At last, a promising alternative to antipsychotics for schizophrenia

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antipsychotic drugs, causes, cognitive treatment, delusion, dropout rates, hallucinations, medication, psychosis, schizophrenia, side-effects, treatment

At last, a promising alternative to antipsychotics for schizophrenia

Imagine that, after feeling unwell for a while, you visit your GP. “Ah,” says the doctor decisively, “what you need is medication X. It’s often pretty effective, though there can be side-effects. You may gain weight. Or feel drowsy. And you may develop tremors reminiscent of Parkinson’s disease.” Warily, you glance at the prescription on the doctor’s desk, but she hasn’t finished. “Some patients find that sex becomes a problem. Diabetes and heart problems are a risk. And in the long term the drug may actually shrink your brain … ”

This scenario may sound far-fetched, but it is precisely what faces people diagnosed with schizophrenia. Since the 1950s, the illness has generally been treated using antipsychotic drugs – which, as with so many medications, were discovered by chance. A French surgeon investigating treatments for surgical shock found that one of the drugs he tried – the antihistamine chlorpromazine – produced powerful psychological effects. This prompted the psychiatrist Pierre Deniker to give the drug to some of his most troubled patients. Their symptoms improved dramatically, and a major breakthrough in the treatment of psychosis seemed to have arrived.

Many other antipsychotic drugs have followed in chlorpromazine’s wake and today these medications comprise 10% of total NHS psychiatric prescriptions. They are costly items: the NHS spends more on these medications than it does for any other psychiatric drug, including antidepressants. Globally, around $14.5bn is estimated to be spent on antipsychotics each year.

Since the 1950s the strategy of all too many NHS mental health teams has been a simple one. Assuming that psychosis is primarily a biological brain problem, clinicians prescribe an antipsychotic medication and everyone does their level best to get the patient to take it, often for long periods. There can be little doubt that these drugs make a positive difference, reducing delusions and hallucinations and making relapse less likely – provided, that is, the patient takes their medication.

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Unfortunately, dropout rates are high. This is partly because individuals sometimes don’t accept that they are ill. But a major reason is the side-effects. These vary from drug to drug, but they’re common and for many people are worse than the symptoms they are designed to treat.

In addition, antipsychotics don’t work for everyone. It is estimated that six months after first being prescribed them, as many as 50% of patients are either taking the drugs haphazardly or not at all.

The conventional treatment for this most severe of psychiatric illnesses, then, is expensive, frequently unpleasant, and not always effective even for those who carry on taking the drugs. But it is what we have relied upon – which helps to explain why the results of a clinical trial, recently published in The Lancet, have generated so much interest and debate.

A team led by Professor Anthony Morrison at the University of Manchester randomly assigned a group of patients, all of whom had opted not to take antipsychotics, to treatment as usual (involving a range of non-pharmaceutical care) or to treatment as usual plus a course of cognitive therapy (CT). Drop-out rates for the cognitive therapy were low, while its efficacy in reducing the symptoms of psychosis was comparable to what medication can achieve.

So what exactly is CT for schizophrenia? At its core is the idea that the patient should be encouraged to talk about their experiences – just as they would for every other psychological condition. Psychosis isn’t viewed as a biological illness that one either has or does not have. Instead, just like every other mental disorder, psychotic experiences are seen as the severest instances of thoughts and feelings – notably delusions and hallucinations – that many of us experience from time to time.

Working together, the patient and therapist develop a model of what’s causing the experiences, and why they’re recurring. These factors will vary from person to person, so what is produced is a bespoke account of the individual’s experience, which is then used to guide treatment. For example, a person so worried by paranoid fears that they won’t set foot outside might be helped to trace the roots of their anxiety to past experiences; to gradually test out their fearful thoughts; and to learn to manage their anxiety while getting on with the activities they enjoy. An individual troubled by hearing voices will be helped to understand what’s triggering these voices, and to develop a more confident, empowering relationship with them.

These are early days. Nevertheless, most of the meta-analyses of CT’s efficacy for psychosis, when added to standard treatment, have indicated definite (albeit modest) benefits for patients, with the latest showing that CT is better than other psychological treatments for reducing delusions and hallucinations. The latest guidelines from the UK’s National Institute for Health and Care Excellence (Nice) recommend it for those at risk of psychosis and, when combined with medication, for people with an ongoing problem.

But not everyone is convinced, and although the research published in The Lancet is encouraging, it was small scale. CT for psychosis is still evolving, and we think that evolution should prioritise three key areas.

