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Early Help or Aggressive Marketing?

My county, Lane County, Oregon, is one of a number of places around the country just starting to participate in a new “early intervention” program sponsored by NIMH, called RAISE, that says it aims to help people soon after they begin experiencing their first psychotic episode.  While there are some good reasons to offer help to young people as soon as they start having problems that might be labeled psychosis, I have serious doubts about the program here being offered.

For one thing, the very name of the program (RAISE stands for “Recovery After an Initial Schizophrenic Episode”) suggests the program will be reckless in applying labels and stigma.  Even the DSM cautions against calling a psychotic episode “schizophrenia” unless the mental health condition has lasted at least 6 months, but people will be recruited into the RAISE program as soon as possible after their problems with psychosis begin, a much shorter time period.  Nevertheless, just due to the name of the program, they will feel defined  as having had a “schizophrenic” episode. 

Second, the NIMH website advertises that the program involves “intense and sustained pharmacological intervention.”  This implies a reckless use of medication as well as of labeling.  (Of course, the two go together – the sooner a person is labeled with “schizophrenia” the more justification can be made for “intense and sustained” drugging.) 

Early intervention programs that really aim to help are very cautious about the use of both labels and drugs.  The lack of caution in the design of this program suggests that the true purpose of the program is the early recruitment of young people into a life as labeled consumers of psychiatric medication.  Tobacco companies have to recruit their own customers, but pharmaceutical companies have government assistance in capturing their market.

It’s interesting that an old friend of mine, John Bola, did a review of all the studies that ever compared programs that started people out on drugs immediately, with programs that didn’t, and where the comparison period was at least a year.  You can read his paper here.  What he found was that in each case, the program that didn’t rush people into drugs did better – and that was before taking into account the fact that the people not on drugs didn’t have to deal with drug side effects.  And of course the best effects reported for an early intervention program are those of the Open Dialogue program, which also avoids using drugs wherever possible.

I wait for the day when we will treat young people with “psychosis” based on the evidence, and not based on the wishes of those more interested in profit.

13 comments… add one
  • Robert Whitaker’s new book makes a clear cut case for not introducing drugs at all.
    People shouldn’t be fooled about the NIMH being anything other than a platform to launch new drugs. These early intervention programs seem “very noble” and the age of the target grou
    p is a fresh market to exploit. .

    • Since I wrote my post, I have been assured by someone working within the RAISE study that the study calls for using “low” doses of medication, rather than the “intense” medication suggested by the NIMH website. So it might not be quite as bad as I thought.
      Still, I agree with Rosa, competent treatment would seek to avoid introducing drugs at all whenever possible. As just a few programs already do.

  • Hey there…

    I wanted to throw my two sense in, if that’s all right. I work on a RAISE Connection Team that is “agressively” medicating these kids. I can assure you that our psychiatrist does NOT just dole out medications with disregard for the opinion of the child or the parents. She does extensive research and meets with the patient, the family and the rest of the connection team to work out a plan as to what is the best course of treatment for the patient. I can assure you both that none of the kids we work with are on heavy doses of medication and we also prefer that they aren’t on ANY medication, but they’re so early on in the psychosis that we are taking every avenue to help them. The emphasis in the study is on employment/education and skills training, demonstrated by the fact that our consumers work with the Employment and Education Specialist and Skills Trainer much more intensely than the psychiatrist…and so far, it is working. We make it clear that the hope is that the individual can make the choices for themselves, be it needing medications or not. Medications work wonders for some and work horribly for others. We on the connection team tailor all our treatment to each person individual.

    As for the name RAISE, we actually don’t use it when working with people. We use “connection team” and RAISE does realize that the name can be stigmatizing and is working to allieviate that problem.

    RAISE is too early in its infancy to make judgement calls…let’s just see how this invervention works first.

    • I am interested in understanding what the “extensive research” is comprised of before doling out the meds.

      I am certain the program’s objectives are admirable. It comes down to the fundamental question of what works and what does not.

      Should developing brains be medicated with neuroleptic drugs?

      What underlies this psychotic coping mechanism for adolescents?

      So long as the debate continues with respect to whether psychosis is a brain disease or a pychosocial defense mechanism we will be engaged in debate about how to best treat it.

      To my mind until someone can isolate the purported “disease” for observation under a microscope in a pitrie dish I am loathe to accept that this is a biological disease.

      While my opinion of Peter Breggin can change from a good day to a bad day I agree that it is absolutely criminal to tranquilize developing brains with psychiatric drugs.

  • Hi Alyssa, thanks for commenting here, I hope you feel welcome to express your opinion even if I don’t agree with you!

    I’m happy that the people you work with aren’t on “heavy” medication and I’m happy you are providing lots of avenues for assistance, such as employment, education, and skills assistance. But I really take issue with your remark that “we also prefer that they aren’t on ANY medication, but they’re so early on in the psychosis that we are taking every avenue to help them.”

