An electronic newsletter of the Coalition's Center for Rehabilitation and Recovery
The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.
Elizabeth Saenger, PhD
Thomas Henry Huxley, the British biologist who championed Darwin's theory of evolution, once referred to the "great tragedy of Science: the slaying of a beautiful hypothesis by an ugly fact.” Tragedies such as this appear imminent in psychiatry, as challenges to the status quo—from the validity of specific diagnoses to the question of whether antidepressant efficacy has been overrated—proliferate.
One of the most controversial, and significant, potential “ugly facts” concerns the role of antipsychotics in recovery.
Many mental health professionals assume that people with schizophrenia need antipsychotics not only when they have a first episode, but for maintenance treatment as well. After all, there have been several studies of people with schizophrenia who went off their medication within the first two years of their initial episode. These individuals often relapsed.
However, a 2013 study calls into question our long-held belief about the long-term benefits of antipsychotics. This investigation looked at both symptom relapse and overall functioning over an extended period in people with a first episode of schizophrenia, or a related disorder, who reached remission—albeit with some symptoms. These people were then randomly assigned to either continue with their antipsychotic, or to taper down, and in some cases, discontinue it.
For a few years, patients who reduced or discontinued their antipsychotic were twice as likely to relapse as patients who did not. After that, however, the two groups had equal relapse rates. Yet after seven years, patients who had reduced or discontinued their antipsychotics were twice as likely (40% vs 18%) to recover functionally as patients who stayed on their medications. It thus looks like antipsychotics might interfere with recovery under some circumstances, perhaps because they might interfere with cognitive abilities.
But why do so many people with schizophrenia relapse when they don’t take their medications in the year or two after their first episode? Some researchers suggest that possibly, after patients take antipsychotics for a while, their bodies adapt to them. Then, when the medication is stopped, they go through withdrawal. Thus comparisons of patients on antipsychotics (vs patients not on antipsychotics a year after a first episode) are really comparisons of patients on antipsychotics, and patients in withdrawal. Naturally, the latter will look worse.
Several other very long-term studies have similarly found that the role of antipsychotics in the maintenance treatment of schizophrenia may be more limited that we assumed. Further research on this critical topic might confirm, and flesh out the details, about how antipsychotics could be used to stabilize people without hindering recovery.
Elizabeth Saenger, PhD
When I worked as a staff psychologist at a community mental health care center, I had a client with schizophrenia. He appeared to have a network of unusual beliefs, and he was plagued by voices. They constantly belittled him, and made it hard for him to focus. Psychiatrists had tried him on many antipsychotics, though none seemed to work.
But when he started clozapine at the center, he changed dramatically. The voices died down. He was able to start community college part-time, and hold a part-time job.
Clozapine was not a complete solution; my client still experienced some symptoms. But it did provide a starting point for a young man who otherwise would have otherwise been too troubled by voices and unusual beliefs to pull his life together.
However, for years, clozapine got a bad rap among psychiatrists for the treatment of schizophrenia. Clozapine caused a horrendous amount of weight gain. Patients complained of hypersalivation and constipation.
Worst of all, clozapine could induce agranulocytosis, a dangerously low level of white blood cells in the blood. Although this side effect was rare, it was potentially fatal. Consequently, white blood cell counts for patients on clozapine had to be monitored according to FDA guidelines to prevent complications. And that meant patients needed to have bloodwork done regularly, which could be a challenge on different levels.
No wonder clozapine was underprescribed for schizophrenia that did not respond to other antipsychotics, even though the FDA had approved it for use in these difficult cases, and the New York State Office of Mental Health noted, “it is one of the most effective antipsychotics for treatment resistant schizophrenia.”
Recognition that clozapine is underprescribed is growing. As one 2014 study notes, "Current clinical practice guidelines have strongly recommended the use of clozapine in treatment-resistant schizophrenia, but prescribing trends do not appear to have followed such recommendations. Clozapine is still underutilized, especially in patients at risk of suicide."
Perhaps the growing literature on the risks, benefits, informed consent, and prescribing patterns for clozapine will persuade prescribers to look at the Cinderella of antipsychotics in a new light.
Elizabeth Saenger, PhD
Your mother is critically ill. Your brother totaled the car you’re still paying for. Your agency is laying off staff. Your son just flunked the third grade.
Have you really aged six months in the last week, or do you just feel that way? And what can you do to calm down that doesn’t involve overdosing on fudge brownies with walnuts?
You’ve probably recommended common, healthy stress reduction behaviors to clients, such as eating salads instead of those brownies, exercising, and even marriage.
However, there’s a new game in town—or at least new recognition of an old one. Loving-Kindness meditation focuses on positive intentions, warmth towards all, and unselfish kindness. Three months of this Buddhist activity enhances positive feelings, strengthens a sense of purpose, and reduces minor aches and pains for women. Researchers also believe that Loving-Kindness, as well as practicing forgiveness, lengthens women’s lives.
How do we know that Loving-Kindness has such effects? The answer lies in our high-tech laboratories, where we can see telomeres.
Telomeres are genes that encase the tips of chromosomes, preventing the chromosome from fraying, like the plastic tips at the ends of your shoelaces. Telomeres get shorter as you age, and this in turn causes your cells – and your body – to age. Anxiety also appears to shorten telomeres, as does childhood abuse, the loss of a parent, and a history of depression or anxiety.
On the other hand, Loving-Kindness increases an enzyme that repairs telomeres.
Robert Post, MD, for decades a leading researcher and clinician specializing in bipolar disorder, recommends that people with affective disorders, and those at risk for them, “consider making some of these positive lifestyle practices part of their daily routine.” Perhaps that is a take-home message we could give to everyone in recovery.
The opinions expressed in RECOVERe-works do not necessarily reflect the views of the Coalition of Behavioral Health Agencies.
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