Psychiatrists are unable to distinguish a schizophrenic from a normal person. Shocking myths of modern psychiatry The effectiveness of treatment of mental illness
Incredible facts
Since the late 19th century, psychiatry has come to be considered a medical specialty in the Western world. By emphasizing that mental disorders are an illness like any other, psychiatrists strive to maintain the same "science" status as their colleagues in cardiology, oncology, and other specialties.
They say mental disorders should not be classified as separate from, for example, heart failure or leukemia.
However, there is not enough evidence to confirm this theory. Psychiatry, cleverly abetted by the pharmaceutical industry, has created an idea of mental health that, to some extent, has little to do with reality.
Below are the 10 biggest myths of modern psychiatry.
Human mental disorders and associated myths
10. Mental illness is the result of a breakdown of some part of the brain.
Most psychiatrists believe that the main cause of mental illness is a brain defect.
We often hear that schizophrenia (a disease in which a person hears voices, has scrambled thoughts, and believes very strange things) is a brain deformity. With the help of new technologies, we are often shown photographs of the brains of people with schizophrenia, full of abnormal bumps and craters.
However, recent research suggests that antipsychotic drugs used to treat schizophrenia may contribute to defects in the human brain. Everything happens in direct proportion.
That is, the more drugs used, the more the brain is damaged. Despite unsuccessful attempts to identify a connection between the “drying out” of the brain and the intensity of the development of schizophrenia, researchers still continue to say that antipsychotic drugs only worsen brain defects.
But it is worth noting that when conducting experiments on macaques, it was found that during the use of these drugs, there was a reduction in brain volume by 20 percent.
In addition, childhood abuse (one of the main factors associated with the risk of developing schizophrenia and other disorders) changes the structure of the brain.
The thing is that childhood traumas trigger systemic changes in the brain, so in adulthood a person begins to suffer from mental disorders.
Thus, we can conclude that brain defects in people suffering from schizophrenia occur due to the harm that life in general and psychiatry in particular has caused them.
Genetics and mental disorders
9. Severe mental disorders are mostly genetic in origin.
Most psychiatrists also link the risk of developing serious mental disorders like schizophrenia to the genes we inherit from our parents. To support this argument, they point to a study of identical twins sharing the same genetic makeup.
Experts emphasize that if one of the twins develops schizophrenia, then the likelihood of the disease developing in the second is very high. Almost 70 years ago, one of the most famous twin researchers, Franz Kallman, came to the conclusion that if one twin is diagnosed with schizophrenia, the other twin will also face this problem in 86 percent of cases.
Experts also conducted studies that analyzed the likelihood of developing schizophrenia in blood relatives separated in early childhood. The idea was to prove that the environmental factor was unimportant.
As a result, the experiment showed that twins separated in infancy and born to mothers suffering from schizophrenia still had almost equal chances of acquiring this disease.
However, after so many decades, experts are still unable to identify the genetic marker that supposedly underlies schizophrenia.
Many psychiatrists, including Jay Joseph, have provided evidence that the genetic basis of schizophrenia is riddled with bias, subtle statistical tricks and some glaringly unreliable data.
According to recent studies, among identical twins the likelihood of both developing schizophrenia is 22 percent, and among twins it is 5 percent. Thus, there is still a genetic contribution, but it is quite modest.
Life experience appears to be a more influential cause of various mental illnesses. For example, sexual abuse of children makes them 15 times more susceptible to psychosis in adulthood.
This factor significantly exceeds the strength of any genetic influence.
8. Psychiatric diagnoses matter
Conventional doctors diagnose a disease in a patient based on symptoms, listening to the patient's complaints and actually seeing everything that happens to the person.
Therefore, if a doctor diagnoses diabetes, the person understands that his body lacks the hormone insulin, injections of which will help him feel better.
However, mental health problems are not primarily the result of some biological defect (or the result of a "broken brain"), so psychiatry faces a serious problem.
So how do psychiatrists overcome this fundamental obstacle? They gather around a round table and invent a list of psychological diseases.
In the USA, for example, this list was developed by the American Psychiatric Association and is majestically called the “Diagnostic and Statistical Manual of Mental Disorders.” The latest edition of the true psychiatric bible was published last year. It provides a list of more than 300 mental illnesses.
A correct diagnosis must be made based on specific symptoms and then instructions regarding appropriate treatment must be given. Moreover, the diagnosis must be accurate (in this regard, two or more psychiatrists, independently of each other, must make the same diagnosis for one patient).
The Guide (like all its predecessors) failed on all three of the above points.
Nervous and mental illnesses: myths
7. The number of mentally ill people is growing
We constantly hear that there are a huge number of people living with mental illnesses in the world, most of whom do not receive professional help, and many of whom do not even know that they have problems.
The main reason for the "increasing number of mental disorders" seems to be that psychiatry is regularly updated with the discovery of new diseases, often the symptoms of which include normal reactions to life's challenges.
For example, according to the information in the guide mentioned in the previous paragraph, if you remain upset for more than two weeks after the death of a loved one, this means that you are suffering from “major depressive disorder.”
An overly active child runs the risk of being labeled “behavior dysregulation disorder.” And forgetfulness, which begins to appear with age, according to the same reference book, is nothing more than a “mild neurocognitive disorder.”
It will be surprising if any of us manage to avoid falling into the ever-lengthening psychiatric tentacles.
Myths about mental health treatment
6. Long-term use of antipsychotic drugs is relatively beneficial
Psychiatry is sometimes unable to recognize cases where its treatments do more harm than good. When it comes to mutilated genitals, botched lobotomies (brain interference), surgical organ removal that induces coma, electroconvulsive therapy, etc., the doctors behind these procedures tend to admit they made mistakes.
Psychiatrists are always the last to admit that they have harmed the person who paid them for their help.
The situation is similar with antipsychotic drugs. Long-term use, especially of first-generation drugs, causes serious harm to 30 percent of patients, causing them to make uncontrollable twitching of the tongue, lips, face, arms, legs.
This often leads to the development of a permanent condition known as tardive dyskinesia. Second-generation antipsychotics are a little more “lenient” in this regard, but their use still does not exclude the possibility of developing such problems.
In addition to causing tardive dyskinesia, long-term use of these drugs puts people at risk for heart disease, diabetes, and obesity.
It would not be amiss to note the fact that today there is a large amount of evidence that psychotropic drugs help reduce brain size.
5. Effective treatment of mental illness is critical to public safety.
Prominent psychiatrists continue to support the myth that the public is in danger due to the emergence of "psycho-killers" in our midst.
The latest dramatic example is Jeffrey Lieberman, president of the American Psychiatric Association, who argues that "shocking acts of mass violence are typically committed by people with mental disabilities who do not receive adequate treatment."
Although a person with paranoia may still commit acts of violence, a recent Dutch study found that only a tiny fraction (0.07 percent) of all crimes committed worldwide are directly related to mental health problems.
A study by UK experts showed that only 5 percent of all murders are carried out by people who have been diagnosed with schizophrenia at some point in their lives.
Moreover, this figure is quite insignificant compared to the number of crimes related to alcohol and drug abuse (60 percent of cases).
Moreover, people suffering from mental disorders are more likely to become victims of crime than criminals. One study analyzing patients with schizophrenia found that these patients were 14 times more likely to be the target of violent acts than to commit an offense themselves.
Consequences of mental personality disorders
4. Many mentally ill people cannot return to normal life.
Such pessimism is not surprising, since many psychiatrists believe that mental illness is caused by defects in the brain and is therefore a lifelong condition, akin to diabetes or cardiovascular disease.
