June 28, 2019 by Sandra Steingard, MD
A Guide to Long-Acting Neuroleptics: Education or Promotion?
Several weeks ago, I received a number of emails notifying me of a new pamphlet released by the National Council for Behavioral Health titled “Guide to Long-Acting Medications for Providers and Organizations.”
The pamphlet begins:
“This Guide to Long-acting Medications (LAMs) is a Call to Action for psychiatrists, other clinicians and behavioral health organizations to increase the use of LAMs.” It goes on to suggest that psychiatrists and their organizations (which comprise the membership of the National Council) rally resources to make these drugs more readily available as “first-line treatment.”
The authors opine upon “What Science Tells Us,” namely, that “there is enough science to demonstrate the degradational effects on brain tissue of each psychotic episode.” Moreover, we are informed that — when started early — the neuroleptic drugs will “avert progressive neurodegeneration and subsequent disability.”
The pamphlet is designed as a public health promotion with this message: If we can stop the progression of schizophrenia, we will improve long-term outcomes. This is purported to be based on science.
I would argue that if one follows the science, one might support instances in which long-acting drugs are useful but not necessarily to the extent suggested in this pamphlet. In addition, one would not promote the newer drugs as first-line treatments.
By downplaying some aspects of the available science, the pamphlet implicitly is acting as a promotional tool for the pharmaceutical industry. Furthermore, this pamphlet serves as an example of why simple disclosures of conflict do not adequately address deeper issues of bias and influence in our field.
While the authors correctly state that this was not funded by pharmaceutical companies, it is nevertheless influenced by their interests via the incursion of commercial interests into academia over the past few decades.
January 14, 2019 by Sandra Steingard, MD
Open Dialogue: Does the Current Research Data Support Further Investment?
Psychiatric Services, a leading US journal, has published two important papers on Open Dialogue. Freeman and colleagues did an extensive literature review and analysis of currently available research. Their paper is accompanied by a commentary by Kim Mueser, PhD, Director of the Boston University Center for Psychiatric Rehabilitation and one of the world’s experts in his field.
Freeman and colleagues begin their paper with a detailed explanation of the criteria for inclusion into their investigation. They identified 23 studies for review. Papers selected were published in English and evaluated Open Dialogue effectiveness using either case study, qualitative, quantitative, or mixed methods. Studies were conducted in Finland, Norway, Sweden, and the US.
As the authors point out, most of the available research comes from the Western Lapland group that developed Open Dialogue (OD). This poses a fundamental source of weakness in the evidence base. Their studies had small sample sizes, there was no control group, and the ratings were not blinded. In addition, there were not consistent methods for either defining or evaluating OD.
Many of us learned of Open Dialogue because of their reported excellent outcomes for individuals who experienced a first episode of psychosis. We are eager to see if these results can be replicated elsewhere. But there are other important questions.
May 5, 2018 by Sandra Steingard, MD
20-year Outcomes for First-episode Psychosis: Impact of Neuroleptic Drug Discontinuation
Standard treatment guidelines in psychiatry recommend that neuroleptic drugs are continued indefinitely after a person has experienced more than one psychotic episode. These recommendations are based on studies which have found a higher rate of recurrence of psychosis among those who stop as compared to those who remain on drug.
Anatomy of an Epidemic raised concerns about the long-term outcomes for those who remain on these drugs. Most psychiatrists, including me, assumed that by reducing risk of relapse one would be improving long-term outcome. However, there seems to be reasonable evidence that this assumption is not correct.
Not only does long-term use of drugs expose people to the risks of weight gain and tardive dyskinesia, the drugs may also impair functional outcome. My own view is that this is a discussion psychiatrists need to have with their patients. A person may choose to accept a higher (and not inevitable) risk of recurrence of psychosis as a way to minimize the long-term risks of negative outcomes associated with staying on drug.
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.
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.
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.
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.
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.
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.”
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.
December 7, 2016 by Sandra Steingard, MD
Vermont Collaborative Network Approach Launched
I 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.