I’ve always been perplexed by the idea of ‘recovery’ as it relates to psychosis. There are some that really do ‘recover’ in the sense they have one episode then never see a symptom again. And there is a middle group of those who drift in and out over time of symptoms with periods of ‘recovery’ in between. Then there is the bottom group where recovery means heavily medicated to the point that you are no longer being arrested or sectioned every week and living in a group home, maybe working part time for minimum wage somewhere. It doesn’t make a whole lot of sense to talk about all these trajectories of a psychotic disorder under a single umbrella of ‘recovery’. I feel like most of the dialoguing on this site focuses on recovery of the top two groups and how meds block those who will go on to full or intermittent recoveries. While groups like NAMI, TAC, and the overall social services industry focus on that bottom group where meds are the only standing between a person and incarceration/ destitution/self-mutilation/suicide/accidental death/ etc. And they are all fighting with each other like they are talking about the same thing. When the reality is a psychotic disorder can have any of these three trajectories, and the approach to managing it is very different depending which group a particular individual falls into. I think we must start talking about the trajectory groups before discussing anything that has to do with treatment and recovery. The evidence shows what works best in terms of meds and supports for each group; but the fact that we keep lumping them all together in studies and in public discourse is only confusing everyone. Just my two sense on ‘Recovery.’
Alexa
Sandra,
Thanks for another intriguing post.
I would like to add two other frustrations with the field of psychiatry that you have alluded to but left off your list — the need to individualize the approach to each patient and the total lack of awareness of the vast knowledge available in the research literature.
The first issue is one of how doctors talk about drug efficacy. A drug study can say that 60% of patients significantly improved but 5% were significantly harmed and doctors conclude this is a good drug – and don’t even try to understand you as a patient and whether you have the factors that will predict which group you are most likely to fall into. (Even though if you dig even deeper into the literature, these factors frequently have been identified .) Conversely they do the opposite when the numbers point the other direction.
Yet ultimately drug efficacy come down to how you as an individual respond and not what some sample produces in means and p-values. Sometimes you are the mean, and sometimes you are the outlier.
As an MH patient, I fell into this trap for many years – only going after the ‘best bets’ and continually coming up in the bottom 5% group. Once I came to understand that “I am not the mean” I was more open to trying a broader range of interventions and I did find something that works – even though the use of it for my DSM code number was considered ‘off label’ and ‘contradicting the evidence.’ Why? Because the specific underlying biochemical problem I had that was exacerbating my symptoms was not at all related to the baseline levels of serotonin or dopamine (but was apparently messing with them on occasion.)
Second, there is a lot that is known about these conditions but there are hundreds of interaction variables that can combine to produce symptom patterns and drug response patterns. This type of complexity requires supercomputing (or super-intuitiveness) to decipher and is not something that can be understood in a 15 minute DSM style question and answer session. Yet that seems to be all that psychiatry’s intelligentsia want to talk about — perpetuating the status quo. And all the countermovement wants to do is play semantics games with the medical lexicon and debate brain-mind duality .
And this is why the field of psychiatry is going no where fast.
It has been an interesting summer to be a psychosis patient to say the least. My providers have gone in under three months from trying to get everyone on medication ASAP and maintained indefinitely to trying to get the relatively stable ones to do a trial period of reduction or withdrawal. It seems Wunderink’s paper was the one that finally flipped them. And considering these are the “thought leaders” at Harvard Medical School — the rest of psychiatry is probably about to start turning soon too. -A
Eleanor,
This is a great TedTalk, Congratulations! I’m wondering if you have faced any challenges with your speeches when mentioning the fact that you came off medication?
I’d love to know how you handle that question (or critique) when it arises.
Alexa
What if there were a way to prevent relapse without using antipsychotics? What if you could use another target that doesn’t cause neuroatrophy. Why is no one trying to answer that question?
Hi Sandy,
The diagnosis I had from the first doctor was ‘Psychosis NOS’ (the second one refused to label) and both said 5 months of therapy had to be tried first before starting any medication. Both were MD psychoanalysts. Maybe this 5 month guideline is the treatment recommendation from the Psychoanalytic Institute? (Which by the way – the clock restarts when you switch doctors, as you have not tried therapy with them yet!)
I eventually got to a research psychiatrist who only sees psychosis patients (and researches antipsychotic medications) and he has been much more like the doctors described here on MIA – trying to convince me to take medications all the time even when I’ve had no symptoms for 6+ months (which ironically I am pushing back for a more measured approach which is not going over too well with him!)
Looking back, I’m not sure if doing those first two years med free was a curse or a blessing in disguise. I was certainly frustrated with those first two doctors at the time, but I can appreciate now that I learned how to ‘exhaust my coping strategies’ first before turning to a pill. Maybe I am better off today for that. đ
Alexa
Very interesting post. Have you read any of Juli McGruder’s work on schizophrenia in Africa? Her theory is that the reason WHO finds better outcomes in those cultures is because they see this dualist model whereby insanity brings both challenges and blessings (and the solution is often appeasing the spirits rather than forcefully removing them).
Of course, try explaining that to a Western mental health professional and you just get an ‘I see’ and a note in your file that you have ‘diminished insight’ leading you to be ‘treatment noncompliant.’ And having humor towards them? That is called ‘inappropriate affect’. :-p
Hi Sandra,
Thanks for another intriguing post. As a counter point to the one you describe – I have had a very difficult time finding doctors (both PCPs and psychiatrists) who will prescribe anything. The emphasis it seems is on curing everything on its own – through diet, exercise, de-stressing, etc. After four years of living with terrible insulin resistance/pre-diabetes, I finally found a PCP (my fifth try) who would prescribe metformin. But he only did it after 20 minutes of me reciting every single scientifically based intervention I’d tried to lose weight from glycemic load diets, interval workouts, etc. I’ve had similar experiences with psychiatrists – it was the fourth one I went to after three psychotic episodes who agreed to do a trial of a neuroleptic (but only after I proved that I’d given talk therapy a try multiple times and it couldn’t ‘cure’ it.)
I’m curious why doctors are doing this. Is there another trend not to prescribe or require trials of non-pharmacologic interventions first? Or do I just have a very unusual experience with doctors?
Do doctors have some set period of time a patient should spend trying to deal with a problem some other way before resorting to medications?
Alexa
There is a reason al Jazeera was for so long banned from the U.S. They blow the lid off everything and there is no topic that is too taboo or too controversial for them to touch.
