What a legacy. The little creepy guy who was the doctor in charge wore a dopey tweed jacket, like he was Mr Chips or something.
This activity by doctors doesn’t surprise. The history of the rise of Nazism reveals a disproportionate membership amongst physicians.
As far as I am concerned psychiatry is a twisted and evil matter.
Recently in Minnesota we had a sponsored bike ride called the MS150, a fundraiser for Multiple Sclerosis. The Noran Neurological Clinic offered to sponsor but they were turned down because of their history of lobotomy; I believe approximately 5000 in Minnesota were murdered.

Fuck them and fuck you.

Not quite total. The first person to undergo a leucotomy in Britain (a young woman in Bristol in December 1940) had already had insulin treatment, ‘endocrine’ treatment and 77 electroconvulsive treatments before her operation.

I think by the way you underestimate the number of leucotomies carried out in Britain. Per head of the population, the use of leucotomy was probably higher than in the US.

Very interesting stuff! Unfortunately all completely unrelated to my current placement so I don’t have much time to read up on it . I’m hoping to work with psychosis in some of my specialist placements. It wasn’t something that really grabbed me until I started training, but now I find myself utterly fascinated by it.

Oh dear, your spam program has probably rumbled my tenuous arguments! I suspect it’s the number of links I’m putting in. Sorry if flooding your blog with these. I’m afraid I’m immersed in all this stuff at the moment and engaging in stimulating dialogue makes it easier to remember – hope you don’t mind!

Well I’m not sure about that, but it is an issue I find interesting and relevant to some work I’m doing at the moment.

Thanks for the Leventhal reference and the Conrad paper looks very interesting. How self-regulation theory sheds light on antipsychotic medication adherence is discussed here:

http://linkinghub.elsevier.com/retrieve/pii/S0277953698002093

The idea that antipsychotic non-compliance is about the same as other physical conditions is controversial, given that Lieberman et al (2005) found discontinuation rates of 74% in their research trial. I struggled to find any recent audit data on UK antipsychotic compliance and there was nothing recent comparing adherence rates in psychosis versus those in physical health, so that remains a moot point I suppose.

http://content.nejm.org/cgi/content/abstract/353/12/1209

With respect to antipsychotics in particular I think the evidence shows that when people are (1) properly educated about the mechanism, efficacy and side-effects of medication; (2) genuinely encouraged to weigh up the pro’s and con’s in a collaborative manner; (3) encouraged to make a properly free decision, and (4) there is a trusting positive relationship between user and provider, then those who choose to take antipsychotics will actually continue to take them despite the side-effects.

There is some evidence that (1) is not always the case, e.g:

http://linkinghub.elsevier.com/retrieve/pii/S0277953605005848

For the importance of (4) see:

http://archpsyc.ama-assn.org/cgi/content/abstract/62/7/717

Unless there is a risk to others, those who express a rational choice not to take antipsychotics should be offered alternatives in my view. If there is a clear risk to others (directly linked to psychotic experiences and mitigated by medication) then I suppose it is not unprecedented to compel people to take medication where there is a public health concern (i.e., tuberculosis).

Where there are doubts regarding a person’s capacity to make such a decision, and where there is only a low risk to others, I think this should be assessed according to the spirit of the new Mental Capacity Act, i.e., people are allowed to make bad decisions, and capacity is presumed unless proven otherwise*.

Regarding the qualitative experience of taking antipsychotic medication, I found this:

http://www.ingentaconnect.com/content/bpsoc/paptrap/2004/00000077/00000001/art00002

I’ve not read it though so not sure how good it is.

Finally, do we need to ask whether a prescription of antipsychotics can cause harm? I’m not sure about this, but if we don’t accept the brain disease model of psychosis, if we start to appreciate that the anxiety, trauma and catastrophic appraisals (”These voices mean I’m going mad”) created by being given a diagnosis of schizophrenia can themselves lead to relapse**, and if more evidence emerges demonstrating links between being told one has a degenerative brain disease and hopelessness***, then it is not an unreasonable question to ask. That is, a prescription of antipsychotics could be interpreted by a young person as good evidence for the catastrophic appraisals that he or she is going mad and that he or she has a degenerative brain disease and so on.

