Serious Mental Illness Blog

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Residual depression has lasting impact on bipolar patientsBy Eleanor McDermid, Senior medwireNews ReporterIn bipolar disorder, depressive symptoms are not only negatively associated with the outcome, but also affect verbal memory performanceA prospective study confirms the detrimental effect of subthreshold depressive symptoms on the outcomes of patients with bipolar disorder.
The findings, published in the Journal of Affective Disorders, also suggest that the effect is partly mediated by cognitive impairment.Researcher Anabel Martínez-Arán (University of Barcelona, Spain) and colleagues say that most studies have been cross-sectional, whereas they followed up 111 patients for 1 year. The patients were aged an average of 40 years and 78.4% had bipolar I disorder; all were euthymic at inclusion.
The team assessed verbal memory (using the California Verbal Learning Test), because impairment in this neurocognitive function is thought to be a core feature of bipolar disorder. Along with subsyndromal depressive symptoms (≤8 on the Hamilton Depression Rating Scale), patients’ composite verbal memory score explained 19% of the variance in their baseline scores on the Functioning Assessment Short Test (FAST).
Subthreshold depressive symptoms and verbal memory were associated with each other, such that patients with more depressive symptoms had larger memory impairments. They were also individually associated with baseline functional status.
“Thus in bipolar disorder, depressive symptoms are not only negatively associated with the outcome, but also affect verbal memory performance,” say the researchers.
Verbal memory had a significant indirect effect on outcome, partly mediating the relationship between depressive symptoms and functional status.
During 1 year of follow-up, patients’ functional status remained fairly stable overall, with average FAST scores of 29 at baseline and 27 at follow-up. Baseline functional status explained 44% of the variance in 1-year functional outcomes.
As baseline functional status was, in turn, partly dependent on depressive symptoms and verbal memory, these variables therefore contribute to follow-up functional outcomes, explain Martínez-Arán et al.The researchers note, however, that the study only assessed verbal memory, and impairments in this domain could be partly caused by other neurocognitive deficits.
“The identification of mediators in the prediction of functional outcome may help to disentangle the complex network of variables that contribute to functional outcome, since many variables with direct and indirect effects might be involved,” they conclude.


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Residual depression has lasting impact on bipolar patients
By Eleanor McDermid, Senior medwireNews Reporter

In bipolar disorder, depressive symptoms are not only negatively associated with the outcome, but also affect verbal memory performance

A prospective study confirms the detrimental effect of subthreshold depressive symptoms on the outcomes of patients with bipolar disorder.

The findings, published in the Journal of Affective Disorders, also suggest that the effect is partly mediated by cognitive impairment.
Researcher Anabel Martínez-Arán (University of Barcelona, Spain) and colleagues say that most studies have been cross-sectional, whereas they followed up 111 patients for 1 year. The patients were aged an average of 40 years and 78.4% had bipolar I disorder; all were euthymic at inclusion.

The team assessed verbal memory (using the California Verbal Learning Test), because impairment in this neurocognitive function is thought to be a core feature of bipolar disorder. Along with subsyndromal depressive symptoms (≤8 on the Hamilton Depression Rating Scale), patients’ composite verbal memory score explained 19% of the variance in their baseline scores on the Functioning Assessment Short Test (FAST).

Subthreshold depressive symptoms and verbal memory were associated with each other, such that patients with more depressive symptoms had larger memory impairments. They were also individually associated with baseline functional status.

“Thus in bipolar disorder, depressive symptoms are not only negatively associated with the outcome, but also affect verbal memory performance,” say the researchers.

Verbal memory had a significant indirect effect on outcome, partly mediating the relationship between depressive symptoms and functional status.

During 1 year of follow-up, patients’ functional status remained fairly stable overall, with average FAST scores of 29 at baseline and 27 at follow-up. Baseline functional status explained 44% of the variance in 1-year functional outcomes.

As baseline functional status was, in turn, partly dependent on depressive symptoms and verbal memory, these variables therefore contribute to follow-up functional outcomes, explain Martínez-Arán et al.
The researchers note, however, that the study only assessed verbal memory, and impairments in this domain could be partly caused by other neurocognitive deficits.

“The identification of mediators in the prediction of functional outcome may help to disentangle the complex network of variables that contribute to functional outcome, since many variables with direct and indirect effects might be involved,” they conclude.





