[NYAPRS Enews] E News Counterpoint: Other Countries Get Better MH Outcomes By Not Relying on Medical Approach

[Harvey Rosenthal]

NYAPRS Note: The following was sent to us courtesy of E News reader
Eileen McGinn MPH of New York City in response to yesterday's posted
Associated Press Report entitled "Poorer Nations Asked to Aid Those with
Psychiatric Disabilities." 

 

The article indicated that "War, poverty and diseases such as AIDS are
adding to mental health problems in poorer countries, which are
generally ill-equipped to respond to depression, schizophrenia and other
such ailments, according to health officials. .....On Tuesday, health
officials called for new strategies and more money to treat the mentally
ill in the developing world in a special issue of the British medical
journal, The Lancet. Unless mental health treatment becomes widely
available, the futures of poor countries will be handicapped, the
writers argue."

 

Eileen responded with the following note: "There have been several
studies that show that people in developing countries with schizophrenia
do much better than those in Western countries in terms of outcomes.
Instead of sending them drugs and getting them stigmatized and
marginalized, maybe we should learn from the poor countries how to help
people in the community. At the end of Whitaker's work (see below), he
wonders about the atypical antipsychotic drugs.  We now know from CATIE
that they are not better in terms of outcomes than the older drugs and
cause metabolic syndrome."

 

Eileen excepts the following response by noted author of 'Mad in
America' and previous NYAPRS Conference keynoter Robert Whitaker, as
noted below. 

 

On such topics, NYAPRS' overriding value is one of informed choice of a
broad range of treatments. The decision to take or forego psychiatric
medications is a highly personal decision that should be made in an
environment of completely balanced up to date and accurate information
and self directed care.

--------------

Question:

Why is the success rate that people recover from schizophrenia higher in
cultures that don't use psychotropic medications to treat it?

D.J.  Crossville, Tennessee

 

Answered by Robert Whitaker:

 

"This is the question that got me interested in this subject nearly four
years ago. 

 

In the 1970s, the World Health Organization conducted its first study
comparing outcomes for schizophrenia patients in "developing" countries
with those in the U.S. and other "developed" countries. The study
followed patients for five years, and it found that 64% of the patients
in the poor countries had outcomes that could be categorized as good at
the end of this period, versus 18% in the rich countries. The difference
in outcomes was so dramatic that the WHO concluded that living in a
developed nation was a "strong predictor" that a schizophrenic patient
would never fully recover. 

 

In response to these poor results, some Western psychiatrists argued
that the difference wasn't real, and that many people in the poor
countries must have been suffering from milder forms of psychotic
disorders. So in the 1980s the WHO conducted a second comparative study,
paying close attention to this diagnostic question, and came back with
the same answer. In this 2-year study, 63% of patients in the poor
countries were in the good-outcomes category, versus 37% in the
developed countries. Now the WHO didn't come up with a reason for this
difference. However, in the second study, it did note that there was a
noticeable difference in medication use. In the developing countries,
only 16% of patients were routinely kept on antipsychotic mediations,
versus 61% of patients in the developing countries.

 

This raises an obvious question: Was the variation in drug use the
reason for the difference in outcomes? I know that it seems like medical
heresy, and against all accepted wisdom, to even think that this might
be so, but I thought that at least I could look at what our own research
showed regarding the use of neuroleptics and long-term outcomes. 

 

Here are some of the main findings in our own research literature that
provide, I believe, rather compelling evidence for why poor outcomes
would be associated with constant use of neuroleptics. (I should note
here that the research below is related to standard neuroleptics
--Thorazine, Haldol -- and not to the newer atypicals like risperidone
and olanzapine.)

