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Treatment outcomes of chronic psychosis and the future of psychiatry

Treatment outcomes of chronic psychosis and the future of psychiatry

Theatment outcomes in chronic psychosis may define the future of psychiatrty

Treatment outcomes of chronic psychosis and the future of psychiatry

                                                          Adonis Sfera, MD

                                                         Patton State Hospital

Nothing is more challenging in psychiatry than the management of chronic psychosis. Indeed, this issue may shape the future of psychiatry in the long run. Today there is excessive pessimism in the field about our ability to influence the outcome of chronic schizophrenia, for example. In my opinion we need a long term vision with emphasis on prevention, early detection and a good dose of optimism.

Winston Churchill once said: “for my self I am an optimist – it does not seem to be much use in being anything else.” Indeed, our perspective on life makes all the difference. For example, some people see the recent government shut down from the “gloom and doom” perspective. Others see it as a proof that American democracy is still vibrant and healthy. After all very few countries in the world would function normally if the federal government took two weeks leave of absence. Yet, in the US local and state governments were about their business as usual and so did the majority of citizens. We had no social unrests, no mass protests and this is why the US is envied by most of the world.

Now, how does this relate to us, psychiatrists? Or, better yet if psychiatry took a leave of absence from the future what would be different and who would notice the difference?

In order to answer this question we need to have an ability to draw fine distinctions between psychiatric treatments in general and the treatment of chronic psychosis such as schizophrenia in particular. There is surely a virtue in blunt, simple thinking and pronouncements. Simplifying complex patterns allows people to see the underlying critical truth they might otherwise have missed. But because chronic psychosis is by nature complex, too much simplification in this area leads to an unsophisticated view of our discipline.

Being mindful of our limitations

Here is a short history of chronic psychosis: at the turn of the last century there were large public institutions for tuberculosis, leprosy and chronic psychiatric illnesses, especially schizophrenia. After enough progress was made in infectious diseases, institutions for TB and leprosy became obsolete. When chlorpromazine was discovered in 1954 there was hope that deinstitutionalization would occur in psychiatry as well. This belief led to the Community Mental Health Act (passed by the U.S. Congress in 1963). However, as of today public institutions treating chronic psychoses remain standing. To put it simply, treatment of these conditions has not made enough progress as to warrant the abolition of hospitals for their long term treatment.

At this point you may not agree with me, after all antipsychotics are very efficacious, aren’t they? Indeed, they are, but only for positive symptoms and acute psychosis. If you filter out the noise and the spin of the industry, this is what remains standing: neither first nor second generation antipsychotic medications do much for returning our patients to leading productive and healthy lives (1). In other words we are unable to influence the chronicity or disability caused by schizophrenia and other chronic psychoses and we should acknowledge our limitations.

In order to take a long view at psychiatry, let’s pause for the moment in the shade of an old olive tree on the road from Athens to Megara in Ancient Greece. It also happens that Socrates sits there resting from the scorching sun of Attica. Being mindful of our limitations, explains Socrates, is part of the Socratic method of thinking. This approach has a long pedigree, dating all the way back to 327 B.C. and the publication of the world’s first work on introspection: Plato’s Apology.

As you may recall, Socrates was on trial – and ultimately sentenced to death – for corrupting the youth of Athens. He had done no such thing, of course. What he had done was educate and inspire students, teaching them to challenge arguments from authority and question what they knew to be true. In the process, he frustrated and embarrassed many powerful people with his persistent line of questioning, known today as the Socratic method.

Why was he such a gadfly? According to the Apology, the oracle at Delphi had pronounced Socrates the wisest man in Athens. Yet no one was more astonished – or more disbelieving – than Socrates himself. So he immediately set out to disprove the oracle by finding a wiser man. He started by examining a politician with a reputation for great wisdom (and the ego to go with it). Not only was the pol unable to justify his beliefs, he resented Socrates’ challenge to his authority. “So I left him,” Socrates laments, “saying to myself, as I went away: Well, although I do not suppose that either of us knows anything really beautiful and good, I am better off than he is, for he knows nothing, and thinks that he knows; I neither know nor think that I know. In this latter particular, then, I seem to have slightly the advantage of him. Then I went to another who had still higher pretensions to wisdom, and my conclusion was exactly the same. Whereupon I made another enemy of him, and of many others besides him” . In the end, Socrates discovered he was indeed the wisest man in Athens. Not because of how much he knew, but because he understood how much he didn’t know.