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Filed under mental illness mental health mental health illness bipolar depressed depression depressive research neuro neuroscience psychology psychiatry psych psy tumblr news mad madness recovery recover mind body brain sad sadness cognition science scientific

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Factors predicting disengagement from psychosis early intervention identifiedBy Afsaneh Gray, medwireNews ReporterA study of first-episode psychosis patients in Hong Kong has found that those with fewer negative symptoms at presentation and poor medication compliance were more likely than others to disengage from an early intervention program.“We have confirmed reports in previous studies, which were mostly conducted in western populations, that diagnosis of a non-schizophrenia-spectrum psychotic disorder, lower baseline negative symptom severity, poor medication compliance and substance abuse history predicted service disengagement,” write study author Wing Chang (The University of Hong Kong) and colleagues.The team identified 700 patients aged 15 to 25 years who were enrolled in the Early Assessment Service for Young People with Psychosis (EASY) program between 2001 and 2003.Data on each patient were retrieved from clinical records, and the Clinical Global Impressions–Severity Scale was used to determine symptom severity. Information on medication compliance was derived from sources including case management notes, medical records and information from caregivers.Disengagement was defined as missing all outpatient appointments until the end of the 2-year service despite therapeutic need and active follow-up from staff, and occurred in 94 patients.The mean age of participants was 20.65 years and the median duration of untreated psychosis was 91 days. Most (69.14%) patients had a diagnosis of a schizophrenia spectrum disorder (ie, schizophrenia or schizoaffective disorder).Multivariate analysis identified three factors that were independently associated with disengagement. Patients were 56% less likely to disengage if they had schizophrenia-spectrum disorders, rather than other types of psychosis. They were 63% less likely to disengage if they were adherent to their medication, and they were 24% less like to disengage if they had high baseline negative symptom scores (>3).Substance abuse history within the initial 6 months of the program increased the chances of disengagement, but, due to the small number of patients affected, was not included in the final multivariate analysis.The team also found that 63% of disengaged patients were in symptomatic remission during the month in which they left the EASY program.“Early intervention teams should pay attention to factors associated with disengagement, and monitor at risk patients closely to detect signs of non-adherence,” Chang and colleagues conclude in Schizophrenia Research.


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Factors predicting disengagement from psychosis early intervention identified
By Afsaneh Gray, medwireNews Reporter

A study of first-episode psychosis patients in Hong Kong has found that those with fewer negative symptoms at presentation and poor medication compliance were more likely than others to disengage from an early intervention program.
“We have confirmed reports in previous studies, which were mostly conducted in western populations, that diagnosis of a non-schizophrenia-spectrum psychotic disorder, lower baseline negative symptom severity, poor medication compliance and substance abuse history predicted service disengagement,” write study author Wing Chang (The University of Hong Kong) and colleagues.
The team identified 700 patients aged 15 to 25 years who were enrolled in the Early Assessment Service for Young People with Psychosis (EASY) program between 2001 and 2003.
Data on each patient were retrieved from clinical records, and the Clinical Global Impressions–Severity Scale was used to determine symptom severity. Information on medication compliance was derived from sources including case management notes, medical records and information from caregivers.
Disengagement was defined as missing all outpatient appointments until the end of the 2-year service despite therapeutic need and active follow-up from staff, and occurred in 94 patients.
The mean age of participants was 20.65 years and the median duration of untreated psychosis was 91 days. Most (69.14%) patients had a diagnosis of a schizophrenia spectrum disorder (ie, schizophrenia or schizoaffective disorder).
Multivariate analysis identified three factors that were independently associated with disengagement. Patients were 56% less likely to disengage if they had schizophrenia-spectrum disorders, rather than other types of psychosis. They were 63% less likely to disengage if they were adherent to their medication, and they were 24% less like to disengage if they had high baseline negative symptom scores (>3).
Substance abuse history within the initial 6 months of the program increased the chances of disengagement, but, due to the small number of patients affected, was not included in the final multivariate analysis.
The team also found that 63% of disengaged patients were in symptomatic remission during the month in which they left the EASY program.
“Early intervention teams should pay attention to factors associated with disengagement, and monitor at risk patients closely to detect signs of non-adherence,” Chang and colleagues conclude in Schizophrenia Research.



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Filed under psy psychosis psychology psychiatry med meds drug drugs research science neuro neuroscience schizo schizophrenia schizophrenic mad madness crazy mind brain body patient therapy psycho psychotherapy bipolar depressed depression manic delusion

