Adrian Preda, M.D.

Adrian Preda M.D.

A Psychiatrist at Large

Schizophrenia, Neuroleptics, and the Illusion of Treatment Resistance

Don't ever give up hope!

Posted Mar 08, 2012

We tend to think of schizophrenia as a chronic and unrelentlessly progressing mental illness. The data indicates that for a majority of patients who meet diagnostic criteria—meaning presenting with a combination of abnormal perceptions (mostly auditory hallucinations), delusions, disorganized thinking or behavior, as well as a lack of interest, motivation, and social isolation—for about six months the course is chronic and the prognosis is fair.

While this is might be true for a number of patients I don't think there is any therapeutical benefit in emphasising the negative and presenting the numbers as representing a life sentence. Even if 60% of patients do have a chronic course, that means that about 30-40% have real chances for recovery. Why not emphasize that our knowledge does not allow at this time for a 100% guaranteed prediction? Implying that, for all we know, the patient we are seeing might be in that percentage of the population that stands a good chance to recover and return to a fully productive life.

Why do this? I find that giving hope is one of the most important ingredients of any succesful medical intervention. At the same time, I don't belive that it is either helpful or in the spirit of the hippocratic oath to take away hope. So between saying "you have a 70% chance of never reaching your dreams" or "you have a 30% chance of making it through this and being fine or even better—as you've learned a lot" I choose the latter.

That being said, there is a group of patients with schizophrenia that do not do well and end up with a significant disability no matter what we try. That's when doctors talk about treatment resistance. When it comes to schizoprenia, it means that many different medications have been tried and nothing really worked. Further, the implication is that there is not much else we can offer, intervention wise. In other words, even if not stated so, treatment resistance is an admission of failure.

And then a new study comes out teaching us that all this gloominess might not be warranted and there is never a good reason to completely give out hope.

What am I talking about?

Here it is:

Persistent negative symptoms in schizophrenia are usually regarded as highly indicative of treatment resistance. When medications don't really work, psychotherapy is not even seen as worth trying (as the brain is the substrate for the mind, right, and when brain directed interventions don't work, what's to expect from mind directed interventions?). However, this new study that is hot off the press, indicates that when specialized psychological support and care is added to standard treatment, low-functioning patients with severe dysfunction might actually get better. But these are the very patients who are not suppossed to get better, remember?

The study has a number of limitations (that I discuss in more detail here), however, the bottom line is that, regardless, this new report is another reminder that taking away hope should never be part of our expert recommendations.