They tell the real story behind the Israel- Palestine conflict (never covered on U.S. news). They also show the photos and stories of the real people impacted from the Iraq and Afghanistan wars and other conflicts around the world. They will cover every angle of a corruption or corporate fraud case. They are the epitome of the free press (and ironically are based in an Arab country) – and a free press is the ultimate threat to the power of the U.S. elites. And that is why they are banned. But luckily, they have a live stream on their website, so if you want to know the hidden story behind the day’s headlines – you can watch their coverage anywhere, anytime! đ
Ron,
I agree whole-heartedly. The benefit of ‘befriending’ therapy for psychosis is quite limited. I found ‘befriending’ to be a role better fulfilled by actual friends (i.e. via people met in peer support groups). The point of going to a therapist is to learn and practice coping skills.
By the way, I also wanted to say thanks to you personally for the fantastic website you put together on CBT skills for psychosis. It was my ‘de facto’ digital therapy for the first few years, while I was trying to get adequate health insurance and then on the long wait list to get into a CBT clinic. I am not sure I would have survived the first years of this without it; keep up the good work!
Alexa
Thanks, this was a great post! I finally got fed up with answering the same 45 minutes of questions (and the eight different diagnoses that were handed to me over the last couple years by different doctors, after answering them all the same way!) So last week when I had my first meeting with my new psychiatrist, I typed up a list of the questions, their answers, told him to spend a few minutes reading it, and then we were going to discuss the real problem. It was the first time I ever walked out of one of these intakes where I felt like the doctor actually understood what was going on.
Stanford psychologist Robert Sapolsky has a great online course on this issue on the interrelatedness of all levels of organization in the brain (genetic, molecular, anatomical, environmental, evolutionary) to explain why behaviors happen. In his first lecture he made a compelling case (see 20:25-33:05 ) on why this type of categorical prioritizations (i.e. the behavioral is more important than the genetic) is not only factually wrong, but has been the foundation for all the great human rights abuses from lobotomies to ethnic cleansing:
The reality of mental/brain/behavioral challenges/illnesses/disorders, whatever one wishes to call them, is that they are a complex web of interactions of genes, epigenetics, environment, and neuroplasticity induced changes of our own free will. It is only in understanding the confluence of all these, as potentially equally powerful forces, that the true nature of reality can be observed.
~A
Sandra,
Thanks for putting together this review on outcomes of DUP. The long term outcome profiles of neuroleptics are well established through Harrowâs studies and others including those you have cited. The question Iâd like to know the answer to though is what are their impacts on short term (first episode) outcomes, and more particularly their impacts on self injury and suicide?
For the problem that clinicians (and patients/families) face immediately is how to protect the patient in the short term, because if they are unable to do that, there will be no âlong term outcomesâ to worry about!
One psychiatrist explained to me the heavy reliance on neuroleptics in the first episode as a technique of risk management. Since there are no other options like Soteria (or even hospitalization past about a 21 day window) available for schizophrenia (which by definition lasts six months or longer in duration) the only option currently to try to manage safety is medication. He also explained that medication has to be used in some patients to âimprove insightâ enough so that the patient can participate in CBT and start learning coping skills.
The issue of insight and outcomes though, is an interesting one all in itself. There was one study in the British Journal of Psychiatry that looked at this issue that is worth reviewing: http://bjp.rcpsych.org/content/192/3/178.full
It notes several paradoxical effects, looking at issues with insight (which neuroleptics are supposed to improve by lessening the effects of delusions and command hallucinations) and outcomes of first episode patients with regards to self mutilations and suicide attempts.
Having been through a first episode without medication and subsequent episode later on with it, I have seen first- hand that there is no âeasy solutionâ to the paradoxes these medications pose. I read Harrow first, before I read the first episode studies, and decided to place my bets on what was going to give me the best long term outcome. But then I realized I was playing a dangerous game of Russian roulette with my life by doing that, and decided to try a neuroleptic in my next episode â which improved my âinsightâ dramatically during the episode and then backfired in the same way they described in this paper.
So, I understand what you are saying when you say you donât know whether you are helping or harming patients by directing them to try something else first. I spent the last few years reading these studies too, convinced I could find the ârightâ answer to this question of whether to use neuroleptics. I am starting to realize now, there may not be a right answer to find.
~Alexa
Hi Alice,
I was at a lecture last year at Harvard Medical School (the name of the lecturer slips my mind at present) and he was explaining that a lot of what we are diagnosing as ADD/ADHD in young children is really just different rates of maturation of certain frontal lobe controls. By around age 8-10, he was saying that these tend to normalize across the group. So really, the problem of education is it is expecting all children who are the same age to have the same level of brain development and able to handle the same environments, which is not accurate. Unfortuantely the ones that mature at a slower rate get pulled aside for being problematic and are often set on a lifelong path of drugging, underachievement, and other social problems.
I realize now I was very fortnuate that I went to an alternative school (except for the very gifted, which also as a group have social challenges) where we could progress through at our own pace (so in a graduating class the age range was 14-18).
Maybe once the rate of childhood psychiatric diagnoses reaches truly unmanagable levels (when they are the majority?) we will start to change our systems to better fit the needs of our diverse minds.
Alexa
What is the alternative for the kids who have ADD/ADHD? Perhaps the solution is changing the way education works to accomodate their brains, rather than changing their brains to accomodate the educational system.
Hi Hermes,
Thatâs a great explanation of it. Elevated dopamine is the end result of a cascade. If you want to do prevention/maintenance of psychosis, the focus has to be on the problems upstream, not on beating down dopamine levels continuously.
The cornerstone to my approach to relapse prevention is stress reduction, as the first step in the domino effect that leads to active psychosis is elevated glucocorticoids (particularly avoiding the worst stress culprit âexpressed emotions!â). I also integrate NAC and Omega 3âs which have shown to have some level of protective factors against transitioning into active psychosis. I use a dietary approach as well that focuses on supplementation of key minerals, stabilization of blood sugar levels, and anti-inflammatory foods. Plus a whole lot of insight meditation/positive thinking/self-awareness practice.
Take any one of the ingredients out, and I start to unravel, take two or three out and I am gone in a matter of weeks. Of course I try to explain this to my doctors, and they think this is all a bunch of new age rubbish (âthe reason your symptoms are coming back is because you are not taking your anti-psychotics!â) Then I typically ask them how many of their âmedication compliantâ SZ patients have been continually full time employed, law abiding and tax paying citizens, and are in great physical condition? There is no way to run a multi-year double blind placebo trial of this, so they will never believe it. The proof is in the pudding, or so they say!
