Schizophrenia recovery rates: psychiatry isn't working

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Courtesy of Chris Harvey Stock Free Images and Dreamstime Stock Photos

Introduction

Psychiatry is a branch of medicine that specialises in the diagnosis and treatment of mental illness. The central assumption underlying psychiatric practice in the developed countries is that severe mental health problems, (such as the disorder known as schizophrenia), are primarily caused by biochemical disturbances in the brain and therefore require medication to achieve a therapeutic outcome. This approach to mental illness has dominated psychiatric practice in the USA and much of Europe for over a century.

But how successful has western psychiatry been in improving the lives of patients suffering with severe mental health problems? To what degree have people in the richest countries of the world benefited from having easy access to both highly trained psychiatric professionals and state-of-the-art medications? Answers to these questions can be gleaned from three lines of inquiry: a comparison of schizophrenia recovery rates between the developed countries and those in the 3rd world; an exploration of the degree of progress made in the treatment of schizophrenia over the last 100 years; and a direct evaluation of the effectiveness of modern psychiatric treatment as compared to an alternative intervention that places much less emphasis on drugs and professional input. The evidence from each of these three areas will now be considered.

© Poco_bw | Stock Free Images & Dreamstime Stock Photos
© Poco_bw | Stock Free Images & Dreamstime Stock Photos

Schizophrenia recovery rates in developed and under-developed countries

Schizophrenia is the medical label given to a cluster of psychotic symptoms, typically some combination of auditory hallucinations (hearing voices that other people cannot hear), delusions (beliefs rigidly held without any objective evidence to support them) and thought disorder (where thoughts seem jumbled and confused). Affecting around 1% of the world’s population, schizophrenia has great human and economic costs. Furthermore, the long-term prospects for most schizophrenia-sufferers are purported to be poor with relapse and residual disability commonplace.

In 1969 the World Health Organisation (WHO) started a long-term scientific study to investigate recovery from schizophrenia in 14 different cultures. The findings were astounding (1). Those people who suffered schizophrenia in the poorer countries appeared to fare considerably better than those patients in the richer, developed countries. Subsequent research studies have confirmed these conclusions (2) (3).

The American journalist, Robert Whitaker, starkly summarised these findings in his book, “Mad in America” (4) (see Table 1). He highlighted how, five years after the initial measures were taken, almost 64% of schizophrenia-sufferers in the poorer countries had fully recovered and were functioning well compared to only 18% of patients in developed countries. Whitaker proposed that the crucial reason for this marked discrepancy was the overuse of anti-psychotic medication in western cultures; “doctors in poor countries did not keep their mad patients on neuroleptics, while doctors in rich countries did.”

Table 1

 
% of patients functioning well/no symptoms at 5-year follow-up
% of patients doing okay, although not fully recovered at 5 year follow-up
% of patients remaining unwell, not recovered at 5-year follow-up
Developed countries e.g. USA, London, Hong Kong
18
17
65
Under-developed countries e.g. India, Nigeria, Columbia
64
12
24
 
 
 
 
Adapted from "Mad in America" by Robert Whitaker

A more recent review of all the scientific evidence (5) reached the same conclusion. Despite poorly organised health-care systems and limited access to psychiatrists, low and medium income nations achieve better outcomes for schizophrenia. As well as less reliance on medication, other suggested reasons for this advantage are that mentally ill people in poorer countries experience less stigma and benefit from more family support.

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Courtesy of Hunor83 - Stock Free Dreamstime

How much progress has been made in the treatment of schizophrenia?

Another way of evaluating the effectiveness of modern psychiatric practice is to compare its progress with the achievements in other branches of medicine. Advances in medical science have realised huge benefits for people across the world. Vaccines for polio and meningitis have saved millions of lives; the introduction of the MMR vaccine in the United Kingdom in 1988 led to the incidence of measles falling from around 75,000 cases each year to less than 10,000 cases each year. The discovery of penicillin, the first anti-biotic, by Alexander Fleming in 1928 has enabled us to fight infections and has undoubtedly saved countless lives. Data from both the US Centre for Disease Control and the UK Office of National Statistics demonstrate that a person’s chance of surviving cancer has significantly improved during the period 1970 to 2000. Survival rates after a heart-attack have improved at a rate of about 1.5% per year since the 1960s.

So what comparable progress has psychiatry made in the treatment of mental illness? Following over a century of research endeavour (much of it funded by the pharmaceutical industry), together with the privilege of routine access to medical expertise, what gains have been made in reducing the distress associated with schizophrenia in western societies? The answer to these questions would seem to be “very little, if any”.

