Consult-Liaison Education Medicine Observations Reading

Hoping for Hope for Psychosis.

The American Board of Psychiatry and Neurology (ABPN) is running a pilot project: Psychiatrists and neurologists can read a set of articles and answer mini-quizzes over the course of a year instead of taking a multiple-choice exam. If the physician answers enough questions correctly in either activity, then this supports the application for board recertification.[1. To be clear, I feel frustration with the American Board of Psychiatry and Neurology and their board recertification procedures. This “read articles and take mini-quizzes” is an encouraging improvement, but there are other aspects of board recertification that give me heartburn. This is why I am also a member of the National Board of Physicians and Surgeons.]

I am enrolled in the “read articles and take mini-quizzes” pilot. One of the mandated articles is “Improving outcomes of first-episode psychosis: an overview“. One of my professional interests is psychotic disorders (e.g., conditions wherein people report hearing voices and beliefs that do not appear rooted in reality). If you share that interest, you may find this article informative, too.

Note I said “informative”, not “encouraging”. Here are a selection of statements I found notable in the article:

Psychotic disorders such as schizophrenia are common, with 23.6 million prevalent cases worldwide in 2013. One in two people living with schizophrenia does not receive care for the condition. The recovery rates… and associated disability… following a first episode of psychosis have not improved over the past seventy years under routine clinical care. Although existing psychopharmacological treatments alone can reduce some symptoms, they have little impact on the outcome of the illness.

Oof. This is the first paragraph of the article! None of the statements surprise me, but when they are all put together like that… well, it makes me wonder: “When are we going to get better at this? When will we consistently help individuals with these conditions?”

At the moment, there are no approved [prevention interventions for individuals who are clinical high risk for psychosis] that have been shown to reliably alter the long-term course of the disorder.

Sigh. This speaks to population-level data. This means that we—the individual at high risk, the family and friends of this person, and any professionals involved at the time, if we happen to meet this person—grope around as we try to minimize the risk of illness. Maybe our efforts will work for This Person, but maybe they won’t for That Person. So we continue to work and hope.

The detrimental impact of illicit substance abuse on the long-term outcome of psychosis is well known, with a dose-dependent association.

Here in Washington State, we see a lot of people with psychotic symptoms who have used or are using methamphetamine. It ruins minds. I wish people would stop smoking/snorting/injecting it.

Marijuana is legal in this state and there is some evidence that cannabidiol (CBD), a compound found in marijuana, may reduce psychotic symptoms. Delta-9-tetrahydrocannabinol (THC), also found in marijuana, can induce psychotic symptoms. This is problematic. Companies sell CBD on the internet and I have concerns about how people will run with this preliminary data.

[There is a] lack of stringent evidence for a robust effect of antipsychotics on relapse prevention in the long term….

The article summarizes evidence that suggests that antipsychotic medications may simply delay the relapse of psychotic symptoms, rather than prevent them from reappearing.

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There were also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

When I reflect on that time, there were no guidelines about this. These decisions to taper medications—always with ongoing discussion and with the individual’s consent—were just an effort to “first, do no harm”. Context matters: I used as much data—from the individual, family and caregivers, and the literature—as I could find before embarking on deprescribing. Was I naive and reckless? Maybe. Was I just lucky? Maybe? Was I doing the best that I could with the information I had? I think so.

Schizophrenia features are strong predictors of poor long-term outcomes… when communicating with patients, it may be preferable to use the broader term psychosis rather than schizophrenia….

As far as I know, schizophrenia is the only psychiatric diagnosis that includes the criterion “Level of functioning… is markedly below the level achieved prior to the onset“. Even the neurocognitive disorders (dementias) don’t explicitly comment on a decline of “level of functioning”.

One wonders if the long-term outcomes in schizophrenia might be even just a little bit better if those of us who give the diagnosis of schizophrenia believed that people with this condition could get better. Do we, as a group, give this diagnosis out of resignation? And what message does that send to individuals experiencing these symptoms?

And what about that recommendation that we don’t discuss “schizophrenia” with individuals with psychotic symptoms? Indeed, for individuals presenting with “first episode psychosis”, this counsel is prudent. People with psychosis do get better. But, again, do we avoid using the term “schizophrenia” because of the connotations associated with that word? “… we don’t think you will ever get better.”

Maybe this is a circular argument: The reason why a decline in function is part of the definition of schizophrenia is because there is a decline in function in people diagnosed with schizophrenia.

But what about the people who meet all criteria for schizophrenia who get better?

The people who discern the pathophysiology of schizophrenia shall win the Noble Prize, for they will have figured out how the brain works. And perhaps, by that time, the articles about psychosis will give us all hope.