All that is solid melts into air

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All that is solid melts into air

• Soteria and other Minimal Medication Approaches
  to the Treatment of Psychosis
• Tim Calton Lecturer in Psychiatry - UoN

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Aims

• The View from Now
• Historical overview
• The Soteria paradigm
• Other approaches
• Choice and Capacity

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The View from Now solid evidence?

• during an acute episode, antipsychotic drugs are
  necessary (NICE, 2002)
• cognitive behavioural therapyand family
  interventions should be available..
• Neuroleptics produce statistically significant
  improvements in schizophrenia symptoms (Davis,
  1976)
• Neuroleptics prevent relapse (Davis et al, 1980)
• Neuroleptics reduce Duration of Untreated
  Psychosis (Loebel et al, 1992)

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Counterpoint

• Two-thirds of people hospitalised in
  enlightened settings make good social
  recoveries (Bleuler, 1968 Ciompi, 1980)
• Two-thirds of back ward patients from Vermont
  State Hospital were living successfully in the
  community 30 years after discharge. Most had
  stopped taking neuroleptic medication (Harding et
  al, 1987)
• People diagnosed with good prognosis
  schizophrenia may be more likely to return to
  hospital (and return sooner) if treated with
  neuroleptic medication (Rosen et al, 1968)

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A case in point

• Rapaport et al (1978)
• 80 young males with Dx of schizophrenia randomly
  assigned to CPZ or placebo on admission
• Post-discharge treated with or without active
  medication depending on condition and concordance
• Antipsychotics are not the treatment of
  choiceif one is interested in long-term clinical
  improvement

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Other issues

• Non-concordance is a major problem with all
  neuroleptic medication (Oehl et al, 2000)
• Non-response (treatment resistance) is
  relatively common (Brown Herz, 1989)
• Aversion to medication oriented services may
  prolong DUP (Warner, 2005)
• Side-effects from all types of neuroleptics are a
  major cause of distress and complications
  (Tardive Dyskinesia - Llorca et al, 2002
  Extra-pyramidal side-effects - Geddes et al,
  2000)
• Neuroleptics can kill (neuroleptic malignant
  syndrome - Jeste Naimark, 1997 heart
  irregularities - Zarate Patel, 2001)

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Conclusion

• Although some individuals may experience a net
  benefit, an objective overall cost-benefit
  analysis would likely be negative or at best
  neutral if side-effects, drug-drug interactions,
  deaths, effects of concurrently prescribed
  anticholinergics, and psychosocial consequences
  were weighed accurately.
• The psychosocial consequences of neuroleptics
  include stigmatization, induction of a passive
  attitude towards ones disorder, dependency on
  government programmes for medication, and
  difficulty driving vehicles or finding
  employment. (Read et al, 2004, p110)

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Historical overview

• Gheel
• Moral treatment
• The Retreat
• Kingsley Hall
• Villa 21

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Psychosis in the Developing World

• US spending on treatment of schizophrenia in 1990
  16 billion (Norquist et al, 1996) 0.3 of
  GDP
• Psychiatric care a low priority in most
  developing countries
• International Pilot Study of Schizophrenia (WHO,
  1979), Determinants of Outcome in Severe Mental
  Disorders (Jablensky et al, 1992)
• Revealed that the outcome for people experiencing
  psychosis in developing countries was
  substantially better than in the developed world
• Authors concluded that differences in
  socio-cultural factors had the greatest
  explanatory power for this finding

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The Soteria Paradigm
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Soteria In Detail

• People aged 15-32 with a diagnosis of
  first-episode schizophrenia, not married, and
  no more than one previous hospitalisation of less
  than 4 weeks
• Small, community-based therapeutic milieu where
  majority of staff non-medically trained
• No or low dose antipsychotic medication (no
  coercion)
• Phenomenological relational style (being
  with) requires unconditional acceptance of the
  experience of others as valid and understandable
  within the historical context of each persons
  life, even when it cannot be consensually
  validated
• Preservation of personal power, social networks,
  and communal responsibilities emphasis on the
  interpersonal
• Most importantly, the atmosphere must be imbued
  with hope (Mosher, 2004)