    It’s very clear that the one avenue you aren’t giving them is a chance to work through and understand their experience without getting them started on antipsychotic drugs. Early on in psychosis is the best time for people to learn that they can make sense of what is happening to them, and that requires being around safe supportive people while not on drugs. Drugs just stop what is going on with the person, and set up a reliance on drugs to cope with the problem if it occurs again.

    It’s also clear that RAISE doesn’t have any protocol for getting people off antipsychotic medications once they are started. (I even wrote to the national leadership, and they said they were going to have a team meeting and get back to me on this, but then didin’t despite my repeated requests – which I take to mean they realized they didn’t have a protocol but weren’t willing to go on record saying so.) I know you want to help these young people not be stuck in psychosis, but what we need is a program that would seek to get them unstuck period, not to trade being stuck in psychosis for being likely stuck on antipsychotics for the rest of their lives.

    RAISE may be new, but antipsychotic drugs are not, and it’s about time we start judging any program that would put people on them without trying safer methods first.

    With that said, I know that if people are starting involvement with the mental health system anyway, they are better off with a program like RAISE than with the traditional approach of drugs only (and often “heavy” doses.) So I appreciate that people working in RAISE programs may be making some positive differences, it’s just that I want us to go quite a few steps further.

  • Alyssa,

    The drugging of children as you describe is criminal.
    From Psychiatrist, Peter Breggin, M.D. –

    http://breggin.com/index.php?option=com_content&task=view&id=38

    Duane

  • Attorney, Jim Gottstein has put together an initiative against the targeting of children and youth with these drugs.

    It’s criminal. Literally. It’s called Medicaid Fraud –

    http://psychrights.org/education/ModelQuiTam/ModelQuiTam.htm

    Duane

  • Ron,

    The NIMH is part of the problem.

    What about looking for underlying causes of these symptoms?

    For instance, the 29 medical causes of “schizophrenia” mentioned in this article by Carl Pfeiffer, M.D., Ph.D. –

    http://www.alternativementalhealth.com/articles/causesofschizophrenia.htm

    Of course, the other thing is treatment for trauma, which drugs hardly address! In fact IMO, they futher traumatize by the fallout to the mind/body!

    Our mental health system….
    Are we doing everything wrong? It sure appears that way!

    Duane

  • Hi Duane,

    As I understand it, Jim Gottstein’s lawsuit is about the use of antipsychotics “off label” in children. (There is a huge amount of use of these drugs just to dullen out kids, especially foster kids, who don’t have any sort of recognized mental disorder for which antipsychotics have been approved. Some of these kids are even preschool.) A program like RAISE however would be giving antipsychotics to adolescents and young adults who are diagnosed with a psychotic disorder, for which antipsychotics are “on label.”

    As you know, that doesn’t mean I think it’s a great idea, especially before competent alternatives have had a chance to be tried, but it does mean that RAISE does not have the legal problems that Jim is attacking in his lawsuit.

  • Ron,

    It’s my understanding that the term “off label” as it applies to children/youth would refer to any antipsychotic drug that had not been FDA-approved for children/youth.

    Respirdal would be one that has been approved (under political pressure, unfortunately). I know there has been a push to get others, but not sure if Pharma has been successful with any others.

    That’s my understanding.
    If this isn’t accurate, please let me know.

    Duane

  • Ron,

    This is from Jim’s Medicaid Fraud Initiative –

    “An indication not approved by the FDA is often referred to as “off-label.” Congress didn’t prohibit reimbursement by Medicaid for all off-label prescriptions, but specifically limited reimbursement for off-label prescriptions to those that have sufficient scientific “support,” as documented in one of the Compendia.”

    “A couple of illustrations: Geodon is not (yet) approved for any use in children and not supported by any citation in any of the Compendia. Thus, any Geodon prescriptions to children and youth submitted to Medicaid constitute fraud. Similarly, I have seen neuroleptics such as Abilify, Risperdal, Seroquel, & Zyprexa, prescribed for “Oppositional Defiant Disorder,” and even for sleep. Such prescriptions are not for “medically accepted indications,” and thus automatically constitute Medicaid Fraud.”

    …. Ron, it would seem that the Geodon example cited above would cover lots of the drugs that are FDA-approved for adults for “schizophrenia” but not children.

    I’m not an attorney, but that’s my understanding.

    My best,

    Duane

  • Duane, I am certainly not an expert in what drugs are or aren’t approved for children, but I have heard that olanzapine (Zyprexa) and Seroquel are both approved for adolescents with psychosis.

  • Ron,

    This is a list from NIMH of psychiatric drugs, with age approved for…

    Thankfully, there are several drugs that are only approved for age 18 and up, but there are a few that are approved for children/youth in various categories, including antipsychotics (neuroleptics) –

    http://www.nimh.nih.gov/health/publications/mental-health-medications/alphabetical-list-of-medications.shtml

    It would be nice to see the FDA take a stronger stand in approving these drugs for kids, and to see the NIMH take a bigger role in promoting non-drug treatment options – especially for children and youth!

    Duane

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