Tuesday, November 13, 2018

Comments by walter.keim

Showing 78 of 78 comments.

  • I think a found the answer: “A critical review reveals that this paradigm of care worsens long-term outcomes, at least in the aggregate, and that 40% or more of all schizophrenia patients would fare better if they were not so medicated. ” in “The case against antipsychotic drugs: a 50-year record of doing more harm than good.” https://www.ncbi.nlm.nih.gov/pubmed/14728997

  • Hi Ken, I had to look into it myself. The result is:
    Neuroleptics are used to ease symptoms and to prevent relapse with evidence at the beginning of the psychosis for a minority of patients. There is no evidence that antipsychotics promote “psychosocial functioning, professional functioning, and quality of life” (Buchanan et al 2010 PORT Treatment Recommendations). Recovery treatment still wins terrain and will be put into a historical context. Mike Slade et al. 2014 describes the implementation of recovery with both usage and abuse of the term. Too high doses of neurroleptics to too many patients over long time cause catastrophic poor treatment outcomes regarding recovery, disability / illness and chronic illness. A paradigm shift to lower doses for fewer patients over a shorter period of time with, for example, Open dialogue quadrupled recovery, reduces schizophrenia per year to one tenth and disability benefit / illness decreases to one third.
    http://wkeim.bplaced.net/files/recovery-en.html
    http://wkeim.bplaced.net/files/Dialogical_practice_is_effektive.png

  • The review does not discuss recovery.
    A shift of paradigm to Open dialogue achieves quadruple recovery rate, reduces schizophrenia per year to one tenth and disability allowance/sickness is reduced to one third.
    http://wkeim.bplaced.net/files/recovery-en.html
    Open dialogue uses approx. 60% less neuroleptics (antipsychotics) for maintenance treatment compared to TAU (Svedberg et al. 2001: http://wkeim.bplaced.net/files/Open-Svedberg.gif ) and achieves more then 60% increase in recovery from approx 20% to more then 80%: http://wkeim.bplaced.net/files/Dialogical_practice_is_effektive.png
    Recovery rates decreased: «17.7% in studies between 1941 and 1955, 16.9% in 1956–1975, 9.9% in 1976–1995, and 6.0% in studies after 1996 (P = .704; table1)» according to (Jaaskelainen et al. 2013).

  • The review seems to consentrate on mortality. However register data in Finnland include information on readmission, disability allowance and if patients are in treament at the end of follow-up:

    Tomi Bergströma, Jaakko Seikkula et al. 2018: The family-oriented open dialogue approach in the treatment of first-episode psychosis: Nineteen–year outcomes. Psychiatry Research Volume 270, December 2018, Pages 168-175 https://authors.elsevier.com/a/1XmgRbZg70VfA

    The family-oriented open dialogue approach in the treatment of first-episode psychosis: Nineteen–year outcomes

    Open Dialogue (OD) is a family-oriented early intervention approach which has demonstrated good outcomes in the treatment of first-episode psychosis (FEP).
    The control group consisted of all Finnish FEP patients who had a follow-up of 19–20 years and who were guided to other Finnish specialized mental healthcare facilities (N = 1763). No difference between the samples was found regarding the annual incidence of FEP, the diagnosis, and suicide rates. Over the entire follow-up, the figures for durations of hospital treatment, disability allowances, and the need for neuroleptics remained significantly lower with OD group. Findings indicated that many positive outcomes of OD are sustained over a long time period. Due to the observational nature of the study, randomized trials are still needed to provide more information on effectiveness of approach.

    The results indicated that with treatment commenced under OD as compared to controls, the overall need for hospital and neuroleptic treatment, and also the time spent on disability allowances, was significantly lower in a follow-up of approximately nineteen years. These findings are in line with earlier studies on OD (Seikkula et al., 2006; 2011), and also with another register-based study with 5-year follow-up, which included all Finnish first-onset schizophrenia patients between 1995 and 2003 (Kiviniemi, 2014). In that study the Western Lapland catchment area presented the lowest figures for the durations of hospital treatment and disability pensions when compared to other Finnish healthcare districts.

    Open dialogue (OD) uses neurroleptics for 20% of patients at the beginning, standard treatment (CG control group) 70%.
    At the end of use with the OD 36% of patients neuroleptics for CG, 81%

    Disability allowance, re-admission and patients under treatment are halved with OD.

    http://wkeim.bplaced.net/files/Bergstroma-2018.png

  • The question is how many patients should get antipsychotics and how long:

    According to TAU all diagnosed schizophrenia are offered drugs. The result is that TIPS prosject medicated all, Svedberg et al. 2001 93%, and in Australia more then 90% tok psykotropic medicine (Waterreus et al., 2012).
    The result: Bjornestad, Jone et al. 2017 found in “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)” with treatment as usual according to the standard guidelines. Recovery rates decreased: «17.7% in studies between 1941 and 1955, 16.9% in 1956–1975, 9.9% in 1976–1995, and 6.0% in studies after 1996 (P = .704; table1)» according to (Jaaskelainen et al. 2013).
    Open dialogue reports more than 80% recovery and the incidence of psychoses was reduced from 33 to 2 per 100,000 inhabitants per year (2, 12).

    Open dialogue uses approx. 60% less neuroleptics (antipsychotics) for maintenance treatment and achieves more than 60% increase in recovery (2, 12). Open dialogue reduces disability allowance/sickness to one third.

    A paradigm shift to Open dialogue achieves quadruple recovery rate, reduces schizophrenia per year to one tenth and disability allowance/sickness is reduced to one third.
    http://wkeim.bplaced.net/files/recovery-en.html
    http://wkeim.bplaced.net/files/Open-Svedberg.gif

  • The authors used a study of death registers in Finland compared the cause-specific mortality in 66,881 patients versus the total population (5.2 million) between 1996 and 2006, suggesting that antipsychotic use decreased all-cause mortality compared to no antipsychotic use in patients with schizophrenia, and that clozapine had the most beneficial profile in this regard (Tiihonen et al., 2009).

    A number of methodological and conceptual issues make the interpretation of these findings problematic, including incomplete reporting of data, questionable selection of drug groups and comparisons, important unmeasured risk factors, inadequate control for potentially confounding variables, exclusion of deaths occurring during hospitalization leading to exclusion of 64% of deaths on current antipsychotics from the analysis, and survivorship bias due to strong and systematic differences in illness duration across the treatment groups. Well designed, prospective mortality studies, with direct measurement of and adjustment for all known relevant risk factors for premature mortality, are needed to identify risk and protective medication and patient factors and to, ultimately, inform clinical practice.

    Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study.
    De Hert M1, Correll CU, Cohen D
    https://www.ncbi.nlm.nih.gov/pubmed/20060684

  • The family-oriented open dialogue approach in the treatment of first-episode psychosis: Nineteen–year outcomes

    Open Dialogue (OD) is a family-oriented early intervention approach which has demonstrated good outcomes in the treatment of first-episode psychosis (FEP).
    The control group consisted of all Finnish FEP patients who had a follow-up of 19–20 years and who were guided to other Finnish specialized mental healthcare facilities (N = 1763). No difference between the samples was found regarding the annual incidence of FEP, the diagnosis, and suicide rates. Over the entire follow-up, the figures for durations of hospital treatment, disability allowances, and the need for neuroleptics remained significantly lower with OD group. Findings indicated that many positive outcomes of OD are sustained over a long time period. Due to the observational nature of the study, randomized trials are still needed to provide more information on effectiveness of approach.

