Schizophrenia is historically one of the worst diagnoses to have. Not only does it come with a high level of stigma and self stigma, it also comes with the worst outcomes.
The outcomes in the UK are particularly bad. Schizophrenics account for 20% of the completed suicide rate. Only about 5% are in work or education and it's one of the lowest rates in Europe. The well regarded IPSS study from the WHO shows people do better in poorer nations than in London on social and clinical outcome measures.
The mainstay of schizophrenia treatment is based on the dopamine hypothesis. I have misgivings about this but it is what is commonly accepted by psychiatrists and what modern drug treatments are based upon.
Modern antipsychotics target dopamine receptors. It's usually the d2 receptor which is targetted though some drugs like clozapine affect a wide variety of other dopamine sites and 5HT receptors too. At a brain level they reduce the tranmission of a particular chemical which is part of how all our brains function.
The drugs are dangerous and have nasty side effects. A report from the Royal College of Psychiatry states the drug caused 1,800 deaths every year in the UK when it was used on the elderly with dementia. The drug is usually used on schizophrenics for their whole life time. The drugs have been shown to halve life expectancy in dementia patients. Placebo controlled studies have shown 11% difference in the brain volumes of Macaque monkeys who were treated with antipsychotics. Reviews of MRI trials show smaller reductions in brain volume caused by ther drug and other studies point to the effect the drugs have which reduces life expectancy.
These dangers are set aside to treat schizophrenia because it seems nothing else works in reviews og high quality treatments. The most dangerous of thes drugs, clozapine, can quickly kill a patient and has the worst impact on life expectancy but it is very effecting according to some of the evidence and is reserved for use after only 2 trials of other antipsychotics are shown not to work.
There is a growing body of evidence which shows alternatives are possible. Many of these are lower quality trials but a few are good quality and point to hope of better options.
It's important to remember what schizophrenia is. In fact it is quite a complex thing to define because of the variety of intepretations. I take an old fashioned view. It is a state of frequent or perpetual unshared perceptions - primarily delusions and hallucinations but in is more complex - which causes distress and disability. Actualluy, it is a human type. Possibly a phenotype from the genotype of schizotaxia but few remember this idea (even though modern genetic studies seem to be showing the same root gene for bipolar and schizophrenia).
Emil Kraeplin is one of the most highly regarded psychiatrists ever. He codified the medical model. He had a famous puzzle which basically asks what is the difference between a manic depressive and a schizophrenic. The people in the psychiatric asylums of the day exhibited both extremes of mood and delusions of perception and reality. In the end a line was drawn and the line between mood and perception of reality as the dominant pathologised feature.
The aspect of distress and disability is also important. Some people manage with altered realities. Some don't experience distress. This happens more often in poorer nations. The psychosocial dysfunction bit is of primary importance to the psychiatric definition.
That said, in the past the diagnosis has been used for nefarious purposes. Promiscousness was associated with schizophrenia and loose women could be diagnosed with schizophrenia; it was ok for men to be loose at the time. Abherrant or different thinking too. Communists in capitalist states and vice versa could have their ideologies pathologised if they didn't fit in. Black protestors in America during the civil rights movement. Their protests were madness and the diagnosis of schizophrenia used to incarcerate and drug them because their activism was a sign of an illness.
The UK still has the shame of overdiagnosing schizophrenia in black people. The rate is about 9 times more. It is less in the US and it is equal in the West Indies between white and black people. A study in 1999 brought a Jamaican psychiatrist to check schizophrenia inpatient diagnoses in a London psychiatric ward. He concurred with their physcians diagnosis about half the time.
So the diagnosis is not a strict concept in practice. Kraeplin's idea is not how schizophrenia is defined in the science, at least not in the measures of treatment.
Measures are very important in science. They need to be accurate but they also need to describe the reality or concept. I don't think modern measures meet expectations. For a start the sub measures are weighted. They're just averaged and at most split into positive and negative symptoms. They're also designed to be sensitive to the effect of medication. This is absolutely ludacrious. A scientific measure is biased to nothing.