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Study: Switching Schools May Give Your Kids Psychotic SymptomsBy Alice Park
Chronic marginalization and chronic exclusion could cause hallucinations and delusions
Changing schools can be a wrenching social and emotional experience for students, say researchers from Warwick Medical School in the U.K. And the legacy of that struggle may be psychosis-like symptoms of hallucinations and delusions.
Dr. Swaran Singh, a psychiatrist and head of the mental health division at Warwick, became curious about the connection between school moves and mental health issues after a study from Denmark found that children moving from rural to urban settings showed increased signs of psychoses. The authors also noted that the students had to deal with not just a change in their home environment, but in their social network of friends at school as well.
Singh was intrigued by whether school changes, and the social isolation that comes with it, might be an independent factor in contributing to the psychosis-like symptoms.
Based on their analysis, says Singh, switching schools three or more times in early childhood seemed to be linked to an up to two-fold greater risk of developing psychosis-like symptoms such as hallucinations and interrupting thoughts. “Even when we controlled for all things that school moves lead to, there was something left behind that that was independently affecting children’s mental health,” he says.
Factors such as a difficult home environment – whether caused by financial or social tension, or both – living in an urban environment, and bullying contributed to the mental health issues, but switching schools contributed independently to the psychosis-like symptoms.
Singh suspects that repeatedly being an outsider by having to re-integrate into new schools may lead to feelings of exclusion and low self-esteem. That may change a developing child’s sense of self and prime him to always feel like an outlier and never an integrated part of a social network; such repeated experiences of exclusion are known to contribute to paranoia and psychotic symptoms.
Bullying created a secondary way in which repeated school moves could lead to mental health issues — bullying is known to be associated with psychotic symptoms, and mobile students are more vulnerable to bullying,
The negative emotional experiences students go through in trying to adjust to new schools can have physiological consequences as well. “Repeated experiences of being defeated in social situations leads to changes in the brain and in the dopaminergic system,” says Singh. That makes the brain more sensitive to stress, and stress, with its surges of cortisol, can lead to unhealthy neural responses that can contribute to mental health problems. “Something about chronic marginalization, and chronic exclusion, is neurophysiologically damaging,” he says.
Singh and his team plan to continue to follow the students for several more years, to determine how frequently the psychosis-like symptoms manifest into true psychotic disorders like schizophrenia. So far, the findings don’t suggest that kids who move schools three or more times are priming themselves for future mental health problems – what the data suggest instead is that children who are more mobile early in development may need more attention and help to settle into their new environments and make strong social connections. “If we start thinking of mobile students as a potentially vulnerable group, then we can shift how we view school moves,” he says. Psychiatrists and psychologists, for example, often ask young children about their family and friends, but rarely inquire about how often they have moved schools. In his continuing investigation, Singh also hopes to dissect the reasons why students moved, to see if that can be another factor explaining the intriguing connection – if children move frequently because they are bullying others or being bullied, for example, that may suggest that the association to psychosis-like symptoms may have more to do with the students’ pre-existing behavioral state than the experience of uprooting themselves so frequently.



For more mental health news, Click Here to access the Serious Mental Illness Blog

Study: Switching Schools May Give Your Kids Psychotic Symptoms
By Alice Park

Chronic marginalization and chronic exclusion could cause hallucinations and delusions

Changing schools can be a wrenching social and emotional experience for students, say researchers from Warwick Medical School in the U.K. And the legacy of that struggle may be psychosis-like symptoms of hallucinations and delusions.

Dr. Swaran Singh, a psychiatrist and head of the mental health division at Warwick, became curious about the connection between school moves and mental health issues after a study from Denmark found that children moving from rural to urban settings showed increased signs of psychoses. The authors also noted that the students had to deal with not just a change in their home environment, but in their social network of friends at school as well.

Singh was intrigued by whether school changes, and the social isolation that comes with it, might be an independent factor in contributing to the psychosis-like symptoms.

Based on their analysis, says Singh, switching schools three or more times in early childhood seemed to be linked to an up to two-fold greater risk of developing psychosis-like symptoms such as hallucinations and interrupting thoughts. “Even when we controlled for all things that school moves lead to, there was something left behind that that was independently affecting children’s mental health,” he says.

Factors such as a difficult home environment – whether caused by financial or social tension, or both – living in an urban environment, and bullying contributed to the mental health issues, but switching schools contributed independently to the psychosis-like symptoms.

Singh suspects that repeatedly being an outsider by having to re-integrate into new schools may lead to feelings of exclusion and low self-esteem. That may change a developing child’s sense of self and prime him to always feel like an outlier and never an integrated part of a social network; such repeated experiences of exclusion are known to contribute to paranoia and psychotic symptoms.

Bullying created a secondary way in which repeated school moves could lead to mental health issues — bullying is known to be associated with psychotic symptoms, and mobile students are more vulnerable to bullying,

The negative emotional experiences students go through in trying to adjust to new schools can have physiological consequences as well. “Repeated experiences of being defeated in social situations leads to changes in the brain and in the dopaminergic system,” says Singh. That makes the brain more sensitive to stress, and stress, with its surges of cortisol, can lead to unhealthy neural responses that can contribute to mental health problems. “Something about chronic marginalization, and chronic exclusion, is neurophysiologically damaging,” he says.

