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Special thanks to
PsychRights.org
for much of the information
below.
Whitaker, R., (2004),
The
case against antipsychotic drugs: a 50-year record of doing more harm than good,
In
Medical Hypotheses,
Volume 62, Issue 1, Pages 5-13.
Whitaker, R., (2004).
Mad
in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the
Mentally Ill. The research analyzed the
information below.
This article was cited in the
British Medical Journal, Vol. 328/414, February, 2004: Maintaining people diagnosed schizophrenic on
neuroleptics maybe a disservice. According to a 50 year review,
long term treatment worsens long
term outcomes, and up to 40% of people would do
better without neuroleptics.
*
Initiation of treatment only after a subsequent episode and
helping patients who are stabilised on neuroleptics to gradually withdraw from them
would increase recovery rates and reduce the proportion of
patients who become chronically ill (Medical
Hypotheses 2004;62:5-13).
Epstein, L., (1962), "An
Approach to the Effect of Ataraxic Drugs on Hospital Release Rates,"
In American Journal of Psychiatry,
119, 36-47. This was the first large scale study of hospital release
rates in the 1950s for schizophrenia patients treated with and without
neuroleptics, and it concluded that
"drug-treated patients tend to have
longer periods of hospitalization." P. 44.
Schooler, N., (1967), "One
year after discharge: community adjustment of schizophrenic patients,"
American Journal of Psychiatry, 123,
986-995. This NIMH study looked at one-year outcomes for 299 patients who had
been treated either with neuroleptics or placebo upon their admission to a
hospital, and was the first long-term study conducted by the NIMH. The
researchers found that
"patients who received placebo
treatment in the drug study were
less likely to be rehospitalized than those who received any of the three active
phenothiazines (thioridazine (Mellaril),
fluphenazine (Prolixin), chlorpromazine (Thorazine)."
However, in spite of this finding, which the
researchers wrote "was so unexpected," the NIMH investigators stated that they
"were unprepared to recommend placebo as treatment of choice." In other words,
the NIMH researchers decided they wouldn't develop treatment guidelines based on
their own research, which found that placebo patients did better than the
drug-treated patients. SEE PAGE 991.
Prien, R., (1968), "Relapse
in Chronic Schizophrenics Following Abrupt Withdrawal of Tranquillizing
Medication," In
British Journal of Psychiatry,
115, 679-86. The critical finding of this NIMH study was that
relapse rates rose in direct
relation to dosage-- the higher the dosage patients were on before the drugs were withdrawn, the
greater the relapse rates.
At the start of the study, 18
patients were on placebo, and only one got worse over the next six months (6%).
Sixty-five patients were on 300 mg. of chlorpromazine at the start of the study,
and 54% of these patients worsened after the drug was withdrawn. One hundred
thirteen patients were on more than 300 mg. of chlorpromazine at the start of
the study, and 66% of these patients got worse after drug withdrawal. SEE TABLE
THREE, PAGE 684.
Prien, R., (1971), "Discontinuation
of Chemotherapy for Chronic Schizophrenics,"
In Hospital and Community Psychiatry, 22, 20-23. In this NIMH study, the earlier finding that relapse rates rose in correlation
with neuroleptic dosage was confirmed. Only 2 of 30 patients who were on
placebo at the start of the study relapsed during the next 24 weeks (7%).
Twenty-three percent of the 99 patients who were on under 300 mg. of
chlorpromazine at the start of the study relapsed following drug withdrawal.
