EssaysPsyche

Challenging the Status Quo on Therapy’s Place in Schizophrenia Treatment

A discussion of recent developments

Historic wisdom has held that high doses of antipsychotic medications are the most effective treatment for schizophrenia — but that wisdom has been challenged by a new study reported in an article in The New York Times entitled, “Talk Therapy Found to Ease Schizophrenia.” The federally-funded  study compared the traditional methods of treating first episode schizophrenia with a new method called NAVIGATE, which combines lower doses of antipsychotic drugs with talk therapy and other family, educational, and vocational interventions. The results suggest that these combined treatments provided better life outcomes for patients with schizophrenia than the more common method of prescribing high doses of antipsychotics and disregarding therapy — a concern recently voiced by psychiatrist Leon Hoffman in his critique of Jeffrey Leiberman’s book.

Schizophrenia, regarded by many to be one of the most debilitating mental illnesses, is characterized by an inability to tell what is “real.” A few common symptoms include auditory hallucinations, clinging to false beliefs, confused logic, and a reduced emotional capacity. The disorder often begins in young adults between the ages of 18 and 28 and persists throughout the lifetime. Mischaracterized by pop culture as violent and dangerous, those who suffer from schizophrenia are actually quite vulnerable and are often unable to care for themselves. As a result, schizophrenia and its treatments have been in the foreground of psychiatry for much of its history.

In the 19th century, Emil Kraeplin, one of the fathers of modern psychiatry, believed that schizophrenia was an untreatable biological disorder with an inevitable deteriorating course. Eugene Bleuler, a contemporary of Kraeplin’s, was more optimistic about the prognosis for schizophrenia. He and his colleagues, most notably Carl Jung, pioneered the use of therapeutic approaches influenced by psychoanalysis. In North America, Harry Stack Sullivan established a reputation for his ability to help treat patients with schizophrenia with a form of milieu therapy, influenced by both psychoanalytic ideas and is own unique form of interpersonal psychiatry. Other notable American psychoanalysts specializing in the treatment of schizophrenia included Freida Fromm Reichman, wife of famed psychoanalyst Eric Fromm, and Harold Searles. In the 1950s the development of the first antipsychotic medication, Thorazine, began a new era in the treatments of schizophrenia, and psychotherapy began to fall our of favor as a treatment modality.

Although Thorazine is clearly a powerful medication, able to calm agitated patients and decrease hallucinations and delusions, patients are often reluctant to continue taking it after being discharged from hospital because of its unpleasant, mind numbing effects. As a result there is a type of revolving door phenomenon in which schizophrenic patients are legally committed to inpatient settings against their wills, medicated, and discharged, only to be readmitted when they go off their medications and experience a recurrence of their more flagrant symptoms. On top of that, Thorazine has a variety of serious side effects including tardive dyskinesia, an incurable neurological disorder which produces Parkinson’s Disease-like symptoms. A second generation of antipsychotic medications, including Risperidone, Olanzapine, and Aripiprazole, was developed with the express purpose of lessening the debilitating side effects of first generation drugs like Thorazine and to reduce the pervasiveness of tardive dyskinesia. These new drugs, however, come with their own sets of debilitating side effects which range from increased risk of heart attack and stroke to sexual dysfunctions and dramatic weight gain.

Since their inception, there has been much debate regarding the effectiveness of antipsychotic medications. Many countries around the world utilize them, but their use in the United States is significantly higher than in other nations, especially in Scandinavian countries like Denmark. In addition, many treatment programs for schizophrenia in Scandinavian countries use lower doses of antipsychotic medications and augment them with extensive aftercare programs following discharge. These aftercare programs combine community support, and a variety of different psychosocial treatments including structured family therapy, psycho-education, and group therapy. There is a substantial amount of empirical evidence showing that combined medication and psychosocial treatment programs of this type, in which lower doses of medication are used, improve patients’ quality of life, reduce the incidence of rehospitalization, and lead to greater long term recovery with a reduced incidence of serious side effects. There is also substantial evidence that integrated treatment approaches actually reduce healthcare costs.

To date, this evidence has had no impact on recommended standards of care for schizophrenia in the United States. Though it sounds like Lieberman’s book stands in the old camp, the study discussed in The New York Times is the first of its kind to be implemented in the United States and its important findings are in the early stages of being disseminated. Whether or not the findings of this study will increase the likelihood of more federal funding for similar research programs that may ultimately have an impact on the American healthcare system remains to be seen. That being said, it is encouraging to see that this landmark study appears to be getting some of the mainstream media coverage that it warrants.

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J.D. Finkelstein

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