The language of psychiatry simply screams hopelessness, often using terms such as “chronic schizophrenia” or “severe mental disorder.” But in reality everything is somewhat different.
Although schizophrenia is considered a disease for which recovery symptoms are vague, typically 80 percent of people with it experience significant improvement over time.
Recovery from mental disorders does not necessarily mean the elimination of all symptoms. For many sufferers, the indicator is achieving their life goals and subsequently maintaining a decent standard of living, regardless of difficulties.
In this sense, human recovery is a shift from a focus on pathology and symptoms to an emphasis on health and wellness. Free from the shackles and pessimism of psychiatric dogma, the meaning of recovery is a realistic goal for everyone.
Effectiveness of treatment for mental illness
3. Psychotropic drugs are very effective
In the United States alone, 3.1 million people were prescribed antipsychotics in 2011 at a cost of $8.2 billion. These drugs continue to be fundamental in the treatment of people suffering from schizophrenia.
As for Europe, according to UK psychiatrists, the first three months of treatment with antidepressants help improve the condition of 50-60 percent of patients. However, despite everything, the effectiveness of both antidepressants and antipsychotics is seriously disputed.
Surprisingly little research has been done to compare the effects of antipsychotics and sedatives in people suffering from any mental disorder. A review of the few studies that have been conducted has shown that sedatives have a very strong effect on the manifestation of psychotic symptoms.
This suggests that the noticeable decrease in a person's reaction to what is happening around them applies to everything, and is not strictly the “antipsychotic effect” that drug manufacturers claim.
A recent review of 38 clinical trials of second-generation antipsychotics found little benefit over placebo.
Conducted studies of antipsychotics specifically (most likely with the support of pharmaceutical companies) kept silent about negative results, selectively publishing only information showing the drug in a good light.
In addition, it has been found that about 40 percent of people suffering from psychotic disorders can significantly improve their condition without using any medications at all. And this fact calls into question the advisability of using antipsychotics in general.
As for antidepressants, the matter is more complicated. However, many scientists agree that the benefits of their use are not much greater than the effectiveness of placebos.
Although in some particularly severe cases of depression the clinical difference between placebo and antidepressant use was still significant, it was more likely to be due to a decrease in the person's ability to respond to placebo rather than due to an increased response to antidepressants.
However, this was followed by another study which found that 75 percent of people who took antidepressants experienced significant improvement in their symptoms, while 25 percent of those who did not take them saw their symptoms worsen.
Based on this information, the study authors concluded that antidepressants should be reserved as a last resort, and if a person does not respond to treatment within a few weeks, then their use should be discontinued in favor of exercise and cognitive behavioral therapy.
Myths about human mental illness
2. The “it’s a disease like any other” approach reduces stigma.
Psychiatrists often complain about the stigma and discrimination faced by people with mental health problems. Experts emphasize the importance of educating the general public about the existence of these disorders.
Under the banner of the need to be medically savvy, they seek to convince the public that schizophrenia and depression are diseases like any other, caused by biological defects such as biochemical imbalances and genetic brain diseases.
Many psychiatrists believe that by speaking more often about the biological causes of mental illness, they thereby help the patient “prove” to others that he is not to blame for the development of the disorder. This, in turn, supposedly improves attitudes towards him.
But in reality, trying to convince people that schizophrenia and depression are illnesses like diabetes will likely only make people more negative about mental illness.
A recent review found that in 11 of 12 studies, citing biological causes for mental disorders led to more negative attitudes toward the sufferers. However, if explanations were based on life events experienced, people's attitudes softened.
In general, the “this is a disease like any other” approach leads to a higher level of social isolation of “sick people” and to inflated perceptions of others about the danger.
1. Psychiatry has come a long way in the last 100 years.
Many areas of medicine can boast of impressive advances achieved over the past hundred years. Vaccines against polio and meningitis have saved millions of lives.
The discovery of penicillin, the first antibiotic, revolutionized the fight against infections. Survival rates among cancer patients and those who have had heart attacks are rising steadily.
But what has society managed to gain from the century of existence of professional psychiatry? Apparently, not so much.
Psychiatry's claims to progress are no longer news. Edward Shorter in the preface to his book A History of Psychiatry ( A History of Psychiatry) wrote: “If there is one intellectual reality of the late 20th century, it is that the biological approach to explaining the nature of psychiatric illness has been a resounding success.”
Nevertheless, prominent psychiatrists continue to stubbornly defend the status of psychiatry as a truly medical field.
However, the facts paint a completely different picture. If you have ever suffered from a psychological disorder, you are much more likely to recover from it faster if you live in a developing country than if you are a citizen of a developed country.
The misuse of "psychiatric treatment" in Western countries is a major reason for this. In addition, the chances of recovering faster from schizophrenia are no greater today than they were 100 years ago.
Therefore, one can hardly talk about incredible progress in psychiatry.
The Norwegian Ministry of Health orders the introduction of drug-free treatment
Robert Whitaker
Tromso, Norway. The well-worn Åsgaard Psychiatric Hospital. Its squat buildings resemble public places of the Cold War era, and it is located as far as possible from the centers of Western psychiatry. Tromsø is located almost 400 kilometers above the Arctic Circle, and tourists come here in winter to see the northern lights. And yet here, in this remote outpost of psychiatry, on the floor of the hospital, which has recently reopened after a recent renovation, a sign hangs at the entrance to the ward with a striking message: “Drug-free treatment.” And the Norwegian Ministry of Health actually ordered the introduction of such an initiative in four of its regional branches.
The very name “Drug-free treatment” does not fully reflect the essence of the care methods that are used here. It's actually a six-bed ward for those who don't want to take psychiatric medications or want help weaning off them. The principle here is that patients should have the right to choose their treatment, and their care should be based on their choice.
“This is a new approach,” says Merete Astrup, head of this drug-free unit. “Previously, when a patient needed help, it was always provided based on what the hospitals wanted, not the patients. We usually told them: “This will be better for you.” Now we ask them: “What do you want?” And the patient understands: “I have a choice. I can make a decision.”
Although the ward is far from the centers of influence in Western psychiatry, it can be considered a springboard for decisive changes in the future, says Magnus Hald, head of psychiatry at the University Hospital of Northern Norway. “We must consider the patient's position as important as the doctor's. If a patient says he wants this or that, that's enough for me. After all, the whole point is how to help people live their best lives, and as effectively as possible. And if a person wants to achieve this with the help of medications, we must help him with this. And if he wants to live without pills, then we must support him in this. This is what we have to implement.”
As one might expect, this initiative, which has been prepared for a long time, cannot help but throw circles in the waters of the entire Norwegian psychiatry. A lot is happening: patient groups are successfully organizing politically; academic psychiatrists are resisting; discusses the pros and cons of psychiatric medications; There is an emerging movement - primarily in Tromsø, but also in other regions of Norway - to reconsider the concept of psychiatric treatment.
“This kind of debate occurs when a paradigm shift is expected,” says Hald.
Hear the patient
The Ministry of Health order to introduce drug-free treatment came as a result of years of lobbying by five patient organizations, which formed the United Movement for Drug-Free Treatment (in psychiatry) in 2011. What is notable about this order is that in adopting it, officials in the Ministry had to overcome objections from members of one of the medical professions and instead listen to those who do not usually have political weight in society.
When I asked the leaders of patient associations about this, they spoke with some pride about the Norwegian political culture, which takes into account the opinions of all segments of the population. This practice has been evolving for decades, and some participants mentioned changes in abortion laws as the first milestone of such social change.