Fifty-two percent of the 91 patients who were on 300 to 500 mg. of
chlorpromazine at the start of the study relapsed following drug withdrawal, and
sixty-five percent of the 81 patients who were on more than 500 mg. of
chlorpromazine at the start of the study relapsed following drug withdrawal. The
researchers concluded: "Relapse was found to be significantly related to the
dose of the tranquilizing medication the patient was receiving before he was put
on placebo--the higher the dose, the greater the probability of relapse." SEE
PAGE 22, AND 23
Sanbourne Bockoven, J., (1975),
Comparison of Two Five-Year Follow-Up Studies:
1947 to 1952 and 1967 to 1972,
American Journal of Psychiatry,
132, 796-801. Researchers compared relapse rates in the pre-drug era to those
in the drug era, and found that patients in the pre-drug era had
done better. Forty-five percent of the
patients treated at Boston Psychopathic Hospital in 1947 had not relapsed in the
five years following discharge, and 76% were successfully living in the
community at the end of that follow-up period. In contrast, only 31% of
patients treated in 1967 with drugs at a Boston community health center remained
relapse-free for the next five years, and as a group they were much more
"socially dependent"--on welfare, etc.--than those in the 1947 cohort.
Other researchers who reviewed relapse rates for New York
psychiatric hospitals in the 1940s and early 1950s reported similar findings:
approx 50%
of no drug discharged schizophrenic patients remained well on follow-ups
periods, which was markedly superior to outcomes with neuroleptics.
See Nathaniel Lehrman, "A state hospital
population five years after admission: a yardstick for evaluative comparison of
follow-up studies,"
Psychiatric Quarterly, 34 (1960), 658-681; and H.L. Rachlin, "Follow-up study of 317 patients
discharged from Hillside Hospital in 1950,"
J. Hillside Hospital, 5 (1956), 17-40.
Carpenter, Jr., W., (1977), "The
treatment of acute schizophrenia without drugs: an investigation of some current
assumptions," In American Journal of Psychiatry,
134, 14-20. In this 1977 NIMH study, 49 schizophrenia patients, placed into an
experimental hospital program that provided them with psychosocial support, were
randomized into drug and non-drug cohorts.
Only 35% of
the non-medicated patients relapsed within a year after discharge, compared to 45% of those
treated with medication. The medicated patients also suffered more from depression, blunted emotions, and retarded
movements.
Rappaport, M., (1978), "Are
there schizophrenics for whom drugs may be unnecessary or contraindicated?"
International Pharmacopsychiatry, 13,
100-111. In
this 1978 study, Maurice Rappaport and his colleagues
at the University of California, San Francisco randomized 80 young male
schizophrenics admitted to Agnews State Hospital to drug and non-drug groups.Only 27% of the drug-free patients
relapsed in the three years following discharge,compared to 62% of the medicated group.
Most notably, only two of 24
patients (8%) who weren’t medicated in the hospital and continued to forgo such treatment after discharge subsequently
relapsed. At the end of the study, this group
of 24 drug-free patients was functioning at a dramatically higher level than drug-treated patients.
Mathews, S. (1979), “A
non-neuroleptic treatment for schizophrenia: analysis of the two-year
postdischarge risk of relapse,”
Schizophrenia Bulletin,
5, 322-332; Loren Mosher, “Community
residential treatment for schizophrenia: two year followup,”
Hospital and Community
Psychiatry, 29 (1978), 715-723; Mosher, “The
treatment of acute psychosis without neuroleptics: six-week psychopathology
outcome data from the Soteria project,”
International Journal of
Social Psychiatry, 41 (1995), 157-173; Mosher,
“The Soteria project: twenty five years of swimming upriver,”
Complexity and Change,
9 (2000), 68-73.
During the
1970s, the head of schizophrenia studies at the NIMH, Loren Mosher, conducted an
experiment that compared non-drug treatment to drug treatment, and he reported
better outcomes for the non-drug patients. See, e.g.: Mosher LR and Menn AZ.
Soteria: An Alternative to Hospitalization for Schizophrenia. In JH Masserman
(Ed), Current
Psychiatric Therapies, (Vol. XIV). New York:
Grune and Stratton, Inc., pp. 287‑296, 1974. Menn AZ and Mosher LR. The
Soteria Project. An Alternative to Hospitalization for Schizophrenics: Some
Clinical Aspects. In J Jorstad and E Ugelstad (Eds),
Schizophrenia 75.
