Monday, October 25, 2010

The Study Psychiatry Wishes Would Just Go Away

This is the fifth in my series based on talking points raised by Robert Whitaker's eye-opening "Anatomy of an Epidemic."

A lot of us have heard the story before, but it strongly bears repeating: In 1969, WHO began tracking schizophrenia patients in nine countries. At the end of five years, those in three developing countries - India, Nigeria, and Columbia - had "considerably better course and outcome" than patients in the US and five other developed countries.

Fluke finding? Bad methodology? In 1978 WHO launched a second study tracking mainly first episode schizophrenia patients in ten countries. The results vindicated the first study. After two years, nearly two thirds of those in the developing countries had good outcomes vs those who were chronically ill. This was virtually the exact reverse of how the patients fared in the western world - 37 percent with good outcomes, 59 percent chronically ill.

According to the researchers: "Being in a developed country was a strong predictor of not attaining a complete remission." Follow-up interviews conducted in 1997 with the patients in these two studies found that 53 percent of those in the developing countries were "never psychotic" again, with 73 percent employed.

Could it be that those in the less developed world have the type of supportive families and communities that prove protective against the stresses of daily living? Or, flipping it around, would it be safe to say that modern society literally sets us up to fail? In a crazy world, where we are subjected to crazy demands with no wiggle room, it's only logical that our rates of mental illness will be higher and rates of recovery lower.

But there is also another big wet matzo ball on the table. As Robert Whitaker in "Anatomy of an Epidemic" reports:

Although the WHO investigators didn't identify a reason for the stark disparity in outcomes, they had tracked antipsychotic usage in the second study, having hypothesized that perhaps patients in the poor countries fared better because they more reliably took their medication. However, they found the opposite to be true. Only 16 percent of the patients in the poor countries were regularly maintained on antipsychotics, versus 61 percent of the patients in the rich countries.

This begs the obvious question: Are our meds obstacles to our recovery? In his book, Whitaker places great emphasis on a 2007 study by Martin Harrow and Thomas Jobe of the University of Illinois. Drs Harrow and Jobe tracked 64 young patients with schizophrenia from two Chicago hospitals over 15 years. After two years, those not on antipsychotics were doing slightly better based on a global assessment scale than those on these meds.

Then, at the next checkpoint - 4.5 years - we find a dramatic divergence. Thirty-nine percent of those off their meds were "in recovery" and more than 60 percent were working. Meanwhile, those on antipsychotics had worsened. Only six percent were in recovery and few were working. These findings held steady over the next ten years. At the end of 15 years, 40 percent of those not on antipsychotics were in recovery and more than half working, with 28 percent dealing with psychotic symptoms. In contrast, just five percent of those taking antipsychotics were in recovery, with 64 percent dealing with psychosis.

As Whitaker reports:

Indeed, it wasn't just that there were more recoveries in the unmedicated group. There were also fewer terrible outcomes in this group. There was a shift in the entire spectrum of outcomes. Ten of the 25 patients who stopped taking antipsychotics recovered, 11 had so-so outcomes, and only four (16 percent) had a "uniformly poor outcome." In contrast, only two of the 39 patients who stayed on antipsychotics recovered, 18 had so-so outcomes, and 19 (49 percent) fell into the "uniformly poor" camp.

These are not exactly the type of findings pharm reps cite to the psychiatrists they visit. Indeed, it is fair to say that the psychiatric establishment would like this study to just go away. Indeed, Whitaker points out, the NIMH, which funded the study, never drew attention to it in a press release (which is a valid criticism) nor does NAMI refer to it on its website (which is way out in left field).

Six years ago, I reported on a presentation that Nassir Ghaemi, now at Tufts, made to a symposium at the American Psychiatric Association annual meeting. Part of my account:

The story begins in 1835 when Pierre Louis first applied the art of counting to the most common medical treatment of the day - bleeding, specifically leeching. Fifty percent of pneumonia patients, Louis discovered, died within three days on the treatment. Prior to the study, 33 million leeches were imported into Paris. Two years after the study, only seven thousand.

Don't expect similar turn-arounds in this day and age. Studies that shake our conceptions tend to raise many more questions than answers, so first we need to be asking questions.

Up next: We ask questions ...

Previous blog pieces:

Is the Cure Worse Than The Illness?

The Whitaker Controversy: An Irony in Search of Nuance

If Meds Work as Well as Our Psychiatrists Tell Us, Why Do We Have MORE Mental Illness Today Rather Than Less?

RIP: Chemical Imbalance in the Brain


Tony the cretin said...

The Martin Harrow and Thomas Jobe study does deserve careful study, but the conclusions I have gained by reading the original Journal of Nervous and Mental Disease are very different from what Whitaker has concluded. After reading it, I see why the psychiatric profession and NAMI haven't raised red flags about the use of antipsychotics. Harrow's and Jobe's analysis show that the population of schizophrenia patients is rather heterogeneous. Some have an episodic course while others are more chronic. The former don't need constant medication and often recover, whereas the latter relapse frequently even with constant medication. The main difference is one group is more sick than the other. Their study points out for the episodic patients, they do well with little medication. The conclusion in their abstract is "[t]he current longitudinal data suggest not all schizophrenia patients need to use antipsychotic medications continuously throughout their lives." They never contend that antipsychotics are why some patients are worse.

John McManamy said...

Hey, Tony. I've been reading the Harrow-Jobe study very carefully, and - yes - both the intention of the study and its findings are rather different from the inferences that Whitaker draws. Since the study did not attempt to measure the efficacy of antipsychotics, there can be no primary outcome measure in this regard.

The study would have had to have been designed a lot differently to get a definitive answer to the $64,000 question: Do antipsychotics worsen the course of schizophrenia over time?

By the same token, someone can take a look at the Harrow-Jobe findings and legitimately ask the same set of questions Whitaker did.

In an ideal world, there would be a flock of researchers asking these very same questions and putting some follow-up studies together. But in the world we're living in, I would be very surprised if even one such study were in progress. Long-term longitudinal studies are virtually impossible to get off the ground and keep going. The NIMH is about the only source willing to put up the funding for these kind of studies, but their resources are extremely limited. It's amazing they were willing to underwrite this particular study, in the first place, such is life.

So, we're likely to be stuck with this one study for a long long time, such is the sorry state of mental health research worldwide. And since this appears to be the best study we have right now, in lieu of answers, we are stuck asking questions.

I am in the process of blogging on these matters. Stay tuned ...