The authors, led by Sarah Smessaert of the Katholieke Universiteit Leuven in Belgium, write:

Clozapine is the current standard of care in treating TRS across different guidelines for the treatment of schizophrenia. It is touted to be effective, particularly for people with schizophrenia who are experiencing suicidality or aggression.

However, clozapine is also associated with a number of common adverse effects, such as fever, sedation, gastrointestinal issues, and excessive saliva flow (which in turn can lead to aspiration pneumonia), among others. There are also less common but more severe side effects caused by clozapine, which include myocarditis or inflammation of the heart muscle, convulsions, and neuroleptic malignant syndrome, which, if left untreated, is potentially life-threatening. Due to the number of negative side effects associated with clozapine, prescribers tend to be reluctant to prescribe it.

The post Despite Safety Risks, Prescribers Receive Little Guidance of Monitoring Antipsychotic Clozapine appeared first on Mad In America.

Published in the Journal of Psychiatric Research, the survey highlights the inadequate support and resources available to patients trying to quit antidepressants, forcing them to turn to online support groups for help. Participants in the survey also identified the need for additional resources, such as smaller doses and a 24/7 helpline, to aid in their transition off the medication.

The lead author, John Read, Professor of Clinical Psychology at the University of East London and Chair of the International Institute for Psychiatric Drug Withdrawal (www.iipdw.org), commented:

Antidepressant prescription rates are high internationally, including in countries like the United Kingdom, the United States, Australia, Belgium, Canada, and Portugal. Across the U.S. and the U.K., antidepressant drugs are prescribed disproportionally to women. In the U.K., they are also more often prescribed to those from low socioeconomic backgrounds and older people.

These high rates have been attributed to increases in the length of prescription periods rather than new prescriptions, with average duration doubling in both the U.S. and U.K. since the mid-2000s. For example, half of the antidepressant users in England take them for longer than two years, and half of the antidepressant users in the U.S. take them for at least five years. Yet, what these antidepressants are being prescribed for long-term appears unknown in some cases, as 58% of individuals taking antidepressants in the U.K. for more than two years were not found to meet the criteria for any psychiatric diagnosis, and 31% lacked a clear clinical reason for continuing to be prescribed an antidepressant.

Difficulty discontinuing antidepressant use may be contributing to longer prescription durations. Stopping antidepressant use has been associated with withdrawal symptoms for more than half of those who attempt it, with about half of those individuals experiencing severe withdrawal symptoms, which can include both physical and psychological symptoms like suicidal ideation, flu-like symptoms, anxiety, and gastrointestinal symptoms, among other effects. Often, antidepressant withdrawal symptoms are confused with relapse of depression by both patients and their providers.

Lack of guidance about how to best assist patients with tapering off medication is also part of the problem. While the U.K.’s National Institute for Health and Care Excellence (NICE) recently updated its guidelines in 2022, it has been criticized for lacking practical advice regarding implementing it in clinical practice.

In the current study, 1,276 members of Facebook groups for antidepressant users from 49 countries, predominantly the U.K. (18.7%) and the U.S. (34.6%), completed an online survey. The majority of participants were white (92.4%), women (79.5%), had an average age of 45.8 years old and had completed undergraduate education (34.1%).

As noted earlier, the majority of participants found their prescribing provider to be ‘unhelpful’ in supporting their tapering off antidepressants. Additionally, most respondents reported that their prescriber was unfamiliar with withdrawal symptoms (82%) and denied that discontinuing antidepressants could lead to withdrawal (60%).

One participant shared: “I think a lot of doctors have no idea! NO ONE explained the withdrawal symptoms to me, NO ONE told me how dependent you become.”

One-third of participants did not reach out for support from their clinician to help them stop their medication, with half of these individuals expressing that they did not feel their prescribers had sufficient knowledge of how to taper safely. In addition, some of these participants reported that negative past experiences, such as being told to stop abruptly or that withdrawal does not exist, informed their decision to not seek help from their prescriber.

One participant reflected on their experience: “She just wanted me to stop cold turkey. She doesn’t believe in withdrawal.”

Moreover, only 1 in 6 participants felt their prescribers could tell the difference between antidepressant withdrawal symptoms and depressive relapse. Others discussed how their prescriber suggested increasing or changing medications instead of stopping them when participants sought their help stopping.

One participant stated their provider: “Told me that the symptoms that I knew were side effects were a relapse of the original problems.”

Another reported: “I had been on antidepressants on and off for 25 years, when I was struggling with withdrawal, I was only ever offered more antidepressants.”

Participants also expressed concern about the lack of resources available to assist with tapering. The services that patients would have found ‘very useful’ but had been unable to access include:

• ‘Smaller doses (e.g., tapering strips, liquid, smaller dose tablets) to ensure gradual reduction’
• A health professional providing a personalized, flexible reduction plan.’
• A telephone/online, video/online chat helpline.’

Co-author Mark Horowitz, a psychiatrist at University College London, added:

The article concludes:

Limitations of the study include its population of predominantly white, female participants and underrepresentation of minority racial and ethnic groups, its inability to reach individuals without access to online support, and the self-selection nature of the survey, as the participants may be reflective of a group of persons who are more adversely affected by withdrawal symptoms.

Access to support in discontinuing antidepressants is sorely needed to ensure that individuals who would like to discontinue their medication can do so safely, under the direction of prescribers with expertise in supporting them best. Increasing attention has been paid to antidepressant tapering, such as in the updated NICE guidelines discussed earlier and in recently published guidance that offers information for primary care doctors regarding how to best support their patients in stopping their antidepressants.

Antidepressant discontinuation has also received more attention in research, with current research urging that very slow tapering is the best approach to stopping antidepressant use. Additional research has highlighted risk factors for withdrawal, such as using drugs for a longer duration, at a higher dose, and using certain types of antidepressants, like paroxetine (Paxil).

As highlighted by the authors and participants of the current study, this topic must continue to receive attention and support so that people can safely discontinue their medication alongside the support and informed direction of their prescribers rather than being unnecessarily stuck on it long-term due to lack of guidance and support about how to stop.

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Read, J., Moncrieff, J., & Horowitz, M. (2023). Designing withdrawal support services for antidepressant users: Patients’ views on existing services and what they really need. Journal of Psychiatric Research, (161), 298-306. https://doi.org/10.1016/j.jpsychires.2023.03.013 (Link)

The post Prescribers Often Fail to Support Patients Discontinuing Antidepressants, Study Finds appeared first on Mad In America.

Withdrawal symptoms from antidepressants are common and can include dizziness, nausea, anxiety, depression, and “brain zaps,” which are sensations of electric shocks inside the head, among other symptoms. Given the overlap in symptoms between depression and antidepressant withdrawal, depressive relapse and withdrawal can be difficult to distinguish, which leads to confusion among patients and their providers.

Additionally, determining who will experience severe withdrawal symptoms from those who will not is difficult to predict, although research has shown that duration of use, previous experiences of withdrawal, and type of antidepressant used provide insight into who may experience withdrawal symptoms upon discontinuation.

Researchers, led by James Phelps, MD, of Samaritan Mental Health in Corvallis, OR, write:

In the current study, Phelps and colleagues analyzed data from the past 7 years of Samaritan Mental Health patients who had discontinued their antidepressants. Data was included for patients who had been prescribed the same antidepressant for at least 6 months before stopping their medication. As tricyclics and trazodone are often also used for pain and sleep, patients taking these medications were excluded. Also, patients who had not been seen in one of Samaritan Mental Health’s clinics in over a 13-month period were also excluded to rule out any patients who may have gone elsewhere for medication management. The final sample included 7,583 patients, who were mostly White (95.9%), female (67%), on Medicare (45.2%), and more than 40 years old (39.6%).

Across the 7-year time frame, 676 or 8.9% of patients were tapered to the lowest available dose of their antidepressant before stopping the medication entirely. Researchers noted an increase in taper rates from 4.9% in 2014 to 9.5% in 2021, highlighting that taper rates have remained steady at around 10% over the past 4 years. Further, Phelps and colleagues found that the antidepressant venlafaxine tended to be tapered significantly more than fluoxetine and paroxetine.

The researchers describe the implications of their findings:

With this in mind, Phelps and colleagues suggest that a standardized approach to tapering be adopted as a way to address the needs of patients who may be at risk for severe withdrawal alongside the need for a straightforward, routine method of tapering. They emphasize the need for the first dose decrease to go smoothly, without any withdrawal symptoms or adverse effects on mood, so that patients will be motivated to continue to taper and ultimately stop taking their medication. Therefore, they recommend that the first taper consists of the smallest reduction possible.

Phelps and colleagues describe how the first successful reduction helps patients to feel confident that their discontinuation is possible and manageable and discuss how some patients may desire more significant or more rapid reductions following a successful initial decrease in dose. They suggest that a period of at least 2 weeks occurs between dose reductions and that tapering occurs at a pace that feels manageable to patients, with reductions likely becoming smaller and slower again as patients approach zero.

The researchers caution that even with a slow-paced careful approach, some patients may still experience severe withdrawal symptoms and may need to follow tapering methods typically used for those who experience severe withdrawal, which include decreasing doses by as little as 10% of the previous month’s dose.

A major limitation of the study is its predominantly White female sample size, as its findings may not be generalizable to individuals of other backgrounds. In addition, the chart review approach used by researchers did not allow for them to analyze data from patients who may have subdivided their existing doses or who reduced their dose but not to the lowest dose of their particular antidepressant.

