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Schizophrenia
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Psychiatric Drug Therapy
Antipsychotics are the most common treatment the for schizophrenia. Research shows they reduce delusions, hallucinations, and relapse rates for some people. Regrettably, they are far from a complete solution. Researchers examining the results of a landmark federally-funded antipsychotic study put it succinctly, "The majority [74%] of patients discontinued their [antipsychotics within18 months]... indicating substantial limitations in their effectiveness..." [1]
To maximize recovery, schizophrenia is best viewed in a broader context that considers drugs' partial effectiveness, risks, and limitations as well as the many evidence-based nondrug options available (see free monograph). This full view helps individuals and their practitioners make the most informed care choices.
Antipsychotics: benefits, risks & limitations
A sobering review of gold standard evidence
Benefits. An exhaustive review of research shows that about 1 in 5 people taking antipsychotics see improvement in their positive symptoms - delusions and hallucinations - due to these drugs (9% see substantial improvement,12% see minimal improvement). [2] Regrettably, the remaining 4 of 5 respond just as well to sugar pills as they do to antipsychotics. In addition, antipsychotics do little to help negative symptoms like apathy and lack of emotion. [3]
Side effects. Almost everyone on antipsychotics has side effects and they are often serious. Frequent sizable weight gain increases the risk of diabetes and cardiovascular disease. Sexual dysfunction is common. Cataracts, lethargy, insomnia, severe restlessness, involuntary Parkinsonian-like movements, dizziness, seizures, brain shrinkage, and more may occur.
Long-term risk. The past Director of the National Institute of Mental Health concluded, "Remaining on [antipsychotics] long-term might impede a full return to wellness". [4] His statement is grounded in research that shows that people with schizophrenia who avoid antipsychotics are much more likely to achieve long-term recovery than those who use them. [5]
This is consistent with a study of people living in recovery from schizophrenia. Although antipsychotics reduced acute psychosis, the drugs compromised normal functioning and recovery. [6] Participants found the drug's physical and cognitive effects impeded their return to normalcy when taken long-term. See the graphic for research statistics on the limitations and risks of antipsychotics.
A New Paradigm
Looking beyond symptoms to causes. Many practitioners are adopting a new paradigm - Integrative Mental Health - that looks beyond drugs. They see numerous factors dynamically interacting to cause mental distress - many we understand, others we don't. The combined weight of these factors can lead to episodes of schizophrenia and sometimes "break the camel's back" and precipitate major psychotic crisis (see graphic).
Offering personalized care. Integrative practitioners delve deeply into the unique constellation of causative factors facing each individual using detailed diagnostic tools. From this analysis they create personalized treatment plans.
Using a broad menu of options. Integrative Mental Health treatment plans nearly always include evidence-based nondrug options. These options are drawn from 27 broad nondrug approaches shown effective for mental wellness. Nearly all options can be used with drugs, they typically have far fewer and milder side effects than drugs, and in many cases their use can reduce - and in some cases eliminate - the need for drugs.
Delivering better outcomes. Drugs alone rarely deliver recovery. Thankfully, you have options. There are hundreds of gold-standard studies that show psychotic symptom relief from select nondrug options. Limiting yourself to drugs limits your avenues to wellness.
Defining a new discipline. Many psychiatrists, GPs, nurse practitioners, naturopaths, psychotherapists, medical specialists, and others are joining the paradigm shift to Integrative Mental Health, embracing the best of drug and non-drug care. These practitioners see that our mind, body, and emotions require a more holistic solution than pills alone can provide. They acknowledge a role for drugs, but consider them with great caution, especially for the developing brain and personhood of children.
Wellness Continuum
4 forms of care for
schizophrenia
Adapted from the U.S. Institute of Medicine and European Union of General Practitioners/Family Physicians. [18]
Back to Basics
Preventive
Preventive approaches help avoid symptoms. These include proper diet, gluten-sensitivity care, mindfulness, stress management, ensuring gut-health, social interaction, and more.
Symptom Relief
Symptom relief addresses symptoms not removed by preventive and restorative care. Voice coping strategies help interrupt or decrease the impact of voices. For instance, listening to music through ear buds can often help quiet voices.
Restorative
Two broad methods work to help address causative factors of schizophrenia.
Biomedical practitioners (see practitioner finder) help identify and support your unique bio-individuality using robust lab tests. 25% of the time mental distress is caused or influenced by physical issues. [7] Testing helps uncover nutrient imbalances, hormonal issues, food allergies, inflammation, and other issues that are directly associated with psychosis. Treatment is grounded in individualized nutrient therapy.
Psychosocial practitioners help address painful human painful experiences. Considering trauma is very important since there is a strong correlation between childhood trauma and schizophrenia. Open Dialogue has been shown effective in first-episode psychosis. Peer Support provides "been there" support from those living in recovery that can be vital. Cognitive Behavioral Therapy for Psychosis helps make voices less malevolent and reduces depression often found with psychosis.
Over-care
Avoidance
Over-care avoidance limits interventions (usually drugs) to only what is necessary.
