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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 2 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 3 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 4 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 5 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 6 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 7 The Neuroleptic Drugs: Paradoxes arising from a diseasecentered understanding of these drugs 8 What is a neuroleptic? • Label from French psychiatrists – – – – – – • • • • • 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 9 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.” 10 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. 11 The Relapse Studies Subjects stabilized on drug ~ 6 months Drugs discontinued Drugs continued Relapse rate ~70% Relapse rate ~20-40% 12 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 • • • • 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 13 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? 14 Non-Controversial Long-term Effects Tardive dyskinesia Abnormal involuntary movements Weight gain Metabolic Syndrome High blood pressure Diabetes Obesity Elevated cholesterol Elevates risk of heart disease 15 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 16 A Drug-Centered Approach Predicts Recent Findings on Functional Outcome 17 The Finnish Open Dialogue Outcomes Svedberg, B et al Social Psychiatry,36:332-337,2001 18 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 19 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. 20 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. 21 Harrow, 2013 Long term outcome: psychosis symptoms 22 Randomized Controlled Trial drug vs. no drug: Relapse rate Functional outcome 23 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 24 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 25 26 Wunderink 27 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 28 Need-adapted approaches and their relevance to humane prescribing practices 29 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 30 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. 31 OD: Seven Principles • Systemic: – Immediate help – Network orientation – Flexibility and mobility – Responsibility – Continuity • Dialogic Practice – Tolerance of uncertainty – Dialogic process 32 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 36 Need-adapted approaches instantiate recovery oriented care. 37 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 38 Recovery Principles: SAMHSA • • • • 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 39 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 40 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 41 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 42