Overall, the study contributes to a growing body of research and calls for safe guidelines for antidepressant tapering. In 2019, the National Institute for Health and Clinical Excellence (NICE)  updated its guidelines regarding antidepressant withdrawal. It recommended that providers have discussions with their patients about potential long-term, severe antidepressant withdrawal symptoms. Others have advocated for a slow tapering process to mitigate the risk of severe withdrawal.

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Phelps, J., Nguyen, J., & Pipitone Coskey, O. (2023). Antidepressant tapering is not routine but could be. Journal of the American Board of Family Medicine Ahead of Print. doi: 10.3122/jabfm.2022.220239R1 (Link)

The post Researchers Seek Standardized and Safe Antidepressant Tapering Protocol appeared first on Mad In America.

The researchers, led by Tania M. Lincoln, faculty member of Psychology and Human Movement Science at Universität Hamburg, write:

“Given the well-documented negative long-term effects for both antidepressants and antipsychotics, it appears necessary to develop a targeted way of providing prophylactic medication to those who need it for as long as they need it rather than ‘playing safe’ by leaving every patient on long-term medication.”

The currently available research on medication discontinuation primarily focuses on the perspectives of clinicians and relapse and rehospitalization. However, service users have provided a number of reasons aside from just avoiding relapse for wanting to stop their medications, such as not wanting to depend on drugs, wanting to reduce potential risks associated with adverse long-term effects of drugs, or reduce negative side effects such as dulled emotions, perceptions, and creativity.

Additionally, some persons diagnosed with psychotic disorders have an appreciation for their symptoms and do not want them to be eliminated – such as those involved with the Hearing Voices Movement, which advocates for alternative understandings of the experiences of persons who have been traditionally understood as “psychotic.”

To include the perspective of service users, Lincoln and colleagues worked together with individuals who had lived experience with stopping their medication to create a questionnaire, the Discontinuation Success Scale (DSS), which captures both the physical and mental benefits and risks associated with medication discontinuation.

Researchers obtained participants via an online survey, and in total, had 396 participants who had tried to stop taking antidepressants or antipsychotics within the past five years. The participants consisted of mostly women (71.2%) with a mean age of 38.8 years old.

The majority of participants had some form of college education, and half were employed or self-employed. In addition, most participants (52.5%) had successfully stopped their medication, a third (33.3%) had partially discontinued their medication, and 13.4% of participants had been unable to stop taking their medication.

Participants answered questions about their attempts to discontinue their medication, completed the 35-item DSS, which asked participants to rate their responses to statements such as “Since trying to discontinue, I feel more alive,” and “Since attempting to discontinue, I often have difficulties concentrating,” and completed a measure (WHO-5) which assessed their subjective well-being through responding to statements like, “I have felt cheerful and in good spirits.”

Through a statistical analysis of their data, Lincoln and colleagues were able to refine the DSS into a 24-item measure consisting of three subscales which assess discontinuation success (Subjective Success subscale) and positive (Positive Effects subscale) and negative effects (Negative Effects subscale) of stopping the medication.

They found that participants who had successfully stopped taking their medication tended to score higher on the subscales examining discontinuation success and positive effects of discontinuation and lower on the subscale assessing adverse effects of discontinuation.

However, the negative effects of discontinuation for participants who had tried to stop taking antipsychotics were reported independently of whether a participant was successful in discontinuing their medication, which suggests that withdrawal effects like difficulties with coping are inevitable when it comes to stopping antipsychotics – although, the effects could be attributed to external stressors as well.

Across participants, researchers found that their measure effectively distinguished between discontinuation success and overall well-being in their subscales. The positive and negative subscales were found to discriminate between participants with high and low well-being clearly.

A few limitations of the study include its reliance on participant self-report, lack of real-time data, and a sample size that was biased towards more educated individuals due to the use of online forums to recruit participants. Additionally, as individuals progressed throughout the measure, they began to skip items that may have influenced bias on the well-being scale.

Major strengths of this study were its large sample size and its analysis of stopping both antidepressants and antipsychotics. However, while the study had promising results, the researchers call for further investigation.

The researchers conclude:

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Lincoln, T. M., Sommer, D., Könemund, M., Schlier, B. (2021). A rating scale to inform successful discontinuation of antipsychotics and antidepressants. Psychiatry Research, 298, 1-8. https://doi.org/10.1016/j.psychres.2021.113768 (Link)

The post New Rating Tool for Tapering Antidepressants and Antipsychotics appeared first on Mad In America.

They also offer suggestions on how to best support grieving individuals both during the COVID-19 pandemic and post-pandemic. The researchers, led by Joanne Cacciatore, Associate Professor in the School of Social Work at Arizona State University, write:

The benefits of social support on human health and wellbeing are well-documented. For example, social support has been shown to positively affect psychological and physiological stress reactions, as seen through an improved immune system, endocrine, and cardiovascular health. On the other hand, lack of social support and loneliness has been shown to negatively affect physical, emotional, and mental well-being, including increased risk of premature death from many causes.

Loneliness and insufficient social support are common in grieving individuals, which raises concerns about their health and wellbeing. In addition, loneliness has been exacerbated by the COVID-19 pandemic, which in turn has contributed to increases in mental health concerns like depression and suicidality.

Conversely, adequate social support, whether in-person or online, can contribute to a better quality of life in bereaved persons. Additionally, both the quantity and quality of support received have been shown to affect grieving individuals’ wellbeing. Social support for bereaved individuals has been demonstrated to be particularly effective for persons who have experienced “traumatic grief,” or the violent or sudden death of a loved one or the death of a child. However, research has also shown that social relationships are prone to fall apart after a loss.

The researchers identify four categories of social support: informational, instrumental, appraisal, and emotional:

In the current study, the researchers provided qualitative surveys to a total of 372 adults who had experienced traumatic grief. The interviews consisted of questions about the participants’ perceptions of social support both directly following the loss and long-term.

The participants were mostly white (91.1%), married or partnered (69%) females (91.4%) with college or graduate degrees (58.1%) who had experienced the loss of a child (75.1%). In addition, the majority of participants had experienced the loss more than five years ago (43.3%), and the cause of death was most frequently an illness or disease (25.8%).

When asked to rate their overall perceptions of support from others since the death of their loved one, 35.7% of participants rated their experience of support as excellent or good, 26.5% reported receiving adequate support, and 37.9% rated their support as poor or very poor.

Mortuary staff were ranked as being the most effective in providing human-to-human support (65%). Conversely, law enforcement and physicians, and hospital social workers ranked the lowest, being the least effective in providing bereavement support at 37% and 35%, respectively.

Interestingly, 89% of the 248 participants who had pets or interactions with other animals reported being extremely or mostly satisfied with the support received. In fact, animals were ranked the highest among all forms of social support, which included categories like friends, family, community members, faith leaders, therapists or counselors, support groups, and faith leaders.

These findings are consistent with research that identifies care farming as a useful intervention for individuals experiencing traumatic grief and research that indicates that pets are effective supports for individuals struggling with mental health problems and mental distress.

In their open-ended responses to survey questions, the participants noted emotional support and “acts of emotional caring,” such as receiving a phone call or text message, as the most effective form of support.

Some of the participants described their experiences of emotional support and acts of emotional caring as:

In their descriptions of actions that felt unsupportive, participants noted failures to provide emotional support or engage in emotional acts of caring as being most problematic. Examples of unsupportive acts include feeling abandoned by loved ones, feeling as if their grief was being rushed, and not feeling listened to.

When asked how others could better support them, participants identified increased emotional support and emotional acts of caring, emphasizing the importance of listening and being present and remembering their loved ones with them without feeling a need to try to fix or resolve their grief.

Although emotional support and acts of emotional caring were mentioned by participants most frequently across the survey questions, both instrumental and appraisal support were also discussed as being helpful. Informational support was infrequently mentioned by participants, with aligns with previous research findings that this form of support is generally not helpful for grieving individuals.

The researchers summarize their findings regarding specific acts of instrumental and appraisal support identified by participants as being particularly effective:

The researchers note their finding that animals are highly effective in providing support as being especially important, as animals are not typically mentioned when considering bereavement support. Recognizing the role that animals can play in providing support during grieving is crucial, particularly when isolation through social distancing or quarantine is required.

The findings also carry implications for healthcare providers and law enforcement, who were ranked the highest in dissatisfaction with social support. As these individuals most often are confronted with persons in crisis, further research must examine why the perception of support from these professionals is so low.

Further, Cacciatore and her colleagues highlight how emotional support was identified as key in the grieving process. Yet, supports were demonstrated to struggle with providing adequate support in this area. Therefore, they call for education for individuals supporting bereaved individuals to assist them with being more responsive to the grievers’ emotional needs.

Limitations of the study include a lack of diversity in participants and the study’s focus on traumatic grief, whose findings may not translate to grieving individuals in the general population.

The researchers conclude by emphasizing how their findings on the importance of animal support can be used to assist grievers and should be investigated in future research:

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Cacciatore, J., Thieleman, K., Fretts, R., & Barnes Jackson, L. (2021). What is good grief support? Exploring the actors and actions in social support after traumatic grief. PLOS One, 16(5), 1-17. https://doi.org/10.1371/journal.pone.0252324 (Link)

The post Pets More Effective for Grief Support than Humans, Study Finds appeared first on Mad In America.