Over-care can be expensive and harmful. It can lead to prescribing cascade where
new drugs are increasingly added to address side effects created by previous ones.
Studies show that taking multiple simultaneous antipsychotics is associated with a shorter life span and a variety of worsening health conditions.[8] Unfortunately, the practicer is common for schizophrenia, with some countries seeing rates as high as 70%. [9] As a result, the American Psychiatric Association is working to to curb the practice.[10]
Psychiatrists are considering de-prescribing plans for their patients based on psychiatric drugs' risk/benefit profile. [11]
Complementary Option: Nutrient Therapy
The Walsh Institute has what is likely the largest blood chemistry database in the world for those with schizophrenia. From this data they have identified five primary schizophrenia biotypes: overmethylation, undermethylation, pyrrole disorder, gluten intolerance, and a category that includes thyroid deficiency. [12] Oxidative stress and methylation issues - processes related to our immune response - are common across biotypes. Determining your biotype from comprehensive biomedical tests helps identify an individualized nutrient response.
When people with schizophrenia use customized Nutrient Therapy based on the Walsh Institute’s protocols, 75% report significant symptom improvement and the ability to reduce medication, while about 5% can eliminate medication altogether. [12]
Nutrient Therapy for Schizophrenia. Dr. William Walsh, PhD
Courtesy Walsh Institute. www.WalshInstitute.org.
Complementary Option: Dialog Therapies
Dialogue Therapies are a cluster of interventions that seek to engage the voices of schizophrenia in a meaningful way. Dialogue Therapies have shown strong success in some cases and can be a valuable way to understand, accept, and honor an individual’s experience as a first step in recovery.
Hearing Voices Network (article, U.S. site) is a peer support group where people can share voice experiences and insight in a collaborative atmosphere. In one survey, 79% of attendees found the groups helpful to change their voices, or improve their relationship or understanding of them. [13] See accompanying video.
Some people find benefit in treating their voices respectfully as hidden aspects of themselves that seek expression. Engaging these voices may yield greater self-understanding and control over the voices. One such approach, Talking with Voices (video, article), includes a trusted facilitator who asks questions of the voice through the individual. Avatar Therapy (video) has the individual speak with a computer-generated likeness of their voice to help shift power away from the voice and toward the individual.
Elenor Longden
Excerpts from her TED talk on her experience of hearing voices and the benefit of Hearing Voices Network.
Your life. Your choice.
The limited effectiveness and many challenges of antipsychotics make their risk/reward profile much less favorable than most people think.
This is one reason why key voices in mainstream psychiatry support nondrug options.
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NAMI. Dr. Kenneth Duckworth, Medical Director of the National Alliance on Mental Illness, is clear: "... psychiatric medications... are rarely enough to promote recovery alone... Use of non-medication strategies is crucial for most clinical situations." [14]
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Mental Health America advocates many nondrug options. [15]
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American Psychiatric Association sponsors a special interest caucus of psychiatrists grounded in Integrative Mental Health. [16]
In addition, Dr. James Scully, past American Psychiatric Association Medical Director and CEO, understands well the implications of psychiatric drugs. He says:
Physicians and patients together should be thinking carefully, ‘Are the medications really needed and are there downsides and negative consequences for overuse?’... Patients really need to be a part of the decision… of their own treatments. [17]
Carefully consider Dr. Scully’s question – your recovery may well depend on it – and be an active participant in determining your treatment. If you make adjustments to the drugs you take, do so slowly under practitioner care.
Always work closely with your doctors as you make care decisions. They are your trusted guides. Also independently educate yourself since Integrative Mental Health is not yet prevalent in psychiatric care. You will likely need to expand your team to include integrative practitioners if you seek to use nondrug options as part of your recovery.
Although non-drug options aren't a panacea, many people are reclaiming their lives thanks to the expanded menu of options of Integrative Mental Health. Their self-determined return to normalcy can offer you compelling and pragmatic reasons for hope.
Resources
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Free! Schizophrenia Monograph - Overview of non-drug options
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Choices in Recovery - Detail on evidence-based non-drug options for schizophrenia and other major diagnoses.
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Understanding Schizophrenia. British Psychological Association.
Footnote references are removed in the mobile version of this page to respect small screen sizes. They can be found in the desktop version.
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Note: To make this material more understandable, we use commonly understood phrases to represent rigorous statistical metrics. See our definitions.
References:
[1] Lieberman J et al, Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia, N Engl J Med. 2005, PMID: 16172203, https://goo.gl/hQeWv5.
