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

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