Alexa
It would be great to see what the cost savings would be on a state or national level. Since we are in sequester season, SAMHSA and the other agencies need some help envisioning how to cut that 5%. Everyone is complaining about how bad this sequester will be for mental health. Yet this may be the best thing that ever happened to the mental health field, if we use this opportunity to innovate and start doing things more wisely.
Hi Sandra,
Thanks for the great review on neuroleptics. In one your future blogs, Iâd be curious to hear your opinion on the use of anti-epileptics and other drug classes (as well as supplements like N-acetyl cysteine and omega-3 fatty acids) as tools for relapse prevention. There has been quite a bit coming out in the last few years on the role of the stress cascade, HPA axis dysfunction, hippocampal atrophy and their resulting rises in glutamate as the biochemical precursors to acute psychosis. This is currently being looked at in the context of âprevention of conversion to psychosis in the prodromal stage of the first episodeâ but I have wondered recently if these same mechanisms are involved in relapse and could provide some insight into alternatives to the current paradigm of âmaintenance with neuroleptics.â
Alexa
Hi Alice,
Your article makes a good point – It is not reasonable to expect all doctors to be advocates, or fighting the system, or publicly speaking out as anti-APA or anti-big pharma. This is a role for advocates and journalists; the role of doctors is to be doctors. However, it is reasonable to expect doctors to be up to date on empirical findings in their field, and honest with their patients about why they recommend what they do and the risks that accompany them. (Yet sadly, many are neither.)
Doing things differently does count. Sometimes the most powerful agents of change donât come from outspoken critics of a system, but from those inside the system who simply choose to quietly do things differently . For example, a doctor who is concerned that patients are not receiving adequate information about the risks of taking medication can provide more information in the clinic in simple handouts comparing the risks of different drugs.
To manage the risk of over-medicating patients, some community mental health centers are integrating therapy and primary care in the same facility that allows patients to address other things that are fueling their psychiatric symptoms and compounding the medicationsâ side effects (drug/alcohol use, smoking, poor diets, sedentary lifestyle, bad relationships, too much stress) at the same time.
I have found the key ingredient for me for successful management of my condition was 1) to be fully educated about treatment options including all the drugs and their side effects and 2) to be in an integrated clinic with treatment teams that work together, so that the psychiatrist has a clearer picture of what is going on, and what other coping techniques are being used, and what does actually need medication to keep in check. When the condition is being addressed comprehensively, I have found I can keep the amount and duration of medication down to a bare minimum so that I have very few side effects and minimal disability.
I realize this is not the norm in clinical practice, and Iâm not the norm in patients, because I do demand this high standard of care. But the doctors I work with arenât advocates either; they just chose to try to be better at their jobs.
Alexa
Hi Alice,
Thanks for taking on this important issue.
How often is it though that a diagnosis is challenged in psychiatry as a potential fraud of the system? It seems that it would be quite easy to give a patient a diagnosis without it being easily challenged, since the whole process of psychiatric diagnosis is subjective. For example, some patients have five or ten different diagnoses in their records given by different doctors â but no would accuse the doctors of fraud or incompetence for not agreeing. (Although it would certainly raise red flags in other medical specialties where there are objective tests like blood work, biopsies, MRIs etc. to rule on these things.)
I can appreciate the potential ethical issue of giving a patient a particular diagnosis to allow them to receive benefits (or the clinic to be paid). The difference ultimately comes down to whether your ethical system is deontological (believing you have an ethical duty to uphold certain rules or standards, even if they produce bad outcomes) or if you are teleological (believing a good end justifies the means, even if it requires bending the truth or breaking some rules.) Neither system is necessarily more moral than the other from an objective standpoint.
As Iâm sure you are aware, patients also face similar ethical dilemmas when interacting with providers and others in the mental health system, due to the complexity of the requirements. I use to attend a patient support group that served as a forum where patients got together to share experiences on what to say (and not to say!) in all kinds of situations â when talking to SSDI and other benefits administrators, in ER evaluations to ensure you would (or would not) be admitted, what to say to get a doctor to discharge you from a hospital, a judge to release you during a commitment hearing, or to a college administrator to be allowed to re-enroll in classes after a medical leave.
Interestingly, those in the group who were actually somewhat functioning, were the purest teleological thinkers â they were clever, learned the rules of the game, and had no qualms when it came to manipulating the system to get what they wanted out of it. The purest deontological thinkers – the ones that had a strong commitment to honest communication and were unwilling to change their stories to fit the requirements set by the systemâ were the ones who were revolving in and out of treatment, on and off their benefits, and ultimately falling through the cracks.
The system is clearly broken on both sides. There has got to be an easier way that allows the treatment, payment, safety net and recovery process to work in a more straightforward way while still protecting against legitimate cases of fraud and abuse.
Are the mentally ill a special group of violent offenders that require additional risk management for the protection of the community?
It is an interesting question.
The mentally ill may not be more likely to commit violent acts but they are apparently more likely to commit violent acts that trigger cognitive bias.
That is to say the mentally ill seem to have a certain panache for acts that are more memorable because they are bizarre, against strangers, and in mass quantity â and thus attract more media attention and encoding into our memory banks via the avaialability heuristic.
Thus the approximately 0.3% of people who were murdered in the USA this year in these acts (i.e., Aurora and Newtown) are given higher level of salience by the brain than the other 99.7% (14,000+) who were murdered â disproportionately by ânormalâ people who did so to their family members, lovers, frienemies, and âbusiness associatesâ for understandable motivations such as money, drugs, religion, politics or sex . (By the way, people who assign inappropriate levels of salience to potential threats has a label in psychiatry, doesnât it?)
The appropriate policy response, therefore, is not to focus the risk management on the mentally ill, but on the non-mentally ill, as they pose a greater risk to the overall safety of society. However, no such government agency currently has a mandate to conduct this profiling and monitoring of the 4/5ths of Americans without psychiatric labels who, as a group, are statistically more likely to kill.
As representatives of the mentally ill, who are statistically more likely to be victims of this violence, we have a moral obligation to stop this threat from ânormalâ people in the community, by ensuring they have all been carefully assessed for their risk of violence and are appropriately monitored by state authorities. Fortunately there is an agency in the progressive state of Massachusetts with a penchant for managing community risk, capable to take upon this noble cause. This may seem draconian to subject vast number of honest, law-abiding citizens to this type of dehumanizing treatment, but then again, thereâs âtoo much concernâŠabout the civil liberties of people who have horrifically distorted thinking.â
Godspeed, comrade.