[2] Leucht S et al, Sixty Years of Placebo-Controlled Antipsychotic Drug Trials in Acute Schizophrenia: Systematic Review, Bayesian Meta-Analysis, and Meta-Regression of Efficacy Predictors, 2017, Amer J of Psychiatry, https://goo.gl/bndxBq. Note: 23% of people taking antipsychotics had a "good response" (we call this "substantial benefit") compared to 14% who took placebo. 23%-14%=9% saw substantial benefit attributable to antipsychotics. 100%-9% = 91% did NOT see substantial benefit attributable to antipsychotics. 51% of people had at least a "minimal response" on antipsychotics and 30% had at least a minimal response on placebo. 51%-30%=21% had at least a minimal response attributable to the drugs. 100%-21=79% of people did NOT see at least a minimal response. The 21% includes the 9% of people who experienced a "good response:, so 21%-9%=12% of people experienced a "minimal response" attributable to antipsychotics. This analysis considers the "Number Needed to Treat" which is considered one of the best available methods to assess the true value of drugs. See definitions.
[3] Remington G et al, Treating Negative Symptoms in Schizophrenia: an Update, 2016, Curr Treat Options Psychiatry, PMCID: PMC4908169.
[4] Insel T, National Inst of Mental Health Director’s Blog: Antipsychotics: Taking the Long View, Aug 2013, http://goo.gl/LFmP0V.
[5] Harrow M, Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study, Psychological Medicine, 2012, PMID: 22340278, https://bit.ly/31BAfx1; Wunderink 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, PMID: 23824214.
[6] Bjornestad, J et al, Antipsychotic treatment: experiences of fully recovered service users. 2017, Journal of Mental Health, https://goo.gl/eqFRtF.
[7] Koranyi EK et al, Physical illnesses underlying psychiatric symptoms, Psycho Psychosom. 1992, PMID: 1488499, http://goo.gl/V9Wi23.; Koran L, MEDICAL EVALUATION FIELD MANUAL, 1991, http://goo.gl/TPNL9t, copied 10/30/2013.; Hall RC, Physical illness manifesting as psychiatric disease. II. Analysis of a state hospital inpatient population, Arch Gen Psychiatry. 1980, PMID: 7416911.
[8]. Waddington JL, Mortality in schizophrenia. Antipsychotic polypharmacy and absence of adjunctive anticholinergics over the course of a 10-year prospective study, Br J Psychiatry 1998, PMID: 9926037; Joukamaa M et al, Schizophrenia, neuroleptic medication and mortality. Br J Psychiatry, 2006, PMID: 16449697; Ito H et al, Polypharmacy and excessive dosing: psychiatrists' perceptions of antipsychotic drug prescription. Br J Psychiatry. 2005, PMID: 16135861; Correll CU et al, Does antipsychotic polypharmacy increase the risk for metabolic syndrome?, Schizophr Res. 2007, PMCID: PMC2718048; Paton C et al, Patterns of antipsychotic and anticholinergic prescribing for hospital inpatients, J Psychopharmacol. 2003, PMID: 12870571.
[9] Fleischhacker W et al, Critical review of antipsychotic polypharmacy in the treatment of schizophrenia, J Neuropsychopharmacol. 2014, PMID: 22717078, https://goo.gl/7Pg9w7.
[10] American Psychiatric Association, Five Things Physicians and Patients Should Question, Choosing Wisely, 2015, http://goo.gl/t3blZ8.
[11] Gupta S, A Prescription for "Deprescribing" in Psychiatry, Psychiatr Serv. 2016 PMID: 26975524. Ontario Pharmacy Evidence Network, Deprescribing Guidelines, https://goo.gl/8VpYFx. Grudnikoff E et al, Deprescribing in Child and Adolescent Psychiatry—A Sorely Needed Intervention, Am J Therapeutics, 2017, PMID: 28059976. Gupta, S et al, Deprescribing antipsychotic medications in psychotic disorders: How and why? Betham Science, 2018, https://goo.gl/mR9jJ1.
[12] Walsh W, Nutrient Power Heal Your Biochemistry and Heal your Brain, Skyhorse Publishing, 2014, http://goo.gl/DxoIvQ.
[13]. Hornstein G, How do hearing voices peer-support groups work? A three-phase model of transformation, Psychosis, 2020, https://bit.ly/31DRUEt.
[14] Duckworth K, The Sensible Use of Psychiatric Medications, NAMI Advocate Magazine, Winter 2013, https://goo.gl/GMIuSU.
[15] Mental Health America, Complementary & Alternative Medicine for Mental Health, 2013, http://goo.gl/fTQlAo.
[16] The American Psychiatric Association has formed the “APA Caucus on Complementary, Alternative and Integrative Medicine”, http://bit.ly/2OXtXSj.
[17]. James Scully (MD, APA Medical Director and CEO), excerpt from a video of him speaking to the APA’s participation in the Choosing Wisely® campaign, 2013, http://goo.gl/TrEZdx, copied 2015.
[18] Martins C et al, Quaternary prevention: reviewing the concept Quaternary prevention aims to protect patients from medical harm, Eur J Gen Pract, 2018, PMC5795741; European Union of General Practitioners/Family Physicians, UEMO position on Disease Mongering / Quaternary Prevention, 2011, https://goo.gl/usrpEC. “Preventive”, “restorative”, “symptom relief” and “over-care avoidance” are more descriptive terms and used in place of “primary”, “secondary”, “tertiary” and “quaternary” used in these references.