Imagine that, after feeling unwell for awhile, you visit your physician. "Ah," says the doctor decisively, "what you need is medication X." “That’s great”, you say. "Yes," the doctor replies, "it’s often pretty effective, though there can be side effects. You may gain weight. Or feel drowsy. And you may develop tremors reminiscent of Parkinson’s disease..." Warily, you glance at the prescription on the doctor’s desk, but she hasn’t finished. "Some patients find that sex becomes a problem. Diabetes and heart problems are a risk. And in the long term the drug may actually shrink your brain…"
If this scenario sounds far-fetched, it is in fact precisely what faces people diagnosed with schizophrenia. Since the 1950s, the illness has generally been treated using so-called neuroleptic or anti-psychotic drugs—which, as with so many medications, were discovered by chance. A French surgeon hunting treatments for surgical shock found that one of the drugs he tried—the antihistamine chlorpromazine—produced powerful psychological effects. This prompted the psychiatrist Pierre Deniker to administer the drug to some of his most troubled patients. Their symptoms improved dramatically, and a major breakthrough in the treatment of psychosis seemed to have arrived.
Many other anti-psychotic drugs have followed in chlorpromazine’s wake and today these medications account for almost 5 percent of total drug spend in the US and up to 10 percent of psychiatric prescriptions in the UK’s national health service. They are costly items: in the US, more than $13 billion is estimated to be spent on neuroleptics each year. The UK spends more on these medications than it does for any other psychiatric drug, including antidepressants.
Since the 1950s the strategy of all too many mental health teams has usually been a simple one. Assuming that psychosis is primarily a biological brain problem, clinicians prescribe a neuroleptic medication and everyone does their best to get the patient to take it, often for long periods. There’s no doubt that these drugs can make a positive difference, reducing delusions and hallucinations and making relapse less likely—provided, that is, the individual sticks with the meds.
Yet therein lies a very considerable problem, because dropout rates are high. Partly this is because individuals sometimes don’t accept that they are ill. But a major reason is the side effects: these vary from drug to drug, but they’re common and for many individuals worse than the symptoms they are designed to treat. Moreover, anti-psychotics don’t work for everyone. All in all, it’s estimated that after six months as many as 50 percent of patients are no longer following their prescription, either taking medication haphazardly or not at all.
The conventional treatment for this most severe of psychiatric illnesses, then, is expensive, frequently unpleasant for patients, and not always effective even for those who actually carry on taking the drugs. But it’s what we’ve relied upon—which helps explain why the results of a clinical trial, published in The Lancet, have generated so much interest and debate among mental health professionals. A team led by Professor Anthony Morrison at the University of Manchester randomly assigned a group of patients, all of whom had opted against anti-psychotic medication, to treatment as usual (covering a range of non-pharmaceutical care) or to treatment as usual plus a course of cognitive therapy (comprising an average of 13 sessions over nine months, plus four booster sessions over the next nine months). Drop-out rates for the cognitive therapy were low, while its efficacy in reducing the symptoms of psychosis was clear and apparently comparable to what medication can achieve.
What is cognitive therapy for schizophrenia? At its core is the idea that the patient should be encouraged to talk about their experiences—just as they would for every other psychological condition. Psychosis isn’t viewed as a biological illness that one either has or does not have. Instead, just like every other mental disorder, psychotic experiences represent the severest instances of thoughts and feelings (notably delusions and hallucinations) many of us undergo from time to time.
Working together, the patient and cognitive therapist develop a model of what’s causing the psychotic experiences, and why they’re recurring. These factors will vary from person to person, so what’s produced is a bespoke account of the individual’s experience, which is then used to guide treatment. For example, a person so worried by paranoid fears that they won’t set foot outside might be helped to trace the roots of their anxiety in past experiences; to gradually test out their fearful thoughts; and to learn to manage their anxiety while getting on with the activities they enjoy. An individual troubled by hearing voices will be helped to understand what’s triggering these voices, and to develop a more confident, empowering relationship with them.
These are relatively early days. Nevertheless, most of the many meta-analyses of CT’s efficacy for psychosis, when added to standard treatment, have indicated definite (albeit modest) benefits for patients, with the most recent showing that CT is better than other psychological treatments for reducing delusions and hallucinations. The latest guidelines published by the UK’s National Institute for Health and Care Excellence recommend it for those at risk of psychosis and, when combined with medication, for people with an ongoing problem, but not everyone is convinced (the most prominent critic has likened it to the vogue in the 1940s and 50s for treating schizophrenia by means of insulin-induced coma). And though the research covered in The Lancet is encouraging, it was small scale. CT for psychosis is still very much evolving, and we think that evolution should prioritise three key areas.
First, we must focus on understanding and treating individual psychotic experiences. As we’ve reported previously in Know Your Mind ("What's Wrong with the Concept of Schizophrenia?"), there’s increasing reason to doubt the usefulness of the diagnosis “schizophrenia”: the term has been used as a catch-all for an assortment of unusual thoughts and feelings that often have no intrinsic connections, and which aren’t qualitatively different from those experienced by the general population. Each psychotic experience may require a tailored treatment.
Second, we must build on the recent transformation in understanding the causes of psychotic experiences, taking one factor at a time (insomnia, say, or worry), developing an intervention to change it, and then observing the effects of that intervention on an individual’s difficulties.
And finally, we must listen to what patients want from their treatment—for example, by focusing on improving levels of wellbeing (which tend to be very low among people with schizophrenia).
For too many people diagnosed with schizophrenia, the drugs don’t work—or, at least, not in a way that makes them a tolerable option. As the psychiatrist Robin Murray has commented: “So what to do for patients with continued psychotic symptoms who don’t want to take antipsychotics? Until now little was done except lecture them on how silly this was, with the usual result that the patients would simply stop attending.” If the real promise of cognitive therapy can be fulfilled, we may at last have a genuinely effective, relatively cheap, and side effect free alternative. Watch this space.
Daniel and Jason Freeman are the authors of Paranoia: the 21st-Century Fear. On Twitter they are @ProfDFreeman and @JasonFreeman100. A version of this blog first appeared in The Guardian: http://www.theguardian.com/science/blog/2014/mar/07/treat-schizophrenia-antipsychotics-drugs-cognitive-therapy