Treating Madness With Drugs
There are two major pharmaceutical treatments for serious mental illness. For psychotic symptoms there are antipsychotics - also called neuroleptics. For mood disorders there are mood stabilisers, lithium being the most widespread. Many clinical trials on antipsychotics have shown that psychotic patients suffer fewer symptoms and later relapses when taking them. Indeed there are many people for whom medication provides their only effective lifeline.
But this is far from the whole story.
- There is little evidence that the drugs available, such as chlorpromazine, an antipsychotic and lithium carbonate, are actually specific to the categories of mental illness described in an earlier post.
- Despite advances in medication, studies into long-term outcomes of those with serious mental illness suggests that patients are not better off now than they were a century ago. (Recovery from Schizophrenia: Psychiatry and Political Economy)
- Many of the drugs used to treat psychosis and mania have very considerable side-effects. The physical side-effects include: about 50% suffer pronounced weight gain, about 33% have sexual dysfunction and 25% have uncontrollable tremors. The psychological side-effect include feeling restless, agitated and depressed.
- Finn, Bailey, Schultz & Faber (1990) looked at the subjective utility of antipsychotics in treating schizophrenia. They found that 41 patients experienced the side-effects of antipsychotics as just as bad as the symptoms they were supposed to be treating. Even more surprising, 34 psychiatrists making parallel judgements of utility agreed with them. That was until they were asked to consider the benefits of antipsychotics to society. Then the psychiatrists agreed that, for society, it was better to administer antipsychotics.
- Some evidence claims that a new generation anti-psychotics - called 'atypical antipsychotics' - show reduced side-effects but there is criticism of the studies that have been carried out.
- Geddes, Freemantle, Harrison & Bebbington (2000) analysed the data from 52 separate studies into the new 'atypical' antipsychotics. They found that their apparently reduced side-effects and increased effectiveness had been significantly exaggerated.
- New 'atypical' antipsychotic medications are considerably more expensive than their 'typical' counterparts. This is because the old drugs have passed out of patent and so can be manufactured generically and hence cheaply. The new drugs are much more profitable for their manufacturers.
- In the treatment of serious mental illness, the influence of large pharmaceutical companies, 'Big Pharma', cannot be ignored. The investments made in new drugs, especially in the new 'atypical' antipsychotics is often huge. Only one study into the effectiveness of clozapine is estimated to have cost the pharmaceutical company Sandos $5 million.
- Bentall claims that many psychiatrists are continuing to prescribe much higher levels of antipsychotics than is actually necessary, thereby causing many unnecessary side-effects.
Acknowledgement: This post is based, to a large degree, on ideas put forward by Richard P. Bentall in his book, 'Madness Explained'.
Utility of Categorising Mental Illness
Nevertheless, the categories, flawed as they are, do have practical utility. Indeed, the DSM-IV states that no assumption should be made that there are entirely separate categories of mental illness. Similarly it states no assumption should be made that there is a clear dividing line between the sane and the insane. Despite these disclaimers, what is the practical effect of categorisation?
The three most important uses of a classification system are in aetiology, treatment and prognosis; or where the illness has come from, what can be done about it and, what might happen to you. Perhaps the most important of these for the patient is prognosis: "What will happen to me?".
Bentall points out the difficulty of assessing the outcomes of people with a mental illness because they are often variable across different domains. Clinical outcome attempt to measure the persistence of symptoms, occupational outcomes measure the ability to keep a steady job, while social outcomes measure a patient's network of relationships.
Despite this, Bentall reports 3 general findings from the evidence on the outcomes of those diagnosed as psychotic.
- The course of psychosis is unpredictable. The only fairly solid finding is that the occurrence of psychotic episodes seem to increase the probability that they will occur again in the future. This process is known as kindling.
- There is little predictive power for individual patients from a diagnosis. This conclusion comes from the evidence that there is enormous variability in the outcomes of people with the same diagnosis.
- Patients with a diagnosis of manic depression have a better outcome, on average, than those with a diagnosis of schizophrenia. Despite this, evidence has shown there is no sharp delineation between the two diagnoses. Kendell & Brockington's (1980) study showed the difference manifested itself in a sliding scale. The more a person's symptoms were typical of schizophrenia rather than an affective disorder, the poorer was the outcome.