In the 18th and 19th centuries, when the asylums were run on moral grounds offering humane care for patients who had previously been bound in chains, discharge rates were in the region of 60 – 70%; when medical treatments were introduced, the discharge rates reduced (6).

Two comprehensive reviews provide further damning evidence for the ineffectiveness of psychiatry in the western world. An examination of 68 studies conducted on samples of patients in the USA and Europe found that the recovery rates for schizophrenia had not improved since the start of the 20th century (7). A similarly negative conclusion was reached by Whitaker (4) who estimated that mental illness in the USA had increased six-fold between 1955 and 2003.

A more mixed picture was described by American psychiatrist, James Hegarty (8), who reported modest improvements in schizophrenia recovery rates between the 1950s and early 1980s, but a worsening of outcomes in the subsequent decade. Hegarty proposed that recovery rates for mental illness may correspond to economic factors and improve during periods of low unemployment.

Consideration of these studies as a whole lead to the conclusion that over 100 years of intense modern psychiatric research and practice has failed to achieve any appreciable progress in the prevention or treatment of severe mental illness.

Loren Mosher talks about the Soteria project

A comparison of the effectiveness of modern psychiatric treatment with an alternative approach

The most potent test of the effectiveness of any approach is to directly compare it with an alternative. Unfortunately, as traditional psychiatric practice (with its emphasis on medical treatments) has dominated the treatment of people with schizophrenia since the end of the 19th century, it is very rare for a radically different approach to be implemented and evaluated to find out how it matches up. The exception has been the outstanding work of Loren Mosher.

Mosher once occupied the top position within the American Psychiatric Association (APA) but became increasingly disillusioned with his profession’s reliance on drug treatments. Following decades of deepening alienation from fellow psychiatrists, he resigned from the APA in 1998 stating in his resignation letter that “the major reason for this action is my belief that I am actually resigning from the American Psychopharmacological Society.”

Many years earlier, Mosher initiated a way of helping people with severe mental health problems that placed far less emphasis on the prescribing of anti-psychotic medication (9). His project, referred to as Soteria House, was based in an impoverished area of California and first opened in 1972. It accommodated six residents at a time, all recruited from the Emergency Rooms of local hospitals where they had presented with acute psychotic episodes (and would have therefore acquired the diagnosis of schizophrenia). Soteria House was staffed by caring, supportive people who did not possess professional mental health qualifications and who tried to empathise with the residents and help them make sense of their psychotic experiences. Apart from emergencies, no drugs were used in the first six weeks of their stay.

Mosher rigorously evaluated this innovative approach in comparison to treatment as usual within the conventional psychiatric system (typically involving medication, admission to an acute psychiatric hospital and regular contact with mental health professionals). In the short-term Mosher found that both the Soteria and traditional patients achieved equal and significant improvement in their symptoms. At 2-year follow-up, 43% of Soteria patients had not received any psychiatric drugs and were still doing at least as well as those patients in the professional psychiatric system; if anything, there was evidence of modest superiority over those receiving conventional treatments.

Despite the reporting of further, similarly positive results, the Soteria project closed in 1983 largely as a result of lack of support from the psychiatric profession and the drug companies.

Conclusions

1. A schizophrenia-sufferer in the under-developed world (e.g. Nigeria) has a better chance of recovery than a schizophrenia-sufferer in richer countries (e.g. USA).

2. In contrast to every other medical speciality, and despite over 100 years of intense psychiatric research, schizophrenia recovery rates are no better today than they were at the beginning of the 20th century.

3. An approach based predominantly on respect and compassion is at least as effective in helping people with schizophrenia as traditional psychiatric practice with its emphasis on toxic drugs (as well, of course, as being much less expensive to deliver).

So there can only be one overarching conclusion: western psychiatry isn’t working!

References

(1) World Health Organisation (1973). Report of the International Pilot Study of Schizophrenia, Vol. 1. Geneva: World Health Organisation.

(2) Jablensky, A., Sartorius, N., Ernberg, G. et al (1992). Schizophrenia: manifestations, incidence and course in different cultures: a World Health Organization ten-country study.Psychological Medicine,Monograph Suppl.,20,1-97.)

(3) Harrison et al. (2001). Recovery from psychotic illness: a 15- and 25-year international follow-up study.British Journal of Psychiatry 178, 506 – 517.

(4) Whitaker, R. (2002). Mad in America: Bad Science, Bad Medicine, and the enduring mistreatment of the mentally ill.Basic Books: New York

(5) Isaac. M. et al. (2007)Schizophrenia outcome measures in the wider international community. British Journal of Psychiatry 91, 71 – 77.

(6) Bockoven, J.S. (1972). Moral Treatment in American Psychiatry. Springer Publishing.