    The results indicated that with treatment commenced under OD as compared to controls, the overall need for hospital and neuroleptic treatment, and also the time spent on disability allowances, was significantly lower in a follow-up of approximately nineteen years. These findings are in line with earlier studies on OD (Seikkula et al., 2006; 2011), and also with another register-based study with 5-year follow-up, which included all Finnish first-onset schizophrenia patients between 1995 and 2003 (Kiviniemi, 2014). In that study the Western Lapland catchment area presented the lowest figures for the durations of hospital treatment and disability pensions when compared to other Finnish healthcare districts.
    https://www.sciencedirect.com/science/article/pii/S0165178117323338

  • Bob,

    thank you very much for your interest. I am looking forward to reading your report about mortality.

    I looked briefly at mortality, life expactency and Standardized Mortality Ratios (SMR) and found 12 referances: http://wkeim.bplaced.net/files/mortality-references.html

    Basicly reading abstracts I could not find any referance giving the quantitative contribution of suicide to mortality. But David Healy et al 2012 write: “The most striking figure in this study is that eliminating suicide in schizophrenia would restore life expectancy to normal.”

    Therefore I looked at the numbers of dramatic increase ofsuicides in hospitals from the 50’s to the 80’s. But I could not find the contribution of inpatient suicide to mortality and life expactancy of people diagnosed psychosis and schizofrenia.

  • Thank you for writing about patients who do not fall into the few who get reduction of symptoms.

    Most of patients deteriorate
    Levine et al 2012 ( https://www.schres-journal.com/article/S0920-9964(12)00039-4/pdf ) looked at treatment reactios for Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). Ca. 73% became drop-outs. «Trajectory analysis of the entire sample identified that 18.9% of participants belonged to a group of responders. This figure increased to 31.5% for completers, and fell to 14.5% for dropouts.» For 72,9 % of drop-outs PANNS symptoms increased from ca. 3% in the beginning to 35% after 18 months (see http://wkeim.bplaced.net/files/Levine-2012-drop_outs.png ). For 23,7% of completers PANNS symptoms increased from ca. 8% in the beginning to 30% after 18 months (see http://wkeim.bplaced.net/files/Levine-2012.png ).

  • Thank you for this article about antidepressants.

    Danish investigators, led by Carsten Hjorthoj found in 2014:

    . 44.3 times higher for people admitted to a psychiatric hospital

    Should the use of neuroleptics be included in the discussion?

    This may be a littke bit off-topic but I would like to add a historic perspective going back to the introduction of neuroleptics.

    There was a dramatic increase of suicides in hospitals from the 50’s to the 80’s.

    In the mid-50s antipsychotics / neuroleptics where introduced. In the 3 decades from 1950s to 1980s inpatient suicides in psychiatric hospitals ten doubled in Norway (Retterstøl 1988: https://link.springer.com/chapter/10.1007/978-3-642-73358-1_12 ), raised from 50 to 400 per 100 000 in V.A. Hospitals ( Farberow 1975: http://wkeim.bplaced.net/files/antipsychotics-Figure-2-1024×768.gif ). Similar tendencies are reported from more that 8 countries (Chart 1: Bowers et al. 2008: http://wkeim.bplaced.net/files/Bowers-2008.png).

  • Thank you for adding long time harm of antipsychitcs use.
    I knew all the studies of Award-winning science writer Robert Whitaker you mention. I agree that his contribution is important. His contributions can explain why Open dialogue can optain so good outstanding treatment results.
    If you click on the link I provided you can find that Whitaker is mentioned more then half a dusin times.

    Summary of longtime problems:
    Psychiatric patients have approx. 25 years shorter life. Recent research recommends reduced long-term use of antipsychotics to increase life expectancy for patients (Athif Ilyas et al, 2017). PETER C. GØTZSCHE, Professor, Dr. Med., Rigshospitalet Copenhagen writes “(T)o sum up, psychotropic drugs are the third most common cause of death in Western countries after cardiovascular disease and cancer.” (7). In ‘Deadly psychiatry and organized denial’ (2015) P. Gøtzsche writes: “we could reduce our current usage of psychotropic drugs by 98% and at the same time improve patients’ mental and physical health and survival”(8). Professor Peter C Gøtzsche concludes 10. January 2018 «Psychiatry is a disaster area in healthcare that we need to focus on» (BMJ 2018;360:k9). see http://wkeim.bplaced.net/files/recovery-en.html

  • Here is the quantitative effect of antipsychotics:

    Little effect in the beginning
    Reduction of 50% or more of psychotic symptoms are achieved according to Leucht et al 2009 effect of “(overall 41 versus 24% responded under SGA drugs and placebo, respectively) or an NNT of 6” i.e. for a small minority (1 in 6 patients) at the beginning of psychosis. Studies cover short-term and mid-term length. The Paulsrud committee found the same effects (1 in between 5 and 10 patients).

    Leucht et al 2012 deals with maintenance treatment with neuroleptics. The studies range from 7 to 12 months. The results for preventing readmission are 1 in 5 patients (NNT = 5) and the conclusions for further research are “focus on outcomes of social participation and clarify the long-term morbidity and mortality.” “Nothing is known about the effects of antipsychotic drugs compared to placebo after three years “(Leucht et al. 2012, p. 27).

    Very small effect for acute psychosis
    Leucht et al 2017 fond (“Sixty Years of Placebo-Controlled Antipsychotic Drug Trials in Acute Schizophrenia”) for acute psychosis that 23% minus 14% placebo I. e.s. 9% for 50% or more reduction of symptoms PANSS. This effect is NNT=11. For 20% «minimal» symptom reduction the effect is 51% minus 30% placebo that equals 21% I. e. NNT=5.

    No evidence of long-term effect
    There is no evidence of maintenance treatment for more than 3 years (FHI: ISBN 978-82-8121-958-8). Bjornestad, Larsen et al. 2017 admits that evidence of maintenance medication is missing: “Due to the lacking long-term evidence base (Sohler et al. 2016) …”

    So the effect in terms of numbers is very small. It only affects symptom reduction. Placebo is effect is already higher/better.

    Patints want to become healthy again, i. e. recovery. Open dialogue with only 17% of pasients medicated in long time perspective has much better results: Open dialogue achieves quadruple recovery rate, reduces schizophrenia per year to one tenth and disability allowance/sickness is reduced to one third. http://wkeim.bplaced.net/files/recovery-en.html

  • Thank you for pointing out that recovery decreased ” Jääskeläinen (2013) In 1941-1955 the recovery rate of schizophrenics was 17.7%. In 1996-2012, it was only 6%!”
    In order to lift recovery rates a paradigm shift may help: Open dialogue achieves quadruple recovery rate, reduces schizophrenia per year to one tenth and disability allowance/sickness is reduced to one third: http://wkeim.bplaced.net/files/recovery-en.html

  • Historical context: Mortality and Standardized Mortality Ratios (SMR) for Mental Illness including Schizophrenia

    The standardized mortality ratio or SMR, is a quantity, expressed as either a ratio quantifying the increase or decrease in mortality of a study cohort with respect to the general population.

    Dramatic increase in suicide in hospitals from the 50’s to the 80’s
    In the mid-50s antipsychotics / neuroleptics where introduced. In the 3 decades from 1950s to 1980s inpatient suicides in psychiatric hospitals ten doubled in Norway (Retterstøl 1988), raised from 50 to 400 per 100 000 in V.A. Hospitals ( Farberow 1975). Similar tendencies are reported from more that 8 countries (Chart 1: Bowers et al. 2008).

    Highly reduced life expectancy for psychiatric patients in the 2000s
    “SMRs for the 1970s, 1980s, and 1990s were 1.8, 3.0, and 3.2, respectively” (John McGrath et al. 2008) i.e. mortality rates continue to increase in several countries. “The most striking figure in this study is that eliminating suicide in schizophrenia would restore life expectancy to normal.” (David Healy et al 2012). Tiihonens 2009 FIN11 cohort study suggested that antipsychotic use decreased all-cause mortality. De Hert et al. 2010 showed incomplete reporting of data e. g. “exclusion of deaths occurring during hospitalization leading to exclusion of 64% of deaths on current antipsychotics from the analysis”.