-A
Dr. Torrey has still failed to address the core question that your article posed to TAC â why are they utilizing a term âanosognosiaâ that is used to describe a certain type of parietal lobe damage in neurological patients â to explain the very complex phenomena of âlack of insightâ in psychiatric patients?
The two are very clearly not the same thing. Beyond the MRI studies of which brain regions are involved in neurological anosognosia and âlack of insightâ- patient interview studies reveal that those who have âlack of insightâ in psychosis have several psychosocial issues at play. For example when someone says âIâm not sick, I donât need helpâ they may be trying to say that they wish to decline care for lack of trust of the physician, or because of prior negative experiences with the mental health system or with medication side effects. (Or because they read Anatomy of an Epidemic and know that the outcomes may actually be higher over the long term without treatment!) When someone says they donât want treatment, it may also simply mean the person would rather work through their problems on their own without involving mental health professionals. In the case where someone is having grandiose delusions like the one the lady in Lafyette Park was having, these often develop as a psychological defense to block against very traumatic memories that damage oneâs self-image.
Dr. Torrey needs to realize that the reason so many of us deny care is not because our brains are anatomically flawed â but because we feel degraded by the patronizing attitudes we receive from those providing the care such as himself. Before he accuses us schizophrenics of having âlack of insightâ he needs to look in the mirror – long and hard.
David,
Perhaps you can try to mobilize some expert testimony to challenge the concept of anosognosia in mental illness. Did you see Sandra Steingard’s article on this site: ‘Anosognosia: how conjecture becomes medical âfactâ’? She explains how it cannot be confirmed on MRI the way it is for neurological patients.
There are several studies that investigate what insight is as well. They found that patients who denied having mental illness and refused treatment in actuality had concerns about side effects, doubted the honesty of the physician or their family members etc. which is why they make those statements declining treatment.
There is a lot of evidence out there to discredit the anosognosia theory. It is really important that the legislators understand that.
What are they asking to clarify with this bill exactly? I thought that AOT was only for convicted violent offenders (a form of plea bargain to get out of doing jail time). Is this letter requesting that judges should be allowed to order ANYONE diagnosed with mental illness into AOT?
I’m not opposed to AOT as a form of plea bargain (as it is giving those who may have been in an altered state of mind at the time of the crime an option not to go into the criminal justice system)but there is absolutely no justification of using AOT as a means to ‘prevent’ someone from committing some hypothetical crime. NAMI is really crossing a constitutional line with this one.
The article does raise an interesting point I’ve been wondering about myself – what is the agenda of the anti-psychiatry movement today? Over the last few decades it has achieved many important reforms – deinstitutionalization, limiting criteria and lengths for involuntary hospitalizations, providing patients with rights to refuse medication, limiting use of seclusion and restraints.
What is the focus of the movement now? The key difference between now and 20 years ago is that it is largely a voluntary system today. If one is in receiving psychiatric care today, it is overwhelmingly by choice (minus those of course in forensic facilities, on AOT outpatient court orders or on 72 hour holds).
It seems that if one is truly anti-psychaitry, one should simply exercise the option not to utilize psychiatric services. However, if one is choosing to utilize them, coming in with the attitude of being ‘anti-psychiatry’ is not going to be particularly helpful. If one is not in agreement with the over-prescribing habits of a particular physician, one always has an option not to take the medication prescribed or to find a different physician who will prescribe more cautiously (or not at all).
The failure of regulatory oversight of pharmaceuticals is not something unique to the psychiatry field of medicine(or to big business in general – look at what is happening today with regulators for Wall Street, the oil industry, etc.). We need to advocate for more responsible regulation and disclosure of medication effects by the FDA – but this is something that needs to be done by mobilizing all drug safety interest groups – it will not be achieved under a banner of being ‘anti-psychiatry.’
Perhaps a more productive model would be a collaborative approach focusing on improving the inpatient experience, providing better education and choice, developing ombudsmen to resolve grievances and disputes on care, etc.
The reform movement may have finally reached a point where we will now catch more flies with honey than with vinegar.
Sandra,
It seems to me that in the end the final decision comes down to the patient (consumer) whether or not to take medications that are suggested or prescribed. Perhaps the focus should not be on changing the profit motives of the pharmaceutical industry or the ‘biological psychiatry ideology’ of the doctors. It should be on creating more educated and savvy consumers. A more mainstream platform needs to be launched — not with a message of ‘anti-psychiatry’ but rather a ‘need to know facts’ for users of psychiatric drugs that explains what is known about their benefits and side effects/long term effects in plain English, questions to ask a doctor, etc.
Patients in other areas (cancers, heart disease, etc.) are very well organized, well read and informed on their treatments, side effects, efficacy levels, survivior rates, alternative and complementary treatments etc. There is no reason that patients of psychiatric conditions could not be the same.
Most successful public health campaigns have focused primarily on changing consumer beliefs and behaviors (smoking, fast food, etc.). And in turn the ‘producers/providers’ tend to adapt to the changes in demand – although not without a lot of resistance to such change – as we have seen already in reactions to things like Soteria in the 70’s.
But ultimately, the power is in our hands, not theirs.
Hi Sandra,
This is a problem that is affecting all industries at this point in history, not just medicine. It is a sign of a deeper malaise spreading through out the advanced capitalist world, but in particular the United States which has by law protected shareholder interests above other groups such as a company’s employees and customers in many instances.
No amount of advocacy work will change the profit motive of large pharmaceutical companies. Instead, the focus must be on requiring full disclosure of risks (both by the drug manufacturers and by doctors prescribing to patients) to ensure there is fully informed consent before choosing to take any medication. The fact that drug companies are easily able to manipulate the FDA to bypass this disclosure process is the biggest concern we should be focused on at this time. Patients also should be required to sign a disclosure of side effects form in a doctors office before they are handed a prescription.
And like in any other industry, the best way to get the attention of a company that has behaved in a socially irresponsible way is simply not to buy their products! Both doctors and patients can play that role.
As for the lack of interest in alternative programs like peer respites etc. – this why we have such a large and active not-for-profit sector in the U.S. They can take on these roles. If there is a broad enough interest in them by clients/consumers and they are financially viable, they will sustain themselves on their own, irregardless of whatever ‘lucrative’ products big pharama wants to pursue next.
