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For Those With Mental Illness, the Facts Matter

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Selective quotes taken out of context do not benefit our understanding of serious and persistent mental illness. So, imagine my surprise when I discover that the Mad in America people are using an academic paper by Dr. Robert Zipursky of McMaster University as proof of the evils of antipsychotic medication. Their website states "decreases in brain tissue volumes are attributable to antipsychotic medication, substance abuse, and other secondary factors. The authors conclude that the majority of people with schizophrenia diagnoses have the potential to achieve long-term recovery."

And, one of the comments on the site states "Thank you for finding these studies -- for helping build a catalogue of research on MiA -- one that helps dispel the 'myth' of biospsychiatry." MiA is Mad in America. I happen to know Zipursky and even quoted him in my own book on the need for medication in schizophrenia so I was intrigued.

I've now read his paper in its entirety and he is not advocating against medication use. In fact, the paper says "with appropriate care, including the skillful prescription of antipsychotic medication, the early years following a FEP (first episode psychotic break) are not typically periods of decline but rather of substantial ongoing improvement in symptom severity and functioning." About 70-74 per cent of patients achieve remission in the first year.

He then states that the rates of remission up to nine years of follow-up is 78 per cent but that for those who discontinue medication early, the relapse rate is up to 78 per cent compared to 0-12 per cent for those who remain on medication.

The paper differentiates between remission (the reduction of symptoms), functional recovery (an adequate level of social and vocational functioning, capacity for independent living and social interactions at a regular frequency) and recovery. Recovery, he says, has had many definitions for schizophrenia but he uses it to mean levels of social and vocational functioning within the normal range and with the remission of symptoms.

Functional recovery can be achieved, the paper states, by about 40 per cent of people while recovery can be achieved by about 17 per cent. So, 60 per cent do not even achieve functional recovery and 83 per cent do not accomplish full recovery. The paper suggests that clinical deterioration is not inevitable but is the result of nonadherence (to medication) and the resulting relapses but also to factors such as poverty, homelessness, unemployment and lack of social support as well as other co-morbidities that complicate.

As for brain deterioration, he does state that MRI studies show significant brain volume reduction in chronic schizophrenia and in patients presenting with first episode psychosis and schizophrenia. Those changes seen in patients at first episode are developmental changes in the brain. The changes in the brain are present initially before any medication has been given. And, he points out that changes in brain volume are also caused by cannabis and tobacco use for everyone. Those with schizophrenia smoke more than those who do not. A sedentary lifestyle and stress in everyone also results in reduced brain volumes again, regardless of antipsychotic use.

That these medications cause brain changes should not be of any surprise. As Dr. Fuller Torrey states, "It is important to study the brain changes caused by antipsychotic drugs, since this may tell us how these drugs work and/or predict which individuals are more likely to experience side effects." He also points out that this effect is not unique to antipsychotics as structural brain changes are also caused by drugs used to treat Parkinson's disease, epilepsy, and other brain diseases.

What was truly interesting in this study was the reference to the Clinician's Illusion by Cohen and Cohen. Psychiatrists often have an overly pessimistic view of schizophrenia simply because the ones in their practices are the ones who are doing the worst. They then commit the fallacy of attributing these poor outcomes to all who suffer with schizophrenia. The same could be said of those who espouse anti-psychiatry views and believe that all who suffer can recover without medications. They see a small segment of the total but attribute the potential achieved by them to all.

As this paper says "schizophrenia is not a discrete illness with a single cause or course, rather it appears to be a syndrome with multiple interacting causes, both genetic and environmental, and a heterogeneous outcome."

The Mad in America comments on this article state "the majority of people with schizophrenia diagnoses have the potential to achieve long-term recovery." What this paper actually said in the abstract is "most people can achieve a substantial degree of recovery." There is a difference between "long-term recovery" and "a substantial degree of recovery."

Why more do not achieve recovery is stated in the paper and, for me, is key: "Sadly, many people with schizophrenia do not have access to the skilled mental health services and social supports that are needed for them to achieve recovery and a good quality of life."

In a phone interview with me, Zipursky reiterated the need for medication which he described as "critical" for anyone with schizophrenia. Medication is needed, he said, for life so that the person with schizophrenia can remain well. And, he was a bit surprised that his paper was being used to refute the need for medication. It is important for all (consumers, family and professionals) to have a shared understanding of all the facts.