(7) Warner, R (1985). Recovery from Schizophrenia: Psychiatry & Political Economy

(8) Hegarty J.D et al. (1994). One Hundred Years of Schizophrenia: a meta-analysis of the outcome literature. American Journal of Psychiatry, 151, 1409 – 1416.

(9) Mosher, L. (1978). Community Residential Treatment for Schizophrenia. Hospital and Community Psychiatry, 29, 715-723

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Comments 10 comments

Dr Billy Kidd profile image

Dr Billy Kidd 4 years ago from Sydney, Australia

Good question.

I’ve been a part of a team that treated lots of people who had schizophrenia. So, I know that some of the newer medications can help a few people cope better with reality. What worked best was when there were work farms. People with mental illness had a job and felt productive. In some underdeveloped societies, this sort of over-looking someone’s work is done in the community.

But the idea of recovery is not a valid idea from my experience. MRI pictures and brain autopsies have shown that folks with schizophrenia have “non-normal” brains and brain functions. I’ve seen people with such problems do well in community clinics that offer intensive guidance and day programs. I have not, however, ever heard of anyone with true schizophrenia being cured. There are, of course, methamphetamine, LSD, and cocaine users that have true-to-life schizophrenic symptoms. I’ve seen those people cured.

The other issue in the U.S. is that few people have any empathy for people with mental problems. They tend to say, “Get over it.”


annerivendell profile image

annerivendell 4 years ago from Dublin, Ireland

Hi Gsidley. Read your Hub with interest. I just came across this woman: Emma Bragdon at www.emmabragdon.com I think you might be interested in her work and other's in Brazil with psychotic patients.


gsidley profile image

gsidley 4 years ago from Lancashire, England Author

Dr Billy Kid, I appreciate you taking the time to leave a detailed comment.

I agree with most of your points. Without a doubt, for many people anti-psychotic medication has a beneficial effects on psychotic symptoms. I'm not arguing that medication has no role. What I do reject is the idea that so-called schizophrenia (I'd abandon the label, but that's probably best left for another debate) has a primary biological cause. The "non-normal" brains that you refer to are more likely to be the result of long-term anti-psychotic use and/or childhood trauma, the latter of which we know to be a powerful predictor of future psychotic episodes.

I agree with your suggestions about the importance of work/productive activity and the negative impact of prejudice and social exclusion.

Thanks again for your interest.


gsidley profile image

gsidley 4 years ago from Lancashire, England Author

Annerivendell, thanks for dropping by.

I will certainly chase up Emma Bragdon - I appreciate the reference.


bankscottage profile image

bankscottage 4 years ago from Pennsylvania

Very interesting hub. We had a son with schizophrenia. Like many parents we missed the signs in high school. Drugs and alcohol, we thought it was just acting out and rebelling. He dropped out of school and eventually had a full psychotic break. Got great care and control. I don't believe Brian heard specific voices, just noise that he couldn't get away from and thus the drugs and alcohol to self-treat.

Never was cured in the sense of being disease free, but was able to function independently. Lived on his own, drove, worked part-time and most importantly, went to college and earned an associate's degree in Respiratory Therapy and was working on a bachelor's degree.

We felt that when you have a physical injury, you go to physical therapy. If you have a mental illness, you exercise your mind. We wanted his mind kept occupied with positive activities. It seems psychiatric care and the US government no longer want these patients locked in mental hospitals. Instead, they give them a disability check, subsidized housing and basically keep them out of sight. There didn't seem to any real effort to get them integrated and productive in society.

Brian died unexpectedly from a medical problem (not suicide). The last semester before he died, he had all A's in his classes. A Beautiful Mind.

If you would like to know more about Brian's story, check out the Hub I wrote on what would have been his 30th birthday, "A Father Remembers".


gsidley profile image

gsidley 4 years ago from Lancashire, England Author

Bankcottage, I appreciate you taking the time to comment.

I must admit to feeling humbled by your recollections of Brian and his tragic death in the prime of his life. As a mental health professional of many years I have spent much time (and continue to spend much time) as a minority voice arguing for a radical change in approach to people with severe mental health problems. Shamefully, when routinely immersed in inter-professional conflicts there is a danger of forgetting the human tragedies faced by psychosis-sufferers and their loved ones. Your poignant story (and associated hub) jolted me and will ensure that I must never forget the turmoil that psychosis inflicts on both the sufferer and loved ones.