First, we must focus on understanding and treating individual psychotic experiences. As we’ve reported in a previous post, there is increasing reason to doubt the usefulness of the diagnosis “schizophrenia”. The term has been used as a catch-all for an assortment of unusual thoughts and feelings that often have no intrinsic connections, and aren’t qualitatively different from those experienced by the general population. Each psychotic experience may therefore require a tailored treatment.

Second, we must build on the recent transformation in understanding the causes of psychotic experiences, taking one factor at a time (insomnia, say, or worry), developing an intervention to change it, and then observing the effects of that intervention on an individual’s difficulties.

And finally, we must listen to what patients want from their treatment – for example, by focusing on improving levels of wellbeing, which tend to be very low among people with schizophrenia.

What about costs compared with drug treatment? A course of CBT is typically just over £1,000, but if it leads to a reduction in the amount of time patients spend in hospital and their use of other services, or a return to work, then it easily pays for itself.

The Nice guidance on psychosis and schizophrenia, updated this year, is unequivocal:

“The systematic review of economic evidence showed that provision of CBT to people with schizophrenia in the UK improved clinical outcomes at no additional cost. This finding was supported by economic modelling undertaken for this guideline, which suggested that provision of CBT might result in net cost savings to the NHS, associated with a reduction in future hospitalisation rates.”

If the real promise of cognitive therapy can be fulfilled, we may at last have a genuinely effective, relatively cheap, and side-effect-free alternative to antipsychotics for those patients who don’t wish to take them. Watch this space.

Daniel and Jason Freeman are the authors of Paranoia: the 21st Century Fear. Daniel is a professor of clinical psychology and a Medical Research Council Senior Clinical Fellow at the University of Oxford, and a Fellow of University College, Oxford. Twitter: @ProfDFreeman. Jason is a psychology writer. Twitter: @JasonFreeman100

If psychosis is a rational response to abuse, let’s talk about it

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abuse, cbt, culture, diagnosis, hearing voices, medication, paranoia, psychological support, psychosis, schizophrenia, trauma

If psychosis is a rational response to abuse, let’s talk about it

There is something of a sea change in the way we understand experiences that have traditionally been labelled as psychotic. In our culture at least, experiences such as hearing voices or seeing visions have long been viewed by the medical establishment as unequivocal symptoms of mental illness. Treatment has tended to focus on the suppression of such “symptoms” using antipsychotic medication.

Research (often funded by drugs companies) has been largely concerned with the brain as a physical organ, rather than with the person within whose head it is housed, or indeed with their life experience. And, because of the presumption that psychotic symptoms are the preserve of mentally ill people, estimates of the numbers affected have been based on the numbers who have received a particular diagnosis.

But a report published last week by the British Psychological Society’s division of clinical psychology, challenges many of these assumptions.Understanding Psychosis and Schizophrenia presents a compelling case for trying to understand psychotic experiences as opposed to merely categorising them. It argues that such experiences can be understood from a psychological perspective, in the same way as other thoughts and feelings, rather than being placed on the other side of an artificial sick/healthy divide.

And, indeed, they appear to be much more common than is frequently supposed. According to the report, up to 10% of the population has heard a voice speaking when nobody was there and almost one in three holds beliefs that might be considered paranoid. Two in three people who had heard voices or seen visions did not seek help because they were untroubled by them. And, of course, there is huge diversity in the way such experiences are understood and valued in different cultures.

For those who find their experiences unwelcome and disturbing (and they can be extremely disturbing; I don’t think anyone questions that) the range of help on offer is decidedly limited. Despite the National Institute for Health and Care Excellence recommending that everyone with a diagnosis of schizophrenia is offered cognitive behaviour therapy(CBT), only one in 10 has access to it. Treatment by medication alone, forcibly if needed, is the norm.

It is widely accepted that early life experience, trauma, abuse and deprivation greatly increase the risk of developing psychosis. Indeed,research suggests that experiencing multiple childhood traumas gives approximately the same risk of developing psychosis as smoking does for developing lung cancer.

Many people object to the psychotic label because they consider their experiences a natural reaction to the abuse they have suffered, and even a vital survival tool. What they want above all is space and time to talk about their experiences and to make sense of them. It is shocking how few are given this opportunity.

Of course, psychological approaches to helping those with psychosis will not suit everyone. There are those for whom a diagnosis can come as a welcome relief. Many people find medication helpful, as treatment on its own or alongside talking therapies.

In fact, one of the most persuasive messages of the report is that people should be allowed to understand their experience in their own way, without professionals insisting on a particular interpretation.

It is a highly collaborative approach and fitting that at least a quarter of those who contributed to the report have lived experience of psychosis. Their opinions and experiences are as varied as you would expect with any group of individuals but together they comprise an enormously powerful and vivid testimony to the full range of human experience and to the many and varied ways in which we can help each other to make sense of it.