*This is the opinion of psychiatrist and philosopher Bill Fulford in his Oxford Textbook of Philosophy and Psychiatry (2007)

** http://journals.cambridge.org/action/displayAbstract?aid=48627
http://journals.cambridge.org/action/displayAbstract?aid=80756
linkinghub.elsevier.com/retrieve/pii/S000579670700006X

***www.ncbi.nlm.nih.gov/pubmed/18091189

Some psychiatrists are very drug happy – if one doesn’t work, they’ll add another, then another, then another and before you know it the individual is on quite a cocktail. Others will tend to switch between drugs and find one that best suits the individual (probably a better practice).

However, you are right about non-adherence. My background in health psychology tells me that most people don’t take most medications as prescribed. I blether on about it constantly, but I think Leventhal’s model of self-regulation is the best model we have for understanding what people do with the health advice they’re given – they do what fits their broader understanding and goals, not what makes best medical sense to their doctors.

This is a brilliant paper if you can get hold of it:
http://psycnet.apa.org/?fa=main.doiLanding&uid=1986-01915-001

It would be fascinating to find out more about people who take antipsychotic’s perceptions and narratives around the role of medication. Paul, you seem to be quite the expert – do you know of anything?

I don’t have a reference, but one of my consultants likes to quote a study where the adherence to medication was examined for people on anti-rejection drugs for kidney transplants. We might think that given the life-or-death nature of this then people might be very diligent in taking these. Not so apparently and adherence rates were not much better than any other drugs.

First of all – no, I’m not medically qualified – I’m a trainee clinical psychologist. I currently attempt to provide cognitive therapy to people at high risk of psychosis and I’m conducting research with people across the spectrum, from people at first episode to those with chronic and severe problems. I support a minimum medication / maximum kindness approach to understanding and treating psychotic complaints as advocated by the likes of psychologist Richard Bentall and psychiatrist Loren Mosher.

My main points were simply:

1. Long-term high dose polypharmacy is significantly associated with increased mortality.

I certainly was not arguing antipsychotic medication, when prescribed at BNF recommended levels or in accordance with NICE guidelines, is linked to increased mortality.

I hardly think it’s controversial or unorthodox to acknowledge the increased risks associated with the prescribing practices I was criticising, and to acknowledge that the gains of such practice are actually minimal. I believe the burden of proof lies with someone who advocates long-term high dose polypharmacy to prove the benefits! I expect this is not something either of you advocate in your practice? However if so I’d be interested in studies supporting the efficacy, effectiveness and ethics of such an approach.

The paper I cite was illustrative of this point, not exhaustive. Anyway here’s another one:

http://bjp.rcpsych.org/cgi/content/full/188/2/122

Anecdotally, my guess would be that if you go into any inner city ICU and ask the consultant if he or she thinks there’s a link between antipsychotic use of the sort described and increased mortality, they’ll give you a much firmer answer.

2. I believe there is a relative disregard (at a societal level, not necessarily a medical one) of the impact of antipsychotic medication on people who are compelled to take it.

You’ll note this was a point levelled at the “public response”, not necessarily psychiatry and the law – although I feel you read it as such. My awareness of the literature is that many people operate with a highly stigmatising view of people who have received a diagnosis of schizophrenia, believing them to be out of control and dangerous, and probably aren’t even aware of the side-effects people have to endure if they take their meds. I’m also aware that there is little media interest in the cost to people of taking such medication, but disproportionate attention given to rare acts of violence.

I believe this has a knock-on effect in that the prescription of antipsychotic medication is less tightly regulated than a comparable drug in physical health – which is one reason long-term, high dose polypharmacy is tolerated. When was the last time you heard a public outcry over the sudden death of a psychiatric patient linked to such practice?