Antidepressants are commonly used in the treatment of depression and anxiety. Current guidelines suggest that people should continue antidepressant use for at least six months after beginning to feel better and for at least two years if they have experienced multiple depressive episodes. Half of the people prescribed antidepressants are on them for longer than two years.

Surveys of people taking antidepressants show a lack of evidence to support 30-50% of long-term users still being on the drug. Long-term use may cause more harm than benefit, as antidepressant use can cause negative side effects, such as sleep disturbances, weight gain, sexual dysfunction, gastrointestinal bleeding, emotional numbing, among other issues. Additionally, other research has highlighted that antidepressants are, on average, ineffective and potentially harmful.

In the current study, Cochrane researchers looked at the findings from 33 RCTs, the gold standard for evidence-based research, which included 4,995 individuals who had been prescribed antidepressants for 24 weeks or longer. Antidepressant use was stopped suddenly in 13 of the studies examined. In 18 of the studies, antidepressant use was tapered over the course of a few weeks, with most tapering periods lasting about four weeks or less.

The researchers found that the available research does not provide any conclusive evidence of the safest and most effective approach to stopping antidepressants. Although most of the studies resulted in an apparent relapse of depressive symptoms, there was a lack of differentiation between relapse and withdrawal symptoms.

Most studies also included participants who had a history of repeated depressive episodes, further muddying the waters around whether the depressive symptoms that manifested after stopping antidepressants resulted from relapse or withdrawal.

None of the studies used slow, measured approaches to stopping antidepressant use – which has been recommended as a safe way of tapering from SSRIs and antipsychotics. Instead, the studies that included a tapering regimen used a rapid approach, explaining why abrupt discontinuation and tapering resulted in relapse/withdrawal.

Additionally, the current studies do not offer a clear consensus on how long antidepressant use should continue after the individual’s symptoms have abated. The researchers highlight how the current prescribing guidelines are not grounded in research evidence, raising cause for concern, particularly in light of the problematic side effects attributed to antidepressant use.

The researchers make several suggestions for future research into safe discontinuation guidelines. They encourage clinicians to formally monitor how their clients are responding to tapering and eventually discontinuation, as a way to better determine whether the symptoms are withdrawal or relapse, as well as knowing when to slow down the tapering process if symptoms do arise.

Further, they recommend that researchers more clearly delineate between withdrawal and relapse symptoms. They also suggest that slow approaches to tapering be investigated to minimize potential withdrawal symptoms as much as possible.

They call for research that examines the benefits and harms of stopping antidepressant medications, acknowledging the pharmaceutical industry’s and researchers’ lack of investment in the de-prescribing movement. Research investigating de-prescribing, including shared decision-making between client and clinician, effective rates of discontinuation, withdrawal symptoms, and other adversities, and overall quality of life, is needed to provide a clear picture of how to navigate stopping medication in a way that is both safe and successful.

Other key aspects to be addressed include having a more widely represented patient population, including those experiencing milder forms of depression and other psychiatric diagnoses. As most antidepressants are prescribed by general practitioners, research in primary care settings must be conducted, and that general practitioners talk with their clients about continuing and stopping their medication.

Also, gaining a deeper understanding of how general practitioners and other clinicians perceive discontinuation would allow for further awareness of the complexity of the contributors that help and hinder stopping the medication.

Exploration of therapeutic interventions that could assist with discontinuation, like cognitive-behavioral therapy (CBT) or mindfulness-based cognitive therapy (MBCT), in addition to interventions such as online support, psychoeducation, etc., could allow for a clearer picture of how practitioners can best support clients undergoing the process of stopping their medication.

UCL-based researcher and psychiatrist Mark Horowitz emphasizes the importance of further investigation into safe approaches to stopping psychiatric medications:

Looking to the future, Van Leeuwen writes:

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Van Leeuwen E., van Driel M.L., Horowitz M.A., Kendrick T., Donald M., De Sutter A.I.M., Robertson L., Christiaens T. (2021). Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database of Systematic Reviews, 4. Art. No.: CD013495. DOI: 10.1002/14651858.CD013495.pub2. (Link)

The post Cochrane Review Calls for More Research on Antidepressant Withdrawal appeared first on Mad In America.

A new article, featured in the Journal of Critical Psychology, Counselling Psychotherapy, highlights these issues. The authors were led by Volkmar Aderhold of the University Clinic for Psychiatry and Psychotherapy in Hamburg-Eppendorf. They discuss barriers to discontinuing psychotropic medication and providing suggestions regarding how to stop taking psychotropic medication safely.

A key factor to successfully discontinuing psychotropic medication is access to supportive, competent physicians who can assist their clients in tapering in such a way that is safe and minimizes withdrawal symptoms. Unfortunately, however, doctors traditionally do not learn how to most effectively taper people off medication, focusing instead on putting individuals on medication.

The authors caution patience when tapering, advocating for a gradual process. Others have echoed this sentiment, calling for a measured approach to tapering from antipsychotics and antidepressants. The transition from the final dose to no medication should be taken with extreme care, as individuals have reported experiencing withdrawal symptoms after completely stopping their medication. If taking small doses is difficult due to the type of capsule or tablet being used, the authors suggest requesting prescriptions for individual dose preparations to make tapering easier.

Suggestions about discontinuing psychotropic medications that address physiological, psychological, legal, environmental, and other domains are made. They recommend learning about potential withdrawal symptoms and half-lives of psychotropic drugs, as some symptoms can last for months or years. They urge individuals to avoid doctors who try to talk them out of stopping their medication. Becoming aware and informed of the potential impacts of stopping medication on access to resources like welfare or housing benefits is key.

Having a secure support system of individuals who are aware of the plan to discontinue, including informal and formal supports such as doctors, will also assist in the process of tapering. Along similar lines, reaching out to others who have been through withdrawal and can provide support is recommended. The role that service users play in assisting researchers with developing safe, individualized approaches to tapering has been explored elsewhere.

The effects of physical and psychological withdrawal symptoms can be made more bearable by having a quiet environment, engaging in exercise, practicing good nutrition, and getting enough sleep. The authors suggest drinking herbal teas, eating chlorophyll-rich and Sulphur-containing foods, which include things like green plants, herbs, vegetables, and more, and using naturopathic remedies as well as taking omega-3 fatty acids, folic acid, vitamin C and E. Engaging in mindful, self-care activities such as spending time with friends, listening to calming music, writing, planting, playing with animals, and so on, can also assist in easing the tension of the withdrawal process.

Addressing the legal domain, the authors suggest that individuals obtain legal direction if possible to protect themselves against potential compulsory administration of psychotropic drugs and forced treatment. They warn that refusing to take neuroleptics like clozapine has been used to justify forced electroconvulsive therapy.

Moreover, the authors emphasize the role that self-responsibility plays in the process. Individuals stopping medications assert responsibility for their own person and begin to understand the deeper issues underlying their mental health symptoms. Understanding the underlying issues and making necessary life changes is crucial to maintaining a life free of psychotropic drugs.

There are several resources available with further advice on safely tapering from psychotropic drugs, including:

• “Competent help when discontinuing antidepressants and neuroleptics” by Jann E. Schlimme (2017) offers guidelines to stop psychotropic medication use.
• Other resources include www.absetzen.info, the book, Coming off psychiatric drugs: Successful withdrawal from neuroleptics, antidepressants, mood stabilizers, Ritalin and tranquilizers (Lehmann, 2004, 2020), which offers cross-cultural, first-hand accounts of discontinuation and withdrawal, in addition to highlighting the perspectives of relatives, doctors, therapists, and other professionals who assisted in the process of tapering.
• Professional associations, such as the German Society for Social Psychiatry and the British Council for Evidence-based Psychiatry, also provide information regarding how to reduce risk when stopping a medication.

Lastly, the authors implicate doctors who do not provide adequate education about the risk factors associated with psychotropic medication as contributors to failed discontinuation attempts and perpetuate continued, unsolicited administration of psychotropic drugs.

They highlight the work that a group of German psychiatrists has done in providing clear, informed consent to potential patients about the risks associated with medication and alternatives to medication. They also offer assistance with discontinuation from the beginning of treatment, which should become the norm in psychiatric care instead of the outlier.

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Aderhold, V., Lehmann, P., & Rufer, M. (2021). Discontinuing psychotropic drugs? And if so, how? Journal of Critical Psychology, Counselling, and Psychotherapy, 20(4), 66-75. (Link)

The post Lack of Guidance Available for Discontinuing Psychiatric Drugs appeared first on Mad In America.

The researchers, led by Tomi Bergström of the Department of Psychiatry in the Länsi-Pohja Hospital District in Kemi, Finland, write:

Antipsychotic medication aims to reduce severe psychotic symptoms in individuals diagnosed with schizophrenia or other psychotic disorders. However, they have been long critiqued for their adverse effects, causing changes to the brain, reducing cognitive functioning, and impairing psychosis recovery, among other detrimental effects. Recently, antipsychotics were also linked to severe cases of COVID-19, including those that resulted in fatalities.

The risks associated with antipsychotics have led to investigations into other forms of treatment for psychotic disorders, such as more individualized, needs-based approaches, and psychosocial support. A highly stigmatized mental health disorder, psychosocial explanations of psychosis have been found to reduce stigma.

