Monthly Archives: April 2018

The Continuing Proof of the Efficacy of Anti-Psychotics

By Marvin Ross

Despite the protestation from the anti-psychiatry advocates, medication for schizophrenia works and another study has just been published to support that position. A new study based on a nationwide data of all patients hospitalized for schizophrenia in Finland from 1972 to 2014 found that the lowest risk of rehospitalization or death was lowest for those who remained on medication for the full length of time.

The risk of death was 174% to 214% higher among patients who never started taking antipsychotics or stopped using them within one year of their first hospitalization in comparison with patients who consistently took medications for up to 16.4 years.

It should be pointed out that this is real life data rather than a clinical trial involving a total of 8,738 people.

What is particularly significant for me in this study is that it is from Finland which is the home in one isolated part of that country (Lapland) to the alternative Open Dialogue espoused by the anti-psychiatry folks including journalist Robert Whitaker of Mad In America fame. Whitaker claims that 80% of those treated with Open Dialogue are cured without need for drugs.

I wrote about Open Dialogue very critically back in 2013 in Huffington Post and pointed out that there is very little research to demonstrate its efficacy. I actually asked a Finish psychiatrist, Kristian Wahlbeck who is a Research Professor at the National Institute for Health and Welfare, Mental Health and Substance Abuse Services, in Helsinki about Open Dialogue.

This was his answer:

“I am familiar with the Open Dialogue programme. It is an attractive approach, but regrettably there has been virtually no high-quality evaluation of the programme. Figures like “80 per cent do well without antipsychotics” are derived from studies which lack control group, blinding and independent assessment of outcomes.”

He went on to say that:

“most mental health professionals in Finland would agree with your view that Open Dialogue has not been proven to be better than standard treatment for schizophrenia. However, it is also a widespread view that the programme is attractive due to its client-centredness and empowerment of the service user, and that good studies are urgently needed to establish the effectiveness of the programme. Before it has been established to be effective, it should be seen as an experimental treatment that should not (yet?) be clinical practise.”

As for the claim that psychiatric hospital beds in Finland have been emptied, he said “in our official statistics, the use of hospital beds for schizophrenia do not differ between the area with the Open Dialogue approach and the rest of the country.”

My blogging associate, Dr David Laing Dawson also wrote about Open Dialogue in this forum with very skeptical view. He stated that the director of the program admitted that about 30% of the patients in Open Dialogue are prescribed medication so arguing that medication is not used is not correct.

At the time my article appeared in Huffington Post, someone on Mad In America agreed with me that there was insufficient evidence on the efficacy of Open Dialogue and said that a US study was set to begin in, I think, Boston. I did find a completed study on Open Dialogue done by Dr Christopher Gordon. His study involved 16 patients and he states at the outset that

“Since this was not a randomized clinical trial and there was no control group, we cannot say that these outcomes were better than standard care, but we can assert that they were solidly in line with what is hoped for and expected in standard care.”

In the paper that is in a legitimate psychiatric publication, he states that of the 16, two dropped out and a further 3 had disappeared at the end of the study so no data is available for them. This is a study of 11 people who completed the one year term.

He then points out that:

“Of note, four individuals had six short-term psychiatric hospitalizations (two involuntary).”

and that:

“three of the six individuals who were not on antipsychotics at program entry started antipsychotics. Of the eight already on antipsychotics, four had no change in their medication, and four elected to stop during the year. Both groups of four had similar outcomes and continued to be followed in treatment. Shared decision making and toleration of uncertainty contributed to these choices.

Hardly the success he suggests if the goal was to help them get well without medication.

But, coming up at the end of May in Toronto we have a conference with Robert Whitaker and others on Shifting the Narrative on Mental Health from the psychiatric disease model to the relational/recovery model, and on the challenges that are stacked against that eventuality.

Now I would say that the challenges against that shift are science but they define it as “The challenges and resistances to progressive change are of an ideological, macro-economic nature guaranteeing a protracted and difficult struggle for recovery advocates.”

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Dwayne Johnson and Heroic Narratives

By Dr David Laing Dawson

Within the same time frame I was reading Marvin’s blog on the Mental Health Commission and the associated commentary, Dwayne Johnson’s story of depression popped up on multiple news sites. None of the sites gave much detail and I remain unsure if he suffered bouts of what we used to call “clinical depression”, and before that “endogenous depression” or if he simply suffered some difficult discouraging periods in life when his football career and a relationship ended.

In these brief news items Dwayne’s story is shaped as the narrative of an “heroic struggle”.

And I realized that most such stories are shaped and told in that form. It is a classic narrative form, and one we all want to hear.

Facing great odds, our hero, perhaps after learning some life lesson (humility, confession, love, trust, openness) battles his way through to success, health, and happiness. His weapons are will power, strength, hope, perseverance, and a little help from his friends.

It is the narrative form in the story of A Beautiful Mind’s John Nash. And it is the narrative form when the story is told about a victim of cancer.

The difference is that when we read the story and see the pictures of someone’s struggle with cancer, we know he or she has undergone one or many courses of radiation or chemotherapy, that he or she is still undergoing treatment.

The focus of the story may be on the courage and optimism of the patient, their loving  family, a special group of supportive friends, a cancer support group, or all that the patient is able to accomplish despite their illness – but we never lose sight of the fact of medical treatment for cancer.