Hi Ron,
I’ve always been perplexed by the idea of ‘recovery’ as it relates to psychosis. There are some that really do ‘recover’ in the sense they have one episode then never see a symptom again. And there is a middle group of those who drift in and out over time of symptoms with periods of ‘recovery’ in between. Then there is the bottom group where recovery means heavily medicated to the point that you are no longer being arrested or sectioned every week and living in a group home, maybe working part time for minimum wage somewhere. It doesn’t make a whole lot of sense to talk about all these trajectories of a psychotic disorder under a single umbrella of ‘recovery’. I feel like most of the dialoguing on this site focuses on recovery of the top two groups and how meds block those who will go on to full or intermittent recoveries. While groups like NAMI, TAC, and the overall social services industry focus on that bottom group where meds are the only standing between a person and incarceration/ destitution/self-mutilation/suicide/accidental death/ etc. And they are all fighting with each other like they are talking about the same thing. When the reality is a psychotic disorder can have any of these three trajectories, and the approach to managing it is very different depending which group a particular individual falls into. I think we must start talking about the trajectory groups before discussing anything that has to do with treatment and recovery. The evidence shows what works best in terms of meds and supports for each group; but the fact that we keep lumping them all together in studies and in public discourse is only confusing everyone. Just my two sense on ‘Recovery.’
Alexa
Sandra,
Thanks for another intriguing post.
I would like to add two other frustrations with the field of psychiatry that you have alluded to but left off your list — the need to individualize the approach to each patient and the total lack of awareness of the vast knowledge available in the research literature.
The first issue is one of how doctors talk about drug efficacy. A drug study can say that 60% of patients significantly improved but 5% were significantly harmed and doctors conclude this is a good drug – and don’t even try to understand you as a patient and whether you have the factors that will predict which group you are most likely to fall into. (Even though if you dig even deeper into the literature, these factors frequently have been identified .) Conversely they do the opposite when the numbers point the other direction.
Yet ultimately drug efficacy come down to how you as an individual respond and not what some sample produces in means and p-values. Sometimes you are the mean, and sometimes you are the outlier.
As an MH patient, I fell into this trap for many years – only going after the ‘best bets’ and continually coming up in the bottom 5% group. Once I came to understand that “I am not the mean” I was more open to trying a broader range of interventions and I did find something that works – even though the use of it for my DSM code number was considered ‘off label’ and ‘contradicting the evidence.’ Why? Because the specific underlying biochemical problem I had that was exacerbating my symptoms was not at all related to the baseline levels of serotonin or dopamine (but was apparently messing with them on occasion.)
Second, there is a lot that is known about these conditions but there are hundreds of interaction variables that can combine to produce symptom patterns and drug response patterns. This type of complexity requires supercomputing (or super-intuitiveness) to decipher and is not something that can be understood in a 15 minute DSM style question and answer session. Yet that seems to be all that psychiatry’s intelligentsia want to talk about — perpetuating the status quo. And all the countermovement wants to do is play semantics games with the medical lexicon and debate brain-mind duality .
And this is why the field of psychiatry is going no where fast.
It has been an interesting summer to be a psychosis patient to say the least. My providers have gone in under three months from trying to get everyone on medication ASAP and maintained indefinitely to trying to get the relatively stable ones to do a trial period of reduction or withdrawal. It seems Wunderink’s paper was the one that finally flipped them. And considering these are the “thought leaders” at Harvard Medical School — the rest of psychiatry is probably about to start turning soon too. -A
Eleanor,
This is a great TedTalk, Congratulations! I’m wondering if you have faced any challenges with your speeches when mentioning the fact that you came off medication?
I’d love to know how you handle that question (or critique) when it arises.
Alexa
What if there were a way to prevent relapse without using antipsychotics? What if you could use another target that doesn’t cause neuroatrophy. Why is no one trying to answer that question?
Hi Sandy,
The diagnosis I had from the first doctor was ‘Psychosis NOS’ (the second one refused to label) and both said 5 months of therapy had to be tried first before starting any medication. Both were MD psychoanalysts. Maybe this 5 month guideline is the treatment recommendation from the Psychoanalytic Institute? (Which by the way – the clock restarts when you switch doctors, as you have not tried therapy with them yet!)
I eventually got to a research psychiatrist who only sees psychosis patients (and researches antipsychotic medications) and he has been much more like the doctors described here on MIA – trying to convince me to take medications all the time even when I’ve had no symptoms for 6+ months (which ironically I am pushing back for a more measured approach which is not going over too well with him!)
Looking back, I’m not sure if doing those first two years med free was a curse or a blessing in disguise. I was certainly frustrated with those first two doctors at the time, but I can appreciate now that I learned how to ‘exhaust my coping strategies’ first before turning to a pill. Maybe I am better off today for that. đ
Alexa
Very interesting post. Have you read any of Juli McGruder’s work on schizophrenia in Africa? Her theory is that the reason WHO finds better outcomes in those cultures is because they see this dualist model whereby insanity brings both challenges and blessings (and the solution is often appeasing the spirits rather than forcefully removing them).
Of course, try explaining that to a Western mental health professional and you just get an ‘I see’ and a note in your file that you have ‘diminished insight’ leading you to be ‘treatment noncompliant.’ And having humor towards them? That is called ‘inappropriate affect’. :-p
Hi Sandra,
Thanks for another intriguing post. As a counter point to the one you describe – I have had a very difficult time finding doctors (both PCPs and psychiatrists) who will prescribe anything. The emphasis it seems is on curing everything on its own – through diet, exercise, de-stressing, etc. After four years of living with terrible insulin resistance/pre-diabetes, I finally found a PCP (my fifth try) who would prescribe metformin. But he only did it after 20 minutes of me reciting every single scientifically based intervention I’d tried to lose weight from glycemic load diets, interval workouts, etc. I’ve had similar experiences with psychiatrists – it was the fourth one I went to after three psychotic episodes who agreed to do a trial of a neuroleptic (but only after I proved that I’d given talk therapy a try multiple times and it couldn’t ‘cure’ it.)
I’m curious why doctors are doing this. Is there another trend not to prescribe or require trials of non-pharmacologic interventions first? Or do I just have a very unusual experience with doctors?
Do doctors have some set period of time a patient should spend trying to deal with a problem some other way before resorting to medications?
Alexa
There is a reason al Jazeera was for so long banned from the U.S. They blow the lid off everything and there is no topic that is too taboo or too controversial for them to touch.
