Ask Science
By BENEDICT CAREY
Published: March 23, 2006
The New York Times
Benedict Carey answered reader questions about his article "Revisiting Schizophrenia: Are Drugs Always Needed?" from this week's Science Times.
Related Revisiting Schizophrenia: Are Drugs Always Needed? (March 21,2006)
Q: Treatment of schizophrenia, as most mental disorders, in the U.S. is in sharp contrast to European approaches. That some schizophrenics can do well without medications is not news...in England. For many years Timothy Owens and co-workers compared the patients at their clinic, largely on drugs, with a clinic on the other side of London that did not believe in drugs. That generated a wealth of information.
As to the question in your article, to treat or not to treat? It was shown 30 years ago that the discharge environment was one of the major determining factors in outcome (CE Vaughn & JP Leff, Br. J. Psychiatry 129:125-137, 1976). Patients discharged to an environment determined at time of admission to be a low emotional expression environment had the same percentage of relapses regardless of the addition of drugs or not. Those discharged into a high emotional expression environment with exposure greater than 35 hours per week, had 92 percent relapse without medication and 53 percent with full medication. Studies that do not factor in the discharge environment of the patient are uninformative and differences in environments may account for the differences across studies, but since few report that you cannot determine causative factors for relapse.
— Brian A. McMillen, professor of pharmacology and toxicology, East Carolina University
A: Decades ago, the United States also had programs exploring non-drug options; and there are some small, private clinics here that also minimize medication. But at least in recent years, doctors in Europe have been more open to trying non-drug or minimal drug treatments, perhaps in part because of better tracking and support of patients through nationalized health services. In England, doctors have been in the lead experimenting with cognitive psychotherapy for psychosis—the same kind of "thought-stopping," as some call it, that has been effective for depression—and psychiatrists in both Finland and Sweden are studying how well psychoses can be managed with minimal medication, as mentioned in the article. The Finnish program in particular takes into account the "discharge environment" which many studies have now shown can make a big difference in how people live with symptoms of schizophrenia. That program involved intensive family therapy to help parents and siblings. U.S. psychiatrists also engage family members, when they can, although usually in the context of drug treatment.
Q: The old phenothiazines compared to the next generation of atypical antipsychotics are like using leeches compared to laser surgery (speaking from personal experience). Much of my effort to utilize the phenothaizines involved finding ways I could tolerate the drugs. I was not very successful and as a borderline schizo-affective, I would rather be on no drugs at all than take something like Haldol or Stelazine, which I credit with causing my one suicide attempt. I have since discovered Risperdal and an even more effective drug for me, Abilify. These drugs don't seem to have debilitating side effects and have given me real hope and progress. I can only hope that the likes of Haldol and Stelazine with their shotgun approach to neurotransmitter mediation are discarded for the surgical precision of drugs like Abilify. I know I am better off taking Risperdal and Abilify than I would be without the drugs. I am appalled/astounded that the best the pharmacy could offer for the research was drugs a generation or two out of date. It is no wonder to me that the untreated borderlines fared as well as the treated borderlines.
Most of the treated probably tossed their supply of phenothiazines in the trash as soon as they left the office. The older, more sedative phenothiazine, Thorazine, may still have psychopharmilogical use (recalling one incident when I was hospitalized) in controlling unruly clients but surely drugs like Stelazine and Haldol are of little use to anyone anymore.
— R. W. Kinserlow Jr.
A: The newer antipsychotics were a godsend to many people who hated old drugs like Haldol. But the older drugs were also given in doses that many psychiatrists say were too high. With lower doses, they say, those drugs are not as hard to take and are less likely to cause neurological problems, like tardive dyskinesia. A huge, government-sponsored study recently found that people were about as likely to quit taking newer drugs like Risperdal and Geodon as they were an old-line drug—perphenazine—when given in modest doses (most switched drugs, which is common). But psychiatrists and many people with schizophrenia say that drugs should be individualized; one person may do very well on a drug that is unbearable for another.
Q: A reference is made in the article to Scandinavian countries and the available alternatives to medication in a society where therapy and hospitalization are within reach of the majority. Can the debate about early aggressive treatment be made without reference to the sociocultural meaning and context of psychosis (in the US, "flat-out nuts", to [mis]quote Dr. Lieberman), or the significant economic underpinnings to our 'treatments of choice', e.g., hospital defunding/managed care?
— J. Ames, clinical psychologist
A: Both the cultural meaning of psychosis and the underlying health system are very relevant to the issues surrounding treatment. But the story was focused on how and whether to treat first psychosis in the context of the current system. The other issues deserve their own stories.
Q: Does anyone care that there is convincing evidence that "schizophrenia" does not really conform to accepted definitions of what constitutes a disease? See recent detailed evidence by Mary Boyle, Professor at University of East London, for example. See also the extensive evidence that psychotic behavior is effectively reduced by supportive relationships. When will a competent reporter, relying on evidence, not authority, overturn this pile of misinformation?
— George W. Albee, emeritus professor, University of Vermont
A: The issue of whether any psychiatric disorder can be called a physical disease is still an open one, as you say, but that debate was not the subject of the article. Call it what you like, psychosis causes people problems, and the question addressed in the article is whether or how to treat it.
