All that is solid melts into air by sdfwerte


									All that is solid melts into air

     Soteria and other Minimal
    Medication Approaches to the
      Treatment of Psychosis

   Tim Calton – Lecturer in Psychiatry - UoN
• The View from Now

• Historical overview

• The Soteria paradigm

• Other approaches

• Choice and Capacity
 The View from Now – solid evidence?
• “during an acute episode, antipsychotic drugs are
  necessary” (NICE, 2002)

• “cognitive behavioural therapy…and family
  interventions… should be available..”

• Neuroleptics produce statistically significant
  improvements in schizophrenia symptoms (Davis, 1976)

• Neuroleptics prevent relapse (Davis et al, 1980)

• Neuroleptics reduce Duration of Untreated Psychosis
  (Loebel et al, 1992)
• Two-thirds of people hospitalised in “enlightened”
  settings make good social recoveries (Bleuler, 1968;
  Ciompi, 1980)

• Two-thirds of “back ward” patients from Vermont State
  Hospital were living successfully in the community 30
  years after discharge. Most had stopped taking
  neuroleptic medication (Harding et al, 1987)

• People diagnosed with “good prognosis” schizophrenia
  may be more likely to return to hospital (and return
  sooner) if treated with neuroleptic medication (Rosen et
  al, 1968)
                       A case in point
•   Rapaport et al (1978)              Hospital/outpatient   Readmission
                                       treatment             rate
•   80 young males with Dx of
    schizophrenia randomly assigned    Placebo/no
    to CPZ or placebo on admission                           8%
                                       medication (n=24)
•   Post-discharge treated with or
    without active medication          CPZ/no medication     47%
    depending on condition and         (n=17)
                                       Placebo/neuroleptic   53%
•   “Antipsychotics are not the        (n=17)
    treatment of choice…if one is
    interested in long-term clinical
    improvement”                       CPZ/neuroleptic       73%
                     Other issues
• Non-concordance is a major problem with all neuroleptic medication
  (Oehl et al, 2000)

• Non-response („treatment resistance‟) is relatively common (Brown
  & Herz, 1989)

• Aversion to medication oriented services may prolong DUP (Warner,

• Side-effects from all types of neuroleptics are a major cause of
  distress and complications (Tardive Dyskinesia - Llorca et al, 2002;
  Extra-pyramidal side-effects - Geddes et al, 2000)

• Neuroleptics can kill (neuroleptic malignant syndrome - Jeste
  &Naimark, 1997; heart irregularities - Zarate & Patel, 2001)
“Although some individuals may experience a net
benefit, an objective overall cost-benefit analysis would
likely be negative or at best neutral if side-effects, drug-
drug interactions, deaths, effects of concurrently
prescribed anticholinergics, and psychosocial
consequences were weighed accurately.

The psychosocial consequences of neuroleptics include
stigmatization, induction of a passive attitude towards
one’s disorder, dependency on government programmes
for medication, and difficulty driving vehicles or finding
employment.” (Read et al, 2004, p110)
             Historical overview
• Gheel

• Moral treatment

• The Retreat

• Kingsley Hall

• Villa 21
 Psychosis in the Developing World
• US spending on treatment of schizophrenia in 1990 = $16 billion
  (Norquist et al, 1996) = 0.3% of GDP

• Psychiatric care a low priority in most developing countries

• International Pilot Study of Schizophrenia (WHO, 1979),
  Determinants of Outcome in Severe Mental Disorders (Jablensky et
  al, 1992)

• Revealed that the outcome for people experiencing psychosis in
  developing countries was substantially better than in the developed

• Authors concluded that differences in socio-cultural factors had the
  greatest explanatory power for this finding
The Soteria Paradigm
                    Soteria In Detail
•   People aged 15-32 with a diagnosis of „first-episode‟ schizophrenia, not
    married, and no more than one previous hospitalisation of less than 4

•   Small, community-based therapeutic milieu where majority of staff non-
    medically trained

•   No or low dose antipsychotic medication (no coercion)

•   „Phenomenological‟ relational style („being with‟) – requires unconditional
    acceptance of the experience of others as valid and understandable within
    the historical context of each person‟s life, even when it cannot be
    consensually validated

•   Preservation of personal power, social networks, and communal
    responsibilities – emphasis on the interpersonal