They tell the real story behind the Israel- Palestine conflict (never covered on U.S. news). They also show the photos and stories of the real people impacted from the Iraq and Afghanistan wars and other conflicts around the world. They will cover every angle of a corruption or corporate fraud case. They are the epitome of the free press (and ironically are based in an Arab country) – and a free press is the ultimate threat to the power of the U.S. elites. And that is why they are banned. But luckily, they have a live stream on their website, so if you want to know the hidden story behind the day’s headlines – you can watch their coverage anywhere, anytime! đ
Ron,
I agree whole-heartedly. The benefit of ‘befriending’ therapy for psychosis is quite limited. I found ‘befriending’ to be a role better fulfilled by actual friends (i.e. via people met in peer support groups). The point of going to a therapist is to learn and practice coping skills.
By the way, I also wanted to say thanks to you personally for the fantastic website you put together on CBT skills for psychosis. It was my ‘de facto’ digital therapy for the first few years, while I was trying to get adequate health insurance and then on the long wait list to get into a CBT clinic. I am not sure I would have survived the first years of this without it; keep up the good work!
Alexa
Thanks, this was a great post! I finally got fed up with answering the same 45 minutes of questions (and the eight different diagnoses that were handed to me over the last couple years by different doctors, after answering them all the same way!) So last week when I had my first meeting with my new psychiatrist, I typed up a list of the questions, their answers, told him to spend a few minutes reading it, and then we were going to discuss the real problem. It was the first time I ever walked out of one of these intakes where I felt like the doctor actually understood what was going on.
Stanford psychologist Robert Sapolsky has a great online course on this issue on the interrelatedness of all levels of organization in the brain (genetic, molecular, anatomical, environmental, evolutionary) to explain why behaviors happen. In his first lecture he made a compelling case (see 20:25-33:05 ) on why this type of categorical prioritizations (i.e. the behavioral is more important than the genetic) is not only factually wrong, but has been the foundation for all the great human rights abuses from lobotomies to ethnic cleansing:
http://www.youtube.com/watch?v=NNnIGh9g6fA&list=PL45A5E21ECA5FA850
The reality of mental/brain/behavioral challenges/illnesses/disorders, whatever one wishes to call them, is that they are a complex web of interactions of genes, epigenetics, environment, and neuroplasticity induced changes of our own free will. It is only in understanding the confluence of all these, as potentially equally powerful forces, that the true nature of reality can be observed.
~A
Sandra,
Thanks for putting together this review on outcomes of DUP. The long term outcome profiles of neuroleptics are well established through Harrowâs studies and others including those you have cited. The question Iâd like to know the answer to though is what are their impacts on short term (first episode) outcomes, and more particularly their impacts on self injury and suicide?
For the problem that clinicians (and patients/families) face immediately is how to protect the patient in the short term, because if they are unable to do that, there will be no âlong term outcomesâ to worry about!
One psychiatrist explained to me the heavy reliance on neuroleptics in the first episode as a technique of risk management. Since there are no other options like Soteria (or even hospitalization past about a 21 day window) available for schizophrenia (which by definition lasts six months or longer in duration) the only option currently to try to manage safety is medication. He also explained that medication has to be used in some patients to âimprove insightâ enough so that the patient can participate in CBT and start learning coping skills.
The issue of insight and outcomes though, is an interesting one all in itself. There was one study in the British Journal of Psychiatry that looked at this issue that is worth reviewing:
http://bjp.rcpsych.org/content/192/3/178.full
It notes several paradoxical effects, looking at issues with insight (which neuroleptics are supposed to improve by lessening the effects of delusions and command hallucinations) and outcomes of first episode patients with regards to self mutilations and suicide attempts.
Having been through a first episode without medication and subsequent episode later on with it, I have seen first- hand that there is no âeasy solutionâ to the paradoxes these medications pose. I read Harrow first, before I read the first episode studies, and decided to place my bets on what was going to give me the best long term outcome. But then I realized I was playing a dangerous game of Russian roulette with my life by doing that, and decided to try a neuroleptic in my next episode â which improved my âinsightâ dramatically during the episode and then backfired in the same way they described in this paper.
So, I understand what you are saying when you say you donât know whether you are helping or harming patients by directing them to try something else first. I spent the last few years reading these studies too, convinced I could find the ârightâ answer to this question of whether to use neuroleptics. I am starting to realize now, there may not be a right answer to find.
~Alexa
Hi Alice,
I was at a lecture last year at Harvard Medical School (the name of the lecturer slips my mind at present) and he was explaining that a lot of what we are diagnosing as ADD/ADHD in young children is really just different rates of maturation of certain frontal lobe controls. By around age 8-10, he was saying that these tend to normalize across the group. So really, the problem of education is it is expecting all children who are the same age to have the same level of brain development and able to handle the same environments, which is not accurate. Unfortuantely the ones that mature at a slower rate get pulled aside for being problematic and are often set on a lifelong path of drugging, underachievement, and other social problems.
I realize now I was very fortnuate that I went to an alternative school (except for the very gifted, which also as a group have social challenges) where we could progress through at our own pace (so in a graduating class the age range was 14-18).
Maybe once the rate of childhood psychiatric diagnoses reaches truly unmanagable levels (when they are the majority?) we will start to change our systems to better fit the needs of our diverse minds.
Alexa
What is the alternative for the kids who have ADD/ADHD? Perhaps the solution is changing the way education works to accomodate their brains, rather than changing their brains to accomodate the educational system.
Hi Hermes,
Thatâs a great explanation of it. Elevated dopamine is the end result of a cascade. If you want to do prevention/maintenance of psychosis, the focus has to be on the problems upstream, not on beating down dopamine levels continuously.
The cornerstone to my approach to relapse prevention is stress reduction, as the first step in the domino effect that leads to active psychosis is elevated glucocorticoids (particularly avoiding the worst stress culprit âexpressed emotions!â). I also integrate NAC and Omega 3âs which have shown to have some level of protective factors against transitioning into active psychosis. I use a dietary approach as well that focuses on supplementation of key minerals, stabilization of blood sugar levels, and anti-inflammatory foods. Plus a whole lot of insight meditation/positive thinking/self-awareness practice.
Take any one of the ingredients out, and I start to unravel, take two or three out and I am gone in a matter of weeks. Of course I try to explain this to my doctors, and they think this is all a bunch of new age rubbish (âthe reason your symptoms are coming back is because you are not taking your anti-psychotics!â) Then I typically ask them how many of their âmedication compliantâ SZ patients have been continually full time employed, law abiding and tax paying citizens, and are in great physical condition? There is no way to run a multi-year double blind placebo trial of this, so they will never believe it. The proof is in the pudding, or so they say!