    Reduced lifetime expectancy for male psychiatric patients in the 21st century was 22 years in Denmark, 19 years in Finland and 20 years in Sweden. This corresponded to the SMR for life expectancy of 2.5 for Denmark, 1.8 for Finland and 2.2 for Sweden, respectively. SMR for suicide was 25, 9 and 21, i.e. suicide is the dominant cause. Women’s numbers are lower (Wahlbeck et al 2011).

    Therefore “Antipsychotics should be used more selectively, for shorter durations and with lowest possible effective dose.” (Weinmann et al. 2010).

    “People with serious mental illness die up to 20 years younger …” … “Healthcare services should consider a shift away from physical health monitoring strategies and instead focus their resources on primary prevention strategies … These include assertive smoking cessation (with pharmacological support), diet and exercise interventions and where possible, to avoid long-term prescription of antipsychotics associated with adverse metabolic outcomes.” (Athif Ilyas et al. 2017)

    http://wkeim.bplaced.net/files/mortality-references.html

  • Thank you for giving the relation of Cohens effect size and NNT.

    I have tried to find out how many patients are medicated by neuroleptics (antipsychotics).

    – Svedberg et al. 2001 reports 93% used neuroleptics and 75% ongoing (See: http://wkeim.bplaced.net/files/Open-Svedberg.gif )
    – In Australia over 90% of people diagnosed with a psychotic illness are prescribed medication, and polypharmacy is common (Waterreus et al., 2012 http://journals.sagepub.com/doi/abs/10.1177/0004867412450471 )
    – Treatment and Intervention in Psychosis (TIPS) early-detection study medicated all in the beginning and approx 70% ongoing (Wenche ten Velden Hegelstad et al 2012: https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2011.11030459 )
    – Open Dialogue Therapy in Western Lapland 33% use neuroleptics and 17% ongoing (See: http://wkeim.bplaced.net/files/Open-Svedberg.gif )

    But only one in 6 patients get a symptom reduction og 50% or more according to Leucht et al. 2009.

    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.

    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. “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. Disability allowance or sick leave goes up more then 40%. Open dialogue reduced the incidents of psychosis from 33 to 2 per 100 000 annually.

    Is it possible to give a very rough guess on the long-term effect/harm of antipsychotics on recovery? http://wkeim.bplaced.net/files/question-recovery.html
    Would between 2/3 and 80% be appropriate?

  • The study seems to be about death and relaps. From a patient point of view the most importent question for me is does “stayng on meds” promote to become healthy (recovery) and functioning well (e. g. cognitive functions). This has become mainstream i strategies. Both the United States, Canada, New Zealand, Australia, the UK and Ireland are building their national strategies on recovery. I can not see the study even looked at this question. What happens with patients never been on meds? Looking from this perspective I found: A paradigm shift to reducing meds from beginning is favorable: Open dialogue achieves quadruple recovery rate, reduces schizophrenia per year to one tenth and disability allowance/sickness is reduced to one third: http://wkeim.bplaced.net/files/recovery-en.html

  • Beeing trained as physist and ingeneer I object that my dicioplines are like “every discipline has a belief system”. If engineers base on belief are make mistakes the products (bridges, plains and so on) will collaps. Every phisicist knows that the only thing science really can do is “falsify” theories.
    Psychatry is a week science and psychiatrist disregard its results. Unfortunately many of us patients beleive in what psychiatrist are telling then also the results are a desaster i. e. 8.1 to 20% recovery. Open dialogue achievs quadruple recovery rate, reduces schizophrenia per year to one tenth and disability allowance/sickness is reduced to one third: http://wkeim.bplaced.net/files/recovery-en.html
    The only solution I see is that we patients make a revolution and stop to accept thatwe are made sicker.

  • I would like to support that neuropetics are the better word.
    “In the 1950s, when the drugs we now call ‘antipsychotics’ first came along, psychiatrists recognised that they were toxic substances that happened to have the ability to suppress thoughts and emotions without simply putting people to sleep in the way the old sedatives did” (Joanna Moncrieff, MD 13. August 2013; Deniker P. Compr Psychiatry 1960 Apr;1:92-102.). Mainstream psychiatry was uncomfortable with the notion that its principle treatment worked by being a neurological toxin and transformed it into a sophisticated, treatment. At last the misleading expression “antipsychotics” was chosen.
    Breggin clls this medication neurotoxin.
    “Antipsychotics” do not cure psychisis as the word suggests but reduce symptoms for a small minority.

  • Let us quantify “For many people, antipsychotics reduce psychosis.” from a patient perspectice.
    Reduction of 50% or more of psychotic symptoms are achieved according to Leucht et al 2009 effect of “(overall 41 versus 24% responded under SGA drugs and placebo, respectively) or an NNT of 6” i.e. for a small minority (1 in 6 patients) at the beginning of psychosis.
    What about longterm-effects?
    Leucht et al 2012 deals with maintenance treatment with neuroleptics. The studies range from 7 to 12 months. The results for preventing readmission are 1 in 5 patients (NNT = 5) and the conclusions for further research are “focus on outcomes of social participation and clarify the long-term morbidity and mortality.” “Nothing is known about the effects of antipsychotic drugs compared to placebo after three years “(Leucht et al. 2012, p. 27).
    There is no evidence of maintenance treatment for more than 3 years (FHI: ISBN 978-82-8121-958-8). Bjornestad, Larsen et al. 2017 admits that evidence of maintenance medication is missing: “Due to the lacking long-term evidence base (Sohler et al. 2016) …”
    From a patients perspective recovery is what we patients want.
    There is no evidence that antipsychotics promote “psychosocial functioning, professional functioning, and quality of life” (Buchanan et al 2010 PORT Treatment Recommendations). Recovery treatment still wins terrain and will be put into a historical context. Mike Slade et al. 2014 describes the implementation of recovery with both usage and abuse of the term. http://wkeim.bplaced.net/files/recovery-en.html

    Thank you for an article giving much valuable information, but “For many people, antipsychotics reduce psychosis” is obiously wrong. Psychosis is not reduced but only one in 6 patients get reduced symptoms (not psychosis) 50%.

  • Let us talk about qantitative numbers of the benefit of drugs.

    What is the goal: Symptom ease or recovery?

    Neuroleptics are used to ease symptoms and to prevent relapse with evidence at the beginning of the psychosis. There is no evidence that antipsychotics promote “psychosocial functioning, professional functioning, and quality of life” (Buchanan et al 2010 PORT Treatment Recommendations). Recovery treatment still wins terrain and will be put into a historical context. Mike Slade et al. 2014 describes the implementation of recovery with both usage and abuse of the term. Why is there still resistance despite very good treatment outcomes of recovery orientation such as Open dialogue (2)? How can a paradigm shift be made in the interest of patients’ health and health professionals who want their efforts to benefit many more patients?

    Open dialogue reports more than 80% recovery and the incidence of psychoses was reduced from 33 to 2 per 100,000 inhabitants per year (2, 12).

    Open dialogue uses approx. 60% less neuroleptics (antipsychotics) for maintenance treatment and achieves more than 60% increase in recovery (2, 12). Open dialogue reduces disability allowance/sickness to one third.

    Bjornestad, Jone et al. 2017 found in “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)” with standard treatment according to the standard guidelines.

    Little effect in the beginning
    50% reduction or more of psychotic symptoms are achieved according to Leucht et al 2009 for 41% minus 24% for placebo equal to 18%, ie one for a small minority (1 in 6 patients) at the beginning of psychosis. Studies cover short-term and mid-term length. The Paulsrud committee found the same effects (1 in between 5 and 10 patients).

