Patient measures and psychiatric ones: the value for treatment

I can't do a full rant on this. There can't be the usual suggestions about my chocolate salty balls. The reason is I haven't looked for the evidence I expect not to exist.

What I'm taking about is an evidence review which looks at patient measures for the treatment of psychosis. I mean a quantitative paper, not a qualitative one. I also mean a specific measure not related to comorbid common mental disorders such as depression and anxiety. What I'm taking about is a review of evidence which reanalyses previous studies but looks only at the measures which patients and the public expect from mental health treatments for psychosis: the cessation of the delusions or hallucinations which plague their life.

I'm most interested in the value of antipsychotics, specifically clozapine but other antipsychotics too including the typical antipsychotics which have lost favour.

This comes from a year or two of reading in the area of treatments for schizophrenia. Initially I discovered that PANSS was designed to be medication sensitive. This meant psychological therapies were less able to perform well in studies compared to antipsychotics.

I've come a little further. PANSS is a simple measure made up of a combination of 6 other measures. BPRS is another commonly used measure in psychosis studies and has 15 submeasures. In both these psychiatric measures there are 2 submeasures which are what patients primarily want. Patients experiencing psychosis for the first time and going to see a doctor about it want the delusions and hallucinations to stop. Their doctor gives them antipsychotics almost without exception (or psychiatrist because psychosis isn't usually dealt with in primary care as far as I am aware).

The problem is the antipsychotic may not be antipsychotic. It is also known as the major tranquiliser and also the chemical cosh. It is used in other conditions to sedate people without putting them to sleep. This is not the hope which patients have. They want antipsychotics.

In truth I know doctors want this too. The problem is they have no evidence base to go from because the measures are designed around psychiatric concepts of psychopathology, not what patients and good doctors want.

This means when a drug doesn't work for what the patient wants they either up the dose or switch drug. If they've switched drug once already then current clinical practice sort of says they need to use a drug called clozapine.

Apparently this is the most effective drug for treatment resistent schizophrenia. And yet in the only qualitative paper on clozapine in the BJPsych the authors say it only reduced the delusions and halucinations in some people. I fear therefore that the drug doesn't actually do what patients want but achieves psychiatric goals.

The other thing which is necessary is a placebo controlled trial of antipsychotics. These don't exist in modern times as far as I am aware. Ethically they can't allow patients to take a placebo. There is no other treatment for schizophrenia.

Except there is. Soteria is one paradigm and there are others which offer alternative treatment for psychosis and have had studies published (but I guess may suffer from publication bias too) which show better results for no dose, low dose or medication postponement. I've read 2 reviews, one a systematic review of Soteria and the other a review by John Bola which both inform my hope for an alternative to current medical practice based on evidence.

There's also an unusual incident which might offer an opportunity to establish just how strong the placebo effect can be. In the UK there was an incident where counterfeit Zyprexa - an antipsychotic - ended up in the supply chain. It was a scandal and eventually the culprits were caught. It provides an interesting opportunity for research because the counterfeits had much less of the active drug. Many peope would have had relapses without the placebo effect. Perhaps using modern science and a bit of detective work it could be guesstimated just how powerful this effect is.

What's most important is giving patients what they want. Ultimately there are recovered patients who'd prefer not to have to use the chemical cosh. It would be great to have treatment options for them too. But that's another battle.