Alexa
It would be great to see what the cost savings would be on a state or national level. Since we are in sequester season, SAMHSA and the other agencies need some help envisioning how to cut that 5%. Everyone is complaining about how bad this sequester will be for mental health. Yet this may be the best thing that ever happened to the mental health field, if we use this opportunity to innovate and start doing things more wisely.
Hi Sandra,
Thanks for the great review on neuroleptics. In one your future blogs, Iâd be curious to hear your opinion on the use of anti-epileptics and other drug classes (as well as supplements like N-acetyl cysteine and omega-3 fatty acids) as tools for relapse prevention. There has been quite a bit coming out in the last few years on the role of the stress cascade, HPA axis dysfunction, hippocampal atrophy and their resulting rises in glutamate as the biochemical precursors to acute psychosis. This is currently being looked at in the context of âprevention of conversion to psychosis in the prodromal stage of the first episodeâ but I have wondered recently if these same mechanisms are involved in relapse and could provide some insight into alternatives to the current paradigm of âmaintenance with neuroleptics.â
Alexa
Hi Alice,
Your article makes a good point – It is not reasonable to expect all doctors to be advocates, or fighting the system, or publicly speaking out as anti-APA or anti-big pharma. This is a role for advocates and journalists; the role of doctors is to be doctors. However, it is reasonable to expect doctors to be up to date on empirical findings in their field, and honest with their patients about why they recommend what they do and the risks that accompany them. (Yet sadly, many are neither.)
Doing things differently does count. Sometimes the most powerful agents of change donât come from outspoken critics of a system, but from those inside the system who simply choose to quietly do things differently . For example, a doctor who is concerned that patients are not receiving adequate information about the risks of taking medication can provide more information in the clinic in simple handouts comparing the risks of different drugs.
To manage the risk of over-medicating patients, some community mental health centers are integrating therapy and primary care in the same facility that allows patients to address other things that are fueling their psychiatric symptoms and compounding the medicationsâ side effects (drug/alcohol use, smoking, poor diets, sedentary lifestyle, bad relationships, too much stress) at the same time.
I have found the key ingredient for me for successful management of my condition was 1) to be fully educated about treatment options including all the drugs and their side effects and 2) to be in an integrated clinic with treatment teams that work together, so that the psychiatrist has a clearer picture of what is going on, and what other coping techniques are being used, and what does actually need medication to keep in check. When the condition is being addressed comprehensively, I have found I can keep the amount and duration of medication down to a bare minimum so that I have very few side effects and minimal disability.
I realize this is not the norm in clinical practice, and Iâm not the norm in patients, because I do demand this high standard of care. But the doctors I work with arenât advocates either; they just chose to try to be better at their jobs.
Alexa
Hi Alice,
Thanks for taking on this important issue.
How often is it though that a diagnosis is challenged in psychiatry as a potential fraud of the system? It seems that it would be quite easy to give a patient a diagnosis without it being easily challenged, since the whole process of psychiatric diagnosis is subjective. For example, some patients have five or ten different diagnoses in their records given by different doctors â but no would accuse the doctors of fraud or incompetence for not agreeing. (Although it would certainly raise red flags in other medical specialties where there are objective tests like blood work, biopsies, MRIs etc. to rule on these things.)
I can appreciate the potential ethical issue of giving a patient a particular diagnosis to allow them to receive benefits (or the clinic to be paid). The difference ultimately comes down to whether your ethical system is deontological (believing you have an ethical duty to uphold certain rules or standards, even if they produce bad outcomes) or if you are teleological (believing a good end justifies the means, even if it requires bending the truth or breaking some rules.) Neither system is necessarily more moral than the other from an objective standpoint.
As Iâm sure you are aware, patients also face similar ethical dilemmas when interacting with providers and others in the mental health system, due to the complexity of the requirements. I use to attend a patient support group that served as a forum where patients got together to share experiences on what to say (and not to say!) in all kinds of situations â when talking to SSDI and other benefits administrators, in ER evaluations to ensure you would (or would not) be admitted, what to say to get a doctor to discharge you from a hospital, a judge to release you during a commitment hearing, or to a college administrator to be allowed to re-enroll in classes after a medical leave.
Interestingly, those in the group who were actually somewhat functioning, were the purest teleological thinkers â they were clever, learned the rules of the game, and had no qualms when it came to manipulating the system to get what they wanted out of it. The purest deontological thinkers – the ones that had a strong commitment to honest communication and were unwilling to change their stories to fit the requirements set by the systemâ were the ones who were revolving in and out of treatment, on and off their benefits, and ultimately falling through the cracks.
The system is clearly broken on both sides. There has got to be an easier way that allows the treatment, payment, safety net and recovery process to work in a more straightforward way while still protecting against legitimate cases of fraud and abuse.
Are the mentally ill a special group of violent offenders that require additional risk management for the protection of the community?
It is an interesting question.
The mentally ill may not be more likely to commit violent acts but they are apparently more likely to commit violent acts that trigger cognitive bias.
That is to say the mentally ill seem to have a certain panache for acts that are more memorable because they are bizarre, against strangers, and in mass quantity â and thus attract more media attention and encoding into our memory banks via the avaialability heuristic.
Thus the approximately 0.3% of people who were murdered in the USA this year in these acts (i.e., Aurora and Newtown) are given higher level of salience by the brain than the other 99.7% (14,000+) who were murdered â disproportionately by ânormalâ people who did so to their family members, lovers, frienemies, and âbusiness associatesâ for understandable motivations such as money, drugs, religion, politics or sex . (By the way, people who assign inappropriate levels of salience to potential threats has a label in psychiatry, doesnât it?)
The appropriate policy response, therefore, is not to focus the risk management on the mentally ill, but on the non-mentally ill, as they pose a greater risk to the overall safety of society. However, no such government agency currently has a mandate to conduct this profiling and monitoring of the 4/5ths of Americans without psychiatric labels who, as a group, are statistically more likely to kill.
As representatives of the mentally ill, who are statistically more likely to be victims of this violence, we have a moral obligation to stop this threat from ânormalâ people in the community, by ensuring they have all been carefully assessed for their risk of violence and are appropriately monitored by state authorities. Fortunately there is an agency in the progressive state of Massachusetts with a penchant for managing community risk, capable to take upon this noble cause. This may seem draconian to subject vast number of honest, law-abiding citizens to this type of dehumanizing treatment, but then again, thereâs âtoo much concernâŠabout the civil liberties of people who have horrifically distorted thinking.â
Godspeed, comrade.