Oslo, Norway: Universitetsforlaget, pp. 347‑372, 1976. Mosher LR and Menn AZ.
Dinosaur or Astronaut? One‑Year Follow‑Up Data from the Soteria Project. In M
Greenblatt and RD Budson (Eds), "A Symposium: Follow‑up of Community Care".
American Journal of
Psychiatry, 133:8, 919‑920, 1976. Mosher LR
and Menn AZ. Lowered Barriers in the Community: The Soteria Model. In LI Stein
and MA Test (Eds),
Alternatives to Mental Hospital Treatment. New
York: Plenum Press, pp. 75‑113, 1977.
Muller, P., & Seeman, P.,
(1978), "Dopaminergic
Supersensitivity after Neuroleptics: Time-Course and Specificity,
Psychopharmacology
60, 1-11. Guy Chouinard, “Neuroleptic-induced
supersensitivity psychosis,”
American Journal of Psychiatry,
135 (1978), 1409-1410; Chouinard, “Neuroleptic-induced
supersensitivity psychosis: clinical and pharmacologic characteristics,”
American Journal of
Psychiatry, 137 (1980), 16-20. In the late
1970s, Canadian investigators identified the biological changes induced in the
brain by neuroleptics that led to the higher relapse rates.
Because the drugs dampen down
dopamine activity, the brain tries to compensate by becoming
"supersensitive" to dopamine. (The drugs trigger an increase in the density of
dopamine receptors.) This perturbation in dopamine function
makes the patients more biologically prone to psychosis and to
worse relapses upon drug withdrawal.
Chouinard concluded:
"Neuroleptics can produce a dopamine
supersensitivity that leads to both dyskinetic and psychotic symptoms. An
implication is that the tendency toward psychotic relapse in a patient who has
developed such a supersensitivity is determined by more than just the normal
course of the illness . . . the need for continued neuroleptic treatment may
itself be drug-induced."
Gardos, G., & Cole, J. (1976), “Maintenance
Antipsychotic Therapy: Is the Cure Worse than the Disease.”
American Journal of Psychiatry, 133, January, pager 32-36. After discussing the
problems with neuroleptics, the authors conclude,
"every chronic schizophrenic
outpatient maintained on an antipsychotic medication should
have the benefit of an adequate trial without drugs."
Jonathan Cole was the head of the
NIMH, I believe, in the 1960s. This is just a general discussion paper, but note
his conclusion: “An attempt should be made to determine the feasibility of drug
discontinuance in every patient.”
The WHO Studies-
The evidence of an association between use of
neuroleptics and poor long-term outcomes can be seen in studies by the World
Health Organization.
1st
Study:
Leff, J. (1992), "The
International Pilot Study of Schizophrenia: five-year follow-up findings,"
Psychological Medicine, 22, 131-145.
The first World Health Organization study that compared schizophrenia outcomes
in "developed" and "developing" countries was called The International Pilot
Study of Schizophrenia. It began in 1968, and involved 1202 patients in nine
countries. At both two-year and five-year follow-ups, the patients in the poor
countries were doing much better.
The researchers
concluded that schizophrenia patients
in the poor countries "had a considerably better course and outcome than
(patients) in developed countries. This
remained true whether clinical outcomes, social outcomes, or a combination of
the two was considered." Two-thirds of the patients in India and Nigeria were
asymptomatic at the end of five years. The WHO investigators, however, were
unable to identify a variable
that explained this notable difference in outcomes. SEE
PAGES 132, 142, 143.
2nd
Study
Jablensky, A., (1992), "Schizophrenia:
manifestations, incidence and course in different cultures,
A World Health Organization ten-country study,"
Psychological Medicine,
suppl. 20 (1992), 1-95. The second WHO organization study of this type was
called the Determinants of Outcome of Severe Mental Disorders. It involved 1379
patients from 10 countries, and was designed as a follow-up study to the
International Pilot Study of Schizophrenia. The patients in this study were
first-episode patients, and 86% had been ill fewer than 12 months. This study
confirmed the findings of the
first: two-year outcomes were much better for
the patients in the poor countries. In broad terms, 37 percent of the patients
in the poor countries (India, Nigeria and Colombia) had a single psychotic
episode and then fully recovered; another 26.7% of the patients in the poor
countries had two or more psychotic episodes but still were in "complete
remission" at the end of the two years. In other words,
63.7% of the
patients in the poor countries were doing fairly well at the end of two years.