It is good to bring mental illness out of the shadows. It is good to tell our stories. But we need to drop the euphemisms of mental health issues, and (a new one for me) mental health “situations”, and we need to include the fact of medical treatment for serious mental illness, because we don’t assume it as we do with cancer narratives. In fact, a very popular heroic struggle narrative is “I overcame my (illness, depression) without resorting to medication.”

This heroic struggle narrative has shaped the recovery movement; it has clearly influenced members of the mental health commission.

And who would bother watching a show, or reading a story with a tagline of: “A man develops depression, goes to his doctor; the doctor treats his depression and he gets better.”

This is not to denigrate the role of courage, optimism, hope, and support required to live with a chronic illness, or recover from an acute illness. But…

Update:

Another day, April 5 to be exact, and it seems it is OCD Day with several news items and videos appearing. Much is shared in these articles and videos, distinguishing crippling OCD symptoms from mild everyday forms of compulsions and obsessions. Psychological treatment is also explained, exposure and desensitization therapy. But not once, not once in the articles and videos I watched was it explained that there are medical pharmacological treatments that work with great success for about 90% of sufferers. Not once is this mentioned.

One of these medications has been around since the 1960’s, though at the time we didn’t know how effective it was for OCD and psychological/psychoanalytic thinking about the illness dominated.

I am not sure who or what is to blame for this. But for the psychologists who were interviewed to not mention this readily available medical treatment is akin to naturopaths not mentioning antibiotics when discussing the treatment of pneumonia.

Paradoxically, Jack Nicholson starred as a novelist with OCD in “As Good as it Gets” 20 years ago. At the end of the movie Nicholson’s character decides to be a better man and go back on his medication. Critics were not happy with that ending, and it did ruin the “heroic struggle” narrative. It was, as the third act of a story, very unsatisfying. “What? To quell his OCD all he had to do was take his medication?”  Well, yes.

 

Is This The End of the Mental Health Commission?

By Marvin Ross

In December, I wrote a blog pointing out that the Mental Health Commission of Canada should be disbanded. Those of you who follow my writing on Huffington Post know that this has been a constant theme of mine over the past few years. Last Fall, the Federal Health Minister set up an inquiry into what they called Pan Canadian Health Organizations (PCHOs). These are federally mandated groups established to carry out specific tasks in health across the country when, in fact, health care comes under provincial rather than  federal jurisdiction.

The review was to evaluate the role and relevance of these groups in advancing federal health policy objectives and meeting national goals. One of the PCHOs is the Mental Health Commission and my advocacy colleague Lembi Buchanan and I submitted a brief on the Commission through the Best Medicines Coalition.

With amazing speed for a government report, the findings were just released. Much to our delight, the Commission recommended that the Mental Health Commission either be ended or radically altered.

The basic premise for health care in the 21st Century as outlined by the World Health Organization and endorsed by most countries including Canada is that it be people centred. “It puts people at the centre of the health system and promotes care that is universal, equitable, and integrated. The framework emphasizes a seamless connection to other sectors, notably those focused on the social determinants of health. This framework also promotes providing a continuum of care that requires high-performing primary care.”

The conclusion the reviewers reached about the Mental Health Commission of Canada is that “Mental health is now “out of the shadows”. The integration of mental health care services into the core of Canadian health systems requires a different type of leadership, capable of driving a bottom-up approach in which patients and families, providers, researchers, and the broader mental health community come together to break down silos.”

As a positive, the report states that “The MHCC has been particularly effective in developing strategies around mental health, along with initiatives and campaigns to increase awareness and reduce stigma. It has made great strides in delivering on its objectives and helped to bring mental health “out of the shadows at last.” It has also created valuable contacts and built trust among its closest stakeholders.”

It did develop a mental health strategy mostly ignored and it did help to raise the awareness of mental illness. However, the report states that:

“The need to build greater capacity in Canada on mental health is still as pressing today as it was when the MHCC was established. What has changed, however, partly as a result of the advocacy work undertaken by the Commission, is the overarching policy goal. What Canada needs today is the complete and seamless integration of mental health into the continuum of public health care. What Canadians want is public coverage of proven mental health services and treatments, beyond physicians and hospitals. To be successful, those services must be integrated with primary care and supports for physical health, rather than isolated from them. We came to the conclusion that MHCC, in its present form and with its current orientation, is not the best instrument to achieve the objective of integrating mental health into Medicare.

They then state that these goals might be achievable if the MHCC changed itself but suggest that to accomplish this they would have to engage “health leaders at provincial and territorial levels in joint decision-making over service funding and quality standards; a different “knowledge base” in support of evidence-informed advice and performance evaluation; and a different, more flexible, and less centralized structure.”

This, in fact, is one of the many criticisms I’ve made over the years. The MHCC churns out papers but has zero influence in decision making and that is exactly what is needed. Policy papers are fine but they need to be implemented and the MHCC has yet to accomplish that from what I’ve seen. The report concludes in its section on the MHCC that “It is because mental health is so critically important to Canadians- and their governments- that a new approach is now needed.”

I was impressed with the team tasked with this job and I’m impressed with the speed in which it produced its report (October 2017 to March 2018). Let us hope that the Health Minister implements the recommendations.

And, a documentary we did on schizophrenia