    Leucht et al 2012 deals with maintenance treatment with neuroleptics. The studies range from 7 to 12 months. The results for preventing readmission are 1 in 5 patients (NNT = 5) and the conclusions for further research are “focus on outcomes of social participation and clarify the long-term morbidity and mortality.” “Nothing is known about the effects of antipsychotic drugs compared to placebo after three years “(Leucht et al. 2012, p. 27).

    No evidence of long-term effect
    There is no evidence of maintenance treatment for more than 3 years (FHI: ISBN 978-82-8121-958-8). Bjornestad, Larsen et al. 2017 admits that evidence of maintenance medication is missing: “Due to the lacking long-term evidence base (Sohler et al. 2016) …” Thus, positive effects for patients are not evidence-based after 3 years and the probability of evidence-based positive effects is strict taken zero.

    Symptoms relief (12) and relapse prevention (Leucht et al 2012) are achieved only for a small minority in the beginning, RCT evidence beyond 3 years lacks completely and long-term use co-varies with more than approx. 40% reduction in recovery and approx. 40% increase in disability disability allowance/sickness (12). Nevertheless, psychiatry professors Jan Ivar Røssberg, Ole A. Andreassen, Stein Opjordsmoen Ilner (who educate psychiatrists) has a change-resistant, unrealistic and knowledge-resistant misrepresentation that antipsychotics contribute for “the vast majority contributing to the symptoms, functioning and higher self-reported quality of life. “(Doctors Journal, 12.05.2017). This delusion prevents the opening of drug-free treatment (3,4) in the psychosocial guidelines (“experimental, unethical”, Larsen: “giant mistake”, professional irresponsibility) and legitimises illegal forced medication. There is no evidence that antipsychotics promote “psychosocial functioning, professional functioning, and quality of life” (Buchanan et al 2010 PORT Treatment Recommendations). The county administration’s practice regarding complaints against forced medication has been weakened by naive unscientific belief in psychiatrists’ allegations and delusions. The county governor legitimises it by just giving 3% of the complaints pursuant and thus appears as a ridiculous appeal body (Ketil Lund). The Civil Ombudsman points out in law and order 05/2017 (Volume 56). Mental Health and Forced Medicine: “We are here in the core area of ​​the principle of legality: Forced medication should not occur without the requirements of the law being met.” Actually, “forced medication must be forbidden” (Ketil Lund).

    Experience data shows that recovery is weakened in the long run
    Harrow, M. & Jobe, T.H. (2012), Harrow et al 2014 (12) Long-term study shows that patients diagnosed with schizophrenia subject to drug-free treatment manage better in the long run, ie 50% significantly improved (higher recovery rate) after 15 years compared with 5%.

    Wunderink randomized study replicated results. After 7 years, 40.4% recovery recovered and 17.6% with neuroleptics (12).

    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 has 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 (Wils et al. 2017) the study of Lincoln and Jung in Germany, and the studies of Bland in Canada, “(Among RC 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. I tillegg til resultatene som indikerer rariteten af ​​perioder med fuldstændig recovery for patienter med schizofreni-antipsykotika for forlængede intervaller, vores Research has indicated a significantly higher rate of periods of recovery for patients with schizophrenia who have gone off antipsychotics for prolonged intervals. ”

    Using minimal neuroleptics is beneficial.

    The effects of current medication: More harm then good?
    Only little effect of symptom reduction in the beginning (Leucht et al 2009), no evidence for effect after three years (Leucht et al 2012), no evidence for promotion of recovery (Buchanan et al 2010 PORT Treatment Recommendations) and the excellent recovery results (Seikkula 2014) of Open dialogue with 83% unmedicated long-term (5, Seikkula 2016) have raised the question if antipsychotics do more harm then good in the long term.

    What is the possible harm?

    There have been questions about increased drug use of neuroleptics and antidepressants and increased disability benefits have a connection: Whitaker: Causation, Not Just Correlation: Increased Disability in the Age of Prozac (6).

    Clare Parish found that brain volume shrinks (“Antipsychotic deflates the brain”) also see Andersen et al. The reduction in brain volume due to prolonged “antipsychotic” use reduces cognitive abilities (PLOS Medicine: Antipsychotic Maintenance Treatment: Time to Rethink? Joanna Moncrieff. Published: August 4, 2015).

    Psychiatric patients have approx. 25 years shorter life. Recent research recommends reduced long-term use of antipsychotics to increase life expectancy for patients (Athif Ilyas et al, 2017). PETER C. GØTZSCHE, Professor, Dr. Med., Rigshospitalet Copenhagen writes “(T)o sum up, psychotropic drugs are the third most common cause of death in Western countries after cardiovascular disease and cancer.” (7). ‘Deadly psychiatry and organized denial’ (2015) writes P. Gøtzsche writes: “we could reduce our current usage of psychotropic drugs by 98% and at the same time improve patients’ mental and physical health and survival”(8). Professor Peter C Gøtzsche concludes 10. January 2018 «Psychiatry is a disaster area in healthcare that we need to focus on» (BMJ 2018;360:k9).

    http://wkeim.bplaced.net/files/recovery-en.html

  • Where is the revolution the headline talks about?

    Peter C Gøtzsche concludes 10 January 2018 (BMJ 2018;360:k9): «Psychiatry is a disaster area in healthcare that we need to focus on» (15):

    Firstly, the effects of psychiatric drugs are not specific.

    Secondly, the research in support of the paradigm is flawed

    Thirdly, the widespread use of psychiatric drugs has been harmful for the patients.

    Fourthly, all attempts at showing that psychiatric disorders cause brain damage that can be seen on brain scans have failed.

    There are four main problems with psychiatric drug trials:

    1)Almost all placebo-controlled trials are flawed due to their cold turkey design

    2)The trials are insufficiently blinded

    3)Psychiatrists assess the effect using rating scales, the relevance of which for the patients is often uncertain

    4)Selective reporting of outcomes is very common and can be very serious

    Psychiatry needs a revolution. Reforms are not enough. We need to focus on psychotherapy and to hardly use any psychiatric drugs at all.

    http://www.bmj.com/content/360/bmj.k9/rr-15

    How to do it at least partly:

    A paradigm shift to Open dialogue could achieve quadruple recovery rate, reduction of schizophrenia per year to one tenth and disability allowance/sickness is reduction to one third: http://wkeim.bplaced.net/files/recovery-en.html

    It seems a typical win-win situation: Patients can get recovery, psychatrists would be rewarded seeing more patients become healthy.

  • Hi juidi,

    yes you are right that Open dialogue uses diagnoses when comparing there treatment results to standard treatment (TAU). (See: Scientific Symposium. Pharmaceuticals – risks and alternatives. The 15th of October 2016 in Gothenburg, Sweden. Jaakko Seikkula, Professor of Psychotherapy, Clinical Psychologist, Finland. Naturalistic study designs for developing the system to reduced medication http://extendedroom.org/en/scientific-symposium/ )

    However they descripe the basis of treatment as “accepting others unconditionally” http://wkeim.bplaced.net/files/Open_dialogue.png and are therefore not busy with diagnosis. Unlike TAU they can tell their pasients that more then 80% come back to study, work and family. I have heart from many survivors having been told to suffer from a lifelong disease and have to take drugs for the rest of their lifes. That’s true for TAU with 8.1 to 20% recovery only (Jaaskelainen et al., 2013).

    Open dialogue is the only psychiatry in Northern Finland. So there only “problem” is that they reduse diagonsis schizofrenia per year to one tenth. Therefore they have less patients. But they prioritise new cases and they can respond within 24 hours. The overall cost per inhabitant is less then TAU. So they employ fewer people.