Singh and his team plan to continue to follow the students for several more years, to determine how frequently the psychosis-like symptoms manifest into true psychotic disorders like schizophrenia. So far, the findings don’t suggest that kids who move schools three or more times are priming themselves for future mental health problems – what the data suggest instead is that children who are more mobile early in development may need more attention and help to settle into their new environments and make strong social connections. “If we start thinking of mobile students as a potentially vulnerable group, then we can shift how we view school moves,” he says. Psychiatrists and psychologists, for example, often ask young children about their family and friends, but rarely inquire about how often they have moved schools. In his continuing investigation, Singh also hopes to dissect the reasons why students moved, to see if that can be another factor explaining the intriguing connection – if children move frequently because they are bullying others or being bullied, for example, that may suggest that the association to psychosis-like symptoms may have more to do with the students’ pre-existing behavioral state than the experience of uprooting themselves so frequently.





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Filed under smi serious mental illness serious mental illness mental illness mental health health study research neuroscience neuro psych psy psychology psychological psychologist school student kid kids child children chronic marginalized margin exlusion exclude trauma reject

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A first step in addressing the mental health aspect of mass shootingsBy Rep. Ron Barber (D-Ariz.)Barber has represented Arizona’s 2nd Congressional District since 2012. He sits on the Armed Services; the Homeland Security; and the Small Business committees. Follow him on Facebook or Twitter at RepRonBarber or contact him through his website at barber.house.gov.When the omnibus spending bill was signed into law by the president, most of the attention was – quite understandably – on the big-ticket items: defense, border security, health care and the like.But included in that budget was a $15 million gem that is an important positive step for those of us working to reduce the incidence of gun-related violence.The legislation included $15 million for Mental Health First Aid training – a program I have been calling for since I took office more than 1½ years ago.Let me explain why this funding is so important:In the wake of the mass shootings in Tucson, in Newtown and elsewhere, I and many of my colleagues in Congress – both Republicans and Democrats – understood that we must work together to prevent such tragedies.While there is no single answer to preventing mass shootings, we know that untreated or undiagnosed serious mental illness has been a factor in a number of the recent tragedies.It was a factor in the January 2011 shooting in Tucson.The young man who killed six people and wounded 13 of us in Tucson had displayed symptoms of serious mental illness for at least two years prior to the shooting. And yet he never received a mental illness diagnosis or treatment – until he was sent to prison.People who knew the shooter did not understand what he was going through or how to get him help. So we are left to ask, “Could this tragedy have been prevented if he and others had been provided mental health services?” I believe several of the recent mass shootings could have been averted if the public was more aware of the indications of mental illness and how to get help.We must do more to reduce the stigma surrounding mental illness. And we must invest in the early identification of mental illness and in treatment programs.Nationally, 60 percent of people living with a mental illness are not receiving the services that they need. We must do better. Mental illness, like so many other illnesses, can be recognized and will respond to treatment.It is important to note that more than 95 percent of individuals living with a mental illness are not violent. They are far more likely to be the victims of violence than the perpetrators.It is clear, however, that we must expand mental health awareness of and treatment services for 100 percent of individuals living with mental illness. That is why I worked with Republicans and Democrats last year to introduce the Mental Health First Aid Act.This legislation will provide training to first responders, educators, students, parents and the general public on how to identify and respond to signs of mental illness.The $15 million in the budget bill begins nationwide implementation of this crucial program.As mental illness impacts the lives of millions of Americans and their families and too many mental health disorders continue to go unaddressed and untreated, we must make prudent investments to support mental health awareness in our communities.We should have acted after six people were killed in Tucson two years ago. We should have acted after seven people were killed in Oakland. Or 12 people killed in Aurora. Or six people killed in Oak Creek. Or 26 children and adults killed in Newtown. Or 12 people killed at the Washington Navy Yard.We had so many opportunities to act.Now we have begun to act by funding Mental Health First Aid training. When the president signed the bill, an important first step was taken.This single act won’t solve everything. But if it prevents just one death, it will be money very well spent.


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A first step in addressing the mental health aspect of mass shootings
By Rep. Ron Barber (D-Ariz.)

Barber has represented Arizona’s 2nd Congressional District since 2012. He sits on the Armed Services; the Homeland Security; and the Small Business committees. Follow him on Facebook or Twitter at RepRonBarber or contact him through his website at barber.house.gov.

