Integrated Treatment and Implications for Off-Medication Periods

Abstract

The group of psychosis patients (DSM-IV) is very heterogeneous. Some members of this group exhibit a remarkable self-curing capacity when given psychological support and optimal overnight facilities. In our experience1,2 with an unselected first episode of psychosis (FEP) group of 175 patients, 20% had not been medicated at the 1-year follow-up with no obvious negative effects. The prerequisite is a special care organization directed to the needs of FEP patients. Another group had received small doses of antipsychotic medication (1.5–3 mg/day haloperidol equivalent dose), in addition to benzodiazepines, for limited periods of time. A third group, around 40%, was given antipsychotic medication for extended periods but still in moderate doses. Prescribing was based on a needs assessment and clinical judgment. We are presently making a 5-year follow-up and comparing the outcomes. The 3 clinically most interesting studies cited by Bola (this issue) are all quasi-experimental and not randomized with reference to who was given antipsychotic medication. Still, they demonstrate that the very low medication, in addition to the social and psychological milieu, is as effective as ordinary treatment. But none of the studies show that most FEP patients can be treated without antipsychotic medication, as the inexperienced reader may believe. They show that not every patient needs such medication and that the daily dose given can be much reduced for most patients. One conclusion is that medication treatments must have an important position in our arsenal but not the unique, “most important” position. The “most important” is the triad of psychological treatments, social context, and medication. This is analogous to new cases of juvenile diabetes, which should be granted continuous treatment contacts, psychological and social support for having optimal chances to survive through the decades to come, in addition to the monitoring of insulin needs. Bola does not discuss how to demonstrate the diverse medical needs of individual FEP patients. Clinical trials where each patient who is randomly assigned to a treatment group gets the same therapeutic procedures do not address the basic “need-adapted” clinical issues. A placebo-controlled study with FEP patients where the treatment program is the same for all patient participants, except for the random assignment to drug or placebo, will always show the drug advantage (assuming efficacy) without testing need-adapted integrated care. This creates the impression that drug therapy is required by all patients. Clinical trials' methodology always hides the individual's treatment needs. Thus, we need more research on how to know which patients should be treated with which mix of the therapeutic triad. Today we are just in the beginning stages, but we know enough to counter the aggressive, unnuanced claims from the pharmaceutical industry that every FEP patient needs immediate antipsychotic drug therapy. This belief has been reinforced by speculations regarding psychosis as neurotoxic. The data presented by Bola do not support this speculation, and other studies also fail to find evidence of long-term harm from periods of psychosis off-medication.3 Thus, the field is open for carefully designed studies. Ask yourself how you would have your own close relative treated if met with an FEP!