Until 1978, to terminate a pregnancy, a woman had to apply to a commission of two doctors, and the application had to be submitted by her doctor. If she was married, her husband's consent was required. However, under the influence of a powerful feminist movement, Norway passed a law allowing abortion on demand. The right to make a choice passed to the woman.
In the same year, Norway adopted a law on gender equality, where men and women were guaranteed equal opportunities in education, employment, cultural and professional development. Today, gender equality laws require that each gender be assigned at least forty percent of the composition of official committees, governing bodies of government agencies, and local governments. Likewise, trade unions have retained their influence in Norway, and today private companies are required to hold annual staff meetings to discuss business and how it can be improved.
All this reveals a picture of a country that has set out to create a society in which the voices of all citizens are heard, and this philosophy has permeated the healthcare sector. It's no longer unusual to see hospitals and other health care providers forming "patient councils" with the idea that "health care consumers should have a voice and be listened to," says Haakon Ryan Ueland, a leader in the movement of former psychiatric patients. “Unbending” patients - and not only in psychiatry. Listening to patients and their families should be done in all areas of medicine.”
Although this has created fertile ground for the emergence of psychiatric patient groups that can appeal to politicians and the Ministry of Health, the potential political influence of such coalitions has been tempered by the fact that different groups have held different principles regarding psychiatry and the merits of psychiatric treatment. On the one hand, the Unbreakables appeared. This association was founded in 1968. This is a union of former psychiatric patients aimed at protecting the civil rights of such people. There are more moderate groups such as Mental Health(Mental Health), with approximately 7.5 thousand members, is Norway's largest organization in the field of mental health. Due to differences in approaches, patient groups have long been unable to successfully lobby the government for the required changes.
“We can’t agree on anything,” says Anna Grete Therjesen, leader LPP, the Norwegian association of families and carers in the field of mental health - so the government says: "You want one thing, others want another." And in the end they successfully ignored us.”
However, over the past 15 years, patients' associations have all witnessed with horror how one remarkable feature of modern psychiatry is gaining momentum in Norway: the rise in cases of compulsory treatment. At least one study has found that compulsory treatment is used more widely in Norway than in any other country in Europe. As a rule, orders for such treatment remain in effect even after patients are discharged and returned to the community, which is considered by patient groups to be a shameful, disgusting practice of oppression. Leaders of these groups report that "ambulatory care watchdogs" now go into people's homes to ensure compliance with medication orders, which "can last a lifetime for the patient."
“That’s the problem,” says Terjesen. - they will once write down in their books that you must take medicine, and it will be very, very difficult to get rid of this order. If you say you don’t want to accept it, you can appeal the appointment to the commission, but that doesn’t help anyone.”
Per Overrein, leader of the Aurora patient association, adds that he has “never heard” of a “patient winning” in such an appeal.
In 2009, Greta Johnsen, an experienced mental health advocate, collaborated with other activists to create a manifesto called “Collaboration for Freedom, Safety and Hope.” “We wanted to create some kind of alternative to psychiatry,” she explained, “to create something of our own. Our goal was to establish some kind of institution, a center where there would be freedom, there would be no forced treatment, and the treatment itself would not rely on drugs.”
Soon enough, five very different organizations came together and began working together to achieve these changes. LPP- the organization is more moderate, like Mental Health. "Aurora", "Unbreakable" and "White Eagle" largely represent the interests of survivors of psychiatric treatment.
“All of these associations are very different from each other, so we had to agree for a long time on how to formulate what, how to present our ideas to authorities at different levels and who exactly to send from us so that he would convey our message, common and unified,” says Ueland.
Although each group sought to end involuntary treatment, this was considered unattainable. Instead, the focus has been on getting the government to support “drug-free” treatment for those who want to go without drugs. This requirement is less drastic because it is consistent with the principle that hospitals and other health care providers should listen to consumer groups and design care based on their wishes. Since 2011, the Norwegian Minister of Health has issued annual “letters” instructing the four regional branches of the Ministry of Health to establish at least a few hospital sites where such care could be provided. And yet, year after year, these letters from the minister were constantly ignored in the ministry's branches, explains Terjesen:
“They just didn't want to listen. The hospitals did nothing. Nothing happened, and we gave up. All of Norway didn't care."
Then, she continues, “something happened.”
What happened was this: there was a whole stream of revealing stories about the state of psychiatry in Norway in the news. Articles appeared about “abuses in psychiatric wards” and how “knitting is back in fashion these days,” Ueland says.
One study concluded that forced treatment is 20 times more common in Norway than in Germany. And its results for patients leave much to be desired.
“We were lucky,” says Terjesen. - the treatment turned out to be bad. If it were good, it would be more difficult for us. But now the government has begun to say that the results leave much to be desired, people are dying early, we are throwing money away, consumers of medical services are unhappy, and in general everything is bad. The minister said that this cannot continue.”
On November 25, 2015, the Norwegian Minister of Health, Bent Høie, issued a directive in which the “recommendations” from his previous letters became “directions.” The four regional branches of the ministry were ordered to build a “dialogue with patient associations” and thus create a system of “treatment methods without the use of drugs.”
“Many mental health patients do not want to be treated with medication,” the minister wrote, “we must listen to them and take this issue seriously. No one should be forced to take drugs if the necessary care and treatment can be provided in other ways. “I believe that the development of drug-free treatments is not progressing at a sufficient pace, and therefore I have requested that all regional health authorities begin providing (drug-free treatment) by June 1, 2016.” In addition, the minister indicated, the relevant authorities are obliged to offer services for “a controlled reduction in the intensity of drug therapy to those patients who wish it.”
Thus, the ministry took the first step. This initiative fit into the b O a greater goal, which Høye outlined even earlier in one of his letters. “We will create a healthcare system where the patient is at the center...Patients will have rights...Patient rights need to be strengthened.”
Resistance from psychiatry
Today United Movement leaders say it was a "brave move" on Høie's part and he showed himself to be "a man who listens." But they also knew that the order, which questioned the usefulness of antipsychotics and other psychiatric drugs, would provoke resistance at all levels of psychiatry. And so it turned out. Not a single regional branch of the ministry fulfilled the requirement within the specified deadline of June 1, 2016, and many representatives of Norwegian psychiatry offered fierce resistance. Thor Larsen, professor of psychiatry at the University of Stavanger, tried to ridicule the initiative as a "monstrous mistake".
“Drug-free treatment is not just a bad idea. It could be a step towards introducing systemic negligence in Norwegian psychiatry. In the worst case, this will lead to ruined human lives,” he wrote, “the most seriously ill often do not understand their illnesses... (they) do not consider themselves sick. Therefore, the freedom of choice that the Minister of Health wants to impose on us will lead to the fact that many seriously ill people will be denied the right to the best possible treatment.”
Psychiatrists have repeatedly raised this argument as the main objection to the new initiative: the drugs are effective; no drug-free treatments have been shown to be effective for psychosis; and patients who do not want drugs simply do not understand their illness and the fact that they need drugs.
This initiative will “strengthen the position of skepticism towards drug therapy,” wrote Norway’s largest newspaper Aftenposten(Evening Post) Jan Ivar Rössberg, professor of psychiatry at the University of Oslo. “My concern is that this measure will mean that later people with psychotic disorders will return to optimal treatments, which you know are effective... I cannot be responsible for teaching psychiatry at the University of Oslo if they support this development” (drug-free treatment).