    What I criticize is psychiatry in the rest of Finland and other countries. Both USA, Canada, New Zealand, Australia, UK and Irland have national stategies with recovery as aim, bur refuse to even look at what Open dialogue is doing and achieving. This is cynical.

    Do not get me wrong I have a statement in my official medical records that I be not examined, not diagnosed and not treated: http://home.broadpark.no/~wkeim/files/patverfue-en_anonym.html by TAU.

    My main objection to Robert Nikkel article is that he is professionally “promoting recovery”. But his is attacking antipsychiatry not the sick psychiatry he works for anly achieving approx. 20% recovery. Psychiatry is doing the opposite of what they tell.

    What we can learn her is that we should fight for common goals.

    I support peacefull revolution but consider antipsychiatry as allies in the fight against forced drugging. I hope that those who promote evolution join.

    Let us fight together forced and violent psychiatry and refuse to follow Roberts attempt to fight each other 🙂

  • Thank you for your constructive comment Someone Else.

    A paradigm shift to Open dialogue could achieve quadruple recovery rate, reduction of schizophrenia per year to one tenth and disability allowance/sickness is reduction to one third: http://wkeim.bplaced.net/files/recovery-en.html

    It seems a typical win-win situation: Patients can get recovery, psychatrists would be rewarded seeing more patients become healthy.

    Why is there so little interest for change?

  • Psychiatry can not continue as it is now:

    Peter C Gøtzsche concludes 10 January 2018 (BMJ 2018;360:k9): «Psychiatry is a disaster area in healthcare that we need to focus on» (15):

    Firstly, the effects of psychiatric drugs are not specific.

    Secondly, the research in support of the paradigm is flawed

    Thirdly, the widespread use of psychiatric drugs has been harmful for the patients.

    Fourthly, all attempts at showing that psychiatric disorders cause brain damage that can be seen on brain scans have failed.

    There are four main problems with psychiatric drug trials:

    1)Almost all placebo-controlled trials are flawed due to their cold turkey design

    2)The trials are insufficiently blinded

    3)Psychiatrists assess the effect using rating scales, the relevance of which for the patients is often uncertain

    4)Selective reporting of outcomes is very common and can be very serious

    Psychiatry needs a revolution. Reforms are not enough. We need to focus on psychotherapy and to hardly use any psychiatric drugs at all.

    http://www.bmj.com/content/360/bmj.k9/rr-15

  • Is this TAU Treatment as usual?
    It would be interesting to look at spread and the results of different treatment protocols.
    Robert Whitaker talks about the Open Dialogue model in Finland. This program gets 80% recovery rates from what would have normally been called, “Schizophrenia.” They delay the initial use of medications and diagnoses and instead address the needs for family and social supports. Recorded by Corinna West at the 2011 SAMHSA Pharmacology Dialouge
    https://www.youtube.com/watch?v=5wELX6xaRVc

  • Thank you for analysing the history of psychiatry.

    Is it possible to give a rough guess on the long-term harm 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. Hospitalisation was also reduced NNT=5. “This effect must be weighed against the side effects of antipsychotic drugs. Future studies should focus on outcomes of social participation and clarify the long-term morbidity and mortality associated with these drugs”.
    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%. Open dialogue reduced the incidents of psychosis from 33 to 2 per 100 000 annually.
    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 antipsychotics being “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.”
    Choice

    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.

    Follow-up: Jim Gottstein: Schizophrenia Drugs Reduce Recovery Rates from 80% to 5% (Comparison Open dialogue/Harrow results)

    References:
    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
    http://www.nature.com/mp/journal/v14/n4/full/4002136a.html
    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.
    https://www.ncbi.nlm.nih.gov/pubmed/22592725
    3)Council of Evidence-based Psychiatry
    http://cepuk.org/unrecognised-facts/long-lasting-negative-effects/
    4)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
    http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1707650
    5)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
    6)Robert Whitaker. Harrow + Wunderink + Open Dialogue = An Evidence-based Mandate for A New Standard of Care:
    https://www.madinamerica.com/2013/07/harrow-wunkerlink-open-dialogue-an-evidence-based-mandate-for-a-new-standard-of-care/
    7)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
    8)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
    https://www.ncbi.nlm.nih.gov/pubmed/21914252?dopt=Abstract
    9)Klingberg S, Wittorf A. Evidence­based psychotherapy for schizophrenic psychosis. Nervenarzt 2012; 83: 907-918.
    https://www.ncbi.nlm.nih.gov/labs/articles/22733380/
    10)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
    11)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
    12)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

  • Thank you for your contribution.

    I would like to draw your attention to the CRPD Committee (UN Convention on the Rights of Persons with Disabilitie), 30 March 2015 to overcome these human right violations with the suggestions:

    Restitution (restoration of liberty)
    Compensation (economically, moral damage)
    Rehabilitation (official declaration, public apologies)
    Satisfaction (e. g. truth commission)
    Guarantees of non-repetition

    https://dk-media.s3.amazonaws.com/AA/AG/chrusp-biz/downloads/294485/Side_event_CRPD_Art15_March2015_Hege.pdf

  • I agree.
    This was suggested at the “Side-event to the CRPD Committee, 30 March 2015, PW, conference room”
    – urgent need for effective remedies, redress and guarantees of non-repetition
    https://dk-media.s3.amazonaws.com/AA/AG/chrusp-biz/downloads/294485/Side_event_CRPD_Art15_March2015_Hege.pdf

    Suggestions:

    Restitution (restoration of liberty)
    Compensation (economically, moral damage)
    Rehabilitation (official declaration, public apologies)
    Satisfaction (e. g. truth commission)
    Guarantees of non-repetition

  • Yes I agree. What about authorities?
    There was a conference “What is the knowledge base for treatment with or without the use of psychotropic drugs?” (1) of Humania FOUNDATION, where Fellesaksjonen (medication free treatment), Ivar Røssberg (psychiatrist), Robert Whitaker and Jaakko Seikkula (open dialogue) gave contributions (see https://www.youtube.com/watch?v=Vu8i0SeHqjQ ).
    I wrote a open letter to the authorites e. g. government agencies (Directorate of Health, Knowledge Centre, Public Health, Medicines Agency, Patient Safety Program) on the outcome: “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 (sorry for spelling).
    I did not get an answer. Unfortunately authorities listen to psychiatrists not scientific results.

  • Thank you for your interest.
    It took me 2 years to collect this information and I have published it here: http://home.broadpark.no/~wkeim/files/question-recovery.html
    However nobody answered up to now.
    Here is a overhead of the impressive effects of Open dialogue: http://home.broadpark.no/~wkeim/files/Dialogical_practice_is_effektive.png
    and a comparison to traditional “care”: http://home.broadpark.no/~wkeim/files/Open-Svedberg.png
    Open dialogue reports 19% were on disability allowance or sick leave with 17% ongoing neuroleptics. Sveberg (2001) reported for traditional care 62% on disability allowance or sick leave following standard care and 75% ongoing neuroleptics.
    Goff and other do not include real world results because these results are not RCT. But psychiatry has no own RCT studies.

  • 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.”
    Choice

    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.

    References:
    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
    http://www.nature.com/mp/journal/v14/n4/full/4002136a.html
    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.
    https://www.ncbi.nlm.nih.gov/pubmed/22592725
    3)Council of Evidence-based Psychiatry
    http://cepuk.org/unrecognised-facts/long-lasting-negative-effects/
    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
    http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1707650
    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:
    https://www.madinamerica.com/2013/07/harrow-wunkerlink-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
    https://www.ncbi.nlm.nih.gov/pubmed/21914252?dopt=Abstract
    8)Klingberg S, Wittorf A. Evidence­based psychotherapy for schizophrenic psychosis. Nervenarzt 2012; 83: 907-918.
    https://www.ncbi.nlm.nih.gov/labs/articles/22733380/
    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

  • Harrow has been replicated by others:
    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.”

    http://www.sciencedirect.com/science/article/pii/S0165178116321278

  • Thank you for your contribution. Great article.