In the current study, researchers used data from Finnish national registers, which was originally collected to examine long-term outcomes of various treatment approaches. Researchers examined data over a 19-year period, which ultimately included a little over 1,300 individuals, ages 16-50 years old, with one or more hospital admissions due to non-affective psychosis.

The majority of the study participants were men (55%), with the average age being 31 years old. Using the national register data, researchers could access information regarding individuals’ demographics, mental health and medical care, mortality, and disability allowances. They were also able to access information on purchased antipsychotics from the onset of first-episode psychosis through the duration of the individual’s care.

Researchers found that those with higher antipsychotic exposure during the first 5 years following FEP tended to be men and more often had schizophrenia diagnoses. 19 years later, most of these individuals, as opposed to those with little or no exposure to antipsychotic medication, were still in treatment in some form, receiving disability payments, and prescribed antipsychotic medication.

Individuals with no exposure to antipsychotics were found, after 19 years, to be much less likely to be enrolled in mental health treatment than those who were. Additionally, those with higher exposure to antipsychotic medication were at greater risk of premature death.

The researchers write:

However, they also encourage caution when interpreting their findings. They point to limitations associated with using national register data, such as lack of information regarding the actual use of antipsychotics and the lack of a control group.

In their conclusion, the researchers highlight the need for controlled research trials of the long-term outcomes associated with antipsychotic medication to provide clear and decisive information. They also emphasize the need for these controlled trials to compare long-term antipsychotic usage with more individualized treatment approaches, to best determine the potential benefits and consequences of each.

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Bergström, T., Taskila, J. J., Alakare, B., Köngäs-Saviaro, P., Miettunen, J., & Seikkula, J. (2020). Five-year cumulative exposure to antipsychotic medication after first-episode psychosis and its association with 19-year outcomes. Schizophrenia Bulletin Open. DOI: 10.1093/schizbullopen/sgaa050 (Link)

The post Greater Exposure to Antipsychotics Associated with Worse Long-Term Outcomes appeared first on Mad In America.

The need for a reduction in antidepressant use is clear to see when examining the ever-increasing rates of antidepressant prescriptions across western countries over the past 30 years. This increase in antidepressant prescriptions is primarily due to increases in treatment duration, or how long an individual is on antidepressants, with treatment duration doubling every ten years over the past three decades.

The frequency of long-term antidepressant use is concerning, considering the risk of adverse effects, such as weight change, sleep disturbance, sexual dysfunction, impairments of autonomy and resilience, and dulled or blunted experience of emotions. For older individuals, the risks are more significant, as the side effects produced by antidepressants can worsen with age. Those 65 and older taking antidepressants are at increased risk for mortality, falls, stroke, gastrointestinal bleeding, and seizures, among other health issues.

Additionally, being on antidepressants for an extended period increases an individual’s risk of experiencing withdrawal symptoms when they attempt to stop using their medication. Common withdrawal symptoms include sensory issues, insomnia, anxiety, depression, and suicidal thoughts.

These withdrawal symptoms may mimic the original issue, like depression, that brought the individual to treatment, which may lead them to restart their medication under the assumption that their presenting symptoms have returned. These assumptions are often reinforced by their primary care physicians, rather than waiting for the withdrawal symptoms to go away on their own. This then reinforces the belief for the individual that they need to remain on antidepressants.

Moreover, the longer an individual is on antidepressants, the less likely it is that their general practitioner will reassess whether the medication is still necessary or appropriate. Individuals are typically provided with repeat prescriptions and are usually prepared to continue taking antidepressants indefinitely. Fears of relapse or becoming unstable, and lack of communication from their general practitioners about weaning off, fuel individuals’ willingness to commit to a lifetime of antidepressant use.

In addressing strategies to reduce antidepressant prescription, Kendrick urges against antidepressant prescriptions for individuals experiencing mild symptoms of depression or anxiety. He highlights how avoiding beginning antidepressant treatment during the initial meeting between practitioner and patient allows for time for the individual to improve without treatment, which occurs for a significant number of individuals.

If the symptoms remain persistent, antidepressants should be prescribed only under certain circumstances: if an individual has not benefited from or would not be a good fit for psychosocial interventions (therapy, self-help, or an exercise regimen), the individual is at risk for developing more severe depression or anxiety, or the individual has a history of recurrent depression or anxiety and is requesting to begin a new course of treatment for an antidepressant they had been prescribed in the past.

Kendrick urges general practitioners to avoid spreading misinformation about antidepressants, such as they are used to treat deficiencies of serotonin in the brain. This claim is not supported by brain research and is problematic as it can lead patients to believe that they require indefinite treatment to “fix” this imbalance.

The chemical imbalance myth, along with other misconceptions about antidepressants, is prevalent across popular websites. This is concerning, considering many patients are citing serotonin deficiency as the reason why they need antidepressants.

Other misinformation about antidepressants has been spread by pharmaceutical companies as well. This has resulted in a lack of attention to the significant impact placebo effects have on the efficacy of antidepressants (88% of short-term antidepressant efficacy is attributed to placebo effects and only 12% being attributed to the actual pharmacology of the drug) and to patient withdrawal symptoms, which are often explained away as being part of the patient’s underlying mental health issues.

Kendrick also emphasizes the need to adequately educate patients about antidepressant use by informing them from the start that they will be on antidepressants for a limited time, after which they will be assessed to determine if the medication is still necessary. Patients should be informed of withdrawal symptoms associated with antidepressant use so that they can make a fully informed decision about whether they would like to begin taking antidepressants, knowing the potential risks.

Clear, national guidelines are vital in reducing antidepressant prescriptions. Guidelines acknowledging the limited efficacy and potential side effects and withdrawal issues may have yielded positive results, with prescribing for first-time experiences of depressive episodes decreasing from 70% to 60% of episodes.

Unfortunately, national guidelines can also work counteractively. The NICE guidance indicates that antidepressants should be prescribed for two years or longer for episodes of depressive symptoms that are reoccurring, which has resulted in the overall antidepressant prescribing remaining amount the same, even though first-time episodes prescriptions decreased.

In a review of barriers to stopping antidepressant use, fear of withdrawal and relapse, lack of guidance from practitioners, and time constraints related to follow-up appointments were found to be major roadblocks. Some of these barriers, such as patient fears and lack of practitioner guidance, can be assuaged in part through increased support for the patient by the practitioner, which others, also pointing to the concern individuals have with coming off of antidepressants, have called for as well.

Kendrick points to the importance of practitioners initiating discussions about ending antidepressant treatment with their patients, rather than operating under the assumption that their patients will initiate it. Along similar lines, having regular reviews of the medication and the patient’s treatment is crucial to determine whether the drug is still needed or whether it can be discontinued.

Kendrick also identifies several different drug tapering programs that allow patients to be weaned off of the medication, and therefore avoid experiencing potentially unpleasant or distressing withdrawal symptoms. Although further research needs to be conducted to determine the best method to use to wean off of antidepressants, broadly speaking, the process should be one that is negotiated between patient and practitioner via a process of mutual decision-making.

Psychotherapy is also highlighted as an essential part of the tapering process, as it provides a space for individuals to express their fears related to withdrawal and experience a sense of support. The available literature suggests that those who receive psychological or psychiatric care as they are tapering from antidepressants have higher success rates – with between 40% and 95% of individuals discontinuing antidepressant use altogether.

However, a significant limitation to psychotherapy is access – resources are limited, and not all have the means to access therapy. In England, the program Improving Access to Psychological Therapies (IAPT) was developed to help individuals in need access therapy. As of 2016, only 15% of individuals diagnosed with depression and anxiety in primary care were referred or self-referred to psychotherapy. Although the Mental Health Taskforce hopes to increase this to 25% by 2021, the vast majority of individuals will still fall through the cracks.

Kendrick proposes an alternative: online psychological support coupled with primary care support as a way to assist patients with stopping antidepressants, which would address the gaps left behind by psychotherapy. He highlights the REDUCE program in England, which is funded by the National Institute for Health Research (NIHR).

Through qualitative research, the program identified factors that both harm and help patient’s attempts to discontinue antidepressants. Through this program, both the general practitioner and patient have access to online programs that are designed to assist with antidepressant withdrawal. The patient also has access to three phone call sessions with a psychological wellbeing practitioner.

For practitioners, the REDUCE program developed internet modules that provide practitioners with information and assistance on topics such as how to talk to patients about tapering and outlines tapering schedules for antidepressants. The reduction schedules have been adapted for all antidepressants. They are adjusted depending on the withdrawal symptoms associated with each particular antidepressant, as well as the history of the patient (such as if they have a history of distressing withdrawal symptoms or are particularly fearful of withdrawal). The plans are also adaptable themselves, in that practitioners are encouraged to slow down tapering, or return to the previous dose if withdrawal symptoms become too distressing or severe.

The REDUCE program is currently being assessed as to whether it is an effective intervention to assist with antidepressant discontinuation. There is a similar program in development in Australia. Although promising, these programs require additional research to determine whether they work.

Overall, increasing antidepressant rates driven by long-term antidepressant use points to an issue in prescribing. Resources are needed to assist practitioners to consider initiating antidepressant treatment more carefully. If they do prescribe, guidance is needed on the duration of time they are keeping patients on these medications.

A thorough review of the research literature indicates that tapering safely can be accomplished through the increased practitioner and patient education and support, tapering strategies, and psychological support, both in-person and online. The review points to the need for further research into this matter, so that clear guidelines and programs can be put into place to ensure that patients are not remaining on medications that are no longer needed.