*       Standard neuroleptics work by profoundly blocking dopamine
activity in the brain. At a therapeutic dose, they block 70% to 90% of
all D2 receptors (this is a particular type of receptor for dopamine).
So rather than balance dopamine activity in the brain, standard
neuroleptics actually produce a notable deficiency in dopamine
transmission. Indeed, it is a deficiency somewhat similar in kind to
what occurs in Parkinson's patients, which is why standard neuroleptics
so often cause Parkinsonian symptoms. This blockage of dopamine activity
is also why many patients on standard neuroleptics complain of feeling
empty inside -- dopamine is involved in mounting emotional responses to
the world. 

*       In 1959, researchers reported that the drugs could cause tardive
dyskinesia (TD), a form of often irreversible motor dysfunction. Later,
researchers determined that this affected 5% of patients per year, and
that the effect was cumulative (10% of patients kept on drugs two years,
15% at end of three years, and so forth.). More than 20 studies have
also now found that tardive dyskinesia doesn't simply impair motor
movement, but that TD patients are also cognitively impaired on a
variety of measures, which include memory, intellectual functions, etc.
Some researchers have compared TD to Huntington's disease, or
"postencephalitic brain damage."

*       In 1963, the NIMH reported that neuroleptics were better than
placebo over a six-week period in reducing psychosis, a study that is
still cited today as showing the drugs' efficacy. However, the NIMH then
did a one-year followup study of the patients in that first 6-week
trial, and they found, much to their surprise, that the drug-treated
patients were more likely to have been rehospitalized than those treated
with placebo. This suggested that while the drugs produced a short term
benefit, over the long-term they actually made people more biologically
vulnerable to psychosis. (This long-term study is almost never cited,
and was quickly forgotten.)

*       In 1971, the NIMH reported that in a drug-withdrawal study,
relapse rates rose in direct correlation to drug dosage, such that the
higher the dosage before withdrawal, the greater the relapse rate. This
furthered the sense that the drugs were causing some sort of biological
change that made people more biologically prone to psychosis. Around
this time researchers also reported that it appeared that relapse in
drug-treated patients was more severe than relapse in placebo-treated
patients. 

*       These disturbing results led the NIMH to fund at least three
studies in the 1970s that compared treatment with psychosocial care and
minimal or no use of neuroleptics with conventional care. Each time
relapse rates were lower for the experimental group over follow-up
periods ranging from one to three years. The favorable outcomes in these
studies led some researchers to conclude that there was, at the very
least, a subgroup of schizophrenia patients -- 40% or more of all people
so diagnosed -- who could do well without the drugs. 

*       In 1979, Canadian investigators put forth an explanation of why
the drugs could make people more biologically vulnerable to psychosis.
In response to the blocking of dopamine activity, the brain tries to
compensate by increasing the number of its dopamine receptors, thus
becoming "supersensitive" to this neurotransmitter. Once a person's
brain undergoes this change, then he or she is at very high risk of
relapse should the drug be abruptly withdrawn. As the Canadian
investigators concluded: "Some patients who seem to require lifelong
neuroleptics may actually do so because of this therapy." This finding
has particular relevance for the sub-group of patients, 40% or more, who
had done well in the trials in which they were treated with psychosocial
care. They may not have naturally needed neuroleptics, but once they
were exposed to the drugs, they would likely find it difficult to get
off them, and thus would be pushed along a path that involved lifelong
medication, with all its associated problems.

*       In the past decade, there have been several MRI studies that
have documented structural changes in the brain associated with
neuroleptic use. These drug-induced changes include atrophy (or
shrinkage) of the cerebral lobes, and an abnormal enlargement of the
basal ganglia area of the brain. 

 

That is the bare outline of the research record involving standard
neuroleptics, and it is, I believe, a research record that provides
rather convincing evidence of why our Western paradigm of care -- that
patients diagnosed with schizophrenia as a matter of course need to take
antipsychotic medications indefinitely -- produced the poor outcomes
found by the WHO. It's important to reiterate, however, that this is a
research record related to standard neuroleptics. One hopes, of course,
that long-term outcomes with the newer atypicals will prove much
superior, but that research record is still in its early stage."   

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