Socrates makes an important point. He tells us to acknowledge our limitations, to face up to our own ignorance. How much we need Socrates in psychiatry today. The tectonic plates under our discipline are shifting and we are called to adapt our thinking and practices. Armed with the Socratic method let us bid farewell to Socrates and take a long view at psychiatry vis-à-vis the treatment of chronic psychoses. Two pillars appear immediately in our sight: prevention and rehabilitation both anchored in neuroscience.

Prevention – the first pillar of the future treatments

Throughout the past two centuries we have been treating psychosis after we diagnose it, meaning after the fact. You would not start treating schizophrenia in the absence of delusions, hallucinations or negative symptoms, right? Even our diagnostic criteria insist on “continuous signs of the disturbance persisting for at least six months”. However a look at preventative interventions demonstrates that in medicine more progress was made by preventative as opposed to curative interventions. Hand washing saved more lives than antibiotics. More than 60% reduction in mortality due to coronary artery disease (1.1 million deaths each year) was achieved by controlling the blood pressure, diet and cholesterol.

Treating psychosis after the fact may be too little and too late. For example, in neurodegenerative diseases such as Parkinson’s disease, Alzheimer’s disease and Huntington’s disease changes in the brain precede changes in behavior sometimes by more than a decade. In Parkinson’s disease symptoms only emerge after 80% of dopamine cells have been lost (2).

Birth cohort studies demonstrate that individuals who develop schizophrenia later on differ from the general population on a range of developmental indices some of which occur as early as the first year of life, so why wait?(3)

But how can we proceed to treat psychosis prior to its onset? As a psychiatrist my knee-jerk reaction is to think: “shall I start prescribing medications before someone shows signs or symptoms of psychosis?” Again, too much simplification leads to an unsophisticated view of life. Who mentioned medications?

Diagnosis of schizophrenia in its prodromal phase is done by psychological testing such as Structured Interview of Prodromal Symptoms (SIPS), Neurocognitive Test Batteries for at Risk Mental States (ARMS) or Cognitive Perceptive Basic Symptoms (COPER). These tests were found to have a positive predictive power for conversion to psychosis of 75% (2).

What about prodromal treatment? Here too the approach is psychological. Cognitive rehabilitation (or remediation) is believed to be a key component of early intervention programs in the prodromal phase of the disease (4).

Maintenance treatment of chronic psychosis: the second pillar of future treatments

Throughout our training we were thought that maintenance antipsychotics treatment should never be stopped, after all you would not discontinue insulin in a diabetic type one patient, would you? All of us can recall schizophrenic patients from our practices who went off their medications and suffered disastrous consequences. But maintenance treatment of chronic psychosis may be changing.

Results from recent outcome studies suggest that antipsychotic maintenance may have limited efficacy for the outcomes that matter to our patients: full return to well-being and a productive place in society (5)(6). In Europe only 20% of people diagnosed with schizophrenia are able to hold a job for more than one year. Moreover a recent study seems to suggest that at least a subgroup of patients with schizophrenia had superior recovery rates when maintenance medications were discontinued (7 ).

A study published last year demonstrates via neuroimaging that both schizophrenia and some antipsychotics may cause brain gray matter loss (8)(9). Thus it appears that despite successful treatment of delusions and hallucinations some schizophrenias (because there are many) progress unabated towards disability and cognitive deficit.

This is where cognitive rehabilitation fits in. Most psychiatrists today may not be familiar with cognitive rehabilitation even though it is rapidly emerging in being as important, if not more important, than psychopharmacological interventions.