When the omnibus spending bill was signed into law by the president, most of the attention was – quite understandably – on the big-ticket items: defense, border security, health care and the like.
But included in that budget was a $15 million gem that is an important positive step for those of us working to reduce the incidence of gun-related violence.
The legislation included $15 million for Mental Health First Aid training – a program I have been calling for since I took office more than 1½ years ago.
Let me explain why this funding is so important:
In the wake of the mass shootings in Tucson, in Newtown and elsewhere, I and many of my colleagues in Congress – both Republicans and Democrats – understood that we must work together to prevent such tragedies.
While there is no single answer to preventing mass shootings, we know that untreated or undiagnosed serious mental illness has been a factor in a number of the recent tragedies.
It was a factor in the January 2011 shooting in Tucson.
The young man who killed six people and wounded 13 of us in Tucson had displayed symptoms of serious mental illness for at least two years prior to the shooting. And yet he never received a mental illness diagnosis or treatment – until he was sent to prison.
People who knew the shooter did not understand what he was going through or how to get him help. So we are left to ask, “Could this tragedy have been prevented if he and others had been provided mental health services?” I believe several of the recent mass shootings could have been averted if the public was more aware of the indications of mental illness and how to get help.
We must do more to reduce the stigma surrounding mental illness. And we must invest in the early identification of mental illness and in treatment programs.
Nationally, 60 percent of people living with a mental illness are not receiving the services that they need. We must do better. Mental illness, like so many other illnesses, can be recognized and will respond to treatment.
It is important to note that more than 95 percent of individuals living with a mental illness are not violent. They are far more likely to be the victims of violence than the perpetrators.
It is clear, however, that we must expand mental health awareness of and treatment services for 100 percent of individuals living with mental illness. That is why I worked with Republicans and Democrats last year to introduce the Mental Health First Aid Act.
This legislation will provide training to first responders, educators, students, parents and the general public on how to identify and respond to signs of mental illness.
The $15 million in the budget bill begins nationwide implementation of this crucial program.
As mental illness impacts the lives of millions of Americans and their families and too many mental health disorders continue to go unaddressed and untreated, we must make prudent investments to support mental health awareness in our communities.
We should have acted after six people were killed in Tucson two years ago. We should have acted after seven people were killed in Oakland. Or 12 people killed in Aurora. Or six people killed in Oak Creek. Or 26 children and adults killed in Newtown. Or 12 people killed at the Washington Navy Yard.
We had so many opportunities to act.
Now we have begun to act by funding Mental Health First Aid training. When the president signed the bill, an important first step was taken.
This single act won’t solve everything. But if it prevents just one death, it will be money very well spent.



For more mental health news, Click Here to access the Serious Mental Illness Blog

Filed under serious mental illness serious mental illness mental health mental illness health mind brain body biology bio neuroscience neuro psychology psychological psychologist psychiatry psych psychiatrist psy shoot shooter gun guns murder mass shooting mass shooting united states