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Kendrick, T. (2020). Strategies to reduce the use of antidepressants. British Journal of Clinical Pharmacology. DOI: 10.1111/bcp.14475 (Link)

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In the current study, researchers used several Swedish national databases to collect demographic information as well as information on pharmaceutical prescriptions, violent crimes, hospitalizations, incarcerations, emigration, and psychiatric diagnoses. Impressively, the study included all individuals in Sweden, aged 15-60 years-old, who had received SSRI prescriptions between 2006 and 2013.

The researchers only included violent crimes that resulted in convictions for their study, with the violent crimes examined, including homicide, manslaughter, robbery, assault, stalking, and sexual crimes, among others.

In total, researchers identified 785,337 individuals with SSRI prescriptions who were ages 15-60 between 2006 and 2013. 20,821 (2.7%) of these individuals had violent crime convictions, with a total of 32,203 violent crimes overall. Younger individuals (age 15-24 years), men, and those with a prior history of violent crime were found to comprise the majority of offenders. Most participants (99%) had changes in their antidepressant use over the course of the seven years examined for the study.

Yet, despite 15-24 year-olds appearing to be more impacted by SSRI treatment than other age groups, the researchers found that there was an increased risk for violent crime across all age groups when comparing individuals during periods on medication versus periods off medication. Moreover, the risks associated with SSRI treatment appeared to extend beyond the end of treatment, up until 84 days after treatment had ended.

The authors urge caution when interpreting the results, however, pointing to the association between mood disorders, which are often treated with SSRIs, and violent crime. They highlight the limited effectiveness of SSRIs among children and adolescents as compared to adults, and suggest that perhaps ineffectively treated mood disorders, coupled with behavioral activation shown to be triggered in children and adolescents by SSRIs, may explain the increase in violent behavior in younger individuals on SSRIs.

Moreover, they note that meta-analyses of randomized controlled trials (RCTs), which assess the effectiveness of treatment, found that SSRIs can cause aggression. But, as discussed, these increases were predominantly found in younger individuals. Additionally, participants in RCTs are carefully selected for studies and are not representative of the entire population. Therefore, they do not offer definite answers as to why younger persons are more impacted.

The researchers also acknowledge that 2.7% of individuals were convicted of violent crime over seven years, which shows how this is a rare occurrence. They urge people not to discontinue their SSRI medication in response to their findings.

Although the researchers cannot point to clear cause in this study, risk pertaining to violence and antidepressant use has been documented in a number of other studies. SSRI use has been linked to violent crimes in individuals aged 15-24. Antidepressants have been found elsewhere to induce a state of agitation and restlessness, and potentially, preoccupation with violent thoughts, known as ‘akathisia’.

SSRIs have also been found to be associated with more aggressive and violent suicide attempts, which is concerning considering that violent means could increase the likelihood that the suicide is completed. Further, risks of suicide and violence associated with antidepressant use have been shown to occur across the lifespan, pointing to concerns about their use.

In the current study, the researchers acknowledge the limitations of their work, such as being unable to confirm whether the medications filled were actually taken, and not truly knowing the treatment period, or length of time the person was taking the drug. The design of the study was not to point to an exact cause, but rather to begin an exploration into the risk associated with SSRI use.

The researchers emphasize that their work offers a pathway by which to open up possibilities for future exploration and research to examine more fully the particular risks that can are associated with SSRIs.

They conclude:

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Lagerberg, T., Fazel, S., Molero, Y., Franko, M. A., Chen, Q., Hellner, C., Lichtenstein, P., Chang, Z. (2020). Associations between selective serotonin reuptake inhibitors and violent crime in adolescents, young, and older adults – A Swedish register-based study. In press, European Neuropsychopharmacology. (Link)

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Informed consent, or being provided with information regarding the risks and benefits of a particular treatment, is crucial in the medical and mental health fields. Although the treating professional is responsible for providing this information, many prospective patients do their own research online before deciding whether to follow through with treatment. This research often impacts how the individual views or understands a particular treatment. When it comes to information about medical and mental health treatments, it is crucial that accurate information is provided online.

In an attempt to assess whether there is accurate information available online about antidepressant treatment, researchers reviewed search results related to “depression,” “antidepressants,” and “depression therapy,” on the most popular websites in ten English or Nordic-speaking countries, which included Australia, Canada, Denmark, Ireland, New Zealand, Norway, South Africa, Sweden, UK, and the USA.

Thirty-nine websites were ultimately included in the researchers’ analysis, all of which mentioned the benefits and consequences of antidepressant use. Yet, most of the sites analyzed did not accurately portray the potential costs of antidepressant treatment.

A shocking twenty-nine or 74% of websites describe depression as being caused by a “chemical imbalance,” or suggest that antidepressants are effective in repairing said imbalance. Yet, there is no research evidence to support that depression can be attributed to a chemical imbalance in the brain. The myth that depression is the result of a chemical imbalance was widely promoted by Eli Lilly, the creators of Prozac, which was one of the first most predominantly utilized medications to treat depression.

Unfortunately, although this has been disproven, the chemical imbalance myth appeared on the majority of the websites reviewed, and is also reflected in the beliefs in the general population as well – 88% of participants in an Australian study were found to believe that chemical imbalance in the brain is the cause of depression.

This misinformation is problematic as it can encourage individuals to continue taking antidepressants, as these persons are operating under the assumption that their experience of depression is something that needs to be “managed” for the rest of their lives, just like diabetes must be managed through insulin.

This idea that antidepressants are required as lifelong treatment was a claim made by some of the websites reviewed in the current study. Some suggested that antidepressants may need to be taken across a lifetime, which is particularly concerning considering there are no current research studies that provide evidence that lifetime antidepressant use is necessary. There is no good evidence even to support that patients require antidepressants for 6-9 months, which is the standard timeframe for treatment as referenced by 56% of the websites reviewed.

Moreover, contradictory evidence was found throughout the website review. One UK website, in particular, claims that antidepressants can help improve life through improving one’s mood, one’s ability to take care of oneself, improving relationships, and increasing satisfaction in sexual relations. Yet, this same website also warns that potential side effects include decreased sex drive and a potential negative impact on relationships with friends and loved ones.

In addition to contradictory evidence, the researchers found that most websites neglected to clearly outline significant risks associated with antidepressant use. Only 13% mentioned the experience of emotional numbing, or a sense of dulled emotional experience, as being attributed to antidepressant use.

Most (29) of the websites failed to mention the potential harms of antidepressants use in pregnancy or suggested that pregnant women consult with their doctor. The majority of sites (59%) did, however, mention the negative impact that antidepressant use can have on sexual functioning, such as reduced sex drive, difficulty orgasming, and erectile issues in men.

Although twenty-five websites addressed the increased risk of suicidal thoughts associated with antidepressant use, most of them (92%) presented inaccurate information related to suicidality. While the Food and Drug Administration (FDA) has warned that suicide risk is increased for individuals of all ages who are taking antidepressants, only two websites mentioned this. One site even falsely claimed that the FDA has still not yet determined if there is a relationship between suicide risk and antidepressant use.

The Mayo Clinic misleadingly suggested that antidepressants can be used as a buffer against suicide and downplayed the harms associated with suicidal and homicidal thoughts or behavior, suggesting that they aren’t as concerning as suicide. The authors write:

In addition to downplaying suicide risk, several websites suggested that fluoxetine (Prozac) is safer than other antidepressants for use in children. However, research has challenged the effectiveness of antidepressants in children.

Others have written about how diagnoses of depression in children and adolescents increased significantly following the introduction of Prozac in 1988. Prior to this, depression was thought to be highly uncommon in children, pointing to how mental health professionals have over time, pathologized normative childhood and adolescent experiences, such as moodiness.

Moreover, the researchers found inaccurate information on the effects of antidepressant withdrawal to be present on 46% of the websites reviewed. Most sites shied away from or explicitly denied the addictive nature of antidepressants, explaining away antidepressant withdrawal as merely being the body needing to “adjust.” Yet, withdrawal reactions to selective serotonin reuptake inhibitors (SSRIs), used in the standard treatment of depression, are comparable to benzodiazepines such as Xanax.

Although all websites suggested that antidepressants are effective in treating depression, all of them failed to explain what the results of antidepressant research mean. The authors describe how the results of randomized trials, which are used to assess the effectiveness of antidepressants, might have effects so small that they are clinically insignificant, or the effects might not exist at all as the trials have not been appropriately blinded.

Antidepressant research is conducted using randomized controlled trials (RCTs) wherein some participants receive an antidepressant, whereas others receive a placebo or sugar pill. Participants must remain blind to what group they are in, as their expectations can influence the outcome of the study. However, as described elsewhere, participants were demonstrated to “break blind” or identify whether they belong to the treatment or placebo group in 78% of antidepressant RCTs in the most extensive study conducted on this matter.

Further, researchers in the current study identified that the benefits of antidepressants were highly exaggerated, claiming that antidepressants relieve symptoms of depression in more than half of individuals who take them. The authors write:

Finally, while 95% of the websites mentioned psychotherapy as an alternative or addition to antidepressant treatment, the information on it was inconsistent. Some sites touted psychotherapy as useful, whereas others claimed that it was effective only when used alongside antidepressants.

