (about 9% per year), mainly caused by the demographic structure of the hospitals (many old people, few young people)

    > Before neuroleptics, psychotics remained locked up all their lives

    In 1922, in the USA, for 100 schizophrenics admitted, 57.4 were discharged during the year.

    It’s a bad result, but not as bad as some would have us believe.

    The other psychoses had the following discharge rates:

    bipolar disorder: 75%

    melancholy depression: 64%

    paranoia: 61.9%

    neurosis: 95%

    The study of real statistics will make it possible to replace the mythology of psychiatry with the history of psychiatry.

    In french: https://psychiatriedroit.wordpress.com/2017/07/21/idees-fausses-sur-lhistoire-de-la-psychiatrie/

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  6. Thank you. I am part of a recovery forum for those who take at least 9 months to regain a beginning of functionality after a neuroleptic injection. Many of us have been told that the effects of the drug are just “who we are now” since we have experienced psychosis. My mother chose to see my personality on the drug as the negative symptoms of schizophrenia. On the forum we have a hard time differentiating from “relapse” and “withdrawal”. Almost everyone experiences a second psychosis after 12 months of withdrawal, and many end up back on the medication for life. I have had two psychotic experiences since quitting the drug in 2019, each with diminishing severity, and the last one recovering on my own without the use of medication despite being prescribed Zyprexa by a doctor who spoke to me for five minutes on video chat. If I were on medication, I would be forced to live with my parents and be unable to shower or cook, as I was for a year whilst recovering from the drug. As it is now, I live a healthy and functional life free of it.

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