In contrast, only 36.9% of the patients in the U.S. and six other developed
countries were doing fairly well at the end of
two years. The researchers concluded that "being in a developed country was a
strong predictor of not attaining a complete remission."
Although
the WHO researchers didn't identify a variable that would explain this difference in outcomes, they did note that in
the developing countries, only 15.9% of
patients were continuously maintained on neuroleptics, compared to 61% of
patients in the U.S. and other developed
countries.
This difference in outcomes is
also consistent with research in the U.S. showing that neuroleptics induce
brain changes that make people more biologically prone to psychosis. One would
expect that drugs that induced such changes would lead to increased chronic
illness, and the failure of most patients to attain a complete remission. See,
Table 4.10 page 64 and page 90. [Table
9.1 from Mad in America reproduced because
of quality in original]
Also see, "Culture
and Schizophrenia: Criticisms of WHO studies are answered,"
by A. Jablensky, N. Sartorius, J.E. Cooper, M. Anker, A. Korten and A.
Bertelsen, British Journal of
Psychiatry (1994) 165, 434-436.
Studies by the esteemed Dr.
Courtenay Harding show that it is the patients who do not use psychiatric
medications regularly on a long-term basis that are the ones that tend to
recover from schizophrenia. In Harding, C., Zahniser, J. (1994),
Empirical
Correction of Seven Myths About Schizophrenia with Implications for Treatment,
In ACTA Psyciatrica
Scandinava, 90 (suppl 384): 140-146. These
Studies have consistently found that half to two thirds of patients
significantly imporved or recovered, including some cohorts of very chronic cases.
The universal criteria for
recovery have been defined as no current signs and symptoms of any mental
illness, no current medications, working, relating well to family and friends,
integrated into the community and behaving in such a way as to not being able to
detect having ever hospitalized for any kind of psychiatric problems.(p. 140)
There are no data existing which
support the myth these people need to by on medication all their lives. When
analyzing the results from the long term studies,
it was clear that that a surprising
number (at least 25% - 50%), were completely off their medications, suffered no
further signs and sympoms of schizophrenia, and were functioning well. (p.
143). "Even in the second and third decades of
illness, there is still potential for full or partial recovery." All of the
recent long-term follow-up investigators have recorded the same findings.
Harding, C., Brooks, G. at el
(1987),
The
Vermont Longitudinal Study of Persons With Severe Mental Illness, II: Long-Term
Outcomes of Subjects Who Retrospectively Met DSM-III Criteria for Schizophrenia,
In American Journal of Psychiatry 144:6,
June, 727 at p. 730.
68% of people diagnosed with
schizophrenia had recovered and of these
50% never took psychiatric medications and another
25% only took them periodically when they felt they needed to control symptoms.
See, also Harding, C., & Brooks, at el (1987),
American Journal of Psychiatry
144:6, June 1987, 718,
Hegarty, J., Baldessarini, R. at
el (1994),
One
Hundred Years of Schizophrenia: A Meta-Analysis of the Outcome Literature,
American Journal of
Psychiatry: 151, 1409-1416. At the same time
that the WHO was reporting on poor outcomes in developed countries, Harvard
Medical School researchers published a study concluding that outcomes for schizophrenia patients
in the U.S. had declined since the 1970s, to the point they were no better than they had been in 1900.
Since 1986,
ONLY 36.4% of patients in the
U.S. have had favorable outcomes or were "improved" during a
follow-up period that averaged 5.6 years. The authors did not blame neuroleptic
use for the poor outcomes; on the contrary, they argued that despite the poor
outcomes in the modern era, neuroleptics still should be seen as beneficial, but
this part of their conclusions is not supported with any research.