The authors point to research evidence that psychotherapy for the treatment of depression is superior, especially long-term, in the treatment of depression. Another study provides similar evidence, demonstrating that antidepressants are not more effective than psychotherapy in depression treatment.

The researchers in this study assert that psychotherapy should be the primary treatment for depression of all severity levels, citing how psychotherapy has been shown to reduce suicide attempts. In contrast, antidepressants have been shown to increase suicide risk in individuals across the lifespan.

The results obtained by researchers bring to light the large swath of misinformation present on popular websites regarding antidepressant treatment for depression. As discussed, this is of concern as individuals interested in learning more about antidepressant medication are provided with an inaccurate portrayal of the benefits and harms associated with antidepressant use.

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Demasi, M., & Gøtzsche, P. C. (2020). Presentation of benefits and harms of antidepressants on websites: A cross-sectional study. International Journal of Risk & Safety in Medicine, 1¸ 1-13. (Link)

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Medscape Medical News, quoting Daniel S. Budnitz, MD, MPD, director of the Medication Safety Program, Centers for Disease Control and Prevention (CDC), in communication with Medscape Medical News, reports:

“Although benzodiazepines are typically not problematic in terms of acute overdoses when used alone, patients often don’t take them as prescribed or use them with other substances in a self-harm attempt.”

Benzodiazepines, such as Xanax, are used to treat symptoms such as anxiety, insomnia, and seizures. However, they have a number of negative potential side effects, such as increasing the risk of physical dependence, being highly addictive, and causing severe respiratory depression when used in conjunction with other central nervous system depressants like alcohol or opioids. They have been shown to increase cognitive impairment, falls, and fractures, in elderly adults. Elsewhere, benzodiazepines have been shown to cause risk for dementia to more than triple.

Researchers examined data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance (NEISS-CADES) project, which is a “collaboration between the CDC, US Consumer Product Safety Commission, and the Food and Drug Administration” writes Medscape Medical News. The sample includes 60 hospitals that comprise a demographic that is nationally representative.

Researchers examined intent of patients’ benzodiazepine use, by looking at whether the use was therapeutic, related to self-harm, or nonmedical, with nonmedical reflecting use for recreational purposes or using someone else’s medication to self-treat anxiety. Most ED visits relating to adverse events associated with benzodiazepine use involved self-harm (30.4%) or nonmedical use (55.9%).

The authors of the study suggest that better screening tools are necessary to identify patient risk for self-harm, advocating in particular for a free resource developed by the National Institute of Mental Health, the Ask Suicide-Screening Questions (ASQ), which is used to assess youth suicide risk. As reported in Medscape Medical News, the authors found that more than half, or 53.8%, of visits involving nonmedical benzodiazepine use included patients who were 15-34 years old, making this age group particularly vulnerable.

They also express concern about benzodiazepine exposure for both older and younger adults. Despite benzodiazepine use being discouraged by the American Geriatric Society due to negative effects, ED visits attributed to benzodiazepines for adults 65 and older total over 16,000 per year. On the other end of the lifespan, almost 2,500 ED visits examined in the study involved children younger than 5 who had accidentally ingested benzodiazepines. The researchers promote the safe storage of medication as a preventative measure.

Moreover, as 20% of ED visits involving benzodiazepines included concurrent use of other drugs, such as opioids (29.9%), the researchers urge clinicians to ask their patients about substance use when prescribing benzodiazepines. They suggest steps such as urine testing, if opioid or cocaine use is suspected, and encourage clinicians to refer their patients to substance abuse treatment if needed. Furthermore, the authors promote psychiatric and social assessments and follow-up for patients who are at risk for self-harm. They offer mental health assessment and treatment as options for patients who engage in nonmedical benzodiazepine use, to address underlying issues that may be contributing to their drug use.

Authors Vega and Maust, as reported by Medscape Medical News, encourage healthcare providers to limit benzodiazepine use across the board, and especially with high-risk patients, such as those with a history of substance misuse or self-harm behavior. They suggest that clinicians gain a better understanding of patients who engage in nonmedical benzodiazepine use, as well as the negative events that come along with this use. They point to the potential harm that has been shown to be caused by benzodiazepines and urge caution when prescribing. Elsewhere, others have urged against the prescription of benzodiazepines at all, citing disastrous individual and societal side effects.

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Anderson, P. (2020). Benzodiazepines implicated in high rate of ED visits across US. Medscape. (Link)

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In a new article for Psychiatric Services, VA psychiatrist Mark Warren and psychologist Leigh Smithkos, highlight some of the problems associated with the evaluation procedures at the VA, exploring how although they are well-intentioned, are falling short. Others have argued that the VA’s suicide prevention efforts are contributing to the continued rise in veteran suicide. The authors write:

“If we approach our work with suicidal patients in a bureaucratic, policy-driven, and overly regimented manner, we risk adopting the reductionist view that screening instruments and standardized assessments are sufficient to reduce veteran suicide.”

New suicide risk evaluation procedures have been put in place across the VA system that require clinicians to complete a standardized comprehensive evaluation for certain individuals during the initial meeting. It is a lengthy process, taking 30-45 minutes, and is even needed for individuals who have been shown, through other measures or previous relationship to the clinic, to pose no risk of suicide.

A potential unintended consequence of policies such as the new evaluation procedures is clinician burnout. Policies that do not match the available resources of the program require the clinician to take on a heavier workload. Clinician burnout has been shown to be caused, in part, by “excessive workload, clerical burden, and inefficiency in the practice environment [and] loss of control over work.”

In addition to lengthy, and at times unnecessary, evaluation procedures, VA clinicians are also required to provide same-day care to any veteran needing behavioral healthcare. While intended to provide veterans with needed care immediately, an unintended consequence of this mandate is that clinicians are pressured to maintain full schedules, which may negatively impact their ability to do good therapeutic work.

Another consequence of the policy of the VA may be the destruction of the therapeutic relationship or the relationship between therapist and client. In order to accurately and more completely understand the individual, their triggers for suicide, and overall behavioral risk, it is imperative that the clinician hears the story of the patient.

The authors point to research that supports their work, highlighting the effectiveness and cost-efficiency of brief interventions that attempt to elicit patient narrative. They argue that although the current tools using for screening and behavioral risk assessment do attempt to get a narrative from the patient, poor implementation, which may be the result of a lack of training or time, or overuse of screening tools, can prevent this narrative from being asked for or heard by the clinician.

Warren and Smithkos argue for an approach to risk assessment and suicide prevention that allows for more of a balance between standardized assessments and the use of clinical skills that emphasize the meaningful engagement with patients through hearing the individual’s story.

The authors write, “Suicide is a problem of humanness, not solely of health care,” arguing that a more balanced approach could allow for better care for veterans, and the overall reduction of veteran suicide.

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Warren, M. B., & Smithkors, L. A. (2020). Suicide prevention in the U.S. Department of Veterans Affairs: Using the evidence without losing the narrative. Psychiatric Services, 1-3. (Link)

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“Consciously or otherwise, perceptions of the here and now are based on conceptions of the past that might be one dimensional at best and misguided at worst. In particular, the mental map of asylums’ past is sharply contrasting (e.g. humanity vs barbarity, knowledge vs ignorance, and good practice vs bad practice), which does not allow for the shades created by the ideological and cultural context in which different locations and types of mental health care have been provided over the past two centuries,” writes Houston.

Institutionalization of psychiatric populations has a contentious history and is still a topic of debate. Some argue that it is a good idea gone wrong, in some cases, whereas others believe that asylums are inherently dehumanizing. Houston attempts to offer a middle ground, exploring a history of asylums using a “bottom-up approach,” or including the perspectives of patients, staff, volunteers, and families, as well as local communities’ experiences of asylums. He argues that this bottom-up approach to understanding allows for an exploration that includes both the positive and negative, the successes and failures, rather than focusing heavily in one camp or the other.

The author highlights the political ideologies underlying supporters and opponents to asylums in their early development. Early asylums were initially private and voluntary but became outnumbered by public asylums during the mid-to-late 19^th and early 20^th centuries. The push for public asylums was inspired by liberal ideologies that promoted state intervention and the improvement of society, although supporters were found on either side of the political aisle. Supporters believed that county asylums would help serve middle-class families who did not have access to the care provided by the social welfare system, but could not afford care at expensive private asylums. Opponents of public asylums were typically members of the conservative political party, which advocated against government intervention and taxation, believing them to be infringing upon their fundamental rights.

In addition, asylums appeared to value public opinion, as shown through annual asylum reports which document prevention of suicide. This was used to demonstrate to the public that it harbored a caring, controlled environment. Patient newsletters, which sought to normalize institutional living, served a similar purpose. Asylums valued their relationships with local entities and individuals, such as communities, medical practitioners, and families, understanding that their very existence depended on this relationship.

Public perception of asylums in the 19^th and 20^th centuries was dependent on the cultural context. In Scotland, in-home care by the family was valued. Domestic settings, including the private homes of farmers, were used in the treatment of those labeled as ‘mentally ill’ or ‘intellectually disabled.’ The Welsh also valued in-home care, which delayed Welsh institutionalization until the 20^th century. On the contrary, Ireland lacked social services due to lack of legislation, polarized social viewpoints, and intense rural poverty. As a result, Ireland’s use of inpatient care was significantly higher than England, and ultimately the rest of Europe, in 1900.

