NIMH Director’s BlogBy Thomas InselAugust 28, 2013
One of the first lessons I received as a psychiatrist-in-training 35 years ago was the value of antipsychotic medications. These medicines have been available for the treatment of psychosis for over half a century, beginning with the prototype first generation drug chlorpromazine [Thorazine] and now extending to some 20 different compounds, including several second-generation medications, often called “atypical antipsychotics.” Symptoms such as hallucinations, delusions, and paranoia are reduced reliably by these drugs. Although these symptoms can be frightening and dangerous for patients, family members, and providers, antipsychotics safely and effectively help people through the crisis of acute psychosis.
However, the long-term management of chronic mental illness is another matter. Recently, results from several studies have suggested that these medications may be less effective for the outcomes that matter most to people with serious mental illness: a full return to well-being and a productive place in society.That is not to say that people are not remitting or recovering from serious mental illness. An article recently posted online in JAMA-Psychiatry tells an interesting story about medications and recovery. Wunderink and colleagues from the Netherlands report on a seven-year follow-up of 103 people with schizophrenia and related disorders who had experienced a first episode of psychosis between 2001 and 2002. After six months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering-off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by seven years, the discontinuation group had achieved twice the functional recovery rate: 40.4 percent vs. only 17.6 percent among the medication maintenance group. To be clear, this study started with patients in remission and only 17 of the 103 patients — 21 percent of the discontinuation group and 11 percent of the maintenance group — were off medication entirely during the last two years of follow-up. An equal number were taking very low doses of medication — meaning that roughly one-third of all study patients were eventually taking little or no medication.
For me, there were three remarkable results in this study. First, the groups did not ultimately differ in their experience of symptoms: about two-thirds of each group reported significant improvement in symptoms at seven years. Second, 29 percent of the discontinuation group reported that they had also achieved a healthy outcome in work and family life — a number that should give hope to those struggling with serious mental illness. And finally, antipsychotic medication, which seemed so important in the early phase of psychosis, appeared to worsen prospects for recovery over the long-term. Or, as Patrick McGorry said in an accompanying editorial, “less is more.” At least for these patients, tapering off medication early seemed to be associated with better long-term outcomes.
What does this say about the long-term use of antipsychotics? Are they potentially harmful? Are they necessary for an individual’s entire lifetime? Earlier this year, Martin Harrow and Thomas Jobe reported an analysis of several long-term follow-up studies of people with schizophrenia to determine if antipsychotics, given long-term, facilitate a return to functional well-being. They describe the following pattern across these studies: [a] within the first 6-10 months after discontinuation, 25-55 percent of patients relapse; [b] for those who do not relapse during this period, subsequent relapses are much less frequent even after prolonged periods off medication…
These new data on the long-term outcomes for people with “schizophrenia” remind us that 100 years after defining this disorder and 50 years after “breakthrough” medications, we still have much to learn.
When Altostrata commented on this blog by Insel, he said, "And this surprise from Tom Insel." and it is a surprise. Some will be surprised that Insel’s so obviously impressed by these articles that implicitly recommend using antipsychotics for acute episodes of psychosis only, and not as maintenance treatment. I wasn’t so surprised by that. I don’t know many psychiatrists who still have the fantasy that the solution to schizophrenia is "keeping people on their meds." That’s more a fantasy in Mental Health Centers where people are frustrated by the chronically relapsing patients – called recidivism. Insel’s usual response to this kind of topic is different, that "we need better drugs." I was instead surprised that these articles caught his attention; that he didn’t say "we need better drugs;" and that he did say "… after ‘breakthrough’ medications, we still have much to learn."
Then I thought of Kopp’s book title "If you meet the Buddha on the Road, Kill Him". The title comes from a Koan attributed to Linji [the founder of the Rinzai sect of Zen] – mirroring the Taoist proverb, "The Tao that can be named is not the eternal Tao." Like many of the paradoxical sayings of Zen and the Taoists, I take it to mean that if you think you’ve found the answer, watch out! There are no the answers, and if you fall for that illusion, you’ll stop learning, stop listening, and get stuck in preaching the gospel of your new the answer.* That’s my complaint about the last thirty years of psychiatry. And that was also the complaint of the people who initiated the changes of the last thirty years in psychiatry.
The reformers of 1980, Mel Sabshin, Robert Spitzer, the Saint Louis group, etc. all felt that the psychoanalysts and other psychotherapists had over-valued their models, inflated their results, and had exerted too much influence on American Psychiatry. They were very taken with the findings from the pharmacotherapies of the 1950s – as well they should have been. An acute schizophreniform psychosis is a formidable event to behold. Seen up close and personal, there’s little question that it needs to be treated, and the idea that it can be ablated in hours to days in a lot of instances would get anyone’s attention. There were other forces in the mix sure enough, but the net result was a radical flip and a love affair with biological treatments as the answer replacing the last the anwer. That idea was irrationally extrapolated and has us back near where we started – offering more than could be delivered. The pharmaceutical industry had a field day with this enthusiastic turn of focus, fanning the flames of hope with a pipeline pouring out lightweight clones disguised as breakthroughs, joined by a chorus of our colleagues who behaved pretty badly.
And Tom Insel of the NIMH has been a part of that problem with his psychiatry-as-clinical-neuroscience sermons and his monocular ideology. But much worse, like the psychiatric leadership in general, he’s run an NIMH that has doled out major treasure to the discredited and the non-productive; he’s inserted and controlled the agendas of researchers rather than following their creative leads; and his silence about rampant corruption in psychiatry has been deafening. He may not pick the grantees. But he should be setting the tone of his organization that does our major funding. He has pandered to industry throughout his tenure, and shows no signs of changing directions.