Psychiatry has its head in the sand: Royal College of Psychiatrists rejects discussion of crucial research on antipsychotics

Two pieces of research have been published over the last two years that should prompt a major reorientation of the treatment of schizophrenia and psychosis, and a fundamental reappraisal of the use of antipsychotic drugs in general.  Put together, these studies suggest that the standard approach to treating serious mental health problems may cause more harm than good. Long-term treatment with antipsychotic drugs has adverse effects on the brain, and may impair rather than improve chances of recovery for some. Many people ask me how the psychiatric profession has responded to this data. Surely, they think, it must have stimulated a major debate within the profession, and some critical reflection about why it took so long to recognise these worrying effects? Sadly, this does not appear to be happening.

I have described both of these studies in detail in previous blogs. Briefly, in 2012 the research group led by Nancy Andreasen, the former editor of the American Journal of Psychiatry, published results of a brain scanning study of people diagnosed with schizophrenia or psychosis. The study found that people’s brains shrank over time in proportion to the amount of antipsychotic drugs they had been exposed to. The report concluded that  ‘antipsychotics have a subtle but measurable influence on brain tissue loss over time‘ (1)(p 128).  The study confirmed that the brain shrinkage observed in animals (2) also occurs in humans.

We don’t know whether these observed effects of antipsychotic treatment are temporary or permanent, and we don’t know whether they have any functional implications. In other words we don’t know whether the brain shrinkage is associated with intellectual decline or other brain-based abnormalities. The evidence is conflicting, with some studies suggesting there is no impact on mental ability (3), but worryingly, other studies, including Andreasen’s study, indicate that there may be an association between reduced brain volume and some cognitive or mental deterioration (4;5). It is obviously a worrying possibility.

The second game changing publication was the paper reporting the seven year follow up results of the Dutch antipsychotic discontinuation study (6). This study, conducted with people who had recovered from a first episode of psychosis, found that people randomised to a flexible and gradual antipsychotic discontinuation strategy were twice as likely to show a full social recovery than those who were allocated to continuous (maintenance) antipsychotic treatment. Moreover, relapses, which had been higher in the discontinuation group at 18 month follow up, had equalised. 

As I have said elsewhere, I am not against the use of these drugs altogether, but these studies suggest that antipsychotics are bad for the brain and can reduce people’s social functioning when used continuously over long periods. When I present these findings to audiences of non-psychiatrists, they are shocked that the drugs can continue to be so freely used in the face of this evidence. ‘How can this be ethically justified?’ someone commented at a recent meeting I attended.

When people ask me how psychiatrists have responded, I have, up to now, tried to give my profession the benefit of the doubt.  Some leading psychiatrists have been publicly critical of the overhyping of antipsychotics (7) and there are undoubtedly many others who are concerned about these research findings and trying to avoid antipsychotic drug treatment if possible, and use low doses for short periods where not. I have expressed the hope that as this research becomes more widely known, others will follow suit.

My illusions were recently shattered, however, by the Royal College of Psychiatrists’ conference planning committee. I proposed a symposium for the 2014 annual conference entitled ‘Re-evaluating antipsychotics- time to change practice?’ I invited Lex Wunderink, the first author of the Dutch study, to discuss his study, along with a leading British psychiatrist involved in brain scanning studies of people with schizophrenia. I was confident the symposium would be accepted, because obviously, I thought, the conference committee would recognise the importance of this research, and want to ensure it was widely publicised to, and debated by, members of the profession.

To my astonishment it was rejected. I wrote to the conference organiser to ask why, pointing out that patients, carers and the general public are wondering what the profession is doing about these research findings. They would be most surprised to know that the profession did not consider the results sufficiently interesting to merit discussion at the principal meeting of UK psychiatrists. She replied that there were too many competing suggestions. So I asked if any of the symposia selected covered these same areas of research.  I did not get a reply.

