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Changing the Balance of Psychosis Treatment Advances in psychiatric treatment (2009), vol. 15, 0–0 doi: 10.1192/apt.bp.108.006361 Advances in psychiatric treatment (2009), vol. 15, 221–223 doi: 10.1192/apt.bp.108.006361 INVITED Changing the balance of psychosis COMMENTARY treatment INVITED COMMENTARY ON … MINIMAL-MEDICATION APPROACHES TO TREATING SCHIZOPHRENIA† Joanna Moncrieff but a further reason is that their benefits may have Joanna Moncrieff is a senior SUmmary been exaggerated. Long before the introduction lecturer in social and community psychiatry at University College Antipsychotic medication is the primary form of these drugs, it was known that a proportion of of treatment offered to people diagnosed with London and an honorary consultant people who have a psychotic breakdown recover schizophrenia or psychosis, but it is associated in rehabilitation psychiatry at the naturally. In addition, it is generally accepted that North East London Foundation Trust. with severe adverse effects, it is often experienced up to a third of patients derive little benefit from She has written numerous papers as unpleasant and its benefits may have been and one book on psychiatric drug overstated. Therefore, it is important to evaluate taking antipsychotics, but continue to manifest treatments, history of psychiatry research into approaches that aim to minimise the disabling symptoms. and research methodology. use of this medication. Existing studies suggest that Correspondence Dr Joanna such approaches can be successful and result in Moncrieff, Mental Health Sciences, Research on antipsychotics Wolfson Building, University College avoidance of antipsychotics in a high proportion It is commonly assumed that research has London, 48 Riding House Street, of clients. demonstrated that antipsychotics substantially London W1N 8AA, UK. Email: [email protected] DECLaration OF INTEREST reduce the risk of relapse, but this research has J.M. is Co-Chair of the Critical Psychiatry Network, serious flaws. In particular, long-term studies in † which challenges conventional biomedical models which patients are randomised to continuation of See pp. 209–217 and 218–220, this issue. of psychiatric practice. She has no financial treatment or replacement of antipsychotics by a interests that will be affected by the publication of placebo have not taken into account the effects of this article. drug withdrawal. The cessation of any psychoactive substance can produce withdrawal effects and therefore many of the episodes of ‘relapse’ recorded Since their introduction in the 1950s, antipsychotic in patients on placebo may simply have been the drugs have been the mainstay of treatment for people manifestation of these effects. This is especially likely diagnosed with psychosis and schizophrenia, rapidly since withdrawal effects of antipsychotics include replacing the sedatives and physical treatments, agitation and insomnia, which may be classified as such as insulin coma and electroconvulsive therapy, relapse when relapse is defined, as it often is, by that were previously used (Moncrieff 2008). Many small increases in rating scale scores. Withdrawal have portrayed them as miraculous drugs that may also occasionally produce withdrawal-related helped to empty the asylums, but it is commonly psychosis (Moncrieff 2006). known that they produce severe adverse effects and many patients dislike taking them. Long-term use is associated with disabling and life-threatening effects How drugs function such as tardive dyskinesia and metabolic syndrome. General assumptions about psychiatric drugs The drugs also increase the risk of premature death and how they act have obscured the nature more than twofold (Joukamaa 2006) and brain of antipsychotics. The orthodox view is that imaging studies suggest that they may reduce psychiatric drugs work by reversing or improving brain volume after only a few weeks of treatment an underlying neurochemical process that produces (Lieberman 2005). In addition to their physical the symptoms of a particular mental disorder. Thus, effects, the use of antipsychotics may perpetuate antipsychotics are thought to act by helping to chronicity by hindering people from developing rectify the pathology that produces the symptoms other coping strategies that might enable them to of psychosis or schizophrenia. Elsewhere, I have better manage future episodes or exacerbations. argued that a more convincing explanation of how The negative effects of antipsychotics provide one antipsychotics ‘improve’ psychosis is that they reason for trying to avoid their use where possible, create an abnormal drug-induced state comprising 221 Moncrieff sedation, slowed thought and flattened emotions for the increasing use of antipsychotics (Alessi- (Moncrieff 2005). This state