Treatment (Part 1)

In the conventional medical model, psychotic symptoms lead to dysfunction and, therefore, deserve treatment; interventions intended to reduce the symptoms and their impact on social function.

The recognized standard for treatment of psychosis in most developed countries of the world consists of antipsychotic medications coupled with support from professionals, family and friends and, in some cases, psychotherapy.

Before delving into the details of treatment it is worth asking whether the recognized standard treatment is always necessary and appropriate. There are two lines of logic that support the idea that the current standard treatment is not always necessary and appropriate.

The first logic is that there are a significant number of people who are, by virtue of their ability to function in society, considered ‘healthy’ (in terms of psychiatric conditions) and yet experience psychosis. The most common situation is a person who has auditory hallucinations. A recent study suggests that 10-15% of the general population report having auditory hallucinations (usually hearing a voice), from time to time. There is even an organized group of such people in the Netherlands who strongly believe the voices they hear are of value to them, and an important part of their life and who they are. These people are not at all interested in ‘treatment’.

The second line of logic comes from clinicians who believe that psychosis, even when it is severe enough to cause considerable social dysfunction, will, for at least some people, resolve or improve without medication if the person is in a supportive therapeutic environment.

Published research in recognized scientific journals examining the therapeutic environment approach for first episode psychosis is rare. One model, called ‘Soteria’ was developed in California in the 1970’s. Outcomes after one year were reported to be the same as for a comparator sample of patients receiving the convention care of the time. Unfortunately both groups had relatively poor outcomes by today’s standards. More recently a group in Berne has used a modified Soteria model, allowing some use of medication. (Soteria references: Carlton et al; Schizophr Bull. 2008 Jan;34(1):181-92. and Ciompi and Hoffman, World Psychiatry. 2004 Oct;3(3):140-6).

More recently a group in Finland tried to minimize use of medication in working with first-episode psychosis patients. They provided an intensive, high quality psychosocial intervention to two groups of patients. One of the groups received antipsychotic medication as usual while the other received the minimum medication consistent with ethical clinical practice. They reported that 40% of the patients in the minimal medication group recovered from the episode without ever taking anti-psychotic medication. (Finland references: Lehtinen et al Eur Psychiatry. 2000 Aug;15(5):312-20 and Bola et al J Nerv Ment Dis. 2006 Oct;194(10):732-9)

The overall lack of research makes it difficult to interpret these isolated findings. It has long been appreciated that there is a very wide range in terms of the inherent severity of conditions involving psychosis. It is not unreasonable to think that some young people experiencing a first episode of psychosis might have a relatively mild condition that could resolve without antipsychotic medication. It is likely, as well, that many people have gone through a psychotic episode and returned to social functionality without ever coming to the attention of the health care system.

There are two practical problems to keep in mind. First, very few, if any clinical services have the resources and expertise to provide intensive, high quality therapeutic environment based support of the kind provided in the Finland study. The second is that, with current knowledge, we cannot determine with sufficient accuracy, at the time of the psychosis emerges, whether an individual has a relatively mild, or relatively severe condition. In a future blog I will talk about some of the research that might help sort that out.

In the meantime, the medical-legal environment in the developed nations (certainly in North America) is such that a psychiatrist who failed to recommend antipsychotic medication to a person with significant psychosis (impacting on their social function) would certainly face malpractice charges.