Surely, these findings are so momentous they deserve a whole conference in themselves? Every department of psychiatry around the country should be considering the implications of these studies, and be thinking about how psychiatric practice should change as a result. Yet the representative body of UK psychiatrists feels the evidence is not worthy of an hour and a half’s discussion at its annual conference.

Although I would like to believe it is was an aberration, I fear that the conference committee’s view is a barometer of the profession’s general attitude. It seems not to be interested in discussing the serious harm its drugs can do to both physical and mental health, and in taking the steps necessary to minimise this harm. The profession appears to believe that if it keeps quiet about these inconvenient findings, and discusses them as little as possible, the fuss will blow over and nothing need change.

It is disgraceful that the profession is not taking these findings more seriously, but sadly not unprecedented.  In the 1970s, the profession was accused of being ‘completely unconcerned’ about emerging evidence on the association between antipsychotic use and the syndrome of brain damage called ‘tardive dyskinesia’ (8).

At best psychiatry appears indifferent and complacent. At worst it is subconsciously attempting to hush up inconvenient data, so that, along with its partner, the pharmaceutical industry, it can continue ‘business as usual.’ Either way, it appears that the critics are right: the profession has its head firmly in the sand.   

Reference List

 

  (1)    Ho BC, Andreasen NC, Ziebell S, Pierson R, Magnotta V. Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia. Arch Gen Psychiatry 2011 Feb;68(2):128-37.

  (2)    Dorph-Petersen KA, Pierri JN, Perel JM, Sun Z, Sampson AR, Lewis DA. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. Neuropsychopharmacology 2005 Sep;30(9):1649-61.

  (3)    DeLisi LE, Hoff AL, Schwartz JE, Shields GW, Halthore SN, Gupta SM, et al. Brain morphology in first-episode schizophrenic-like psychotic patients: a quantitative magnetic resonance imaging study. Biol Psychiatry 1991 Jan 15;29(2):159-75.

  (4)    Gur RE, Turetsky BI, Bilker WB, Gur RC. Reduced gray matter volume in schizophrenia. Arch Gen Psychiatry 1999 Oct;56(10):905-11.

  (5)    Gur RE, Turetsky BI, Bilker WB, Gur RC. Reduced gray matter volume in schizophrenia. Arch Gen Psychiatry 1999 Oct;56(10):905-11.

  (6)    Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial. JAMA Psychiatry 2013 Jul 3.

  (7)    Tyrer P. From the Editor’s desk. British Journal of Psychiatry 2012;201:168.

  (8)    Crane GE. Clinical psychopharmacology in its 20th year. Late, unanticipated effects of neuroleptics may limit their use in psychiatry. Science 1973 Jul 13;181(4095):124-8.

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22 thoughts on “Psychiatry has its head in the sand: Royal College of Psychiatrists rejects discussion of crucial research on antipsychotics

  1. amazing!!..i was just asked today by a friend why i dont become a doctor while sharing my experience as a long term medicated psych patient. Then i read this article. Amazingly i gave the same examples of disbelief concerning available information that Proves physical damage and evidence(personal but not uncommon)that increased mental difficulties arise from use of long term psych meds…keep spreading the facts..we have a long uphill battle that may result in better help for others rather than ourselves.

  2. A fresh direction: Open Dialogue

    ~ Why does the Open Dialogue approach work so well? ~

    Tread softly because you tread on my dreams
    W.B. Yeats

    Schizophrenia is never being able to trust your senses: we see things which ‘are not there’; we hear what no one else does. We therefore live precariously, with a terrific amount of uncertainty and confusion for long periods of time. This is also an experience particular to individuals.

    The Open Dialogue approach gives due recognition to this and seeks to tentatively
    explore exactly what is happening in the lives of individual clients and to find ways
    forward which grow out of current predicaments, evolving solutions to expressed difficulties and weighing each tread-fall with care and attention.