The debate continues. Even after Tromsø opened in early January ( 2017 - approx. translation) ward for drug-free treatment, serious doubts are expressed that the spirit of this directive of the Ministry of Health will be followed in its other regional branches. The Norwegian Psychiatric Association, for its part, officially decided to “maintain an open approach” and consider this issue at its annual meeting. “Are antipsychotics effective,” wrote Anna Christina Bergem, president of the association, “or do they not give the result that we were led to believe?”
"Donald Trump of Anti-Psychiatry"
The Norwegian Psychiatric Association has identified the scientific question at the heart of the new initiative. Compulsory treatment means the use of antipsychotic drugs, and while the controversy continues, the non-profit humanitarian foundation Stiftelsen Humania together with the United Movement organized public hearings on this initiative, which were held on February 8 ( 2017 - approx. translation) in Oslo. The title of the hearing was: “On what knowledge is the choice of treatment with or without psychotropic drugs based?”
“I want to see how they fight this,” Ueland said the day before the hearing. - They require evidence that alternative methods are effective. I tell them: “Where is the evidence that your methods are effective? I read many articles and books and did not see such evidence for your drugs. What I saw is that they make people feel bad, that they lose emotions, that these drugs treat symptoms, but prove to me that they are effective in psychosis, effective in this condition that you call schizophrenia." This is what I want to see before they tell us something without allowing drug-free treatment.”
Leader of the fund Stiftelsen Humania is Einar Plin, businessman, publishing house owner Abstract Forlag, where materials for educational institutions are printed. He became involved in this battle after his wife and son committed suicide without receiving any relief from mental health services. “When I suffered the suicide of people close to me twice, I myself went to psychiatrists, and the only thing I got from them was drugs and electric shock,” he says, “after I finally got off all the pills, I began publishing books, in which psychiatry was criticized, and organize conferences.”
One of the books published by Einar's company was a translation of my Anatomy of an Epidemic into Norwegian. I described the long-term effects of antipsychotics in this book and concluded that research shows that they generally worsen long-term outcomes. So Plin asked me to speak at these hearings. Besides me, Ueland, Rössberg and Jaakko Seikkula performed there. The latter gave a talk about “open dialogue therapy”, which is used in northern Finland, where psychotic patients are not put on antipsychotics all at once. The hearing committee included Magnus Hald.
The hearings took place at the Literary House in Oslo. Even half an hour before the doors opened, an impressive crowd had already gathered in front of them - evidence that the “drug-free” initiative had aroused serious public interest. The hall quickly filled, and those who did not have time to take their seats crowded into an adjacent room, where these hearings were broadcast on screens via the Internet. The audience included mental health professionals, members of patient groups, and at least one representative from the pharmaceutical industry.
The purpose of this study was to determine the benefit of early detection of a “first episode of non-affective psychosis.” One group suffered from “untreated psychosis” for 5 weeks before starting treatment; in the control group - 16 weeks. In both groups, patients received traditional treatment with antipsychotics and were then followed for 10 years. At the end of this period, of those patients who were alive at that time and did not withdraw from the study, 31% of those in the early treatment group were in the recovery stage, and 15% of those in the 16-week psychosis group were in recovery. If antipsychotics had worsened long-term outcomes, Rössberg said, then patients in the early treatment group—who received antipsychotics for 11 weeks longer—would have fared worse.
“If you take a drug that is known to have a poor prognosis and start treatment with that drug earlier, the outcome should be worse. Clear?" - he concluded.
I outlined the history of the research as reported in Anatomy of an Epidemic (since updated), and then Seikkula reviewed the Open Dialogue program, which had shown good long-term results. The discussion generally repeated these arguments, to which Hald added his own thoughts. He posed a question that, it would seem, should not leave any psychiatrist indifferent.
He said: “There are many patients who are considered in psychiatry to not need drugs. But we don't know who they are. And since we don’t know who they are, we can decide either not to give the drugs to anyone, or to give them to everyone. In psychiatry they prefer to prescribe them to everyone. We give antipsychotic drugs to people whose symptoms of psychosis persist. However, they continue to receive them. Why do they continue to receive them if there is no improvement from it?
After the hearing, I asked Plin what he thought of the discussion. I myself was disappointed as it again became apparent how difficult it was to openly discuss the benefits of psychiatric medications. However, Plin took a broader view. The shifts in public thinking required for drug-free treatment to gain public support are not happening quickly.
“It seems to me that there is increasing concern among some psychiatrists, psychologists and nurses about whether there is actually a sufficient evidence base in favor of the ongoing expansion of the use of psychotropic drugs,” he shared, “I hope the conferences that we held will help to understand” their applications.
Once again about TIPS research
After the hearing, I was very sorry that I did not take the time to discuss in detail the very TIPS study that Rössberg cited as evidence of the effectiveness of antipsychotics in the long term. This study aimed to evaluate the effectiveness of early treatment rather than the long-term results of these drugs, and although both groups included patients who stopped taking antipsychotics, it did not report the distribution of 10-year outcomes in each group by level of drug use. There was also reason to doubt that the results were better in the early treatment group. Patients in the control group were older and more severely ill at the start of the study, but their symptoms were similar to those in the early treatment group after 10 years. In addition, the control group had more participants who were “living independently” at the end of the study. More importantly, in the early treatment group, where the emphasis was on immediate and long-term use of antipsychotics, the results did not indicate which form of treatment was effective.
This was a study of younger patients experiencing their first episode of psychosis - such episodes often resolve on their own over time. The early treatment group included 141 patients, and their final results after 10 years were as follows:
· 12 died (9%)
· 28 dropped out of the study and were lost to treatment (20%)
· 70 were still in the study and did not recover (50%)
· 31 remained in treatment and recovered (22%)
In other words, if the results for those patients who died or were lost to treatment are added to the findings, added to those that are stated as results, it turns out that for almost 80% of the participants the case did not end well (if "loss to treatment" considered an unsatisfactory result). “Open dialogue” therapy, which is used in northern Finland, produces very different long-term results: after five years, 80% of participants are either working or back in school, asymptomatic and free of antipsychotics. I regretted not preparing a slide comparing the results of both therapies and asking the Norwegian audience which program they would be more likely to support.
These data alone could become the subject of even more interesting public discussions. However, a few weeks later another study was published, which provided new details about this TIPS study. To learn more about the recovery process, the team of researchers who conducted the TIPS study, including Tor Larsen from the University of Stavanger, sampled 20 "fully recovered" program participants and interviewed them. Although many of them suggested that antipsychotics were not helpful in the acute phase of treatment, the researchers also reported that long-term use "likely compromises the individual's participation in recovery" and "appears to reduce the likelihood of functional recovery."
Of the 20 fully recovered patients, seven refused to take antipsychotics from the very beginning and therefore “never used” the drugs. Another seven had already stopped taking them, meaning 14 of the 20 fully recovered patients were not taking them at the time of the study interview. Rössberg cited this TIPS study as an argument against the drug-free treatment initiative. However, these study outcome data indicated "complete recovery" in patients who were initially treated without antipsychotics and in patients who then stopped taking them. And a new “drug-free” initiative aims to provide patients with these two closely related forms of treatment.
Rethinking psychiatric drugs
As the discussion showed, the implementation of the ministry’s directive on drug-free treatment is still in limbo. At the Tromsø hospital, where Magnus Hald is head of psychiatric services, the ministry's local branch has opened a private ward that provides drug-free treatment. In the rest of the country, local branches of the Ministry of Health allocate separate hospital beds for this purpose; The six-bed wards are largely reserved for non-psychotic patients, meaning the new initiative does not yet constitute an alternative to compulsory antipsychotic treatment.
