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NIMH Director Rethinks Standard Psychiatric Treatment for Schizophrenia

NIMH director Insel now agrees with treatment reform activists that many people diagnosed with schizophrenia and other psychoses could be better served by a more selective and limited use of drugs and more diverse treatments.
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The director of the National Institute of Mental Health (NIMH) now recognizes what treatment reform activists have been talking about for years: People diagnosed with schizophrenia and other psychoses are a diverse group who need diverse approaches. NIMH director Thomas Insel recently acknowledged:

It appears that what we currently call "schizophrenia" may comprise disorders with quite different trajectories. For some people, remaining on medication long-term might impede a full return to wellness. For others, discontinuing medication can be disastrous.

NIMH director Insel now agrees with treatment reform activists that many people diagnosed with schizophrenia and other psychoses could be better served by a more selective and limited use of drugs and more diverse treatments. Such an approach has been utilized in Finland, which has produced the best long-term outcomes in the developed world.

Drug companies have profited enormously from the current standard treatment protocol that calls for lifetime antipsychotic medication after a single psychotic episode. Because of this treatment protocol and the increasing use of antipsychotic drugs for nonpsychotic conditions, antipsychotics grossed over $18 billion a year in the United States by 2011. The antipsychotic Abilify became the highest grossing of all drugs in the first quarter of 2013, and it is on track to gross $6 billion this year (entire corporations that only grossed approximately $5 billion last year include Facebook and Yahoo).

For several decades, mental health treatment reform activists, comprised of mental health professionals (including those at the International Society for Ethical Psychology and Psychiatry) and "psychiatric survivors" (who themselves had received nonproductive and counterproductive treatments), have been engaged in an uphill battle for truly informed choice -- that includes multiple options which reflect the diversity of the population diagnosed with schizophrenia and other psychoses.

These treatment reform activists aroused the curiosity of investigative reporter Robert Whitaker. In 2010, Whitaker's book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America won the Investigative Reporters and Editors book award for best investigative journalism. In his book, Whitaker rescued from oblivion a 2007 study on long-term treatment (15-year) of schizophrenia by Martin Harrow, a psychologist at the University of Illinois Medical School.

In 2012, Harrow published a 20-year follow up, "Do All Schizophrenia Patients Need Antipsychotic Treatment Continuously Throughout their Lifetime? A 20-Year Longitudinal Study," which reiterated his 15-year conclusions. Harrow found that patients diagnosed with schizophrenia who were "not on antipsychotics for prolonged periods were significantly less likely to be psychotic and experienced more periods of recovery."

In addition to the Harrow study, what also convinced Insel to rethink treatment was a study by Dutch researcher Lex Wunderink published in JAMA Psychiatry in July, 2013. Wunderink used a randomized design, the "gold standard" or research, and had similar results as Harrow. In Wunderink's study, patients were randomly assigned to either maintenance on antipsychotic drugs or a tapering-off and discontinuation of the drugs. Insel summarizes Wunderink's results: "By seven years, the discontinuation group had achieved twice the functional recovery rate: 40.4 percent vs. only 17.6 percent among the medication maintenance group."

The kind of treatment that Harrow's and Wunderink's research recommends already exists in northern Finland. It is called Open Dialogue, which Whitaker reports, "has produced the best long-term outcomes in the developed world."

The Open Dialogue therapy protocol delays the use of antipsychotics in first-episode patients, instead utilizing psychosocial support and selective use of anxiety-reducing benzodiazepines (e.g., Ativan, Klonopin, Valium) with the hope that patients can "chill out," and get through their first crisis without ever going on antipsychotic medications. And if patients need to go on antipsychotics, the Open Dialogue protocol allows for them to subsequently try to taper from the drugs. Whitaker reports, "80 percent of first episode patients do fairly well over the long-term without antipsychotics."

The reality is that people do fully recover from psychotic states, and many of them do so by rejecting standard psychiatric treatments and by utilizing more diverse approaches. It is good news that the NIMH has finally acknowledged this reality.

Bruce E. Levine, a practicing clinical psychologist, writes and speaks about how society, culture, politics and psychology intersect. His latest book is Get Up, Stand Up: Uniting Populists, Energizing the Defeated, and Battling the Corporate Elite. Both Bruce Levine and Robert Whitaker will be speaking at the International Society for Ethical Psychology & Psychiatry conference in Greensboro, North Carolina on November 1, 2013.

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