Download Drug - Howard Center

Slow Psychiatry:
A Way Forward
Sandra Steingard, M.D.
Chief Medical Officer
Howard Center
Clinical Associate Professor of Psychiatry
University of Vermont College of Medicine
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Brief Personal Introduction
• Long term critical view of psychiatric diagnosis
• 1990’s: Disgust with pharma and medicine
• Until ~2011: Adhered to medical
conceptualization of psychosis
• 2011: Anatomy of an Epidemic, Whitaker
– Evidence of long-term harms of drugs
– Introduced Open Dialogue
• 2012: International Meeting on the Treatment
of Psychosis, Tornio, Finland
• 2012-2014: Institute for Dialogic Practice
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Medicalization of Mental Health
• Psychiatry in 2015 -specializes in prescribing psychoactive drugs.
• We categorize experiences as illness and offer drug treatment.
• In US: focus on outcomes, increasing push towards rating scales, and
algorithms
• People have and will seek out drugs to alter mental state and mood.
– It is a good idea to have medical practitioners who are experts in
prescribing psychoactive drugs.
• Is there a way to prescribe drugs and
– Remain humane?
– Understand the context in which problems arise?
– Not accept that all human suffering subsumed under the category of
“mental illness” is best understood within the medical model framework?
• Open Dialogue/Need-adapted Approaches offer that path
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Focus For Today
• Describe drug-centered vs. disease-centered
model for understanding psychoactive drug
action.
• Discuss the application of drug –centered
model to antipsychotic drugs.
• Discuss medical model vs. needs adapted
approach.
• Propose the integration of need-adapted and
drug-centered approaches to create a humane
and humble psychiatry
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Disease-Centered vs Drug-Centered
Moncrieff, The Bitterest Pills, 2013
Disease- Centered
• Drugs correct abnormal
brain chemistry
• Drugs as medical
treatments
• The beneficial effects of
drugs are derived from
their effect on a
presumed disease
process
Drug Centered
• Drugs create abnormal
brain state
• Drugs as psychoactive
substances
• Drugs alter the expression
of psychiatric problems
through the
superimposition of druginduced effects
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Disease-Centered vs Drug-Centered
Moncrieff, The Bitterest Pills, 2013
Disease- Centered
Drug- Centered
• Main effects vs. Side Effects
• Drugs treat specific disease
• Drugs have broad
psychoactive effects
• Drugs may be useful in some
contexts
• More likely to consider long
term poor outcomes as a
consequence of natural
course of underlying disease
state
• More likely to consider
recurrence of illness than
withdrawal reaction
• More likely to consider
negative long term impacts of
drugs
• When drugs are stopped,
withdrawal occurs; more
likely to consider withdrawal
effects
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The Neuroleptic Drugs:
Paradoxes arising from a diseasecentered understanding of these drugs
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What is a neuroleptic?
• Label from French psychiatrists
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Synthesized in 1950’s
Neuro: nerve
Leptique: to seize
To take hold of the nervous system
Dries secretions – used in surgery
Laborit – caused indifference
First U.S. label: major tranquilizer
1960’s: “antipsychotic”
1960’s: neuroleptics block dopamine
1960’s: first line treatment for short-term symptom reduction
1970’s: recommended for long-term use
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Schizophrenia and Neuroleptic Drugs: What the textbooks say
Textbook of Psychopharmacology 2009: Schatzberg and Nemeroff
• Schizophrenia is a chronic condition
associated with long-term disability.
– Antipsychotic drugs recommended for long-term
to reduce relapse risk.
• “In normal volunteers, neuroleptics induce
feelings of dysphoria, paralysis of volition,
and fatigue.”
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Why long term treatment?
The Relapse Studies
• Studies in stabilized individuals who were
randomized to continue or stop the
medications
• Most conducted over 1- 2 years
– Relapse rate higher when drugs are stopped but
– We have tended to look only at symptoms and
less at functional outcome.