But even with all this, the directive calls for change, and the day after the hearing I was accompanied by Einar Plum and Inge Brorson, a member of the foundation board Stiftelsen Humania, went to the Lier psychiatric clinic, 40 kilometers southwest of Oslo, to meet with the team at the Vestre-Viken trust, where drug-free treatment is being developed for the southern and eastern branches of the ministry. The trust runs several mental hospitals and serves a region of half a million people, one tenth of the country's population. Brorson previously worked there, and he helped generate public interest in the new initiative by encouraging local psychiatrists and health care providers to review the medical literature on the long-term effects of psychiatric drugs.
The meeting was led by psychologist Geir Nyvoll, and he began by referring to this body of scientific research. Before this, he took four months off to study in detail the research materials on antipsychotic drugs, and then, together with psychiatrist Odd Shinnemon, presented his findings to the clinic staff. “Change is based on knowledge and understanding,” he said, “and we have change coming now.”
As a first step towards creating such changes, the trust is developing a “continuous improvement programme”, which it calls the “Correct and Safe Use of Medicines”. Under this program, employees are required to prescribe reduced doses of psychiatric medications; Monitor closely for side effects from medications; refrain from using them during “treatment for common problems in life, such as adverse events”; and stop using medications if they do not produce good results.
In response to the Health Secretary's directive, the trust allocated one drug-free treatment bed for psychotic patients at the Lier Clinic and five such beds at two other hospitals for patients with less serious disorders. The trust welcomes the principle that “patients should have the right to choose medication-free treatment,” said psychiatrist Torgeir Vethe.
“Every patient should have this opportunity. And if the patient does not want to take drugs, then we must provide him with all the other care that we can, even if we, as specialists, decide that the best treatment is drugs.”
Now that the two 'parallel' projects are underway, the trust is setting up a research program to evaluate their effectiveness - in the hope that it will provide a more complete 'evidence base' for a new 'drug-free' initiative and for a 'shared decision-making' system. with patients. “And we wonder if we’re reaching some new frontier?” - asks psychologist Bror Joost Andersen.
The trust has already developed a research protocol for the therapy, which it calls “basal impact therapy”. It was introduced at the trust in 2007 with the aim of reducing the use of polypharmacy in “treatment-resistant” patients. The therapy is based on the belief that in psychiatric hospitals, patients are "over-regulated," meaning that staff constantly monitor their behavior and help them avoid situations that provoke "existential catastrophic anxiety," according to psychologist Didrik Hegdahl. The goal of basal effect therapy is the opposite. In it, doctors exercise “underregulation” over patients, which forces them to seek help from staff themselves when they need help, and encourages them not to give in to their existential anxiety.
“We give the patient freedom,” says Hegdahl. - The level of regulation in this chamber is very low. We treat the patient as an adult, as an equal, and show him respect as a person who is here to work on himself. We are ready to help patients in this work on themselves. And when we do this, they mobilize their capabilities. There is nothing surprising here.”
A study of 38 patients receiving basal effect therapy (of whom 14 had a diagnosis of schizophrenia spectrum disorder) found that their use of antipsychotics and other psychiatric medications decreased significantly over a period of one year and one month. Of the 26 patients who were taking antipsychotics at the start of the study, nine stopped taking them by the end of the study, and of the ten who were taking mood stabilizers (anti-epileptic drugs), seven successfully did the same.
Vete, Andersen, Hegdahl and others said they felt they were entering a new era in patient care, with both new opportunities and challenges. The usual difficulties: skepticism from colleagues; public expectations that doctors will use antipsychotic drugs for “violent” patients and concerns that failure to adhere to generally accepted standards of care could lead to problems with regulatory authorities in the event of mistakes or failures. There was a lot of anxiety, but in general, as several doctors shared their forebodings, “new, better times” were coming.
“As a clinical psychiatrist and manager, I have been in this business for 35 years, and I am very grateful for the opportunity to take part in the changes that are now gradually permeating psychiatry, because they are sorely needed,” said psychiatrist Karsten Bjerke, chief medical officer of the psychiatry hospitals in Blakstad.
A paradigm shift is in full swing
Over the past few years, the "open dialogue" program run in Tornio, Finland, has come to be seen in the United States and other countries as therapy, promising to treat psychotic patients in a new way that can produce much better long-term results and is gentle. , selective prescription of antipsychotics. Perhaps it is not surprising that Magnus Hald's thinking and beliefs - and therefore the principles on which the drug-free treatment ward in Tromsø is based - are very consonant with the ideas of “open dialogue”.
Huld's close friend was Tom Andersen, professor of social psychiatry at the University of Tromsø, who is often remembered today as the founder of the so-called “dialogue” and “reflective” processes. Andersen and Hald began collaborating in the late 1970s and, having developed the concept of “reflective groups,” they incorporated into their work the “Milanese approach” to family therapy, which involved “systems thinking and practice.” The key principle in this approach, as Hald wrote, is that "men change according to their surrounding circumstances, and essential among these circumstances are those which relate to their family life within their community." The two scientists traveled widely to explain their new methods. In the 1980s they established contact with Jaakko Seikkula and the "open dialogue" team in Tornio.
In subsequent years, the Finnish team was able to better document their results from dialogue practices because they adopted the psychiatric diagnosis system - or at least relied on the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) when reporting results, while the team from Tromsø did not rely on him. Moreover, in Tromsø there was not as much emphasis on limiting the use of antipsychotics, although Anderson became "increasingly opposed" to their use. “It was not easy to refrain from prescribing drugs, and we were not particularly focused on it,” he explained.
Nevertheless, Hald had already observed that people with various kinds of psychiatric symptoms managed well without drugs. With this experience and mindset, he enthusiastically accepted the new directive from the Minister of Health: “For me, this is an opportunity to take something as clear as day and give it an organized form. We must give people the option to avoid antipsychotic drugs when they are experiencing serious mental health difficulties. I always thought it was right."
Since Hald warmly welcomed the new order, the northern branch of the ministry provided the University Hospital of Northern Norway with annual funding of 20 million Norwegian kroner ($2.4 million) to maintain a six-bed ward for drug-free treatment at Åsgaard Hospital. Thanks to this support, Hald and his staff were able to recruit staff from scratch, and Merete Astrup, a psychiatric nurse, took over the ward in August 2016. She had always wanted to work in a place where patients had the “right to choose” whether they wanted to take their medications, an approach now shared by all of the twenty-one employees who will be recruited once the hiring process is complete.
“I really like it here. I know that I work the way my soul wants, says art therapist and nurse Eivor Meisler. “I always dreamed of working without medications.”
Tore Ødegård, a psychiatric nurse, said he hated working in wards where patients were constantly forced into treatment, and that he therefore jumped at the chance to work here: “In the past, to force patients to take their medications, I would argue with them. I was part of that system, and now I'm part of another system, whose main goal is not to give drugs, but to help people cope with problems - without drugs. I find it very inspiring and it’s an honor to work here.”
Then Odegaard shrugs: “But we don’t really know how to do it yet. Those who want to get off drugs tend to come here, and this can be difficult, various problems can arise. Psychiatrists will say that “we were trained not to take people off medications, but only to add new ones.” We need to experience this and learn how to help people get off drugs.”