•   “Most importantly, the atmosphere must be imbued with hope” (Mosher,
            Soteria – the evidence
•   Systematic review (Calton et al, 2007)

•   3 RCTs (2 from US, 1 from Switzerland) – 223 patients – follow-up at 6
    weeks and 2 years

•   At least as effective as conventional treatment at 6 weeks (24% took
    medication as opposed to 100% of control group)

•   At two years there were significant advantages for Soteria with regard to
    global psychopathology, „composite‟ outcome, and living alone or with peers

•   43% used no neuroleptics at all („drug free responders‟)

•   Soteria Berne showed that these results could be achieved at 10-20% lower
    overall cost than conventional treatment
• The apparent comparable efficacy between
  Soteria and TAU suggests that there are few or
  no disbenefits to being treated in a setting with
  low or no use of neuroleptic medication when
  supported by non-medically trained staff

• The Soteria paradigm seems more likely than
  standard treatment to approximate the
  supportive and collectivist socio-cultural context
  often suggested as responsible for better
  developing country outcomes
              Other approaches (1)
•   Carpenter et al (1977)                                      Drug-   Drug-
                                                                free    treated
•   49 people diagnosed with good-
    prognosis schizophrenia, a record
    of adequate prior work and social       Average length of   108     126
    functioning, and a short history of     hospital stay       days    days
    illness, were arbitrarily assigned to
    be treated with or without
    medication                              Rehospitalisation   35%     45%
•   “Antipsychotic medication may
    make some schizophrenic patients
                                            Outpatient          44%     67%
    more vulnerable to future relapse
                                            neuroleptic drug
    than would be the case in the
    natural course of their illness”
              Other approaches (2)
•   Lehtinen at al (2000)                     Two-year           Minimal      Usual
                                              follow-up          medication   medication
•   106 people admitted for treatment of
    a first-episode of psychosis              Took                  57%          94%
    (excluding affective psychoses) in        neuroleptics at
    Finland                                   any time
                                              Less than two         51%          26%
•   At half of the centres patients           weeks in
    received only minimal doses of            hospital in two
    medication, and nearly half received      years
    no neuroleptic medication at all over     No psychotic          58%          41%
    the two-year study period                 symptoms
                                              during past year
•   At 5 year follow-up 37% of                Employed              33%          31%
    experimental participants had still not
    used medication, whilst 88% had not
    been hospitalised (68% TAU)
                                              Good social           66%          55%
         Other approaches (3)
• The Parachute Project – Cullberg et al (2002)

• An extension of „Need-Adapted‟ treatment with an
  emphasis on minimising doses of neuroleptic medication

• Compared a group of people experiencing first-episode
  psychosis (n=253) with prospective (n=64) and historical
  (n=71) controls

• 1 year follow-up showed experimental group had fewer
  inpatient bed days than controls and received lower
  doses of antipsychotic medication
           Other Approaches (4)
• The Open Dialogue Approach – Seikkula et al (2003)

• Part of „Need-Adapted‟ model – aims to treat psychotic people at

• Treatment involves mobilising the person‟s social network and starts
  within 24 hours of first contact

• Emphasises continuity of care and an active attempt to generate
  dialogue to construct a meaningful narrative of the experiences

• Compared to a TAU group, Open Dialogue treated people were
  hospitalised for fewer days, family meetings happened more
  frequently, and neuroleptic medication was used in fewer cases.
• Neuroleptic medication may well not be
  necessary for every person either
  experiencing psychosis or diagnosed with
  (first episode) schizophrenia

• There are many good reasons for
  considering alternative approaches to
  helping people in this context
            Choice and Capacity
• Patient choice central to UK governmental healthcare reforms (DoH,

• An adult has the capacity to decide whether to consent to, or refuse,
  proposed medical intervention, unless it is shown that that they lack
  said capacity (GMC, 1998)

• …Unless you have been diagnosed with a mental disorder and are
  detained under the Mental Health Act

• 75% of people diagnosed with schizophrenia understand information
  and make decisions similar to comparison groups around issues of

• “It is yet to be demonstrated whether patient choice will be fully
  embraced by psychiatry” (British Journal of Psychiatry editorial –
  July 2007)
Where is Hope?

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