Tuesday, October 26, 2010

The Study Psychiatry Wishes Would Just Go Away: Part II

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

Yesterday, I reported on a study by Martin Harrow and Thomas Jobe featured in Robert Whitaker's "Anatomy of an Epidemic." The study tracked 64 young patients with schizophrenia from two Chicago hospitals over 15 years. An eye-popping finding was that 40 percent of those not on antipsychotics were in recovery vs just five percent of those taking antipsychotics.

In his book, Whitaker links this study to "a lengthy chain" of research that shows "evidence that long-term recovery rates are higher for nonmedicated patients." Is Whitaker justified in making this inference? The short answer is yes and no. Now to the long answer:

In their study, Harrow and Jobe did not address the efficacy of antipsychotics in the long term. That would have required an entirely different study design. Rather, Harrow and Jobe sought to tease out subgroups of unmedicated patients who "may show adequate functioning or recovery" over time. The authors were coming from a fairly mainstream point of view, namely: Schizophrenia (or any other mental illness) has many different causes and effects and manifestations across broad populations. Consequently, one-size-fits all treatments are likely to fit very few.

Unfortunately, the psychiatry we know is at the one-size-fits all level, which is the best explanation for why so many patients taking meds get worse rather than better. Psychiatry also wrongly assumes that the same meds and dose levels that work in getting us out of crisis are the same ones that will get us into recovery. We hear much about evidence-based medicine, but this is sadly lacking in psychiatry. Long-term drug trials that actually tell us something are very few and far between.

Clearly, it would help if psychiatry could predict on which specific populations meds are likely to work, especially over the long haul, but Pharma has no financial interest in running its clinical trials that way. Likewise, it would help if we knew which patients were likely to do better NOT staying on their meds, which is what Harrow and Jobe looked into. Specifically, they asked: 1) Can patients not on antipsychotics function well? 2) Which particular groups go off their meds and how does this influence outcome and recovery? 3) Are there various developmental, prognosis, and personality factors that enter into consideration?

In other words, is a patient with a prior work history who is not inclined to attribute his or her circumstances to bad luck, who is showing signs of improvement on their antipsychotic, a possible candidate for weaning off their antipsychotic?

Yes, sort of, conclude the authors. In their own words: "The data indicate significantly better functioning for the patients not on antipsychotic medications." This finding literally turns psychiatry on its head, but it hardly tells the whole story, as the authors note. The finding needs to be read with the study's other main finding, namely: Nearly half the patients not on antipsychotics at the end of the study had "favorable prognostic indices" when hospitalized 15 years earlier, in contrast to little better than one in ten patients still on antipsychotics.

Thus, the patients in the study who remained on antipsychotics were a more-ill group of patients to start with. This second finding hardly overrules the first finding, but it does add nuance. Thus, according to the study's authors:
Patients who are internally orientated and have better self-esteem are the types of patients who are more likely, if their functioning improves, to urge that they try functioning without medications and/or to choose to try functioning without any treatment at all.

And again:

The current data suggest that for the select subgroup of patients with schizophrenia who are not in clinic settings, who have gone off antipsychotics and did not immediately relapse, and stayed off them for a period of time, a surprising number experienced periods of recovery and continued to function well for a considerable period without antipsychotics.

Which leads to this conclusion:

Clearly, the present longitudinal data suggest that not all patients with schizophrenia need to use antipsychotic medications continuously throughout their lives.

Obviously, a lot more work needs to be done to zero in on this particular group of patients. A 40 percent recovery rate for schizophrenia patients not on meds is clearly an astounding finding, one that offers hope to a good many. But that same figure also indicates a 60 percent failure rate. And until we find out more, going off meds is going to be as risky, it seems, as staying on meds. The bottom line is we're still flying in the dark.

Thus the critical need for follow-up studies, to build on the work of Harrow and Jobe and others. Sadly, this is not likely to happen. Longitudinal studies are extremely difficult to get off the ground and sustain, and the NIMH - just about the only available funding source in the US - is not a bank.

Thus, the Harrow-Jobe study is all we are likely to have for years to come. This means, instead of a progressive train of enquiry yielding a steady stream of answers, we will continue to be asking questions.

Questions, questions ...  

Previous blog pieces:

The Study Psychiatry Wishes Would Just Go Away

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

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