Stian Omar Kierstrand is one of those employees who has similar experience. In 2001-2002, he himself went through drug withdrawal, which for him meant bouts of mania, depression, suicidal thoughts and inner voices. As he explained, he “charted his own path to recovery by studying his own history. I realize that I have to be willing to accept whatever happens, and then one morning I wake up and the world is completely different. “I have seen the light in the sense that you need to accept anything from your past and from your whole life.”
It is in this light that he perceives those who come to this ward. “Those who come here don’t want drugs. They are deeply convinced of this. We say: “You can come to us. Come as you are. Come with your delusions, deviations, thoughts, feelings, with your history - it’s okay.” And we can accept them as they are. When people feel this, something important happens. People's mistrust and fear disappear, and they understand that all this is normal. And then a person can grow. That's what matters most."
This ward does not yet provide an alternative to compulsory drug treatment. Patients are referred to it from other hospitals and psychiatric institutions, and they can be transferred here only if they ask for this type of treatment, and if the psychiatrist observing them agrees to this. But here they find themselves in an environment where the patient is the center of attention, and therefore they have a certain freedom of action. All doors are open and everyone can check out and go home if they want to. And while the patient is in the ward, he can manage his time as he wishes. One time when I went there, it was around noon and the patients were out shopping in town.
The furnishings of this six-bed ward are quite spartan: six rooms, each with a single bed and desk, a bit like a student dorm. Meals are prepared in the kitchen, which is also in the ward, and they eat in a large common room, where they often spend time talking. Outside the windows lies a peaceful landscape - the sea and snowy peaks to the west. That winter the sun had only made its first appearance a week or so before my arrival, but now the daylight for several hours a day now bathed the mountains in a soft pink glow.
Therapeutic programs are selected so that the day in the ward passes slowly. The weekly schedule includes reflexive therapy sessions, daily cool walks and exercise in the ground floor gym. As this “therapy” proceeds, patients write down their impressions of how it is going, and these notes are placed in their medical records.
“This way we can understand much better how the patient sees the world,” says Dora Schmidt Stendahl, a psychiatric nurse and art therapist. - Usually (that is, in previous jobs) I wrote reports on conversations with patients, and it seemed to me that I conveyed their perceptions well, but when patients themselves write what they want, it is completely different. When they have the opportunity to express themselves freely, we must show respect for their world. These recordings of theirs allow us to better see the world through their eyes."
Patients can read what their therapists write, too. “You have to think carefully before you write,” Stendhal said. - Patients may not agree with this, and then you can talk to them. Their opinion matters. They are not taken lightly.”
Although the staff here describe patients without using diagnoses from the Diagnostic and Statistical Manual, patients may have been assigned diagnostic categories before arriving on the ward. At the time of my visit there were four people on the ward who, in Guidelines terms, could be described as suffering from depression, mania and bipolar disorder, and one or two had “psychotic” symptoms. One of the patients said that he was like a lightning rod for all the evil in the world, and another talked about the horrors that haunt him at night. Of the four patients, three agreed to sit with me and tell their story.
Merete Hammari Haddad, partly of Sami descent (the indigenous people of northern Norway), has been diagnosed with bipolar disorder for almost ten years.
When her adult life was just beginning, everything was going well. She worked as a teacher and for a time as a school principal, earned a master's degree, and did her research on how people reach their highest potential. She began teaching others, lived for some time in Dublin, then in Oslo. “Things were going very well for me,” she says.
Her husband eventually admitted her to a mental hospital. She was told that she had bipolar disorder and that she would have to take lithium for the rest of her life. “When I drank it, I felt worse than ever,” she says, “all my feelings disappeared. It's like not being alive."
Two years ago she decided she couldn't do this anymore. “I needed to feel happiness again. I wanted to be joyful again. And I accepted my feelings. I knew my sorrows, my fears. When I gave up on this matter, I began to feel something. I could give vent to tears and pour out my misadventures to the whole room. But no one needed it. Neither relatives, nor husband. I could only trust myself.”
Turbulent times continued. Her relationship with her family and with the population of the commune remained strained. Still, she continued to think about how she could help “people realize their human potential.” Following this goal, she founded a company in December 2016 and secured a government grant of 100,000 crowns to conduct research on the subject. But as she did this, she began to distance herself more and more from her husband. At the end of January, he decided that she was “overly enthusiastic” and again admitted her to a psychiatric hospital.
“I was taken away by force and in handcuffs,” says Merete, “And I only received drugs, drugs, and also forcibly.”
However, after spending a little over a week in that first hospital, she achieved a transfer to a ward for drug-free treatment in Tromsø. She stayed there for five days, during which she and her husband were able to look directly at their problems, and then went home.
“My husband and I now understand much better what was wrong. Together we found a new direction. We came here to reconnect and now we have decided which path we want to take in the future.”
In conversational therapy terms, her troubles were caused by a “crack” between her and her husband, so the way to relieve that stress was to repair the rift rather than adjust the chemical balance in her brain. “I only needed a bed, food and a caring attitude,” she said, “here they saw me, listened to me, and here I can talk about anything. Here I was never told that I was sick. Now it seems to me that being human is not bad at all.”
When I was first introduced to Mette Hansen - at one of the group discussions in the common room - she asked me with a sly grin a question that has never left my mind since then. “When you look in the mirror,” she said, “what do you see?”
Of course, the question is amazing, and it seemed to me that it betrayed something in her: a certain sense of freedom that she gained from being in this room, where she could freely express herself.
She was first diagnosed with bipolar disorder in 2005. She was a forty-year-old mother of three, overburdened with work and family responsibilities. “I didn’t have time for myself,” she explained. “I was unable to do what others wanted me to do.”
She was calmed by lithium, so she found it useful. After spending some time on vacation, she returned to work at a grocery store, and her life was fairly stable for several more years. But then, in 2015, she was diagnosed with breast cancer, and after the operation she had difficulty sleeping for several months. In December of the same year, she “went nuts again” and ended up spending another “term” in the hospital. Side effects from lithium accumulated: weight gain, swollen hands, tremors, thyroid problems - and in September 2016 she decided that she wanted to gradually get off it.
It turned out to be a bold step. Her husband and her other relatives did not at all welcome such experiments on her part, because the drug “worked,” but she needed to regain control of her life. “I said I should try it because I’ve been on lithium for 12 years. I am my own boss, and if my husband can’t stand it, then that’s his problem.”
Here, in this ward, as she said, they provide her with “peace” and help her get off the lithium without any problems: “I don’t have to think about my neighbors, my family. I can talk about different things, about my illness, about how to behave. Merete (Astrup) was the first to treat me kindly. This is something new. And it's nice. I really like it here."
When she managed to reduce her dose of lithium by four times compared to September, she began to wonder whether she really needed such a powerful drug: “I became a little taller. For me it's magic. Taking lithium is like being wrapped in a life jacket, only not while fishing, but while hiking in the mountains. Well, why do you need a life jacket in the mountains? Maybe a sleeping bag or brushwood would be more useful there?”
Now she looks to the future, and considers this ward a refuge where she can return if, upon returning home, she again encounters difficulties: “It’s important for me to know that I can come here again and decide for myself what to do,” she says.
Hannah Steinsholm and I spent most of our time talking about her love of music and the Jack Kerouac novel On the Road, which we both read - Sal Paradise, his manic friend Dean Moriarty and her thoughts on them. “I am very close to this example of mania,” Hannah once said. - When you go to something, there is always a lot of suffering and tears along the way. In any light there is always darkness."