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Soteria the evidence

• Systematic review (Calton et al, 2007)
• 3 RCTs (2 from US, 1 from Switzerland) 223
  patients follow-up at 6 weeks and 2 years
• At least as effective as conventional treatment
  at 6 weeks (24 took medication as opposed to
  100 of control group)
• At two years there were significant advantages
  for Soteria with regard to global
  psychopathology, composite outcome, and living
  alone or with peers
• 43 used no neuroleptics at all (drug free
  responders)
• Soteria Berne showed that these results could be
  achieved at 10-20 lower overall cost than
  conventional treatment

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Conclusion

• The apparent comparable efficacy between Soteria
  and TAU suggests that there are few or no
  disbenefits to being treated in a setting with
  low or no use of neuroleptic medication when
  supported by non-medically trained staff
• The Soteria paradigm seems more likely than
  standard treatment to approximate the supportive
  and collectivist socio-cultural context often
  suggested as responsible for better developing
  country outcomes

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Other approaches (1)

• Carpenter et al (1977)
• 49 people diagnosed with good-prognosis
  schizophrenia, a record of adequate prior work
  and social functioning, and a short history of
  illness, were arbitrarily assigned to be treated
  with or without medication
• Antipsychotic medication may make some
  schizophrenic patients more vulnerable to future
  relapse than would be the case in the natural
  course of their illness

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Other approaches (2)

• Lehtinen at al (2000)
• 106 people admitted for treatment of a
  first-episode of psychosis (excluding affective
  psychoses) in Finland
• At half of the centres patients received only
  minimal doses of medication, and nearly half
  received no neuroleptic medication at all over
  the two-year study period
• At 5 year follow-up 37 of experimental
  participants had still not used medication,
  whilst 88 had not been hospitalised (68 TAU)

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Other approaches (3)

• The Parachute Project Cullberg et al (2002)
• An extension of Need-Adapted treatment with an
  emphasis on minimising doses of neuroleptic
  medication
• Compared a group of people experiencing
  first-episode psychosis (n253) with prospective
  (n64) and historical (n71) controls
• 1 year follow-up showed experimental group had
  fewer inpatient bed days than controls and
  received lower doses of antipsychotic medication

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Other Approaches (4)

• The Open Dialogue Approach Seikkula et al
  (2003)
• Part of Need-Adapted model aims to treat
  psychotic people at home
• Treatment involves mobilising the persons social
  network and starts within 24 hours of first
  contact
• Emphasises continuity of care and an active
  attempt to generate dialogue to construct a
  meaningful narrative of the experiences
• Compared to a TAU group, Open Dialogue treated
  people were hospitalised for fewer days, family
  meetings happened more frequently, and
  neuroleptic medication was used in fewer cases.

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Conclusion

• Neuroleptic medication may well not be necessary
  for every person either experiencing psychosis or
  diagnosed with (first episode) schizophrenia
• There are many good reasons for considering
  alternative approaches to helping people in this
  context

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Choice and Capacity

• Patient choice central to UK governmental
  healthcare reforms (DoH, 2003)
• An adult has the capacity to decide whether to
  consent to, or refuse, proposed medical
  intervention, unless it is shown that that they
  lack said capacity (GMC, 1998)
• Unless you have been diagnosed with a mental
  disorder and are detained under the Mental Health
  Act
• 75 of people diagnosed with schizophrenia
  understand information and make decisions similar
  to comparison groups around issues of consent
• It is yet to be demonstrated whether patient
  choice will be fully embraced by psychiatry
  (British Journal of Psychiatry editorial July
  2007)

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Where is Hope?
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ANY QUESTIONS?

• tim.calton_at_nottingham.ac.uk