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Giving Antipsychotics to people just diagnosed with psychosis is NOT an evidence based practice

Almost everywhere in the world, programs set up to do early intervention in psychosis rush to start people on antipsychotics.  This is widely seen to be an evidence based practice:  in fact, it is thought that the evidence is so strong, it would be unethical to withhold the drugs.

Many of us are aware that from a longer term perspective, the use of antipsychotics is likely making things worse instead of better.  But we probably at least assume that evidence does exist that in short term studies, measured against placebo, people just recently diagnosed with psychosis will appear to do better on antipsychotics.  However, a new review by John Bola, Dennis Kao, and Haluk Soydan, “Antipsychotic medication for early episode schizophrenia” shows that very few studies have even been done focusing specifically on early episode schizophrenia, and the evidence from those studies is inconclusive.

So the notion that everyone in an early episode needs antipsychotics is not evidence based, even for the short term.

The problem is that researchers have just been assuming that studies done with groups of people who mostly were not in an early episode could be generalized to apply to early episode groups.  There is much reason however to think that early episode groups may be different in how they respond to medications on average.

So in this case, the emperor clearly has no clothes (well evidence in this case) and we can can start to ask the question, why have so many overlooked this lack of evidence for so long?  What will it take to get more studies going that weigh medication use in early episodes versus competent psychosocial interventions?

See http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006374.pub2/abstract;jsessionid=D780DF4FC7AD910C466DE41552E9AFBD.d02t03

6 comments… add one
  • Isn’t it all about the money? Giving antipsychotics in the first instance of psychosis sedates the person and makes it easy to send them home with a prescription. Of course, the medications do nothing for the psychosis, but this practice allows beds to be freed up in the hospital. Providing real help to a person without drugs can take months, and health systems aren’t prepared to pay for this. I felt that sending my son home from the hospital drugged up to his eyeballs was like giving me the keys to a fancy sportscar that I didn’t have a clue how to drive. I was left on my own to figure out how to put the key in the ignition. That is the cheaper option from the public health point of view, and it’s wrong.

  • Can people recover…. do people recover?

    Yes.
    All the time.

    Will conventional psychiatry ever restore itself to some level of sanity?

    Who knows.

    Duane

  • Ron,

    Actually, psychiatry has only had a smalll window of time where it got things right, namely the ‘moral era’.

    It has gotten things wrong for centuries.

    And this new era, of conventional psychiatry, the ‘pharmacological’ era… is about as therapeutic as the black plague.

    Duane

    • Hi Duane,

      While I appreciate your passion about challenging all the things psychiatry has gotten wrong, and there are so many, I fear you may harm your own credibility if you exaggerate your case. Even psychiatrists I respect use pharmacology at times (with great reservations) and even a decent sleep medication can be considered part of “pharmacology.” So I think that very limited pharmacology can be helpful, while its excess is clearly a plague – on the other hand, even a limited version of the black plague was pretty terrible.

      Anyway, that’s how I think about it.

  • Interestingly, Moral Treatment did not involve psychiatry/the medical profession. Psychiatry hasn’t got anything right, ever. It’s supposed to be a medical speciality, and as such it has always medicalized, still today medicalizes, and will always medicalize existential suffering. As a medical speciality, psychiatry depends on medicalizing existential suffering. Without this medicalization — which IMO is deeply political, and not medical at all –, poof! no more psychiatry. Moral Treatment was an entirely non-medical approach to existential suffering. Open Dialogue, Soteria, and similar approaches are/were non-medical in their understanding of it, and widely non-medical in their approach to help people in distress. A sleeping pill, or two, may be helpful during acute crisis, but we don’t need psychiatrists to prescribe it. Any physician can do that, probably even better than a psychiatrist, who’s trained to see everything as a “symptom” of “mental illness”, and thus easily can overlook physical health problems representing contraindications to, or signs of intolerance of certain substances.

    • Hi Marian,

      I think that’s a good point, that Moral Treatment was not carried out by psychiatrists.

      I do though like to distinguish my own views from those which might be seen as “antipsychiatry” by pointing out that there have been decent psychiatrists, and I do see a role for psychiatrists in a reasonable mental health system. One thing a good psychiatrist knows how to do is to look for and treat any physical health problem that may be contributing to mental and emotional difficulties. A regular doctor might also know how to do that, but a good psychiatrist, who may have a better understanding of this area, may do better. A second thing is that the good psychiatrist knows how to be very cautious in the use of psychiatric medications – being reluctant to use them, being able to encourage people and their families to hold off for awhile even when people are asking for the medications, but also willing to prescribe when other things aren’t working and medication use for awhile is a reasonable gamble. See my prior post, http://recoveryfromschizophrenia.org/2011/04/a-few-proposed-principles-for-a-balanced-psychiatrist/

      Of course, a key problem is that psychiatrists are currently being trained to do the opposite of what would constitute wise practice.

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