Schizophrenia: the most misunderstood mental illness?

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diagnosis, discrimination, fear, help, media, mental health issues, paranoia, psychosis, recovery, schizophrenia, shame, silence, stereotypes, stigma

Schizophrenia: the most misunderstood mental illness?

Let’s face it, when most people think about schizophrenia, those thoughts don’t tend to be overly positive. That’s not just a hunch. When my charity, Rethink Mental Illness, Googled the phrase ‘schizophrenics should…’ when researching a potential campaign, we were so distressed by the results, we decided to drop the idea completely. I won’t go into details, but what we found confirmed our worst suspicions.

Schizophrenia affects over 220,000 people in England and is possibly the most stigmatised and misunderstood of all mental illnesses. While mental health stigma is decreasing overall, thanks in large part to the Time to Change anti stigma campaign which we run with Mind, people with schizophrenia are still feared and demonised.

Over 60 per cent of people with mental health problems say the stigma and discrimination they face is so bad, that it’s worse than the symptoms of the illness itself. Stigma ruins lives. It means people end up suffering alone, afraid to tell friends, family and colleagues about what they’re going through. This silence encourages feelings of shame and can ultimately deter people from getting help.

Someone who knows first hand how damaging this stigma can be is 33 year-old Erica Camus*, who was sacked from her job as a university lecturer, after her bosses found out about her schizophrenia diagnosis, which she’d kept hidden from them.

Erica was completely stunned. “It was an awful feeling. The dean said that if I’d been open about my illness at the start, I’d have still got the job. But I don’t believe him. To me, it was blatant discrimination.”

She says that since then, she’s become even more cautious about being open. “I’ve discussed it with lots of people who’re in a similar position, but I still don’t know what the best way is. My strategy now is to avoid telling people unless it’s comes up, although it can be very hard to keep under wraps.”

Dr Joseph Hayes, Clinical fellow in Psychiatry at UCL says negative perceptions of schizophrenia can have a direct impact on patients. “Some people definitely do internalise the shame associated with it. For someone already suffering from paranoia, to feel that people around you perceive you as strange or dangerous can compound things.

“I think part of the problem is that most people who have never experienced psychosis, find it hard to imagine what it’s like. Most of us can relate to depression and anxiety, but a lot of us struggle to empathise with people affected by schizophrenia.”

Another problem is that when schizophrenia is mentioned in the media or portrayed on screen, it’s almost always linked to violence. We see press headlines about ‘schizo’ murderers and fictional characters in film or on TV are often no better. Too often, characters with mental illness are the sinister baddies waiting in the shadows, they’re the ones you’re supposed to be frightened of, not empathise with. This is particularly worrying in light of research by Time to Change, which found that people develop their understanding of mental illness from films, more than any other type of media.

These skewed representations of mental illness have created a false association between schizophrenia and violence in the public imagination. In reality, violence is not a symptom of the illness and those affected are much more likely to be the victim of a crime than the perpetrator.

We never hear from the silent majority, who are quietly getting on with their lives and pose no threat to anyone. We also never hear about people who are able to manage their symptoms and live normal and happy lives.

That’s why working on the Finding Mike campaign, in which mental health campaigner Jonny Benjamin set up a nationwide search to find the stranger who talked him out of taking his own life on Waterloo bridge, was such an incredible experience. Jonny, who has schizophrenia, wanted to thank the man who had saved him and tell him how much his life had changed for the better since that day.

The search captured the public imagination in a way we never could have predicted. Soon #Findmike was trending all over the world and Jonny was making headlines. For me, the best thing about it was seeing a media story about someone with schizophrenia that wasn’t linked to violence and contained a message of hope and recovery. Jonny is living proof that things can get better, no matter how bleak they may seem. This is all too rare.

As the campaign grew bigger by the day, I accompanied Jonny on an endless trail of media interviews. What I found most fascinating about this process was how so many of the journalists and presenters we met, were visibly shocked that this young, handsome, articulate and all-round lovely man in front of them, could possibly have schizophrenia.

Several told Jonny that he ‘didn’t look like a schizophrenic’. One admitted that his mental image of someone with schizophrenia was ‘a man running about with an axe’. It was especially worrying to hear this from journalists, the very people who help shape public understanding of mental illness.

Many of the journalists also suggested that through the campaign, Jonny has become a kind of ‘poster boy’ for schizophrenia and in a way, I think he has.