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A psychiatrist thinks some patients are better off without antipsychotic drugsBy Matt McClainWhat does it mean that the man who killed 12 people at the Washington Naval Yard had told people that he was “hearing voices”?I have spent 30 years as a psychiatrist treating people who are psychotic. Almost every day I meet with individuals who hear voices that no one else hears, are sure the TV or radio is talking to them or have such confused thinking that it is hard to understand what they are trying to tell me.Sometimes these patients lead quiet lives. But not uncommonly these voices get them into trouble. I’ve had patients who call the police repeatedly, demanding that they stop bugging their phone. And others who stay up all night talking back at the voices. Some accuse family members of being involved in the torment.In many cases, this is a frightening experience — for the people I see and those who love them. And the labels we use — “schizophrenia,” “bipolar disorder,” “psychosis” — only crudely capture these experiences.About 60 years ago, a group of drugs was discovered that appeared to quiet the voices, improve the clarity of thought and lessen the preoccupation with delusion beliefs. Originally called major tranquilizers and later renamed antipsychotic drugs, these have been considered essential for the treatment of people with schizophrenia.Once it was clear that these drugs were helpful in the short term, questions arose over how long people should remain on them. Studies done in the 1970s and 1980s looked at people who were stabilized after being treated with antipsychotic drugs for several months and then followed them for up to two years. Some continued on the drugs, while others stopped taking them. The relapse rate was much higher in the group that stopped the medications. Based on these studies, treatment guidelines now state that people should stay on anti-psychotics indefinitely.The problem with “indefinitely” is that antipsychotic drugs have many troubling side effects. They can cause muscle stiffness, tremor and something called tardive dyskinesia, where muscles in the face or limbs move uncontrollably. But the belief — my belief — was that this was the unfortunate price paid to help people who were suffering.Many people do not want to take these drugs because of the side effects or because they do not think of themselves as ill. After all, if the government is using telemetry to transmit messages into your brain, the solution is to turn off the source of the transmission, not to take a pill. I considered myself a successful psychiatrist when I was able to use my powers of persuasion to convince a reluctant patient to stay on the drugs.Yet, over the past 15 years, my attitude has shifted. I have become deeply disturbed by the marketing practices that many pharmaceutical companies began to use in the 1990s to push their new medications.Like many of my colleagues, I awaited the new drugs with enthusiasm, hoping that they would have fewer terrible side effects. Leading psychiatrists who had worked on the development of the drugs also said that they not only were less likely to cause neurological problems but also were more effective.Quickly, though, I started to think that their benefits were being inflated and their side effects minimized. With one drug in particular, it was clear after a year that my patients were gaining weight at alarming rates: 20, 30, even 100 pounds in a matter of months, a real threat to their health.Researchers test such new drugs on people for years before they reached the market, but little attention was focused on this issue and only then in the context of a product war — i.e., whether one drug caused more weight gain than others. Only a decade after they were released to the market was it widely acknowledged that severe weight gain was common with many of the newer anti-psychotics, increasing the risk of diabetes. Given that people may take these drugs for decades, the health consequences are serious.Yet until 21 / 2 years ago, I still thought that prescribing antipsychotic drugs was necessary. After all, a good number of my patients ended up in the hospital or, worse, the police station, when they stopped taking their medications. I did not think I had any other option than to continue to employ my now well-honed powers of persuasion to convince them to stay on their drugs.And then I read Robert Whitaker’s “Anatomy of an Epidemic,” in which he wondered why, if these new drugs were so great, we were seeing increasing numbers of people on disability for psychiatric conditions. He looked at the studies of long-term outcomes, and what he found surprised me and many of my colleagues: Although it is very hard to do a definitive study that follows people for many years, the research suggested that, over time, the people who remain on these drugs do worse than those who stop using them.Those who remained on the drug were less likely to return to work or develop meaningful relationships. Of equal concern, it appeared that brain shrinkage — thought initially to be due to the illness itself — was in fact caused by the drugs. Even when monkeys took these drugs for a period of months, their brains shrank.If Whitaker was right, everything I had been doing for 20 years was wrong. Many psychiatrists have accused him of cherry-picking the data or distorting the findings of the studies. I have spent much of my time rereading the articles and studies he cites, looking for others, talking to colleagues and reading as much criticism of his work as I can find.And what I concluded is that Whitaker is probably right.The dilemmaThis created a dilemma for me: If the drugs that are helpful in the short run may be harmful over time, what do I do for the person who is unable to have a conversation because the voices in his head are so loud?If the medications stop the voices, do I suggest he come off the drugs and risk relapse? Or do I suggest he stay on them and reduce his chances for a full recovery? If I suggest that he stop the drugs and then something bad happens, I may be blamed for his relapse, while I am unlikely to be blamed 30 years from now when he has diabetes.Doctors are held to a standard of “accepted community practice.” What if my own research has led me to a conclusion that is at odds with accepted community practice? What if accepted community practice is so distorted by pharmaceutical advertising in favor of these drugs that it is suspect and unreliable?Two years ago, I decided to invite my patients into this conversation. I explain to them what I have read and what conclusions I have drawn, as well as the conflicting views of other psychiatrists.I have been monitoring those who have chosen to wean themselves from the antipsychotic drugs they have been taking, in some cases for 20 years or more. What has been most striking is that my patients make careful and deliberate decisions. Many psychiatrists fear that having this conversation will lead to massive dropping of the drugs, but this has not been my experience. Some do — most often, the ones who have stopped them multiple times in the past — but most are cautious. Of the 64 people I have tracked, 40 decided to try a dose reduction, 22 chose to remain in their current dose and only four abruptly stopped taking their medications.Some might think my approach cavalier. When we read about Aaron Alexis, who heard voices and shot 12 people before being killed at the Washington Navy Yard, it raises our fears. However, it is important to keep in mind that the problems I describe are common and that the vast majority of people who experience psychosis are not likely to be violent toward others. One study found an increased risk of violence only among those with mental illness who also abuse drugs or are young men. Such risk factors and an individual’s history would, of course, be a part of any decision about whether to wean someone off medication.In this context, a blog post by Thomas Insel, the director of the National Institute of Mental Health, received much attention this year. Insel described a Dutch study involving 103 people treated for schizophrenia and related disorders. The participants were randomly assigned to one of two groups: Half remained on drugs continuously; the others stopped taking drugs when they became well but restarted them if symptoms emerged. After seven years, the researchers found that those who were not continuously on drugs had a much greater likelihood of getting a job and resuming their regular life activities than those who remained on medications. Remember that people who stop drugs have a higher rate of relapse? It turns out that over the seven years, those who remained on the drugs relapsed as often as the others.“For some people, remaining on medication long-term might impede a full return to wellness,” Insel wrote. “For others, discontinuing medication can be disastrous.”The problem is that we do not know who is in which group.A slow reductionA man I have known for many years has had some serious bouts with psychosis. He has been hospitalized multiple times, and his thoughts have put him — though not others — at personal risk. However, the medications have also put him at risk. He is now overweight and has diabetes and his kidneys are not working well. He spends a good part of his day sleeping and the rest watching TV.We have tried in the past to reduce his dose, but these efforts have never gone well. Within days he would be hallucinating and delusional. However, recently we found that with a very slight reduction in dose, he would relapse for about a month but then improve. Perhaps it was his age or greater experience, but he was able to get through the bad days without getting into trouble, and once things quieted down in his mind he felt better. We have agreed to slowly proceed.His family supports his choice. We all understand the risk of dose reduction, but we see it in the context of all of the risks. Maintaining his current dose is not without consequence. I have known him for a long time, but the problems of schizophrenia tend to start early and he is still a young man. Even if it takes five years to get him on a significantly lower dose, we have the opportunity to improve the long-term quality of his life.The Dutch study shifted the focus away from the belief that we need to eradicate all symptoms of schizophrenia to a focus on improving the quality of patients’ lives and health, the relationships they have, the work they do. Some people can learn to live with voices. Some people find that the voices have a significant meaning for them and that communicating with them is what is most important. Some people can learn to talk themselves down from delusional thoughts. And some people might choose hearing voices over being 30 pounds overweight and tired all of the time. The point is that this is not a choice I should be making for my patients; it is a choice I need to make with them.


