Tuesday, 17 October 2017

Imagining a world without psychiatric drugs

As a 'critical psychiatrist' who has survived a twenty five year career as a senior doctor who has barely ever prescribed any medication, I sometimes feel rather guilty that I have not been 'a real doctor' - or have been doing something seriously wrong for many years - and they will soon find me out!

But really, I know that as a medical psychotherapist - and keen member of the Critical Psychiatry Network - that my work needs to be like this. The feeling of constantly swimming against the tide, being seen as weird / offbeat / alternative, and never quite fitting in with the systems we live by, is actually a completely normal part of being in this territory. There are probably thousands of state-employed psychiatrists with similar thoughts and feelings - but I have the luxury of being in a position where I can make that conflict my life's work. But - although it's often invigorating and quite fun, it is more often rather lonely and disconnected.

By finding a niche in the minuscule field of 'democratic therapeutic communities for personality disorder', I managed to find, and almost hide away, in a cosy world where everything we do is based in therapy, and we can justifiably split ourselves off from the 'real world' of statutory services struggling with insatiable demand and increasing regulation, austerity, and performance management.

Until a few years ago, I lived in that bubble - and our team did good work with a small number of people who were very disabled by their past trauma, abuse, neglect, deprivation and loss. We were recognised as a 'good practice site' for personality disorder treatment - but we were only treating a few dozen people per year, out of a population of over half a million. How many struggled on, in silent desperation, without any help: and how fair is that?

Since joining local mainstream services about eight years ago, I have a different view of it all. Although we can still only do genuinely 'therapeutic things' with a small number of people, we cannot lose sight of how the vast majority of people with mental health problems have only the 'mainstream' services to help them. All too often, this means that they do not ever have the sort of discussion and interview to help them to understand where their problems might come from - and think about what is needed to make their lives different. It also, rather sadly, nowadays means that they do not usually have much of an opportunity to make a therapeutic relationship - with continuity of care - with a suitably attuned clinician. And perhaps, worst of all, it means that the state machinery has the power to coerce them into taking chemical substances that might well do people more harm than good especially in the long term.

With the best will in the world, people with underlying emotional instability end up taking all sorts of medications which can, at best, help to mask their troublesome symptoms. Sometimes I liken it to taking aspirin for a headache - and the doctors involved not having any time or process for finding out about the brain tumour that is really causing the headache. I remember one of my mentors telling me that there are only three disorders in psychiatry, and four medicines. The three disorders were of mood, thinking and consciousness (for example, depression, psychosis and dementia) - and the drugs were 'anti-depressants' and 'mood stabilisers'; 'anti-psychotics' and 'anti-anxiety'. Otherwise called uppers, downers (major and minor tranquillisers), and lithium (and the anti-epileptics). And so many of the people who come into our services are on all four - at high dose -with no good reason, and no noticeable benefit - and without thought to the long-term consequences, as most people are advised to stay on them for may years. If I were visiting from another planet, or in a time machine, I would really wonder why so many people are being systematically and slowly poisoned, sometimes to death but nearly always to passivity and acceptance. But I think we all know that the road to hell is paved with good intentions.

Then I met with like-minced colleagues - mostly online, but also at the conferences of the 'Critical Psychiatry Network'. I was not alone and isolated in my beliefs, and there was some very strong scientific evidence that all was not as the pharmaceutical companies would have us believe. A little later, the announcement of the 'International Institute for Psychiatric Drug Withdrawal' came along, with its Gothenburg workshops.

Although I have been working in non-pharmacological psychiatry for over 30 years, the course gave me the impetus to do something more directly about the over-use of medication (to put it politely). So, hearing about the different projects going on - particularly like the Northampton MA 'alternative town' with its Icarus Project and 'Freedom Centre' - later sanitised for public funding with a meaningless Recovery title - I thought that I should do something locally.

One of the phrases that we mentioned in Gothenburg a few times was 'Pills Anonymous'. So my intention, in the next couple of years, is to introduce 'Pills Anonymous' groups for two of the non-NHS services in which I do clinical work. The principles will be:

  • group and relationship based (ie collaborative, democratic, non-paternalistic)
  • no coercion to reduce medication doasge, nor for it to remain unchanged, nor increase it
  • based on fully informed consent
  • to draw up agreed long-term plan, and agree that with prescribers and the group
  • include expertise on technicalities of withdrawal (eg from pharmacists)
  • monthly follow-up over as long as necessary (maybe years)
  • close recording of dosages over time, and aggegated results
  • with evaluation and research - to be written up as at least case studies (anonymised)
An early draft of the medication diary (to be kept in an Excel spreadsheet)
I have started to prepare the stationery and spreadsheet for keeping the long-term medication plans, and diary of use of all common psychotropic medication. It will be based on the British National Formulary, which gives low, normal and maximum doses for all medications. Each 'low' dose will score 1 point; 'normal' will score 2; and 'maximum' will score 3. Therefore, somebody on high doses of all four categories of psychiatric medication will score 12. It can be more if people are taking more than one preparation of in any category (for example, being on two neuroleptics). 

The overall graph, for each group member, will show how this total changes over time. I imagine there will be some interesting discussions, and a bit of friendly rivalry, between group members when they dicuss each other's scores!

Watch this space - and get in touch if you want to know more.

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