She entered the psychiatric system as a child: she was diagnosed with ADHD, and she also got involved in conflicts with other children in her city. “I was made fun of as a child. But in my youth, it seemed like something was missing in me.” Subsequently, more diagnoses were added to her, and she went through a lot of things: self-harm, intrusive unkind thoughts, worries about how to succeed in this world as a folk singer. “I always felt like they expected me to do some amazing song.”
It is important for her that she can be here without taking Abilify, the antipsychotic drug she was put on earlier. She needed some structure, she needed help in dealing with her self-harm urges:
“Abilify was boring, it felt hopeless, I didn’t want to take it. When I drank it, I couldn't think. And if I have to continue to be in this world, then I must be smart, be such that people like me. People know that I have a disease. I have to prove that I can take this destruction and turn it into something, and something worth celebrating."
She had been in the drug-free treatment ward for several weeks already, and, in fact, no timetable for discharge had been established for her. “I liked it here more than I thought at first. Here you can simply live, live as life flows, and not in the way that you are constantly being asked about something, like in other hospitals, and they suspect that you will kill someone. That they won’t question me all the time - you don’t get used to it right away.”
And then our attention was again occupied by Sal Paradise, Dean Moriarty and their antics. This novel was published 60 years ago, but for some reason it remained so vividly in the memory of both me and Hannah.
Challenges ahead
So here's what the first few patients who receive treatment in this "drug-free" ward have to say. But if this innovation from Tromsø does not go unnoticed in the rest of the world of psychiatry, then the results of such patients will have to be monitored and reported in medical publications. Currently, a plan to conduct such research is still in development.
It will be impossible to conduct a randomized study, as psychologist Elizabeth Klebo Reitan notes. Therefore, one will have to rely largely on periodic surveys containing descriptions of “what kind of people are being treated” and subsequent summaries of their “symptoms, functioning, social activities and other recovery measures” over periods of five and ten years. In some ways, the main outcome will be whether patients can “make changes” in their lives, Elizabeth noted.
Skeptics of Norway's drug-free treatment initiative are already raising questions about what kind of patients will be treated in this ward in Tromsø (and in other drug-free treatment hospitals currently being set up in the country). It is assumed that these will be patients who are “not so seriously ill” and without such behavior problems (that is, without violent behavior and such things) that would “require” the use of antipsychotics. A ward for drug-free treatment cannot be promoted as a full-fledged alternative to compulsory treatment if it cannot also accommodate more difficult patients.
“We want to better understand this difficult problem,” Astrup said.
It is expected that one will work with “emotional” patients here in the same way as with everyone else: interacting with them, showing respect for them, and in addition, the very atmosphere in the ward should have a calming effect. If a patient suddenly becomes agitated, providers will want to know, “What are you worried about? Maybe we somehow excited you? How can we help you with this?
Astrup added that there will be another important point: “We don’t make rules like ‘you can’t break glasses’.” We need to create an atmosphere so that such things simply do not happen. And if someone throws a glass, we will pretend that the whole ward did it. We don’t want a person to have to throw glasses just to get our attention.”
Astrup and her staff return again and again to how new it all is to them and how much they have to learn. However, they are confident that they will be able to cope well with future challenges and that since the chamber was established under the directive of the Ministry of Health, the event will be given a full chance.
As for Hald, for him this endeavor represents a springboard for major changes in Norwegian psychiatry. “Will it be effective? I think so, but I don’t know yet how exactly we will achieve this. It won't be easy. But if we succeed, then the entire mental health system must change. Then radical changes will occur in her.”
The World Health Organization predicts that by 2020 the number of people suffering from depression will increase exponentially. And now this problem affects at least 5% of the world's population. However, only a little more than one percent of them are aware that they are sick. Two-thirds of those suffering from depression are considering a way to end their life, and 15% are putting their plan into action. Experts are discussing what needs to be done to be ready to provide timely and effective assistance to these people at the All-Russian Congress in St. Petersburg.
While the number of people suffering from severe mental illness has remained virtually constant over the years, the number of those living in the so-called borderline state between illness and health is growing. They suffer from depression, anxiety, sleep disorders and headaches, bulimia and anorexia. However, there is essentially nowhere for them to receive treatment. There is one inpatient psychotherapy department for the whole country (the St. Petersburg Neurosis Clinic accepts only St. Petersburg residents).
– Our patients do not suffer from severe psychiatric disorders, such as schizophrenia, for example. They can and should receive other help in order to continue raising children, working, driving a car,” says Tatyana Karavaeva, head of the country’s first department for the treatment of borderline mental disorders and psychotherapy of the National Medical Research Center named after. Bekhterev. “They cannot be loaded with drugs that make it difficult for them to move their legs; they need to carefully select medications and gradually, with the help of psychotherapy, change the attitudes that led to depressive disorders.
According to Tatyana Karavaeva, indications for hospitalization are the severity of clinical symptoms with severe manifestations, for example, a person cannot walk down the street, use transport, or be in public places due to fear. Or a person is constantly in a traumatic situation, it hurts him again and again, and he needs to be removed from these conditions. It happens that a person is able to be treated on an outpatient basis, but in an inpatient setting he needs to select drug therapy. There are situations in which psychological disorders become overgrown with somatic ones: against the background of anxiety, a person may develop problems with the cardiovascular, endocrine systems, and the gastrointestinal tract. The need for their correction is also an indication for inpatient care. Simply put, it is needed for those who cannot be treated at home. But there is nowhere to get it in Russia.
“And it’s not even that inpatient psychotherapy departments are expensive and require appropriate staffing with a large number of psychotherapists and medical psychologists,” says Viktor Makarov, professor, president of the All-Russian Psychotherapeutic League, head of the department of psychotherapy and sexology of the Russian Medical Academy of Continuing Professional Education. – There was a period when such departments worked in psychiatric hospitals throughout the country. But about 15 years ago they began to close. And I think that the reason was the jealousy of doctors: in a hospital with 1000 beds there is one department with 60 beds, in which interesting work with safe patients, in which all doctors want to work. They began to close them, and “borderline” patients were shoved into different departments of the clinic where “chronics” were treated. But a person with sleep disturbances and headaches will not want to lie with patients suffering from schizophrenia. Those who can, travel from other regions to the department of the Bekhterev clinic, because in the regions, even in Moscow, there are no psychotherapy departments where they treat not only with pills. In Moscow, such patients are immediately prescribed 5-7 medications. And it is important for a person to avoid this - to avoid the phenomenon of “delayed life”, when he thinks that he is being treated today and will start living tomorrow. As a result, only a few Russians in so-called borderline conditions receive effective medical care.
At the same time, the system of psychiatric care in the country is not only not preparing for the growing need for psychotherapy, but everything is heading towards the fact that problems with obtaining it will worsen. In St. Petersburg alone, 1,245 psychiatric beds have been cut over three years with the intention of transferring patients to receive care in outpatient facilities, including day hospitals. At the same time, no additional psychotherapeutic beds are being added.
– We need a reorganization of the service, and not a thoughtless reduction of beds; we need to train specialists who are in short supply. The Ministry of Health plans to adopt a new professional standard for a psychiatrist, which today has been formed in such a way that it can eliminate the specialty “psychotherapy” - the specialty “psychiatry” is being introduced with the labor function “psychotherapy,” says Tatyana Karavaeva. – The Russian Psychotherapeutic Association sent proposals to the Ministry for the preservation of the specialty, for the interaction of a psychotherapist with a medical psychologist, as well as for the training of these specialists.