Movements for institutional reform began in the 19^th century and led to developments such as the use of unlocked wards, voluntary admission to public asylums, and the building of “village-style” or “garden-city” asylums, which integrated the landscape and environment, and therapeutic treatment. Those fighting for reform accused asylums of being inhumane, totalitarian, overcrowded, and more, which ultimately fueled the movement for deinstitutionalization. Those in favor of inpatient care believed the opposite — asylums provided a safe space for those who could not function in society. Houston reflects that many psychiatrists still hold this belief today, that an institutional environment is crucial in facilitating therapeutic change and rehabilitation of individuals back into society.

Houston points to the detrimental effects of the closing of asylums, and push for outpatient care. These institutions were major employers, so the loss of jobs with deinstitutionalization impacted communities, especially affecting those in rural and semi-rural settings. Additionally, mental institutions served as an alternative to prison for those diagnosed with mental disorders found guilty of criminal acts. With deinstitutionalization, access to this option became limited and/or unavailable. Further, the reformation of asylums led to changes in laws, which ultimately led to the creation of the welfare state in England.

Moreover, the reformation of asylums spurred new approaches to treatment, and also, Houston argues, contributed to an increase in clinician pessimism, as they felt like they could do nothing to improve the lives of ‘those with disabilities.’ This attitude is tied to beliefs about the inferiority of certain human beings, such as those with learning or intellectual disabilities, which fueled the eugenics movement at the time. It was also reflective of assumptions that mental health issues, sexually transmitted infections, and alcohol and drug abuse were the result of a moral failing or weakness — and therefore unable to be successfully changed or treated.

Another consequence of deinstitutionalization is the emergence of psychosocial approaches to treatment. These approaches worked to help patients reintegrate into society following treatment in order to reduce readmission.

An exploration of patient documentation, including letters, reveals that patients, not surprisingly, report a variety of experiences. Some patients report abusive, anti-therapeutic treatment, while others write of their asylum experience as being transformative and key to their healing. Largely, however, it appears that patients were ambivalent toward their treatment, with their perceptions of their experience in treatment changing throughout their time in the institution.

Additionally, patient advocacy groups have fought for patients’ rights and treatments since the Victorian Era. These groups have had a large impact on the adoption of legislation, such as the decriminalization of suicide in England and Wales in 1961, that upholds the human rights of those suffering from mental health issues. Houston highlights factors including liberalism, libertarianism, psychiatric reform, and fiscal conservativism, as being key to the major changes that have occurred in mental health treatment — particularly, balancing the power between patients and clinicians and deinstitutionalization.

The current review offers an approach to understanding the history of asylums that allows for a more balanced view, one that takes into account the positive and negative impacts of institutional care in the 19^th and 20^th centuries. Having a better understanding of past successes and failures will open up possibilities for future approaches to treatment, that are not guided by ideological thinking, but rather historical evidence and support.

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Houston, R. A. (2019). Asylums: The historical perspective before, during, and after. Lancet Psychiatry,1-9. (Link)

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These findings are concerning as schools in the United States tend to rely on punitive discipline policies as a way to manage student behavior. The results suggest that these discipline tactics are not only ineffective but contribute to racial inequalities and the very behaviors that these modes of punishment are trying to deter. The authors, led by Dr. Jamie Amemiya, write:

“American citizens often misinterpret racial disparities, particularly those in the criminal justice system, as reflecting a behavioral or cognitive deficit of disadvantaged racial groups. This study offers counterevidence to this claim and highlights how educational institutions may perpetuate such disparities through racially biased responses to normative adolescent behavior.”

Rebellious, risky behavior is common in teenagers, as it provides them with a way of gaining a sense of independence from adults, as well as acceptance from their peers, both of which are crucial to adolescent development.  Adolescents may break minor, inconsistently enforced rules at school such as violating dress codes, using their cell phones, or joking around during class in an attempt to test boundaries, assert a sense of autonomy, and to impress their peers. Although disruptive to the classroom, minor misconduct may be fundamental to healthy adolescent development.

The U.S. school system typically takes a punitive approach to discipline, imposing official disciplinary actions, such as infractions, suspensions, or detentions, on students who violate rules to deter future misbehavior. While intended to manage classroom behavior, current research demonstrates that disciplinary action has negative consequences. Suspensions are given disproportionately to African American students and to predict worse outcomes in life, including involvement in the criminal justice system.

Amemiya and her colleagues focus their investigation on the impact of minor infractions on students, pointing to a gap in the research literature, as most research focuses on more severe disciplinary actions, such as suspensions. They aimed to explore whether minor infractions are predictive of further challenging behavior as well as to examine the role of racial bias in the issuing of minor infractions.

The researchers examined a dataset, collected over one school year, from an urban school network located in the Mid-Atlantic region of the U.S. The participants included 729 sixth, eighth, and tenth-grade students from nine schools. The majority of students were sixth and eighth-graders.

Most of the students were African American or white, with seven schools comprised of predominantly black students (71%) and two that were nearly proportionate, consisting of 53% white students. Additionally, most students (73.5%) qualified for free or reduced-price lunch, suggesting economic disadvantage.

Records of disciplinary infractions were examined to determine the number of minor infractions given, and two principals were interviewed about the process of how infractions were given to students. Minor infractions included misbehavior such as inappropriate language and horseplay and consisted of 50% of the infractions given for the school year. Defiant behavior, which included misconduct such as cheating, insubordination, and vandalism, were also included and consisted of 16% of the infractions given for the year.

Researchers also took into consideration the students’ attachment to school, through a survey which asked them to rate their feelings towards various statements of attitudes toward school – for example, “I am proud of my school.” Additionally, to examine racial bias and school disciplinary action, the authors took into consideration the race of the participants.

Interestingly, although the Amemiya and her colleagues found no notable differences between black and white students’ self-reports of attachment to school, impulsivity, or misbehavior at school, they did find that African American students received significantly more infractions and suspensions than white students. The authors connected their findings to prior research that has demonstrated the negative influence of racial bias on teachers’ perceptions of African American students, citing that their work further documents the fact that black students are punished more harshly for normal teenage behavior.

Moreover, more than half of the participants (53.4%) were given at least one minor infraction over the course of the school year. The researchers found that receiving minor infractions was predictive of increases in misbehavior, although receiving more serious infractions, such as for aggressive behavior, was not.

They suggest that the arbitrary and inconsistent nature of the punishment of minor misconduct might be what is contributing to adolescents becoming more reactionary and defiant. Further, the prediction of increased defiant behavior was found to be most significant for students who were highly attached to the school. In other words, the students who most view school as a place of support are most negatively impacted by sanctioned punishment for minor misbehavior.

A major limitation of this study includes the fact that it was conducted within one charter school network, and therefore the findings might not be applicable across other school systems. That being said, however, the findings of this study have been found to support previous research conducted.

Also, further research will need to be conducted with students in elementary school as well, as this study focused solely on middle and high school students. In addition, as this study was based on a dataset, it will be important to conduct future research where data on misconduct is collected at the moment, as opposed to reflecting back only on official reports, which does not capture the entirety of student misbehavior.

A key takeaway from the research findings is that current methods of addressing student misbehavior are ineffective, and in fact, harmful to students. The authors suggest that replacing a punitive approach to discipline with interventions that help build positive student-teacher relationships is crucial to resolving this problem. They offer the Consistency Management and Cooperative Discipline program as a potential alternative, as this approach encourages a more active student role in the classroom, through promoting the co-creation of rules by teachers and students.

Additionally, this study highlights the racial disparities present within the educational disciplinary system and shows how discrimination against African American students can contribute to an increase in future defiant behavior, which in turn, can put them at risk for future criminal justice involvement.

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Amemiya, J., Mortenson, E., & Wang, M. (2020). Minor infractions are not minor: School infractions for minor misconduct may increase adolescents’ defiant behavior and contribute to racial disparities in school discipline. American Psychologist, 75(1), 23-36. (Link)

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“In order to dismantle the view of the patient as the object of examination and treatment, and to see her as a subject, it is necessary to deny the psychiatrist (the subject of study) the position of the invisible and omnipotent eye. Phenomenology offers psychiatrists the tools to reach this awareness and actively engage in the transformation of the psychiatric theory and practice,” writes Sholokhova.

Sholokhova is a teaching associate in the department of Psychology and Educational Sciences at the Catholic University of Louvain in Belgium. The article was published in the journal Philosophy, Psychiatry & Psychology.

Throughout the years, advocates have worked toward person-centered approaches in psychiatry (in which the client is considered the expert of their own experiences). However, the status quo in mainstream psychiatry still regards the psychiatrist as an expert who dictates the care of the client. Even within a person-centered perspective, the subjectivity of the medical professional is mistrusted out of fear of malpractice or undue influence. Although such concerns may be valid in some circumstances, ignorance of clinician subjectivity is problematic as it continues to maintain the idea that knowledge can only be gained through a subject-less, detached observer.

From the perspective of phenomenological psychology, the therapist is not a detached expert, but rather an active participant in the therapeutic process. From this perspective, attending to the therapist’s emotional experiences is also an essential part of therapy.

Key to phenomenological practice is a task called “performing the epoché.” To do this, the therapist must attempt to suspend prior assumptions, beliefs, and prejudices about themselves, others, and the world, in the service of more completely understanding the experience of the client. This task is a dynamic, aspirational process that is never fully completed. This continuous process allows for the therapist to keep learning more about themselves, others, and the world, which is crucial to the process of psychotherapy. When applied to the clinical encounter, such a stance is theorized to enable the clinician to suspend their prior beliefs and allow them to pay more attention to the lived experience of the client.