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A psychiatrist thinks some patients are better off without antipsychotic drugs
By Matt McClain

What does it mean that the man who killed 12 people at the Washington Naval Yard had told people that he was “hearing voices”?
I have spent 30 years as a psychiatrist treating people who are psychotic. Almost every day I meet with individuals who hear voices that no one else hears, are sure the TV or radio is talking to them or have such confused thinking that it is hard to understand what they are trying to tell me.
Sometimes these patients lead quiet lives. But not uncommonly these voices get them into trouble. I’ve had patients who call the police repeatedly, demanding that they stop bugging their phone. And others who stay up all night talking back at the voices. Some accuse family members of being involved in the torment.
In many cases, this is a frightening experience — for the people I see and those who love them. And the labels we use — “schizophrenia,” “bipolar disorder,” “psychosis” — only crudely capture these experiences.
About 60 years ago, a group of drugs was discovered that appeared to quiet the voices, improve the clarity of thought and lessen the preoccupation with delusion beliefs. Originally called major tranquilizers and later renamed antipsychotic drugs, these have been considered essential for the treatment of people with schizophrenia.
Once it was clear that these drugs were helpful in the short term, questions arose over how long people should remain on them. Studies done in the 1970s and 1980s looked at people who were stabilized after being treated with antipsychotic drugs for several months and then followed them for up to two years. Some continued on the drugs, while others stopped taking them. The relapse rate was much higher in the group that stopped the medications. Based on these studies, treatment guidelines now state that people should stay on anti-psychotics indefinitely.
The problem with “indefinitely” is that antipsychotic drugs have many troubling side effects. They can cause muscle stiffness, tremor and something called tardive dyskinesia, where muscles in the face or limbs move uncontrollably. But the belief — my belief — was that this was the unfortunate price paid to help people who were suffering.
Many people do not want to take these drugs because of the side effects or because they do not think of themselves as ill. After all, if the government is using telemetry to transmit messages into your brain, the solution is to turn off the source of the transmission, not to take a pill. I considered myself a successful psychiatrist when I was able to use my powers of persuasion to convince a reluctant patient to stay on the drugs.
Yet, over the past 15 years, my attitude has shifted. I have become deeply disturbed by the marketing practices that many pharmaceutical companies began to use in the 1990s to push their new medications.
Like many of my colleagues, I awaited the new drugs with enthusiasm, hoping that they would have fewer terrible side effects. Leading psychiatrists who had worked on the development of the drugs also said that they not only were less likely to cause neurological problems but also were more effective.
Quickly, though, I started to think that their benefits were being inflated and their side effects minimized. With one drug in particular, it was clear after a year that my patients were gaining weight at alarming rates: 20, 30, even 100 pounds in a matter of months, a real threat to their health.
Researchers test such new drugs on people for years before they reached the market, but little attention was focused on this issue and only then in the context of a product war — i.e., whether one drug caused more weight gain than others. Only a decade after they were released to the market was it widely acknowledged that severe weight gain was common with many of the newer anti-psychotics, increasing the risk of diabetes. Given that people may take these drugs for decades, the health consequences are serious.
Yet until 21 / 2 years ago, I still thought that prescribing antipsychotic drugs was necessary. After all, a good number of my patients ended up in the hospital or, worse, the police station, when they stopped taking their medications. I did not think I had any other option than to continue to employ my now well-honed powers of persuasion to convince them to stay on their drugs.
And then I read Robert Whitaker’s “Anatomy of an Epidemic,” in which he wondered why, if these new drugs were so great, we were seeing increasing numbers of people on disability for psychiatric conditions. He looked at the studies of long-term outcomes, and what he found surprised me and many of my colleagues: Although it is very hard to do a definitive study that follows people for many years, the research suggested that, over time, the people who remain on these drugs do worse than those who stop using them.
Those who remained on the drug were less likely to return to work or develop meaningful relationships. Of equal concern, it appeared that brain shrinkage — thought initially to be due to the illness itself — was in fact caused by the drugs. Even when monkeys took these drugs for a period of months, their brains shrank.
If Whitaker was right, everything I had been doing for 20 years was wrong. Many psychiatrists have accused him of cherry-picking the data or distorting the findings of the studies. I have spent much of my time rereading the articles and studies he cites, looking for others, talking to colleagues and reading as much criticism of his work as I can find.
And what I concluded is that Whitaker is probably right.