Anyway, those were my points. I don’t identify with anti-psychiatry or radicalism, but I do feel criticial of reductionistic approaches and I do identify with a recovery model where psychotic symptoms are not the only measure used of whether something ‘works’.

In addressing some of the points you made I’m assuming that neither of you deny that the side-effects of such medication are considerable for many, and a key factor in non-compliance. I for one am certainly NOT denying that for many people such side-effects are less of a problem than the distress they are experiencing in relation to their psychotic experiences. I also agree only a small number are legally compelled to take this medication, but whether this implies people are then taking it of their own free will is controversial. Many do I’m sure, but equally many are cajoled and pressured into compliance by health professionals who, keen to manage risk, minimise the side-effects and maximise the possibility of compulsion if they don’t ‘comply’.

Frontier, you rightly say polypharmacy is not recommended but then say it is relatively rare to find a patient treated in this way. However according to an audit by Harrington et al., (2002) 48% of 3132 UK patients were being prescribed more than one antipsychotic.

http://pb.rcpsych.org/cgi/content/abstract/26/11/414

DeClerambault, you dispute the argument that these medications don’t work. I wasn’t actually making such a point but I certainly agree that with you that they ameliorate psychotic symptoms, if this is what you mean by working? But I’m sure you’ll agree that perhaps the best outcome measures to use are those identified by service-users? Unusual experiences often do feature here, but other things carry equal if not greater weight (e.g., the young man or woman for whom weight-gain is more distressing than risk of relapse).

Regarding your points on the ethical analysis of medication. I completely agree with both of you on the need for careful weighing up of all factors and I certainly wasn’t intending to open a debate on deontological ethics versus consequentialism!

To address Paul’s comments (in reverse order). I do think that psychiatry suffers from the weight of its history, and of the things done in psychiatry’s name, psychosurgery is one of the more regrettable.

However, as I say in the post we should bear in mind the total lack of effective treatments for serious mental illness at the time of Moniz’s work. I was surprised in my research to learn that a substantial number of people appeared to improve with the procedure. I wasn’t so surprised to learn of the high rate of side effects, but without any sort of trail, we’ll never know whether the treatment was actually effective or not. I don’t think that Dr Freeman’s cavalier approach can be defended in anyway.

Overall though, an incredibly invasive and permanent procedure undertaken on extremely vulnerable people cannot be looked back at with any sort of pride. The best thing we can hope to do is learn the lessons of the past. Other disciplines in medicine have done comparable things to people in the name of affecting cures and we shouldn’t beat ourselves up any more than they do. Times have moved on and so has society and psychiatry too.

As for psychiatric medication. Most psychiatric medication has serious side effects. We shouldn’t single out psychiatry in this – there are few if any drugs which are ‘silver bullets’ in any part of medicine and steroids, which are used in a very large number of diseases, have a side effect profile as long as your arm. With psychiatric medication, as with all treatments its then a matter of balancing risk with the positive effects that the medication can bring. This risk benefit analysis is complicated in psychiatry in that some people consider that people with psychiatric disorders don’t have anything wrong with them in the first place – a least not anything that can be treated with drugs. I don’t hold with this and I refer you to
Trevor Turners article about the effect of Chlorpromazine in clearing out the asylums

Out of the total number of people taking antipsychotic medication, only a small number are compelled to take it, most do so of their own free will.

The papers you cite are interesting. The BJP paper appears to suggest that prescribing two antipsychotics affects a patient’s longevity. Whether this is true or not, this is not recommended practice and it is relatively rare to find a patient treated in this way. deClerambault is right to say that the study is small and they don’t appear to control for other factors that might lead to this reduced lifespan. The thrust of NEJM paper isn’t really about side effects of medications, although I grant that this is an important factor in it. It’s about comparing the relative effectiveness of first and second generation antipsychotics given the claims made that second generation are superior.

We do need better psychiatric medications, and I hope we look back upon our treatments now and models of psychiatric illness as being primitive in years to come.