Jonny has mixed feelings about the label. “I hope that by going public with my story, I’ve got the message out there that it is possible to live with schizophrenia and manage it. It’s not easy, it’s an ongoing battle, but it is possible. But I’m aware that I’m one of the lucky ones. I’ve been given access to the tools I need like CBT, but that’s not most people’s experience. Because of our underfunded mental health system, most people don’t get that kind of support. I can’t possibly represent everyone affected, but I hope I’ve challenged some stereotypes.”

As Jonny rightly says, one person cannot possibly represent such a diverse group of people. Schizophrenia is a very broad diagnosis and each individual experience of the illness is unique. Some people will have one or two episodes and go on make a full recovery, while others will live with the illness for the rest of their lives. Some people are able to work and be independent and others will need a lot of support. Some people reject the diagnosis altogether.

What we really need is a much more varied and nuanced depiction of mental illness in the media that reflects the true diversity of people’s experiences.

What I hope Jonny has managed to do is start a new conversation about schizophrenia. I hope he has made people think twice about their preconceptions of ‘schizophrenics’. And most importantly, I hope he has helped pave the way for many more ‘poster boys’ and girls to have their voices heard too.

For more information, visit Rethink Mental Illness

*Name has been changed

 

‘Catastrophic’ failings in schizophrenia care revealed

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early intervention, physical health, psychosis, schizophrenia, support, treatment

‘Catastrophic’ failings in schizophrenia care revealed

Care for people with schizophrenia and psychosis is falling “catastrophically short”, a report has found.

The Schizophrenia Commission said there were “shameful” standards of care on some acute mental health wards, which could make patients worse rather than better.

The commission, established by the mental health charity Rethink Mental Illness, has called for a radical overhaul of the care system. The report suggests that too much money is being spent on secure care – the most expensive form of care – and more should be invested in prevention and community support.

It expresses concern that early intervention treatment teams are being cut in some areas.

Researchers claim that very few sufferers get the recommended levels of care. The report states that there should be more widespread use of community-based “recovery houses” and a redirection of funding from secure units into early intervention services.

Professor Sir Robin Murray, chair of the commission, said: “We have spent the last year listening to expert professionals and more importantly, the experiences of people who have schizophrenia and psychosis and their families.

“The message that comes through loud and clear is that people are being badly let down by the system in every area of their lives.

“People with psychosis need to be given the hope that it is perfectly possible to live a fulfilling life after diagnosis. We have no doubt that this is achievable.”

Paul Jenkins, chief executive officer of the charity Rethink Mental Illness, added: “It’s been over 100 years since the term schizophrenia was first coined, but care and treatment are still nowhere near good enough.

“It is a scandal that in 2012 people with schizophrenia are dying 15-20 years earlier than the general population and that only 7% are able to get a job. Too many people are falling through the gaps in the system and ending up in prison or homeless.

“Developing ideal treatments might take time, but there are things which can be done today which could transform lives. More money does need to be spent – but the funding that already exists could also be used much more effectively.

“We wouldn’t accept this state of affairs for cancer, why should people with schizophrenia have to endure it?”

Schizophrenia affects more than 220,000 people in England and an estimated one in six people will experience some symptoms of psychosis at some stage in their lives, according to the report.

A Department of Health spokeswoman added: “This report highlights important areas for improvement and shows why we have put better treatment for those with mental health problems at the heart of the new mandate for the NHS.

“This includes plans to hold the NHS to account for improving health and reducing premature deaths in people with serious mental illness.

“We’re setting up pilot sites to improve access to psychological therapies for those who have a severe mental illness including schizophrenia. We are clear that people with mental health problems should be treated with the same high quality and dignified care as anyone else and we expect the NHS to make this happen.”

Andrew McCulloch, chief executive at the Mental Health Foundation, said: “GPs and other health professionals must do more to offer routine health assessments to people with severe mental health problems and address identified needs.

“Some people with severe mental health problems experience a chaotic lifestyle, self-neglect, poor diet and high levels of smoking, all of which significantly increase risk of physical health problems, including cardiovascular disease.

“However, this level of mortality cannot be simply attributed to lifestyle – this could be seen as victim blaming. Social inequality clearly plays a major role.

“The commission’s report points out that about 45% of people who receive a diagnosis of schizophrenia recover after one or more episodes.

“Rates of recovery will only improve when we refocus resources on to the early stages of illness, give people hope, and help them to self-manage their condition better, instead of spending all of our resources downstream.”

The “Truman Show” delusion: Psychosis in the global village

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culture, delusion, psychosis, reality tv, The Truman Show

The “Truman Show” delusion: Psychosis in the global village

The article focuses on a type of delusion in which individuals believe they are being filmed and which they believe will be broadcast to others for their entertainment.

(Please click the above link to access the full article)