Moving away from the patient and thinking of the utility of these categories for the academic, though, how do the fuzzy categories affect research? At first sight, it seems that having a number of categories of mental illness is a serious advantage in research. Before the standardisation introduced in the 70s by categorisation, researchers in different places used different definitions so it was difficult to compare results and theories. Categories provide a common language - and that can provide synergy through a common understanding.
The problem is, over time, categories become embedded within the collective consciousness. It becomes accepted, whether explicitly or implicitly, that research can only be conducted with reference to, and with the use of, the official categories. This clearly limits the possibilities for progress. Categories that have, theoretically, been found wanting, persist simply because the effort required to change that many minds is too great.
A related and more sociological idea is the effect of categorisation on the individual. There is an element by which once people receive a label, they then define themselves, and are defined by others, in relation to that label. A person suffering from manic depression becomes less a person than 'a manic depressive'. If this category is theoretically flawed, then what does this mean about how those suffering mental illness are being defined by others and defining themselves?
More to come about aetiology and treatment in further posts.
Acknowledgement: This post is based, to a large degree, on ideas put forward by Richard P. Bentall in his book, 'Madness Explained'.Labels: Depression
Classifying Madness: Criticisms and Alternatives
Richard P. Bentall, a clinical psychologist and Professor of Experimental Clinical Psychology at the University of Manchester, recently published 'Madness Explained', an attempt to wrestle descriptions of madness away from rigid categorisation as well as provide an alternative. In this, the first of a series of posts, I will discuss Bentall's criticisms of the major categories of mental illness.
The Categorisation of Madness
Traditional psychiatric practice has placed madness in a number of different categories. Two well-known examples of these categories are bipolar disorder - what used to be called manic depression - and schizophrenia. These categories, along with a host of others, are used by many mental health professionals as both a shorthand description of mental illness, and a guide to treatment.
Reliability and Validity
There are two simple criteria used by scientists to measure, amongst other things, whether a system of diagnosis is useful: these are its reliability and its validity. Reliability refers to whether different doctors give the same diagnosis to the same person with the same symptoms. The validity of a diagnosis is a measure of whether it describes what it is supposed to describe. In other words, if you were a doctor and I told you someone you are about to meet is schizophrenic, then, broadly, you would not be surprised by the symptoms they exhibited.
Bentall argues psychiatric diagnoses are neither particularly reliable, nor particularly valid. Here is why.
Not Reliable
Reliability studies of different classification systems are many and varied. One typical study is that carried out by, amongst others, Robert Spitzer, a strong proponent of the DSM classification system. This study found only modest agreement between specially trained psychiatrists of the same patients - and these results were obtained under ideal conditions, probably not representative of the average busy clinician.
To pick any single study as representative of the whole is not very scientific. Bentall, however, who has evaluated many of them, argues that, in general, the research has been less than convincing. Many studies even fail to reach the minimum statistical criteria for reliability.
Not Valid
While there are 201 different diagnoses in the DSM-IV, arguably the most established distinction in psychiatric classification systems is between schizophrenia and bipolar disorder. To question this distinction is not merely to attack a straw man - the difference is fundamental. Nevertheless the research has seriously questioned whether there is a clear dividing line between the two diagnoses.
Kendell & Gourlay (1970) examined the symptoms of nearly 300 patients with diagnoses of either schizophrenia or manic depression - now referred to as bipolar disorder. If the prevailing system of classification is correct then we should see two distinct groups of symptoms. What the study actually found was a continuum of symptoms, with most patients falling in the middle. They had some symptoms typical of schizophrenia and some typical of manic depression. Subsequent research has provided similar evidence of the poor validity of current systems of classification.
So What?
Why, then, is it important that classification systems are valid and reliable? What are the alternatives? Can madness be cured? All questions for future posts...