can help to reduce Severini 2008). However, the replication of this the intensity of psychotic symptoms by dampening trial in Sweden failed to achieve such high levels down all mental activity. Although it is clear that of avoidance of drug treatment, with only 19% of such a state may be helpful at times, it is also likely participants remaining drug-free (Cullberg 2002). to be unpleasant and disabling. In addition, viewing This may be because of decreased efforts to avoid psychiatric drugs as drugs (as extrinsic substances drug treatment and suggests a continuing need for that alter the way the body functions) highlights reinforcement of the rationale of the minimal-drug their capacity to produce adverse effects and changes approach. the way that we evaluate them. Instead of assuming that they are beneficial because they correct an Changing the balance of treatment underlying abnormality, we should assume they are There are some people with severe psychosis for harmful unless we can prove otherwise. whom antipsychotic-induced effects may be helpful or necessary. However, there are many others who Other approaches may be able to endure and survive their psychosis Assessing Soteria without the use of these often unpleasant and potentially harmful drugs. The Soteria and It is therefore imperative that we devise alternative Scandinavian experiments suggest that psychosis strategies for helping people who suffer psychotic may be managed successfully using lesser quantities episodes. The article by Calton & Spandler (2009, of antipsychotic drugs than are currently used and this issue) is to be welcomed for focusing our avoiding them altogether in one-third or more of attention on studies of treatment approaches that patients. Further research is needed to confirm aim to minimise or avoid the use of antipsychotic their results. In particular, pragmatic studies in medication. The largest of these, the US Soteria real-life settings are needed to assess the feasibility Project, was well designed with random or alternating of minimal-medication approaches and help to allocation, but a limitation of the experiment was identify factors that might predict who is most likely that people who were judged to be unmanageable to benefit from avoiding antipsychotic medication. in a Soteria setting were excluded from allocation However, the onus should not be on minimal- and a number of other participants dropped out medication approaches to prove their success, but during the early stages of the experiment. The data on the standard drug-focused approach to prove its certainly suggest that the Soteria Project was at superiority and to demonstrate that this superiority least as good as treatment as usual in terms of adequately compensates for the recognised negative 2-year outcomes (Bola 2003). However, the claim effects of antipsychotic treatment. that residents of the Soteria communities had There is no reason why antipsychotics should superior outcomes is more difficult to evaluate, be used universally and many reasons why they since it is based on a complex statistical analysis should be avoided if possible. Projects that attempt involving numerous outcome measures, which to minimise the use of antipsychotics should be might have resulted in false-positive results. The supported because evidence suggests that use of most important finding is that a high proportion of these drugs is not always necessary and because, Soteria-treated participants in the US study avoided as Calton & Spandler highlight, many patients and the use of antipsychotic drugs altogether (32% of carers want this choice. the intention-to-treat sample). The Finnish trial in perspective References Alessi-Severini S, Biscontri RG, Collins DM, et al (2008) Utilization and The Finnish trial was also well designed and costs of antipsychotic agents: a Canadian population-based study, avoided the problem of exclusions because it was 1996–2006. Psychiatric Services; 59: 547–53. a cluster trial in which the minimal-drug approach Bola JR, Mosher LR (2003) Treatment of acute psychosis without was applied throughout the services of the chosen neuroleptics. Two-year outcomes from the Soteria Project. Journal of areas (Lehtinen 2000). The finding that 43% of Nervous and Mental Disease; 191: 219–29. participants in the experimental areas received no Calton T, Spandler H (2009) Minimal-medication approaches to treating schizophrenia. Advances in Psychiatric Treatment; 15: 209–17. antipsychotic drugs throughout the study and had equal or superior outcomes provides clear evidence Cullberg J, Levander S, Holmqvist R, et al (2002) One-year outcome in first episode psychosis patients in the Swedish Parachute project. Acta that a high proportion of people with a first episode Psychiatrica Scandinavica;
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