Sholokhova argues that coupling phenomenology with psychiatry could allow for a more comprehensive understanding of mental illness. The phenomenological perspective could serve as a critical lens, both challenging and helping to balance the objectifying view of psychiatry. She suggests that phenomenology could allow for a more relational experience of the therapeutic encounter, rather than one that is grounded in seeing client as object. According to Sholokhova, this could open up possibilities for profound transformation in the field of psychiatry.

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Sholokhova, S. (2019). Benefits and challenges of the phenomenological approach to the psychiatrist’s subjective experience: Impassivity, neutrality, and embodied awareness in the clinical encounter. Philosophy, Psychiatry & Psychology, 26(4), p. E-83-E-96. (Abstract)

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“Among the 82 trial reports, there were a total of 54 different primary definitions of relapse,” write the researchers, led by critical psychiatrist Joanna Moncrieff.

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Trials of antipsychotic medication suggest that there are lower rates of relapse with continuous antipsychotic maintenance treatment as opposed to intermittent treatment or discontinuation of antipsychotic medication. However, reviews of the literature indicate that the definitions of what constitutes a relapse vary across studies. As a result, there is a lack of clarity as to what relapse is across the field of psychiatry, raising the question – how can the claim be made that these medications contribute to lower rates of something that thus far, has been unable to be clearly articulated?

Further, as these medications have been demonstrated elsewhere in the research to have potentially dangerous and permanent side effects, it is imperative that the necessity of their use be based in strong, empirical evidence – which the current study calls into question.

In an attempt to examine and describe the definitions of relapse utilized in randomized controlled trials (RCTs) of long-term antipsychotic treatment for individuals struggling with schizophrenia or psychosis, the researchers analyzed studies found in the literature. They examined 82 trials in total, including studies that addressed comparisons between antipsychotic maintenance treatment and placebo, intermittent antipsychotic treatment, and/or medically guided reduction or discontinuation. Further, studies were only included if they addressed outcomes such as relapse, or related areas such as hospitalization, deterioration, and treatment failure.

Of the 82 trials they included, the authors found that there were 54 different definitions of relapse amongst these studies. The researchers compared and contrasted trials occurring before, and after 1990, and found that the definitions of relapse became more complex and detailed as time progressed. In addition, none of the trials that they examined discriminated between individuals who had experienced complete remission of symptoms, versus individuals who were experiencing ongoing psychotic symptoms, which contributes to the murkiness of understanding as to what constitutes a relapse.

Moreover, criteria for relapse that is based on rating scales was demonstrated to differ substantially across trials. Although 23 studies employed the Positive and Negative Syndrome Scale (PANSS), which assesses positive and negative symptoms of schizophrenia, to define relapse, 18 varying sets of PANSS-based criteria were used across the trials. Levels of change varied as well, ranging from a 10 point increase in PANNS total, to a 30 point increase, with scores varying from mild to severe.

Along similar lines, more recent trials typically used the Clinical Global Impressions (CGI) Severity (-S) or Improvement (-I) to describe relapse. However, only 3 of these trials required any change on these scales, which measure patient outcomes, to be categorized as a relapse. Additionally, there was a lack of consensus on what severity level indicates a relapse. The researchers write, “. . . thresholds varied between CGI-S of 3 (mildly ill) to CGI-S of 6 (severely ill) and CGI-I of 6 (much worse).” The researchers also noted a lack of inclusion of behavioral functioning or other clear, noticeable signs of relapse – only four studies included hospitalization or “necessary” or “imminent” hospitalization as part of the criteria for relapse.

Furthermore, the researchers’ ratings of the reliability and clinical relevance of the definitions of relapse across the trials reviewed indicates that more reliable, and clinically relevant definitions of relapse are badly needed. Only 37 trials, or 41.5% of the studies were rated by researchers as reliably defining relapse, and only 7 of the studies were rated to describe relapse in clinically relevant terms. The researchers write, “Only six trials showed both good reliability and clinical relevance of the primary definitions of relapse, and four of these used hospitalizations as the sole relapse criterion.”

The researchers found inconsistencies in the frequency of the use of assessment procedures, like routinely administrating the scales addressed above, across the trials. Thirty-seven of the trials regularly assessed for relapse throughout the study. However, the researchers discovered that none of the studies addressed the issue of how to complete measures that require client cooperation, like the PANNS, with individuals who may be experiencing symptoms of psychosis that prevent or make challenging their full participation and collaboration.

Consistent with the variation described throughout their research, the authors found that what constituted a relapse according to the assessments conducted varied across studies. The trials were demonstrated to most frequently use psychosis item scores and clinical judgment as criteria to define relapse, although other studies included criteria such as hospitalization and suicidal or aggressive behavior.

The findings of this review indicate that further research needs to be conducted to develop a more reliable and clinically relevant description of relapse of schizophrenia and psychosis. The authors offer suggestions for future research, such as clarifying what constitutes a clinically significant change in rating scales, as to how to begin to address the lack of reliable and clinically relevant definitions of relapse.

They also suggest using clinical case notes as a way to avoid the issue of attempting to use measurements with clients experiencing florid psychosis, which could allow for a more consistent understanding of what criteria constitute a relapse. It is vital that clear definitions of relapse related to psychosis be identified, as this could prevent the use of unnecessary antipsychotic maintenance treatment, which has been shown elsewhere to be harmful and lacking in research evidence.

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Moncrieff, J., Crellin, N. E., Long, M. A., Cooper, R. E., & Stockmann, T. (in press, 2019). Definitions of relapse in trials comparing antipsychotic maintenance with discontinuation or reduction for schizophrenia spectrum disorders: A systematic review. Schizophrenia Research. (Link)

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“There is increasing recognition that we need to make mental healthcare more consensual and ensure that the human rights of people with mental health problems are always respected. However, little attention is given within current mental health policies and programs to reducing coercion in clinical practice despite our commitment to clinical safety,” write the authors, led by Dr. S.P. Sashidharan, a professor and researcher at the University of Glasgow.

Coercive practices are used internationally in mental healthcare, yet they remain under-researched. In addition, the available research suggests that they are detrimental to the health, wellbeing, and human rights of mental health clients. Coercive treatment broadly consists of involuntary and forcible treatment, which includes practices such as seclusion, physical restraint, and the forcible administration of medication. Such practices are not confined to mental healthcare but are also used in general healthcare, particularly in the treatment of the elderly, children, and individuals diagnosed with intellectual disabilities.

Despite the pervasive use of coercive practices in treatment, there remains a lack of systematic and reliable data on coercive practices both nationally and internationally. Yet, available research suggests that such practices elicit the opposite effect of what is intended. Although coercive practices are used in the service of keeping the client and others safe, research demonstrates that clients who are subjected to such treatment experience high levels of distress, even traumatization, as a result of such experiences. The authors note:

“. . . coercive practices are often associated with negative outcomes for patients with significantly adverse impacts on satisfaction and quality of life.”

While research identifying potential clinical remedies to coercive treatment is scarce, the research that is available suggests that clinical practices that involve loved ones of the client, client advocacy, and the use of advanced directives and joint care plans all contribute to the reduction of coercive practices in treatment.

In order for practices such as joint care plans, wherein the client and professionals collaborate in the process of treatment planning, to be utilized across psychiatric institutions, a major shift will need to occur regarding how treating professionals view their clients – not as dangerous or lacking the agency to engage in their own treatment, but instead as competent, capable, and worthy of dignity and respect.

Although coercive care is used across mental health and general healthcare settings, it is most prevalent in forensic psychiatry in high-income countries. In order to reduce coercive treatment as a whole, the authors suggest that forensic psychiatry itself needs to be completely restructured into treatment based on rehabilitation, as opposed to its current focus on public protection. Italy provides one example of how such a restructuring lends itself to positive outcomes – rather than indefinitely confining those with mental health issues and criminal histories, Italy has moved toward rehabilitating these individuals, which has resulted in the reduction in reliance on secure psychiatric beds.

Further, while legislative changes will likely not impact the use of coercive care in clinical practice, it can allow for increased protection of rights for those in treatment. Unfortunately, despite current mental health laws being described by the UN Convention of Rights of People with Disabilities (UNCRPD) as being, “fundamentally discriminatory and inconsistent with human rights principles,” there remains a lack of action by the field of psychiatry to make changes in mental health legislation.

There are organizations advocating for the upholding of human rights in mental healthcare. Dr. Sashidharan and his colleagues highlight the QualityRights initiative of the World Health Organization (WHO) as being an entity that promotes the maintenance of human rights across several countries through the use of assessment, training, and measures of treatment quality in mental health facilities.

The review of the literature outlined by the authors clearly indicates that coercive practices are harmful and detrimental to individuals, providing a strong argument to reduce the use of these practices in mental healthcare. Although a major overhaul of the field of psychiatry is required in order to significantly reduce these practices, changes in legislation and in the field of forensic psychiatry can pave the way for a shift in the psychiatric paradigm.

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Sashidharan, S. P., Mezzina, R., & Puras, D. (2019). Reducing coercion in mental healthcare. Epidemiology and Psychiatric Sciences, 1-8. (Link)

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