Further related discussion on MindHacks.Labels: Depression
Benefits of Informal Psychological Helping
Recently I wrote about the difficulties of evaluating mental health phone lines. Following on from this I've been taking a look at research into how the training of therapists affects outcomes. Some of this research provides encouraging reading for helpers with less training - although by round-a-bout means.
There has been a large amount of research into the effectiveness of psychological therapies. Much of it - and bear in mind this is a massive generalisation - has shown that 'the talking cure' is effective. A large part of this research has examined whether a therapist's training affects outcomes. It has been found - disturbingly for professional therapists - that there is not much difference between those with and without specific training. Indeed, sometimes the 'para-professionals' do better. While this is not exactly solid proof that helplines are helping, it certainly suggests the chances are good.
Some mental health helplines, such as Samaritans, now also accept email, as well as trialling text messaging. Can this be helpful to people?
Pennebaker (2003) explains the advantages to health that have been found from simply writing about emotional problems. It seems that even this simple act, while painful to carry out, may have long-term benefits. Still, the writing has to be done in the right way and research is just starting into what that might be. Three particular factors have so far been found to be important:
There has been a large amount of research into the effectiveness of psychological therapies. Much of it - and bear in mind this is a massive generalisation - has shown that 'the talking cure' is effective. A large part of this research has examined whether a therapist's training affects outcomes. It has been found - disturbingly for professional therapists - that there is not much difference between those with and without specific training. Indeed, sometimes the 'para-professionals' do better. While this is not exactly solid proof that helplines are helping, it certainly suggests the chances are good.
Some mental health helplines, such as Samaritans, now also accept email, as well as trialling text messaging. Can this be helpful to people?
Pennebaker (2003) explains the advantages to health that have been found from simply writing about emotional problems. It seems that even this simple act, while painful to carry out, may have long-term benefits. Still, the writing has to be done in the right way and research is just starting into what that might be. Three particular factors have so far been found to be important:
- Use of positive emotion words is helpful
- Some use of negative emotion words
- Use of insight words is helpful
Labels: Emotion
Does Cannabis Cause Psychosis?
An excellent balanced report in The Independent:The Independent
"First, there has been no increase in schizophrenia in this country despite a massive increase in cannabis smoking. Second, there is no evidence that cannabis-growing populations such as Jamaica have a higher incidence of psychosis. Third, you can show an association [between the drug and the illness] but you can't show a cause."
The Independent
Do Helplines Help?
There are a number of problems with many helplines. First and foremost they are often staffed by unpaid volunteers. While standards of training and selection are excellent where I work, volunteers do not claim to be professional. They do what they can with the limited resources available.
Helplines are often quite isolated from the mental health services offered by the NHS. There is strength to be derived from independence, but this disconnect can be disabling in many different ways.
With these problems in mind and, understandably in our scientific age, there is a great appetite for evidence. Just as there should be. Unfortunately the way in which helplines operate does not lend themselves to easy evaluation. For one thing callers are normally assured that their confidentiality is paramount. It can be difficult to reconcile this confidentiality with the processes of research.
Despite this, Rethink, the charity concerned with serious mental ill health, recently carried out a study examining two helplines: Focusline and Lincsline. Both of these services are 24-hour helplines serving a limited geographical area, both with some degree of integration with local statutory services. The positive effects found for the helplines included users reporting a reduction in their anxiety levels, a feeling of greater control and a decrease in isolation.
Unfortunately this is not the whole story. The methods used to investigate these services do suffer some problems common to psychological research. It is cross-sectional - this means it only asks people their opinion once and relies on their memory. This is considered comparatively weak when set alongside a longitudinal study which tracks changes across time.
There are also many problems inherent in asking people who actually use a service what they think of it. At the simplest level is the tendency for people to work out what the researcher wants and give it to them. In this case the researchers, with the best of intentions, have a vested interest in showing helplines are effective and may well have biased the results accidentally.
So to return to the original question: do helplines help? There's a stack of anecdotal evidence that screams 'Yes!' but unfortunately the hard evidence is not there yet. At present it is an area where common sense prevails - people are doing what seems like the right thing. Unfortunately it's easy for wishful thinking to cloud judgement.
Note: This is based on the research summary as the full report is not yet available online.
Rethink