    This is done through the medium of ongoing exploratory treatment meetings which are convened with all the people connected in the social network of the client in attendance and contributing from their perspectives, with as many meetings as it takes to evolve and become the solution and resolution of the difficulties expressed and experienced, finding a way forward launched from the dialogue taking place. This open and thorough dialogue finds a language to best express the realities of life from client-perspectives,
    exploring these towards outcomes which everyone present can approve and give consent to.

    This is a true and meaningful discernment of what is happening in the life of the client. The care taken in achieving this accuracy is well-rewarded in rendering complex issues accessible to practical solutions and removing scope for mis-understanding and discord
    later; maybe this process of ascertaing the facts wll not have to be visited and revisited again, having uncovered the truth at first onset.

    No one jumps to conclusions or imposes stock remedies or solutions, because it is better not to have answers than to apply the wrong ones. When the whole topic is explored with everyone present and conferring, the way forward can become much clearer, with all possibilities explored and only the feasible solutions ruled in. Any sense of
    compulsion is banished from the proceedings and the approach is sensitive,
    commensurate and quite beautiful in its simplicity. Why would it not work!

    So instead of discounting and disregarding the words of people with schizophrenia, these have taken centre-stage. Open Dialogue practitioners are listening carefully and non-judgmentally to the narratives of people with first-onset schizophrenia in a quest to
    ascertain appropriate care and treatment -without naming it. Is this a Revolution?
    What do we all think of this?

    Rodney Yates
    Open Dialogue Nottingham
    http://www.facebook.com/nottinghamopendialogue
    http://hypoconcer.ning.com
    December 2013

  3. They say you are crazy, then they make you crazy from the drugs and deprivation of liberty.

    “Those who can make you believe absurdities, can make you commit atrocities.” Voltaire (1694 – 1778)

    An Anti-psychotic does not exist in reality, there is no psychotic molecule, virus or bacteria.

    Dr Nancy Andreasen wants more drugs developed to fix something that wasn’t broken in the first place.

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 – Beyond Meds

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  7. Joanna, what a refreshing medical attitude you have.

    I have been a Psychiatric Nurse for 20 yrs and struggle daily to justify my actions in ‘persuading’ distressed individuals to accept medications.

    In tend toward the ‘drug centered model’ that you describe in another post, and see antipsychotic treatment as a very blunt instrument of treatment for what can only be described as a complex human state of mind.

    More often than not the drugs merely act as anxiolytics (yes tranquilisers) in my opinion and do create more problems than remedy.

    I ask my self on reading ‘awakenings’ again – are ‘negative symptoms’ of ‘schizophrenia’ just chronic parkinsonion symptoms induced by antipsychotics?

    Do untreated people get ‘negative symptoms’?

    What concerns me is the belief in the disease model held by young graduates and unwittingly impressed upon people experiencing sometimes frightening (sometimes not) phenomenon.

    You have my utmost respect for literally speaking out and for writing such marvellous posts.

    I am not usually one to respond to blogs and am not sure this will even appear, but do keep uo the good work, and let me know if you ever consider presenting in or working in New Zealand!

  8. I think that the reason some psychiatrists refuse to face this and many other issues that suggest change – is because they can’t think of an alternative! If only there was an attitude of supporting people in distress with adequate resources, therapy, counselling, housing, employment etc – I am convinced that we would be able to save billions of dollars/pounds in health, education, prison systems and so on.

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  16. Some one very close to me who suffers with enduring mental illness following a psychotic episode, has suggested that this does not seem to take into consideration the ramifications of not giving this treatment. This person suggests that people would end up dead or incarcerated without it. However there is s lot to be said for reducing dosage and providing alternatives once things have stabilised.
    It’s seems to me that mental health services particularly in the uk are not developed to their full potential in finding different and new treatments . They instead rely on responding to pieces of research where the argument revolves around whether or not the research is valid . This has serious consequences for individuals and society in the longer term and as people get older.

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