Caring for psychotic patients with maximum kindness and minimum medication

Richard Bentall: "It is difficult to decide on the most important psychology experiment that has never been conducted, but the most important one in psychiatry is not hard to identify. Since Haenri Laborit discovered the psychological effects of chlorpromazine in the late 1940s, anti-psychotic medication has been the first-line (and often only) treatment offered to psychotic patients throughout the world. The evidence from clinical trials in favour of this approach appears impressive at first sight, but the drugs have terrible side effects, and their continued use at high doses is associated with a demonstrable reduction in life expectancy (Waddington et al. 1998). Because they are so unpleasant to take, often causing dysphoria and loss of motivation, many patients discontinue them, and this is true of the new atypical anti-psychotics despite their alleged kinder side effect profiles (Lieberman et al. 2005). Although patients who stop their medication in this way have a high probability of relapse, some of the exacerbations of symptoms that are observed are probably a rebound effect caused by the treatment rather than a return of a pre-existing illness – there is evidence that long-term anti-psychotic use leads to a proliferation of dopamine D2 receptors, thereby increasing the sensitivity of the dopamine system and exacerbating the very physiological dysfunction that the drugs are designed to treat. Hence patients who withdraw gradually are less likely to relapse than those who stop their medication suddenly (Moncrieff, 2006).

Bola (2006) recently reported a meta-analysis of clinical trials in which the majority of patients were experiencing their first episode of illness, in which some patients were unmedicated, and in which the follow-up period was at least one year. Amazingly he could identify only six studies that met these criteria and the evidence suggested that unmedicated patients did at least as well and possibly better than medicated patients in the long-term. One of the studies was the controversial Setoria project devised by Leon Mosher (1999), who devised a system of caring for acutely distressed psychotic patients with maximum kindness and minimum medication. No formal psychotherapy was provided, and the patients were looked after by untrained graduates who dealt with their difficulties with acceptance and emotional support. Despite evidence that Setoria patients did as well as first-episode patients treated in conventional psychiatric services, and the fact that Mosher was director of schizophrenia research for the US National Institute of Mental Health, NIMH closed down the project, probably because of pressure from the pharmaceutical industry (Whitaker, 2002).

In Britain, over the last decade, clinical psychologists have pioneered the development of cognitive-behavioural interventions for patients with psychosis, with promising results (Tarrier & Wykes, 2004). However, CBT has always been offered in combination with conventional antipsychotic drugs. Even though Soteria and CBT come from different philosophical roots, close examination of the two approaches reveals many common features, including acceptance and the normalization of symptoms. Psychiatric patients need to know the results of a clinical trial in which a CBT version of Soteria is compared to treatment as usual. Unfortunately, given the corrupting influence of the pharmaceutical industry (Angell, 2004) they are likely to have to wait for a very long time."

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Professor Richard Bentall is at the University of Wales, Bangor, and is the author of several books on the topic of mental illness, including 'Madness explained; psychosis and human nature'.

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