PANSS and BPRS are rubbish. Their design lacks any semblance of use when applied to reality. In a way their bias towards the effect of medication invalidates them and the entire body of psychiatric research which use these measures, but then I have high standards for science.
The measures need to reflect the reality of the prognosis and account for numerous social factors. The latter is way out of my capability to explain but the WHO result is so important to understand scientifically. What is the major variable which means those in developed world nations do worse than those in developing world nations? I could segue off into attemtping to answer this but a more pressing reality is the prognosis.
I've read far too many studies on schizophrenia for any sane person. What I find is a dearth of ones on treatments which really affect the prognosis.
At the moment it feels like the overarching research question is how do we suppress psychopathology. It rarely investigates the treatment of distress or subjective unwellness.
I feel there needs to be a shift. The shift needs to be about the overarching research question. It should be a question related affecting the prognsis. It is assumed this is what suppression of psychopathology does but it is an assumption. There's too much evidence that the current mode of treatment - to which the research is geared - is to reduce pathology rather than directly aim to rectify the social disability and reduce distress.
The research looks at a set of around 15 characteristics a person can show. By the way - the same measures and interview systems are not used in clinical practice. I'm just talking about what happens in a rigorous research study. The effect of treatment is to reduce some or all of these characteristics.
The measures are flawed in many ways but the biggest flaw is they're not tuned to what affects outcomes. The assumption I would have is the science is centred not only on labelling people and suppressing unwanted pathology but also improving quality of life and equality of opportunity in life or whatever other concept means the reduction of the poor prognosis.
When antipsychotics were first introduced it was suggested the suicide rate would increase. The reason was psychiatrists expected their patients to be depressed because of the drug. In fact this doesn't happen and high quality studies show drugs like clozapine can reduce the completed suicide rate and attempted suicide rate. Let me be clear. The antipsychotic drug doesn't make people happy. Well...apart from one which at low levels can act as an antidepressant...but I'm not sure antidepressants actually make a person happy.
There is good evidence to show constituents of cannabis have antipsychotic studies. More than one high quality trial of cannabidols shows them to be as effective as second generation antipsychotics.
Why do you think that might be? If you've smoked cannabis, as I am now, then you'd understand. Cannabis high in cannabidols chills you out. Standard commercial weed has relatively low levels of thc and high levels of cannabidols. High grade skunk, like I'm smoking now while I drink this bottle of red, has higher levels of thc and a mix of the estimated 40-80 different compounds involved in the herbal cannabis high.
Thc is the one which causes psychosis when injected into people in laboratory settings. I've read two studies on it like this. Only one person in either study in the us or uk developed schizophrenia after being injected with thc. It was in the american study which was done first and the subject was in the higher dose group. The uk study only used the lower dose. None of the authors in the study comment on the clear dose response in subjects injected with thc.
Anyway, I've segued off a lot. Essentially it is quite possible the Rastafarians are self medicating. Alternatively they're getting high but the cannabidols chill them out so there's no externalisation.
This idea that all antipsychotics do is chill you out is perhaps surprising. The drugs are also know to doctors as major tranquilisers. They relax a person without putting them to sleep. This is what antipsychotics really do. There is no science which shows they're truly antipsychotic, I.e. they reduce the delusions and hallicinations. There is no trial which looks only at the effect of the drug on the two measures of delusions and hallucination, two sub measures found in every schizophrenia measure but not weight about the several other factors. The most effective drug - clozapine - was reported to have little effect on the voices in a good quality German qualitative study.
Current treatment doesn't do what you might expect. A less commonly used phrase for antipsychotics is the chemical cosh. They're used in high doses in psychiatric wards to knock people unconscious or make them more docile and easy to manage. The latter reason was why they became used to treat dementia symptoms. They don't treat the illness but they make a person docile and easy to get on with and, of course, it also kills them quicker.
It suppresses psychopathology according to science. I'm tired so i'l be blunt. It does fuck all to better a person's life or outcomes or whatever they expect as treatment.
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