    I wonder if it is possible to give quantitive estimates of the damage done by antipsychotics?

    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.”
    Choice

    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.

    Follow-up: Jim Gottstein: Schizophrenia Drugs Reduce Recovery Rates from 80% to 5% (Comparison Open dialogue/Harrow results)

    References:
    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
    http://www.nature.com/mp/journal/v14/n4/full/4002136a.html
    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.
    https://www.ncbi.nlm.nih.gov/pubmed/22592725
    3)Council of Evidence-based Psychiatry
    http://cepuk.org/unrecognised-facts/long-lasting-negative-effects/
    4)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
    http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1707650
    5)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
    6)Robert Whitaker. Harrow + Wunderink + Open Dialogue = An Evidence-based Mandate for A New Standard of Care:
    https://www.madinamerica.com/2013/07/harrow-wunkerlink-open-dialogue-an-evidence-based-mandate-for-a-new-standard-of-care/
    7)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
    8)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
    https://www.ncbi.nlm.nih.gov/pubmed/21914252?dopt=Abstract
    9)Klingberg S, Wittorf A. Evidence­based psychotherapy for schizophrenic psychosis. Nervenarzt 2012; 83: 907-918.
    https://www.ncbi.nlm.nih.gov/labs/articles/22733380/
    10)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
    11)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
    Open letter to the Directorate of Health, Knowledge Centre, Public Health, Medicines Agency, Patient Safety Program, Norment, Experience Expertise 12. February 2017:
    12)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

  • Thank you for this interesting study saying: “The 7-year follow-up involved 103 patients. At 40% compared to 18%, patients in the dose-reduction/discontinuation group showed twice the recovery-rate of maintenance-treatment patients, wrote the authors”.

    Are there other studies replicating these results?

    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.”
    Choice

    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.

    Answer no. 1: «Hi Walter, I am afraid I am going to disappoint you, which is unfortunate given the time and effort you put into your comment.»
    Follow-up: Jim Gottstein: Schizophrenia Drugs Reduce Recovery Rates from 80% to 5% (Comparison Open dialogue/Harrow results)

    References:
    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
    http://www.nature.com/mp/journal/v14/n4/full/4002136a.html
    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.
    https://www.ncbi.nlm.nih.gov/pubmed/22592725
    3)Council of Evidence-based Psychiatry
    http://cepuk.org/unrecognised-facts/long-lasting-negative-effects/
    4)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
    http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1707650
    5)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
    6)Robert Whitaker. Harrow + Wunderink + Open Dialogue = An Evidence-based Mandate for A New Standard of Care:
    https://www.madinamerica.com/2013/07/harrow-wunkerlink-open-dialogue-an-evidence-based-mandate-for-a-new-standard-of-care/
    7)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
    8)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
    https://www.ncbi.nlm.nih.gov/pubmed/21914252?dopt=Abstract
    9)Klingberg S, Wittorf A. Evidence­based psychotherapy for schizophrenic psychosis. Nervenarzt 2012; 83: 907-918.
    https://www.ncbi.nlm.nih.gov/labs/articles/22733380/
    10)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
    11)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
    12)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

  • The Leucht et al 2017 study says: “At least a “minimal” response (at least a PANSS 20% symptom reduction) occurred in 51% of the antipsychotic group versus 30% in the placebo group, and 23% versus 14% had a “good” response.” In order to calculate NNT (NNT=Number Needed to Treat) you have to subtract 30% placebo from 51% equal 21% i. e. NNT=5. For “good response” 23% minus 14% equals 9% effect due to antipsychotics i. e. NNT=10. You have to treat 10 pasients to get a good response for one. Leucht et al 2009 and Leucht et al 2012 calculated NNT. However this showed how low the real effect was. Therefore NNT is no longer used. From a pasient point of view the difference is important, because it shows that it is not necessary to medicate so many avoiding side effects and long-term negative affects.

  • The study says: “At least a “minimal” response occurred in 51% of the antipsychotic group versus 30% in the placebo group, and 23% versus 14% had a “good” response.” In order to calculate NNT (NNT=Number Needed to Treat) you have to subtract 30% placebo from 51% equal 21% i. e. NNT=5. For “good response” 23% minus 14% equals 9% effect due to antipsychotics i. e. NNT=10. You have to treat 10 pasients to get a good response for one. Leucht et al 2009 and Leucht et al 2012 calculated NNT. However this showed how low the real effect was. Therefore NNT is no longer used. From a pasient point of view the difference is important, because it shows that it is not necessary to medicate so many avoiding side effects and long-term negative affects.

  • Yes ED is “early detection” and DUP is “Duration of untreated psychosis”.
    I tried to give numbers and I estimated that with “standard” psych “treatment” (e. g. in Norway “National guideline for diagnosis, treatment and follow-up of individuals with psychotic disorders”) approx. 40% of patients loose long-term recovery compared to non-medicated patients. Disability allowance or sick leave goes up more then 40%.: http://home.broadpark.no/~wkeim/files/question-recovery.html

  • A Profession in Denial: Psychiatry’s 6 head-in-the-sand responses to criticism

    1. The critic lacks expertise or objectivity
    2. The harm is a result of the underlying illness, not our treatments (Brain Shrinkage)
    3. We are on the cusp of a major scientific breakthrough
    4. The damage is justified
    5. Our treatments save lives
    6. We never really believed that (chemical imbalance myth)

    http://www.talesfromthemadhouse.com/a-profession-in-denial-psychiatrys-6-head-in-the-sand-responses-to-criticism-part-i/

  • Jan Ivar Røssberg contributed with: «Psychiatric wards without medication: Why is it a bad idea?» to the conference at Litteraturhuset 8. February 2017 about “What is the scientific basis of treatment with or without neuroleptics?” of the Humania STIFTELSEN. In the Norwegian Early Detection study (known as the TIPS study) both groups where subject to the standard protocoll of medication with antipsychotics. He defended the use of antipsychotics and claimed that the Early Detection group in TIPS showed better recovery results i. e. approx one third. In the Norwegian press he claimed that 10 times more suicide or suicide attempts occured in the group starting treament 11 weeks later.
    However Open dialogue using minimal medication reported 80% recovery.
    See Scientific Symposium. Pharmaceuticals – risks and alternatives. The 15th of October 2016 in Gothenburg, Sweden. Jaakko Seikkula, Professor of Psychotherapy, Clinical Psychologist, Finland. Naturalistic study designs for developing the system to reduced medication

    References:
    Symposium: http://extendedroom.org/en/scientific-symposium/
    Jaakko Seikkulas contribution: http://extendedroom.org/wp-content/uploads/2016/10/Open-Dialogueresearchgothenburg102016.ppt

  • Thank you for patients perspective on medication. One third are satisfied, one third very dissatisfied.
    However what would happen without or very restricted use of antipsychotics?

