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November 13, 2017 by Sandra Steingard, MD

Duration of Untreated Psychosis Revisited: Response to the Goff Paper

Earlier this year, the American Journal of Psychiatry published a paper, “The Long-Term Effects of Antipsychotic Medications on Clinical Course in Schizophrenia.” This was a response to the concerns that have been raised that these drugs negatively impact long-term outcomes. The authors conclude, albeit in a somewhat lukewarm way, that overall, the “evidence for a negative long-term effect of initial or maintenance antipsychotic treatment is not compelling.” Robert Whitaker and Joanna Moncrieff, whose work was cited by the authors, have written critiques of this paper.

Even if one accepts the paper’s conclusions at face value, there is little argument regarding some serious long-term risks such as movement disorders and weight gain. One of the most compelling reasons why these authors support long-term care is related to the relapse data: when one is started on these drugs, the relapse rate is higher when they are stopped than when they are continued (at least over the first two years). However, there is general consensus that there are some individuals who will recover and not need medications long-term. In fact, there is even consensus that some can recover without drugs; the dispute is over numbers.

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March 6, 2017 by Sandra Steingard, MD

Letter to my Classmates on our 40th Reunion

My college publishes a book for each class celebrating a five year reunion.  We are invited to submit an essay. This is mine.

Hello Classmates,

A few years ago, someone sitting in my office looked up at the diplomas on my wall and said, “You went to Harvard? I didn’t know you were smart!”

I mention that not only to brag about how stealth I am with keeping any bit of intelligence I might possess under wraps but also to acknowledge — before I launch into what may seem like a rant — that I understand that I have benefited in small and big ways from my Harvard education.

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February 21, 2017 by Sandra Steingard, MD

Farewell Mickey Nardo, 1 (not very) Boring Old Man

About five years ago, as my own blogging life was beginning, I found John M. Nardo’s outstanding blog, www.1boringoldman. His focus was on the poor quality of studies that formed the evidence base of modern psychiatry. In a painstaking way, he dove into study after study and pointed out their flaws. His outrage was apparent but couched in a graceful eloquence.

There was a comment section and I eventually jumped in. I had some communication with him outside of the blog, but mostly our communication was in the comments. At the beginning, I did not know his name or much about him. Over time, he shared a bit of his story.

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February 20, 2017 by Sandra Steingard, MD

Committed: The Battle Over Involuntary Psychiatric Care

Dinah Miller and Annette Hanson are two of the three psychiatrists who blog at Shrink Rap. After I started blogging, I began to search out other blogging psychiatrists and I found them. They also have articles published in Clinical Psychiatry News. My impression is that they are decent, well-meaning, and thoughtful psychiatrists (not unlike most of the psychiatrists I know) who want to demystify our profession. Their writing is clear, straightforward, and accessible. Like me, they are all practicing psychiatrists and they deal with the pragmatic challenges we face in our daily work. They offer critical views but they overall seem proud of their profession and their careers. While I respect their work, in that area we seem to differ; they do not seem to be burdened by the professional existential angst that besets me.

On one topic we agree — the subject of involuntary care is the most vexing, contentious, and troubling topic for psychiatry. To their great credit, they have directed an enormous amount of attention and effort to this subject in their latest book, Committed: The Battle Over Involuntary Psychiatric Care.

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February 6, 2017 by Sandra Steingard, MD

Sir Robin Murray and Our Collective Mea Culpa

Sir Robin Murray, a distinguished British professor of psychiatry, recently published a paper in Schizophrenia Bulletin titled, “Mistakes I Have Made in My Research Career.” He describes the evolution of his thinking regarding the concept of schizophrenia, including the problems with the neurodevelopmental model, the limitations of the drugs used to treat the condition, and his failure to pay adequate attention to the role of social factors in the etiology of psychotic states. These ideas are not new to anyone who has read Anatomy of an Epidemic. Sir Robin’s ’s paper could be read as a synopsis of Chapter 6, “A Paradox Revealed.”

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January 9, 2017 by Sandra Steingard, MD

Creating lives of meaning

The era when I was a young physician was one of great optimism for science and medicine. We were still riding on the advances made through the discovery of lifesaving antibiotics and the unraveling of our genetic code. We thought it was just a matter of time before most diseases would be conquered.

And that was the language, the language of war — conquering, vanquishing – that constituted our discourse. This discourse and the expectations that lay behind it entered the world of psychiatry with the notion that it was just a matter of time before we would find the genes that cause all of the problems our patients face, which in turn would lead to identification of the molecules – the drugs – that would erase their suffering.

My career began in the aura of this hope and optimism.

But there was a counter narrative, one that has deep roots in Vermont and was embedded in the growth of Howard Center during the 1980s and 1990s. It was the narrative of recovery. It was the narrative of social inclusion. It was the narrative of rights for people who had been marginalized and whose lives had been discounted. This narrative also told us that most people can recover.

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December 7, 2016 by Sandra Steingard, MD

Vermont Collaborative Network Approach Launched

vermont_b-nikkelI have had the great privilege and pleasure of working with a group of colleagues in Vermont who share my interest in bringing the humble and democratic ways of working developed in northern Finland and Norway to our state. Many of us were introduced to this work by Robert Whitaker’s description of Open Dialogue in Anatomy of an Epidemic and Daniel Mackler’s documentary Open Dialogue, and some of us worked with Tom Anderson, who came to Vermont in the 90s.

Some had traveled to Europe to attend the annual meeting of the International Network for the Treatment of Psychosis, the group of clinicians who had been working in this way for the past two decades. Others had the opportunity to train with Mary Olson, PhD at the Institute for Dialogic Practice. We have formed study groups and developed small teams who are beginning to introduce this way of working to our clinics.

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November 22, 2016 by Sandra Steingard, MD

Moving ahead in troubled times

Sandra-SteingardThe Foundation for Excellence in Mental Health Care was founded in 2011 with the hope of expanding what many had come to believe was a narrow and faulty understanding of psychiatric conditions.

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April 18, 2016 by Sandra Steingard, MD

My Journey of Recovery

Sandra-Steingard

I was recently asked to write an article for SAMHSA’s Recovery to Practice newsletter. This is a slightly edited version of that post.

Let me be clear: I was never anti-recovery. I will admit, however, that when the recovery movement first came to my attention in the 1990s, I was not drawn in. Whenever I attended a presentation on the topic, rather than being able to listen openly to the speaker, I felt defensive. At the time, I was working in a state that was pushing hard to close its state psychiatric hospital. While the mantra was of recovery, it seemed to be promoted by fiat. Since people were expected to recover, therefore, we did not need a state hospital.

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February 28, 2016 by Sandra Steingard, MD

Testifying in Vermont: Forced Drugs

Sandra-SteingardVermont is a wonderful state and I am privileged to call it my home. We are known for our progressive ways, and this extends to our mental health care system. However, there are intense disagreements here – as there are everywhere – and I have learned in recent years about how changes that seem positive can have unexpected consequences.

In 2011, our state hospital closed suddenly over the course of a 24 hour period when it was flooded during Hurricane Irene.

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