Dr Torrey Responds
Dr Steingard is correct that we agree that a subset of patients with schizophrenia will recover without antipsychotic medication, as has been noted for over a century. And we agree that many others can be maintained on “doses much lower than are commonly prescribed.” Conversely, for the same reason cited in my original article, a few patients need to be maintained on doses much higher than are commonly prescribed.1
Dr Steingard says I failed to address some of her “core concerns,” although she does not explicitly say what those are. Rather, she cites studies in which individuals who did not continue maintenance antipsychotic medication appeared to have a better long-term functional recovery than those who did. The most interesting of these is the Dutch study by Wunderink and colleagues.2,3 One major problem with this study is that the results are based on a select sample of patients; half (129/257) of the patients recruited for the study refused to participate, were lost to follow-up, or never recovered. Another major problem is that the study took place in the Netherlands, which has excellent mental health services, including rehabilitation services, far superior to those available in the US. Thus, it suggests that select, motivated patients who are not too sick may achieve a better functional recovery with minimum antipsychotics if intense rehabilitation services are available, although this study needs to be replicated.
The other studies cited by Dr Steingard have even greater limitations. For example, the naturalistic study by Harrow and colleagues,4 which did not include a control group, simply illustrates the fact that individuals with schizophrenia who are doing well tend to lower their dose or discontinue their medication. Similarly, the study by Gleeson and colleagues5 can also be interpreted as demonstrating that patients who are doing well are less likely to continue taking their medication. Dr Steingard suggests that this means that “adhering to drugs was associated with a worse functional outcome.”
In contrast to these small studies of nontreatment, I would remind Dr Steingard that the ultimate study of nontreatment has been going on for 50 years and is called deinstitutionalization. Currently, 2.6 million individuals with schizophrenia have more or less randomized themselves to antipsychotic treatment or nontreatment. Among the latter group, approximately 200,000 are homeless and at least that many are incarcerated in jails and prisons, mostly for crimes committed because of their untreated disease. The latter group is also victimized much more commonly. The difference between the two groups on virtually any measure of well-being is highly statistically significant.
It is also important to remember that the patients/consumers who blog on antipsychotic medication Web sites are a select group. They do not include my two former patients with schizophrenia who were told by social workers that antipsychotic drugs are dangerous; both stopped their medication and subsequently jumped off bridges. And they don’t include my former patient who did very well while taking antipsychotics but said he preferred his voices to the sexual adverse effects of the medication. He was subsequently stabbed to death by a woman he inappropriately approached and who became terrified by his bizarre behavior. These individuals are no longer alive to blog about the pluses and minuses of antipsychotics.
So yes, let’s agree that the antipsychotic, mood-stabilizing, and antidepressant medications we have available are far from perfect and should always be used with regard to weighing possible benefits against possible risks. But let’s also agree that schizophrenia, bipolar disorder, and severe depression are not merely “behavioral health problems,” as the Substance Abuse and Mental Health Services Administration calls them, but rather vicious brain diseases that can destroy lives and families. These medications have helped millions of people affected by these diseases lead better lives, and we should regard them as an important and integral tool in our armamentarium to help such individuals recover.
E. Fuller Torrey, MD
Stanley Medical Research Institute
Chevy Chase, Md
1. Torrey EF. Better off without antipsychotic drugs? Psychiatr Times. June 18, 2014. http://www.psychiatrictimes.com/psychopharmacology/better-without-antipsychotic-drugs. Accessed July 21, 2014.
2. Steingard S. A psychiatrist thinks some patients are better off without antipsychotic drugs. Washington Post. December 9, 2013. http://www.washingtonpost.com/national/health-science/a-psychiatrist-thinks-some-patients-are-better-off-without-antipsychotic-drugs/2013/12/06/547f5680-48aa-11e3-a196-3544a03c2351_story.html. Accessed July 21, 2014.
3. Wunderink L, Nieboer RM, Wiersma D, et al. 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;70:913-920.
4. Harrow M, Jobe TH, Faull RN. Does treatment of schizophrenia with antipsychotic medications eliminate or reduce psychosis? A 20-year multi-follow-up study. Psychol Med. 2014. http://www.mentalhealthexcellence.org/wp-content/uploads/2013/08/HarrowJobePsychMedMarch2014.pdf. Accessed July 21, 2014.
5. Gleeson JF, Cotton SM, Alvarez-Jimenez M, et al. A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients. J Clin Psychiatry. 2009;70:477-486.