    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.”
    Choice

    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.

    http://home.broadpark.no/~wkeim/files/question-recovery.html

  • In the Norwegian Early Detection study (known as the TIPS study) both groups where subject to the standard protocoll of medication with antipsychotics. The author claims that the Early Detection group showed better recovery results i. e. approx one third. However Open dialogue using minimal medication reported 80% recovery.
    See Scientific Symposium. Pharmaceuticals – risks and alternatives. The 15th of October 2016 in Gothenburg, Sweden. Jaakko Seikkula, Professor of Psychotherapy, Clinical Psychologist, Finland. Naturalistic study designs for developing the system to reduced medication
    Conference: http://extendedroom.org/en/scientific-symposium/
    Jaakko Seikkulas contribution: http://extendedroom.org/wp-content/uploads/2016/10/Open-Dialogueresearchgothenburg102016.ppt

  • The Norwegian Early Detection study (known as the TIPS study) has been subject to a critical analysis:

    – At 10 year follow-up, all the clinical and functional measures of the original study are not significantly different (and one measure is worse for the treatment group). Despite this, the authors claim in the abstract to have demonstrated that earlier detection of psychosis has reduced deficits and improved function. They base this conclusion on a completely new measure called “recovery”, which was not considered at baseline, 1 year, or 5-year follow-up, and which appears to be a proxy for vocational outcome, itself not significantly different at five-year follow-up.
    – They do not examine the original hypothesis, that longer DUP causes a worse outcome, despite reporting a logistic regression which demonstrates no association between DUP and outcomes.
    – They do not consider the alternative hypothesis, which emerged spontaneously before it was presented, that the intense effort to identify patients with psychosis might also sample selectively and recruit a less affected group of people.
    – They do not report hospitalisation, despite this measure being significantly worse for ED patients at five-year follow-up (suggesting early detection actually caused a worse outcome)
    They discuss only the putatively better outcome of recovery in the ED group, without discussing the relatively worse outcome in independent living for the ED group
    – They suggest that the non-significant results may be due to the selective attrition of relatively higher-functioning patients from the ED group, but do not discuss the fact that there was a selective attrition of patients with longer DUP from the ED group, and not from the no-ED group. If longer DUP is a causal mechanism, this would improve the measured outcomes of the ED patients.

    25 September 2017 from Google cache:
    Long-term Follow-up of the TIPS early detection in psychosis study: Effects on 10-year outcome – facilitated by Dr Andrew Amos
    http://www.crebp.net.au/long-term-follow-up-of-the-tips-early-detection-in-psychosis-study-effects-on-10-year-outcome-facilitated-by-dr-andrew-amos/

  • Thank you very much for your contribution.

    The authorities sponsering the study have an obligation to support openess.

    From a patients point of view it is very important to clarify the death rate. Pasients obviously want to survive and have a right to know about the risk. Where there is a risk there must be a choice.

    The UN Committee against Torture (CAT/C/NOR/QPR/8) asked Norway 2015 preparing Norway’s report for 2016:

    (a) “Whether the use of restraints and the enforced administration of intrusive and irreversible treatments such as neuroleptic drugs and electroconvulsive therapy has been abolished in law…

    (b) Ensuring that every competent patient, whether voluntary or involuntary, is fully informed about the treatment to be prescribed and given the opportunity to refuse treatment or any other medical intervention… ”

    I noted that public funding was done: “Supported by Health West (Norway grant 911369), Norway (Dr. Hegelstad); the Norwegian National Research Council (grants 133897/320 and 154642/320); the Norwegian Department of Health and Social Affairs and the National Council for Mental Health/Health and Rehabilitation, Rogaland County, and Oslo County (grants 1997/41 and 2002/306) (Drs. Vaglum, Johannesen, Friis, Larsen, Melle, and Opjordsmoen); the Theodore and Vada Stanley Foundation; the Regional Health Research Foundation for Eastern Region, Denmark; Roskilde County, Helsefonden”

    From my point of view public authorities have to support that the information has to be given in order to ensure the possibility that patients are informed.
    It may be necessary to file a freedom of information request.

  • Thank you for showing that “Psychiatric drugs are only marginally more effective than placebos, sugar pills. Over seven years, it has been shown that people with the diagnosis of schizophrenia do better without drugs.”

    Is it possible to give a rough guess on the damage i. e. 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.

    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)
    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 cronic 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?
    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.

    Here are the references: http://home.broadpark.no/~wkeim/files/question-recovery.html

  • Service user perspectives on coercion
    and restraint in mental health

    Joint crisis plans or advance directives are coun­
    selled by many as a means of reducing incidents of
    restraint and of listening to the needs of service
    users (Papageorgiou et al, 2002; Amering et al,
    2005). Approaches that include peer facilitators
    and improvements to the frequency and quality
    of communications are crucial. Some existing
    institutional systems make good communication a
    practical impossibility.
    From the perspective of service users, coercion
    and restraint are mostly harmful and must stop
    being legitimised. There is an urgent need to chal-­
    lenge and address these practices as they represent
    gross human rights violations according to the
    stipulations of the CRPD. UK compliance with
    the legislation is due to be monitored in the next
    2 years.
    http://www.rcpsych.ac.uk/pdf/PUBNS_IPv14n3_59.pdf

  • 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 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.

    However is it possible to use other studies to evaluate effects based on other studies and real world results?
    Approx. 60% or so of first-episode patients may recover without the use of antipsychotics.
    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.” 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.
    In order to maintain the narrative of antipsychotis beeing “effective” schizophrenia is falsely declared cronic 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?
    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.

  • Is it possible to give a rough guess on the effect of antipsychotics on recovery?

    Thank you for publishing the Harrow 20 years follow-up showing better functioning without antipychotics.

    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 symptoms on the Positive and Negative Syndrome Scale (PANSS).
    Leucht et al 2012 looks at maintenance treatment with antipsychotic drugs published better results but concludes 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. 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).
    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.

    However is it possible to give a very rough guess?
    Approx. 60% or so of first-episode patients may recover without the use of antipsychotics.
    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.
    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. 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.
    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 rough guess of the long-term effect of antipsycotics on recovery?
    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.

  • Nradabhatse die Katze:
    Thank you for your answer.
    Yes I have read the article “The Case Against Antipsychotics” and “Treatment of Schizophrenia Without Neuroleptics: Psychosocial Interventions Versus Neuroleptic Treatment”. Very interesting.
    I knew http://psychrights.org. The link http://psychrights.org/Articles/articles.htm is new for me and I enjoyed to read the latest news from Open dialogue of Jaakko Seikkula.
    The context I am working on is a follow-up of “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 (sorry for bad language: English is not my mother tongue) about the conference at the House of Literature 8th February 2017. “What is the knowledge base for treatment with or without the use of psychotropic drugs?” with Whitaker and Jaakko Seikkula.
    Now I search to try to quantify the negative long-time effects of the current protocol of teatment.
    I am sure to need good luck 🙂

  • Can you give an estimate of the percentage of pasients who benefit of medication with antipsychotics. Do you refer to reduction of symptoms opening up for other intervetions?
    From a pasients perspective I would like to add recovery as aim. What is the effect of neuroleptics on long-time recovery?
    Leucht et al has 2009 found (How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials) the effect NNT=6 (1). However this was looking at symptoms on the Positive and Negative Syndrome Scale (PANSS).
    Bola et al. Cochrane.org 2011 found just 5 studies with real placebo, i. e. RCT. One og them Rappaport et al 1978 found that umedicated pasients managed better, e. g. readmission into hospital. NNH turned out to be 2.9 (NNH= number need to harm).
    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.

    However is it possible to give a very rough guess?
    Approx. 60% or so of first-episode patients may recover without the use of antipsychotics.
    Jaakko Seikkula 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.
    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.
    Now I know this guess is not exact science, but does it seem that approx. 40% of pasients 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 nonmedicated pasients?

    Would this be a fair rough guess of the long term effect of antipsycotics on recovery?
    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. What will your students be able to tell their pasients?

    I would appeciate your answer based on your knowledge of studies. Thank you in advance.

  • Thank you for giving quantitative results for medication free care.

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

    Leucht et al has 2009 found (How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials) the effect NNT=6 (1). However this was looking at symptoms on the Positive and Negative Syndrome Scale (PANSS).
    Bola et al. Cochrane.org 2011 found just 5 studies with real placebo, i. e. RCT. One og them Rappaport et al 1978 found that umedicates pasients managed better, e. g. readmission into hospital. NNH turned out to be 2.9 (NNH= number need to harm).
    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.