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The Relapse Studies
Subjects
stabilized on drug
~ 6 months
Drugs discontinued
Drugs continued
Relapse rate ~70%
Relapse rate ~20-40%
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The Relapse Studies
Leucht S et al Cochrane Database 2012
• Relapse rate
– drug 27%
– placebo 64%
– 24 RCT(s), n=2669, RR 0.40 CI 0.33 to 0.49
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36% do not relapse when drugs are stopped
27% relapse despite ongoing drugs
Only 37% are benefiting from ongoing drug treatment
Dilemma: we do not know who is in which group
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Relapse studies followed people for
up to 2 years.
Many people start taking them in
their 20’s or 30’s and take them for
decades.
What Happens After 2 Years?
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Non-Controversial Long-term Effects
Tardive dyskinesia
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Abnormal involuntary movements
Weight gain
Metabolic Syndrome
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High blood pressure
Diabetes
Obesity
Elevated cholesterol
Elevates risk of heart disease
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What do people care about when
they ask for our help?
Kerris Myrick:
“A home, a job, and a date on
Saturday night!”
Antipsychotic drugs and functional outcome
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A Drug-Centered Approach Predicts
Recent Findings on Functional
Outcome
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The Finnish Open Dialogue Outcomes
Svedberg, B et al Social Psychiatry,36:332-337,2001
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Functional Outcome:
Harrow Study
• Harrow: Followed patients with psychosis for
20 years
• Naturalistic Study
• Recruited from two Chicago hospitals
• 139 subjects
• 70 with Schizophrenia/Schizoaffective
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Global Adjustment of All Psychotic Patients
Worst
Outcomes
Schizophrenia On
Meds
Other Disorders:
On Meds
Schizophrenia: Off
Mds
Best
Outcomes
Other Disorders:
Off Meds
Source: Harrow M. “Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications.” Journal of
Nervous and Mental Disease 195 (2007):406-14.
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Critique
• Naturalistic study/Non-randomized study
• We always knew there were people who did
well.
• This does not prove that the drugs cause the
worse outcome.
• Those who were destined to do well stopped
their drugs.
• We need randomized controlled studies.
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Harrow, 2013
Long term outcome: psychosis symptoms
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Randomized Controlled Trial
drug vs. no drug:
Relapse rate
Functional outcome
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Wunderink Study
JAMA Psychiatry 70(9): 913-920, 2013
• 128 First Episode Psychosis
• 6 month drug stabilization
• Initial study compared maintenance drugs
(MT) vs. dose reduction/discontinuation (DR)
• At 2 years: higher relapse rate in DR group
• Followed up 7 years after study entry
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Wunderink:
7 year outcomes
• 103 at follow up
• Relapse rate – similar
– Drug continuation appears to delay relapse
• Recovery rate
– DR 40% vs. MT 17%
– Recovery = symptomatic and functional
remission
– Symptomatic remission was similar
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Wunderink
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Neuroleptic Drugs
Disease- Centered
• Drugs target specific
pathophysiology
• When drugs are stopped,
illness recurs
• Long term apathy is due to
the natural course of this
underlying illness.
Drug Centered
• Induce indifference
• This might be helpful at
times when a person is
psychotic
• When drugs are stopped
think about withdrawal
affects
• Drugs could lead to drug
induced apathy
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Need-adapted approaches and their
relevance to humane prescribing
practices
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Need-Adapted Treatment:
The precursor to Open Dialogue
• Developed in Finland during deinstitutionalization in
1980s.
• They invited families into team meetings.
• For many patients, this led to a resolution of the
problem.
• Basic psychotherapeutic attitude
– Acknowledges the potential value of different paradigms
– Flexible
– Democratic, less hierarchical
• In a strict medical model, the diagnosis drives the
treatment plan; in NAT the needs of the patient
drives the plan
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What Is Open Dialogue?
• Organization of a mental health care system.
• A particular form of psychotherapy – dialogic
practice.
• One can offer dialogic practice independent
of the system of care but that should not be
considered OD.