The thrust of my dissatisfaction with western psychiatry is neatly captured in your comment about there having been no real effort to integrate Brian into a productive role in society; Brian clearly had a raft of skills and personal qualities to play such a role. My frustration is about the dominant paradigm in psychiatry that views psychosis as "an illness like any other" with a primary biological cause, despite there being very little evidence to support this approach. What has been shown from research is that the "illness like any other" approach increases stigma, stifles aspirations and works against integration into our society, as well as leading to the over-use of medication. There are many excellent staff working in this system (some of them psychiatrists) and I was pleased to hear that your son received some good support. But I believe better outcomes for people with a severe mental health problems as a whole will only come from us ditching the current dominant medical view (easier said than done, given the vested interests of the psychiatry profession and the pharmaceutical industry).

Anyway, thanks again for sharing your experiences and I wish you strength to cope in the future despite your enormous loss.


bankscottage profile image

bankscottage 4 years ago from Pennsylvania

Gsidley, while some individuals that cared for Brian were phenomenal, we were very disappointed with the system overall. The system promoted was survival, not integration.

Brian did require medication. At one point we could not pay much attention to Brian. He missed several doses of medication and began making poor decisions, almost manic decisions. He would buy things he didn't need and couldn't afford.

Caring for Brian was very labor intense in the sense that he required constant encouragement and reassurance, primarily by his mother and I, but also his extended family. For example, it took years for Brian to complete the process to get his driver's license. But, his academic record proved he had the intellectual capacity to succeed.

My wife and I think treatment involves some judicious use of medication but a significant effort to find ways to keep these people mentally active, challenged, and productive.

Hopefully you will someday have success in your efforts.

Thank you again for your kind comments.


Jena 2 years ago

Recent research and treatment here in America is showing that early intervention for schizophrenia can significantly alter the course of the disease, and quite possibly even avoid the first psychotic break. My best friend works in the field and is specializing in this type of early intervention. Her most recent client started developing schizophrenia when he was 16 years old - he started having paranoid delusions and hallucinations in his mothers basement. Now, about 10 years later, he has been able to come off his medication and is currently in school. They've been seeing results like this more and more. The research is very limited, but based on the results of her treatment center, there is huge potential for this to work.

And as someone in the prodromal stage of bipolar schizoaffective disorder who is receiving this treatment, I hope to God it works as well as they think it does.


gsidley profile image

gsidley 2 years ago from Lancashire, England Author

Thanks, Jena, for reading and leaving a considered comment.

I used to work in/manage an early intervention team here in the UK. The better ones do deliver a more appropriate and helpful response to young people distressed by psychotic experiences. They helpfully give due emphasis to non-drug interventions (i.e. talking treatments, peer support from others with lived experience of psychosis, maintaining links with community resources [leisure/work/education], normalizing unusual experiences) within a context of optimism. Furthermore, some innovative research has suggested that cognitive behavior therapy (a talking therapy) can prevent psychotic experiences in people at high risk of suffering voice-hearing and paranoia. As such, some (but not all) early intervention services offer some of the better elements of current mental health provision.

This hub was not intended to imply that people acquiring the "schizophrenia" label had little prospect of recovery, as this is clearly not the case. The central point of the hub was that the vast majority of psychiatric effort (research and clinical) over the last 60 years or so has been obsessed with drugs and finding biological cures. Much of this effort has been futile with no overall improvements in recovery rates. not least because "schizophrenia" is not a brain disease.

Thanks again for your interest in this hub and I hope you find relief from mental distress and suffering.


Sarah Doyle 18 months ago

I would agree with the author that there is significant proof of patients who regained full recovery from schizophrenia without taking anti-psychotic drugs but the reason why the scientific community has not advised/suggested this approach is because there are people who have also regain full recovery from taking the drugs. In essence, anti-psychotic drugs do not work for everybody. There are about 3 schools of thoughts to consider namely:

(1)patients who recovered through taking the medication(especially those who caught the disease early enough),

(2)Patients who recovered by abandoning medication,

(3)Patients who recovered through alternative treatment options.

In essence, all these methods work but for different people. There has to be ways to determine which method is suitable for each patient individually. Recently, I came across the mental health recovery works of Will Jiang, who suffered from this illness and recovered and went on to write his autobiography called "A Schizophrenic Will: A Story of Madness, A Story of Hope" which is very inspriational, just as is his book, "Guide to Natural Mental Health: Anxiety, Bipolar, Depression, Schizophrenia, and Digital Addiction: Nutrition and Complementary Therapies".

Jiang is one of many schizophrenic survivors who figured out their own ways of treating the disorder, you can visit his page to read more at http://www.mentalhealthbooks.net. And, as it turns out, he's an accomplished artist who earns his livelihood from designing. With over 80% of unemployed schizophrenics, he was determined not to let his condition ruin everything he worked hard for to disappear. This is his lifeline as a professional web designer. at http://www.newyorkwebdesign.nyc . It is hard to believe this man suffered from schizophrenia.

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