    However is it possible to give a very rough guess?
    Approx. 60% or so of first-episode patients may recover without the use of antipsychotics.
    Jaakko Seikkula 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.
    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.
    Now I know this guess is not exact science, but does it seem that approx. 40% of pasients 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 nonmedicated pasients?

    Would this be a fair rough guess of the long term effect of antipsycotics on recovery?
    Patients have a right to know in advance to decide with informed consent the benefit of symptom reduction in the beginning at the price of long-term reduction of recovery.

    I would appeciate your answer based on your knowledge of studies. Thank you in advance.

  • “In this meta-analysis, the authors reviewed double-blind, placebo-controlled, randomized controlled trials of adults with acute exacerbations of schizophrenia or other psychotic disorders.”
    Bola et al. Cochrane.org 2011 found just 5 studies FEP with real placebo, i. e. RCT. One og them Rappaport et al 1978 found that umedicates pasients managed better, e. g. readmission into hospital. NNH turned out to be 2.9 (NNH= number need to harm).
    “The authors highlight that the results must be understood within the context of a “chronically ill” sample that included patients who previously had not responded well to antipsychotics. ”
    Do the chosen trials avoid “cold turkey” problems i. e. include a control group never taken antipsychotics?

  • Is it possible to give a rough guess on the effect of antipsychotics on recovery?

    Thank you Bob for answering.

    Leucht et al has 2009 found (How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials) the effect NNT=6. However this was looking at symptoms.

    Bola et al. Cochrane.org 2011 found just 5 studies with real placebo, i. e. RCT. One og them Rappaport et al 1978 found that umedicates pasients managed better, e. g. readmission into hospital. NNH turned out to be 2.9 (NNH= number nead to harm).

    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 as I understand there are nearly no RCT controlled studies answering my question on recovery.

    However is it possible to give a very rough guess?

    Approx. 60% or so of first-episode patients may recover without the use of antipsychotics.

    Jaakko Seikkula has reported on long term outcome of first-episode psychotic patients treated with Open Dialogue Therapy in Western Lapland approx. 80% recovery. Showing the benefit of using not much medication supported by psychosocial care.

    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)”.

    Now I know this guess is not exact science, but does it seem that approx. 40% of pasients 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 nonmedicated pasients?

    Would this be a fair rough guess of the long term effect of antipsycotics on recovery?

    I would appeciate your answer based on your knowledge of studies. Thank you in advance.

  • I could not find the study Nancy Sohler et al. Am J Orthopsychiatry. 2016; 86(5): 477–485. Weighing the Evidence for Harm from Long-term Treatment with Antipsychotic Medications, A Systematic Review.
    This study shows that “Psychiatry’s Evidence Base For Antipsychotics Comes Crashing to the Ground”: https://www.madinamerica.com/2015/12/timberrr-psychiatrys-evidence-base-for-antipsychotics-comes-crashing-to-the-ground/
    Other studies e. g. “Antipsychotic treatment: experiences of fully recovered service users
    Jone Bjornestad, Larry Davidson, Inge Joa, Tor Ketil Larsen, Wenche ten Velden Hegelstad, Johannes Langeveld, Marius Veseth, Ingrid Melle, Jan Olav Johannessen & Kolbjorn Bronnick
    Journal of Mental Health”
    http://www.tandfonline.com/doi/abs/10.1080/09638237.2017.1294735
    use these results: «Due to the lacking long-term evidence base (Sohler et al., 2016)…»

  • Is it possible to abolish coercive treatment? «Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience» shows that it is possible to abolish forced treatmen and considerable improvements are possible. The rate of inpasients under coersive medication fall to one tenth i. e. under 0.5 %.
    See Martin Zinkler. Laws 2016, 5(1), 15; doi:10.3390/laws501001 Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience: http://www.mdpi.com/2075-471X/5/1/15/htm

  • Is it possible to abolish coercive treatment? «Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience» shows that it is possible to abolish forced treatmen and considerable improvements are possible. The rate of inpasients under coersive medication fall to one tenth i. e. under 0.5 %.
    See Martin Zinkler. Laws 2016, 5(1), 15; doi:10.3390/laws501001 Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience: http://www.mdpi.com/2075-471X/5/1/15/htm

  • Thank you for spredding hope and a positive vison without hiding the difficulties.

    I would like to add the following positive outcome of the discussion. KETIL SLAGSTAD, doctor and editor of the Journal of the Norwegian Medical Association wrote “The inner conflicts of psychiatry exposed. The debate on drug-free programmes in mental health care concerns the nature of psychiatry – and what it ought to be.” http://tidsskriftet.no/en/2017/03/editor/inner-conflicts-psychiatry-exposed underlining the historical dimention.

  • I welcome this initiative and tried a local follow-up.

    First came the campaign “Make Norway respect rights of persons with disabilities” https://www.causes.com/campaigns/93254-make-norway-respect-rights-of-persons-with-disabilities

    However the state ignored this campaign.

    Therefore the German “Alliance against Torture in psychiatry” website “Abolish torture” http://www.folter-abschaffen.de/ was translatet to English: http://home.broadpark.no/~wkeim/files/stop-torture-an.html

    Forced medication seemed the weakest point of forced treatment to collect signitures for “Stop Torture in Psychiatry in Norway”: https://www.causes.com/campaigns/102618-stop-torture-in-psychiatry-in-norway/description

    An extension was to look at Europe: “Call to Abolish Forced Psychiatry in Europe” http://home.broadpark.no/~wkeim/files/stop-torture-europe.html


    Walter Keim
    Netizen: http://walter.keim.googlepages.com

  • Thank you for your valuable contribution. In order pasients to benefit from this knowledge I think that National professional guideline for diagnosis, treatment and follow-up of individuals with psychotic disorders should be updated: Knowledge- and research-based liquidation of current harmful psychiatric medication in favour of evidence-based practice to promote recovery (sorry for poor Google translation): http://home.broadpark.no/~wkeim/files/open_letter_knowledge.html

  • «Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience» shows that it is possible to abolish forced treatment and considerable improvements are possible. The rate of inpasients under coersive medication fall under 0.5 % afterwards. Heidenheim Department of Psychiatry, Psychotherapy and Psychosomatic Medicine succeeds to end forced medication http://www.mdpi.com/2075-471X/5/1/15/htm

  • I would like to add the “Call for Stop Torture in Psychiatry in Norway”

    Abolish Forced Psychiatry on the basis:

    – Page 5 of the speech of Special Rapporteur on Torture Juan E Méndez in 22. meating of the “Human Rights Council” 4. March 2013: “States should impose an absolute ban on all forced and non-consensual medical interventions against persons with disabilities, including the non-consensual administration of psychosurgery, electroshock and mind-altering drugs, for both long- and short- term application. The obligation to end forced psychiatric interventions based on grounds of disability is of immediate application and scarce financial resources cannot justify postponement of its implementation.”
    – Report A/HRC/22/53 of the Special Rapportuer on torture and other cruel, inhuman or degrading treatment of 1. February 2013, Section 32: “For example, the mandate has held that the discriminatory character of forced psychiatric interventions, when committed against persons with psychosocial disabilities, satisfies both intent and purpose required under the article 1 of the Convention against Torture, notwithstanding claims of “good intentions” by medical professionals (ibid., paras. 47, 48)”. Section 82.: “The prohibition of torture is one of the few absolute and non-derogable human rights, a matter of jus cogens, a peremptory norm of customary international law.”
    – “Dignity must prevail” – An appeal to do away with non-consensual psychiatric treatment World Mental Health Day – Saturday 10 October 2015 «The concept of ‘medical necessity’ behind non-consensual placement and treatment falls short of scientific evidence and sound criteria.»

    http://home.broadpark.no/~wkeim/files/stop-torture-an.html