Asking my earlier rhetoric question: if psychiatry as a discipline took a leave of absence from the future would the prognosis of schizophrenia be any different?

As our discipline is changing, psychiatry is gradually becoming a branch of clinical neuroscience. We psychiatrists need more understanding and training in brain neurobiology. Behavioral neuroscience is a curriculum subject in most psychology programs, as well as a specialty of psychology, but not of psychiatry. Why not? The same may apply to cognitive rehabilitation. There is no reason for psychiatry to give up on these powerful tools that, almost surely will define its future.

As an optimist, I see opportunity rather than gloom. Provided a right vision of the future in terms of prevention, and rehabilitation, psychiatry is posed for major advances. These advances are driven by the advent of highly sophisticated neuroimaging and neurophysiological methods and tools for studying brain functions and how changes in brain function relate to neuropsychiatric illness.

A realistic vision for the future of psychiatry vis-à-vis chronic psychosis must include the following:

- psychiatric disorders are brain disorders, and psychiatrists must learn to think about psychiatric illnesses as manifestations of brain and neural circuit dysfunction.

- psychiatrists should start by systematically viewing themselves as clinical neuroscientists and seek a closer clinical and scientific relationship with its sibling discipline of neurology, particularly the aspect of neurology that focuses on cognition and behavior.

- psychiatry must direct clinical efforts towards understanding and diminishing the factors contributing to disability and death caused by chronic schizophrenia and other psychoses. Early detection and prevention is the first pillar of the future treatments of psychosis.

-psychiatry must begin to see itself as being closely aligned with approaches and goals of rehabilitative medicine, particularly cognitive rehabilitation. In addition to psychopharmacological interventions, cognitive rehabilitation of both, prodromal phase and chronic schizophrenic patients is the second pillar of future psychiatric interventions(10).

References:

1. Director’s Blog: Antipsychotics: Taking the Long View; Thomas Insel on August 28, 2013; online: http://www.nimh.nih.gov/about/director/2013/antipsychotics-taking-the-long-view.shtml

2.Thomas R. Insel. Rethinking schizophrenia. Nature Volume:468, Pages: 187–193. November 2010. doi:10.1038/nature09552

3.Sørensen HJ, Mortensen EL, Schiffman J, Reinisch JM, Maeda J, Mednick SA; Early developmental milestones and risk of schizophrenia: a 45-year follow-up of the Copenhagen Perinatal Cohort. Schizophr Res. 2010 May;118(1-3):41-7. doi: 10.1016/j.schres.2010.01.029. Epub 2010 Feb 23.

 

4. Early Detection and Intervention in Schizophrenia: A new Therapeutic Model. Lieberman JA, Dixon LB, Goldman HH. JAMA. 2013;310(7):689-690.

5.Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial. JAMA Psychiatry. 2013 Jul 3. [Epub ahead of print] PMID: 23824214

6. McGorry P, Alvarez-Jimenez M, Killackey E. Antipsychotic Medication During the Critical Period Following Remission From First-Episode Psychosis: Less Is More. JAMA Psychiatry. 2013 Jul 3. [Epub ahead of print] PMID: 23824206

 

7. Harrow M, Jobe TH. Does Long-Term Treatment of Schizophrenia With Antipsychotic Medications Facilitate Recovery? Schizophr Bull. 2013 Mar 19. [Epub ahead of print] PMID: 23512950

8. B.-C. Ho, N. C. Andreasen, S. Ziebell, R. Pierson, V. Magnotta. Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia. Archives of General Psychiatry, 2011; 68 (2): 128 DOI: 10.1001/archgenpsychiatry.2010.199

9. D. A. Lewis. Antipsychotic Medications and Brain Volume: Do We Have Cause for Concern? Archives of General Psychiatry, 2011; 68 (2): 126 DOI: 10.1001/archgenpsychiatry.2010.187

10.Charles Zorumski, Eugene Rubin; Psychiatry and Clinical Neuroscience: A Primer; Oxford University Press, 2011; ISBN-10: 0199768765 | ISBN-13: 978-0199768769

 

 

 

 

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