At the congress, another appeal will be accepted to the Ministry of Health with proposals for changes in regulatory documents on the provision of mental health care. For example, there are still no standards for the number of patients a doctor should see; the issues of workload, training, and delimitation of the functions of a medical psychologist and psychotherapist have not been determined. Experts also raise objections to proposals to shift the prescription of drugs for the treatment of depression to therapists (general practitioners).
– Finding a psychotherapist in a clinic is a very great success, often unattainable, experts say. – So therapists will treat patients with anxiety or depression - or rather, they will prescribe medications. And these are not simple drugs, they have many side effects, there are specific indications and contraindications, and there are problems with drug withdrawal.
The experiment was conducted by a psychologist named David Rosenhan. He proved that it is generally not possible to identify mental illness for sure.
8 people - three psychologists, a pediatrician, a psychiatrist, an artist, a housewife and Rosenhan himself - went to psychiatric hospitals with complaints of auditory hallucinations. Naturally, they had no such problems. All these people agreed to pretend to be sick and then tell the doctors that they were fine.
And this is where things got weird. The doctors did not believe the words of the “patients” that they were feeling well, although they behaved quite adequately. Hospital staff continued to force them to take pills and released the experiment participants only after a course of forced treatment.
After this, another group of study participants visited 12 more psychiatric clinics with the same complaints - auditory hallucinations. They went to both renowned private clinics and regular local hospitals.
So what do you think? All participants in this experiment were again considered sick!
After 7 study participants were diagnosed with schizophrenia, and one of them had depressive psychosis, they were all hospitalized.
As soon as they were brought to the clinics, the “patients” began to behave normally and convince the staff that they no longer heard voices. However, it took an average of 19 days to convince doctors that they were no longer sick. One of the participants spent 52 days in the hospital.
All participants in the experiment were discharged with a diagnosis of “schizophrenia in remission” recorded in their medical records.
Thus, these people were labeled as mentally ill. Because of the results of this study, a storm of indignation arose in the world of psychiatry.
Many psychiatrists began to declare that they would never fall for this trick and would definitely be able to distinguish pseudo-patients from real ones. Moreover, doctors from one of the psychiatric clinics contacted Rosenhan and asked him to send them his pseudo-patients without warning, claiming that they would be able to identify the malingerers in no time.
Rosenhan accepted this challenge. Over the next three months, the administration of this clinic was able to identify 19 malingerers out of 193 patients admitted to them.
Modern psychiatry no longer looks as frightening as is commonly believed from still popular stereotypes. The image of a violent patient who toils and destroys everything in a solitary room with iron doors and bars on the windows is now just a horror story from the past. Today it is common to consult a psychiatrist even at the first symptoms of depression, and you can receive adequate help. Severe psychoses are no longer a death sentence, and people who have gone through them can often return to an active social life. All this was made possible thanks to the power of people who wanted to change psychiatry forever.
Creation of the first psychiatric hospital
Back in the 18th century there were no psychiatric hospitals - there were bedlam. Bedlam is an institution where mentally ill people were brought in the most serious condition, when relatives could no longer tolerate them at home or it was dangerous. In essence, these were shelters that were maintained by inviting spectators for money. Adults and children went to bedlams, like a theater or a zoo, and observed the strange and frightening behavior of the possessed and insane. The mentally ill were kept in chains. They howled, screamed, muttered something, made faces, begged, and made incomprehensible movements.
It is easy to guess that the idea of mental illness at that time was very vivid, and still excites the curious.
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In 1793, a young doctor, Philippe Pinel, was appointed to a Parisian shelter, who for the first time decided to remove the chains from the sick. His view of mental illness was somewhat different from that of his other colleagues. He was the first to say that crazy people are sick people and they need help.
The decision to remove the chains from the patients caused a great stir in the city. Even the head of the Paris commune came here to check that the enemies of the revolution were not hiding here under the guise of being sick. But when it became clear that Pinel was firm in his decision, all attempts to avoid the strange innovation were abandoned.
All the servants of Bicêtre bedlam fled: they were afraid that the madmen would tear them to pieces as soon as they gained freedom. Of course, nothing like that happened. Pinel and his friend remained in Bicêtre and began to treat the mentally ill to the best of their ability at that time. But the most important thing in the new approach was not in the treatment methods, but in the attitude towards patients. Attention to simple human needs and care had a beneficial effect and healed the soul of the mentally ill.
As soon as it became clear that Pinel’s approach gave the mentally ill the opportunity not only to live out their days in agony, but also to have hope for recovery, the bedlams began to be repurposed into psychiatric hospitals throughout Europe.
Philippe Pinel taught psychiatry at the medical university until 1822, and was even a consultant physician to Napoleon.
At the age of 80, the sick and frail old man Pinel died in poverty.
But even now there are institutions for the mentally ill, similar to the bedlam of the 18th century. Indonesian shelters are filled with unfortunate people who live in cages and chains.
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Opening of psychiatric outpatient clinics: free hospital visits
Another person who was able to change a cruel system is Clifford Beers. At the beginning of the 20th century, he was forced to undergo treatment in one of the US psychiatric hospitals for three years. The conditions in which the patients were in the hospital led him to the decision to radically change the organization of mental health care.
In 1909, MentalHealthAmerica was born, the first public organization for the mentally ill, which is still active today. Its founder was Clifford Beers. The result of Mental Health America was the opening of psychiatric outpatient clinics, where patients could come during the day, for a few hours, and then return home.
This approach was very unusual for psychiatry, but it made it possible to provide adequate psychiatric care not only for severe psychoses (schizophrenia, manic-depressive psychosis), but also for neurotic disorders: fears, phobias, obsessions. It also made it possible to monitor patients during the period of remission, and help them if necessary, even before psychosis sets in again.
This change again forced psychiatrists to think about the nature of mental illness and stimulated them to search for new methods of treatment.
Nevertheless, in large-scale psychiatry there were still strict measures for maintaining patients, since there was nothing to combat agitation and aggressive behavior during the acute phase of psychosis. Bars on the windows, heavy, unliftable furniture, iron doors, straitjackets: all this protected both the hospital staff and the patients themselves. It was not possible to fully implement Pinel’s ideals in psychiatry even in the 20th century.
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Discovery of aminazine (chlorpromazine) - the first antipsychotic
In the mid-20th century, psychiatry received its first effective drug.
In 1952, Jean Delay and Pierre Deniker created the drug chlorpromazine, which was intended to calm agitated patients. This changed the entire approach to treatment in psychiatry. Now there was no need to be protected from patients by iron bars, and treatment became more humane, and patients had the prospect of returning home after a difficult period.
Before this, psychiatrists practiced lobotomy, electroconvulsive therapy, insulin comas, and three-day malaria infection (high temperature reduced mortality from progressive paralysis). All these methods were effective to some extent, and even reduced mortality in psychiatry. But the treatment process was more like torture.
Now psychiatrists had a drug that could be administered to patients regularly, stop agitation and help patients fit into normal life even after severe psychosis.
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The disadvantage of the first antipsychotics was their destructive effect on the personality and physical health of the patient. With long-term use of aminazine and haloperidol, neuroleptic syndrome develops. But it was still better than what the patients received before.
Aminazine (chlorpromazine) became the basis for the creation of more advanced drugs that can now be used for a long time without causing severe personality changes.
Now psychiatry has modern medications, the use of which can be combined with the usual lifestyle.
The number of mental patients has increased 40-fold over a hundred years since the beginning of the 20th century. But this does not mean that there are more unhealthy people. This is evidence that psychiatry can now help even with disorders that were previously overlooked.
Natalya Trokhimets