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OD: Seven Principles
• Systemic:
– Immediate help
– Network orientation
– Flexibility and mobility
– Responsibility
– Continuity
• Dialogic Practice
– Tolerance of uncertainty
– Dialogic process
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OD: 12 Key Elements of Fidelity
Olson, M, Seikkula, J, Ziedonis, D 2014
http://umassmed.edu/psychiatry/globalinitiatives/opendialogue/
Funded by Foundation for Excellence in Mental Health Care
• Two or more therapists
• Participation of Family or Social Network
• Open-Ended Questions
– What is the history of the meeting
– How would you like to use this meeting
• Responding to person's utterances
– Use client's words
OD: 12 Key Elements of Fidelity
Olson, M, Seikkula, J, Ziedonis, D 2014
Funded by Foundation for Excellence in Mental Health Care
• Emphasizing the Present Moment
• Eliciting Multiple Viewpoints: Polyphony
– Inner and outer voices
– Engaging absent members
• Creating a Relational Focus in the Dialogue
– Circular questions
• Who else agrees? Who wanted to come? Who didn't?
• Responding to Problem or Discourse as Meaningful
OD: 12 Key Elements of Fidelity
Olson, M, Seikkula, J, Ziedonis, D 2014
Funded by Foundation for Excellence in Mental Health Care
• Emphasizing client's Own Words and Stories – Not
Symptoms
• Reflection Among Professionals in the Meeting
– Professionals in room will talk amongst themselves
– Family can reflect on that
• Being Transparent
• Tolerating Uncertainty
– Professionals do not have answers but provide safety and
make contact with each person in the room
Need-Adapted
Medical Model
• Focus on individual
• Focus on psychopathology
• Family involved as needed
– Psychoeducation
• Offers treatments based
on diagnosis
– Tend to be more fixed
– Treatments seen in a more
technological wayindependent of the
relationship
Need Adapted
• Focus on social network from
outset
• Hold diagnosis lightly
• Hold uncertainty
• “Treatment” proceeds from
individual /network needs
– Flexible
– Psychological continuity
– psychotherapeutic attitude
• Respect
• Everyone has a valued voice
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Need-adapted approaches
instantiate recovery oriented care.
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Recovery Principles
From: Substance Abuse and Mental Health Service Administration
(SAMHSA)
• Hope: expect recovery
• Person-Driven: respect a person’s values and
wished
– For some people, reduction of symptoms may not be
paramount
• Many pathways: non-linear
– One (or two or three) relapse does not mean one is
chronically ill
• Holistic: encompasses all aspects of a person’s
life
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Recovery Principles: SAMHSA
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Peer Support
Relational: value of social networks
Culture: sensitivity to cultural context and diversity
Address Trauma
– What happened to you vs. what is wrong with you?
• Strengths/Responsibility
– Emphasize strengths
– Individual, family and community all have responsibility
• Respect: community and social acceptance
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Integration of drug-centered and
need-adapted approaches
• Humility and uncertainty
• Listen to what the person wants and values
– “Symptoms” may not be highest priority target
• Bring many perspectives into decision making
process - network orientation
• Take the time needed to acknowledge complexity
• Recognize the limitation of psychiatric diagnosis
• Accept that drugs are a tool and not a cure
– Drug action can not be separated from the relationship
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Slow Psychiatry
• Analogy to the slow food movement which pushes
back against industrial agriculture.
– Industrial agriculture values production above all else
– Slow food movement values the environment, the
experience, and cultural significance of food
• Consider our health in context of our environment,
our community.
• Constriction psychiatry’s purview in human distress
but
– This is not the same as 15 minute visits
– When we do get involved, go slow
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Resources
Here’s the link to an excellent paper entitled,
“Key Elements of Dialogic Practice” We have a
few copies at the front desk and it is also
available at www.howardcenter.org
http://www.umassmed.edu/globalassets/psychiatry/open-dialogue/keyelementsv1.109022014.pdf
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