Viguera, A, Baldessarini, R, at
el, (1997),
Clinical Risk Following Abrupt and Gradual Withdrawal,
Archives of General
Psychiatry: Vol 54, Jan. They quantified the
how much the abrupt discontinuation of long-term neuroleptic use increased
relapse rates. This study concluded that the relapse risk was relatively high
within six months; most patients who remained stable for 6 months continued to
do so for long periods without medication; and the risk of relapse was lower
when the medication withdrawal was gradually discontinued as compared to abrupt
discontinuation. On page 52 Figure three shows that two-thirds of those gradually
withdrawn haven’t relapsed at the end of 24 weeks, and they have a good chance of remaining well indefinitely.
Ciompi, L, Dauwalder, L, at el,
The
Pilot Project Soteria Berne; Clincial Experiences and Results,
In this study, Switzerland researchers duplicate Mosher’s results (more or
less.) Note on page 148 conclusion that:
“patients who received no or very
low-dosage medication demonstrated significantly better results.”
Lehtinen, V, Aaltonen, J., at el,
(2000),
Two-year outcome in first episode psychosis treated according to an integrated
model. Is immediate neuroleptisation always needed?,
In European Psychiatry
August; 15(5): 312-20. In this study, 43% of the patients in the
experimental group didn’t receive any neuroleptics at all, and that overall, the outcome for the experimental group “was equal
or even somewhat better" than those
treated conventionally with neuroleptics. The
recommendation out of this study by the authors was that an integrated approach
stressing intensive psychosocial measures be used for first-episode psychosis.
Cullbert, J., (1991)
Integrating intensive psychosocial therapy and low dose medical treatment in a
total material of first episode psychotic patients compared to "treatment as
usual" a 3 year follow-up. In
Acta Psychiatry Scandinavia,
May;83(5):363-72.
This is study from Sweden in which they copied the
Finnish project. Note that only 45 of the patients in the experimental group
were on neuroleptics at 3-year follow-up, and those on it were on 62 milligrams
of Thorazine a day (a very low dose). This experimental group had much lower
hospital use than those treated conventionally over a
three-year followup. In other words, they did better, and this of course saves
money.
(A)
Increase
in Caudate Nuclei Volumes of First-Episode Schizophrenia Patients Taking
Antipsychotic Drugs, Chakos, Lieberman,
Bilder, Borenstein, Lerner, Bogerts, Wu, Kinon and Ashtari,
American Journal of Psychiatry, October 1994;
151:1430-1436; (B) Neuroleptics
in progressive structural brain abnormalities in psychiatric illness
by Madsen, Keiding, Karle, Esbjerg and Hemmingsen,
The Lancet,
Vol 32, September 5, 1998, 784-785; (C)
Subcortical Volumes in Neuroleptic-Naďve and Treated Patients with Schizophrenia
by Gur, Maany, Mozley, Swanson, Bilker and Gur,
American Journal of Psychiatry December 1998;
155:12 1711-1717; (D)
Increased
Volume and Glial Density in Primate Prefrontal Cortex Associated with Crhonic
Antipsychotic Drug Exposure by Selemon,
Lidow and Goldman-Rakic,
Biologic Psychiatry 1999; 46:171-172; and (E)
A Follow-up
Magnetic Resonance Imaging Study of Schizophrenia: Relationship of
Neuroanatomical Changes to Clinical and Beurobehavioral Measures,
by Gur, Cowell, Turetsky, Gallacher Cannon, Bilker and Gur, Archives of General
Pscychiatry: Feb 1998 Vo. 55:145-152.
These last five are studies
showing that the drugs shrink frontal lobes, and cause an enlargement in the
basal ganglia. Please see the Gur MRI study in which she notes that this
enlargement of the basal ganglia were associated with greater severity of
symptoms. In other words, we have here an MRI study that charts brain changes
that lead to greater severity of symptoms.
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