The dilemma
This created a dilemma for me: If the drugs that are helpful in the short run may be harmful over time, what do I do for the person who is unable to have a conversation because the voices in his head are so loud?
If the medications stop the voices, do I suggest he come off the drugs and risk relapse? Or do I suggest he stay on them and reduce his chances for a full recovery? If I suggest that he stop the drugs and then something bad happens, I may be blamed for his relapse, while I am unlikely to be blamed 30 years from now when he has diabetes.
Doctors are held to a standard of “accepted community practice.” What if my own research has led me to a conclusion that is at odds with accepted community practice? What if accepted community practice is so distorted by pharmaceutical advertising in favor of these drugs that it is suspect and unreliable?
Two years ago, I decided to invite my patients into this conversation. I explain to them what I have read and what conclusions I have drawn, as well as the conflicting views of other psychiatrists.
I have been monitoring those who have chosen to wean themselves from the antipsychotic drugs they have been taking, in some cases for 20 years or more. What has been most striking is that my patients make careful and deliberate decisions. Many psychiatrists fear that having this conversation will lead to massive dropping of the drugs, but this has not been my experience. Some do — most often, the ones who have stopped them multiple times in the past — but most are cautious. Of the 64 people I have tracked, 40 decided to try a dose reduction, 22 chose to remain in their current dose and only four abruptly stopped taking their medications.
Some might think my approach cavalier. When we read about Aaron Alexis, who heard voices and shot 12 people before being killed at the Washington Navy Yard, it raises our fears. However, it is important to keep in mind that the problems I describe are common and that the vast majority of people who experience psychosis are not likely to be violent toward others. One study found an increased risk of violence only among those with mental illness who also abuse drugs or are young men. Such risk factors and an individual’s history would, of course, be a part of any decision about whether to wean someone off medication.
In this context, a blog post by Thomas Insel, the director of the National Institute of Mental Health, received much attention this year. Insel described a Dutch study involving 103 people treated for schizophrenia and related disorders. The participants were randomly assigned to one of two groups: Half remained on drugs continuously; the others stopped taking drugs when they became well but restarted them if symptoms emerged. After seven years, the researchers found that those who were not continuously on drugs had a much greater likelihood of getting a job and resuming their regular life activities than those who remained on medications. Remember that people who stop drugs have a higher rate of relapse? It turns out that over the seven years, those who remained on the drugs relapsed as often as the others.
“For some people, remaining on medication long-term might impede a full return to wellness,” Insel wrote. “For others, discontinuing medication can be disastrous.”
The problem is that we do not know who is in which group.

A slow reduction
A man I have known for many years has had some serious bouts with psychosis. He has been hospitalized multiple times, and his thoughts have put him — though not others — at personal risk. However, the medications have also put him at risk. He is now overweight and has diabetes and his kidneys are not working well. He spends a good part of his day sleeping and the rest watching TV.
We have tried in the past to reduce his dose, but these efforts have never gone well. Within days he would be hallucinating and delusional. However, recently we found that with a very slight reduction in dose, he would relapse for about a month but then improve. Perhaps it was his age or greater experience, but he was able to get through the bad days without getting into trouble, and once things quieted down in his mind he felt better. We have agreed to slowly proceed.
His family supports his choice. We all understand the risk of dose reduction, but we see it in the context of all of the risks. Maintaining his current dose is not without consequence. I have known him for a long time, but the problems of schizophrenia tend to start early and he is still a young man. Even if it takes five years to get him on a significantly lower dose, we have the opportunity to improve the long-term quality of his life.
The Dutch study shifted the focus away from the belief that we need to eradicate all symptoms of schizophrenia to a focus on improving the quality of patients’ lives and health, the relationships they have, the work they do. Some people can learn to live with voices. Some people find that the voices have a significant meaning for them and that communicating with them is what is most important. Some people can learn to talk themselves down from delusional thoughts. And some people might choose hearing voices over being 30 pounds overweight and tired all of the time. The point is that this is not a choice I should be making for my patients; it is a choice I need to make with them.



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