-A
Dr. Torrey has still failed to address the core question that your article posed to TAC â why are they utilizing a term âanosognosiaâ that is used to describe a certain type of parietal lobe damage in neurological patients â to explain the very complex phenomena of âlack of insightâ in psychiatric patients?
The two are very clearly not the same thing. Beyond the MRI studies of which brain regions are involved in neurological anosognosia and âlack of insightâ- patient interview studies reveal that those who have âlack of insightâ in psychosis have several psychosocial issues at play. For example when someone says âIâm not sick, I donât need helpâ they may be trying to say that they wish to decline care for lack of trust of the physician, or because of prior negative experiences with the mental health system or with medication side effects. (Or because they read Anatomy of an Epidemic and know that the outcomes may actually be higher over the long term without treatment!) When someone says they donât want treatment, it may also simply mean the person would rather work through their problems on their own without involving mental health professionals. In the case where someone is having grandiose delusions like the one the lady in Lafyette Park was having, these often develop as a psychological defense to block against very traumatic memories that damage oneâs self-image.
Dr. Torrey needs to realize that the reason so many of us deny care is not because our brains are anatomically flawed â but because we feel degraded by the patronizing attitudes we receive from those providing the care such as himself. Before he accuses us schizophrenics of having âlack of insightâ he needs to look in the mirror – long and hard.
David,
Perhaps you can try to mobilize some expert testimony to challenge the concept of anosognosia in mental illness. Did you see Sandra Steingard’s article on this site: ‘Anosognosia: how conjecture becomes medical âfactâ’? She explains how it cannot be confirmed on MRI the way it is for neurological patients.
There are several studies that investigate what insight is as well. They found that patients who denied having mental illness and refused treatment in actuality had concerns about side effects, doubted the honesty of the physician or their family members etc. which is why they make those statements declining treatment.
There is a lot of evidence out there to discredit the anosognosia theory. It is really important that the legislators understand that.
What are they asking to clarify with this bill exactly? I thought that AOT was only for convicted violent offenders (a form of plea bargain to get out of doing jail time). Is this letter requesting that judges should be allowed to order ANYONE diagnosed with mental illness into AOT?
I’m not opposed to AOT as a form of plea bargain (as it is giving those who may have been in an altered state of mind at the time of the crime an option not to go into the criminal justice system)but there is absolutely no justification of using AOT as a means to ‘prevent’ someone from committing some hypothetical crime. NAMI is really crossing a constitutional line with this one.
The article does raise an interesting point I’ve been wondering about myself – what is the agenda of the anti-psychiatry movement today? Over the last few decades it has achieved many important reforms – deinstitutionalization, limiting criteria and lengths for involuntary hospitalizations, providing patients with rights to refuse medication, limiting use of seclusion and restraints.
What is the focus of the movement now? The key difference between now and 20 years ago is that it is largely a voluntary system today. If one is in receiving psychiatric care today, it is overwhelmingly by choice (minus those of course in forensic facilities, on AOT outpatient court orders or on 72 hour holds).
It seems that if one is truly anti-psychaitry, one should simply exercise the option not to utilize psychiatric services. However, if one is choosing to utilize them, coming in with the attitude of being ‘anti-psychiatry’ is not going to be particularly helpful. If one is not in agreement with the over-prescribing habits of a particular physician, one always has an option not to take the medication prescribed or to find a different physician who will prescribe more cautiously (or not at all).
The failure of regulatory oversight of pharmaceuticals is not something unique to the psychiatry field of medicine(or to big business in general – look at what is happening today with regulators for Wall Street, the oil industry, etc.). We need to advocate for more responsible regulation and disclosure of medication effects by the FDA – but this is something that needs to be done by mobilizing all drug safety interest groups – it will not be achieved under a banner of being ‘anti-psychiatry.’
Perhaps a more productive model would be a collaborative approach focusing on improving the inpatient experience, providing better education and choice, developing ombudsmen to resolve grievances and disputes on care, etc.
The reform movement may have finally reached a point where we will now catch more flies with honey than with vinegar.
Sandra,
It seems to me that in the end the final decision comes down to the patient (consumer) whether or not to take medications that are suggested or prescribed. Perhaps the focus should not be on changing the profit motives of the pharmaceutical industry or the ‘biological psychiatry ideology’ of the doctors. It should be on creating more educated and savvy consumers. A more mainstream platform needs to be launched — not with a message of ‘anti-psychiatry’ but rather a ‘need to know facts’ for users of psychiatric drugs that explains what is known about their benefits and side effects/long term effects in plain English, questions to ask a doctor, etc.
Patients in other areas (cancers, heart disease, etc.) are very well organized, well read and informed on their treatments, side effects, efficacy levels, survivior rates, alternative and complementary treatments etc. There is no reason that patients of psychiatric conditions could not be the same.
Most successful public health campaigns have focused primarily on changing consumer beliefs and behaviors (smoking, fast food, etc.). And in turn the ‘producers/providers’ tend to adapt to the changes in demand – although not without a lot of resistance to such change – as we have seen already in reactions to things like Soteria in the 70’s.
But ultimately, the power is in our hands, not theirs.
Hi Sandra,
This is a problem that is affecting all industries at this point in history, not just medicine. It is a sign of a deeper malaise spreading through out the advanced capitalist world, but in particular the United States which has by law protected shareholder interests above other groups such as a company’s employees and customers in many instances.
No amount of advocacy work will change the profit motive of large pharmaceutical companies. Instead, the focus must be on requiring full disclosure of risks (both by the drug manufacturers and by doctors prescribing to patients) to ensure there is fully informed consent before choosing to take any medication. The fact that drug companies are easily able to manipulate the FDA to bypass this disclosure process is the biggest concern we should be focused on at this time. Patients also should be required to sign a disclosure of side effects form in a doctors office before they are handed a prescription.
And like in any other industry, the best way to get the attention of a company that has behaved in a socially irresponsible way is simply not to buy their products! Both doctors and patients can play that role.
As for the lack of interest in alternative programs like peer respites etc. – this why we have such a large and active not-for-profit sector in the U.S. They can take on these roles. If there is a broad enough interest in them by clients/consumers and they are financially viable, they will sustain themselves on their own, irregardless of whatever ‘lucrative’ products big pharama wants to pursue next.