Is Finland really the promised land for schizophrenia treatment? The psychiatric contrarians, those who eschew conventional psychiatric wisdom, seem to think so. Their poster child is Open Dialogue a small, obscure, treatment program for people with early onset psychosis located in the Western Lapland region of Finland. The contrarians claim this program cures 80 per cent of schizophrenia without drugs. If only!
U.S. psychologist Bruce Levine quoted that 80 per cent figure in a recent Huffington Post blog and his source for this quote is not science but medical journalist, Robert Whitaker. Meanwhile, Mind Freedom, a group that opposes conventional psychiatry and demonstrates against them at their psychiatric conventions, devotes web space promoting Open Dialogue.
Open Dialogue is just one of many programs designed to treat the early onset of psychosis in young people -- so what makes this program different from all other similar programs?
It is considered based on research that the longer psychosis is left untreated, the worse will be the outcomes. And note also that these programs treat psychosis and not just schizophrenia. Psychosis is defined as a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality. Psychosis is caused by many factors, one of which is schizophrenia. And, as for prognosis, the medical dictionary states that for brief psychotic disorders, it is quite good but it is less positive for schizophrenia.
The prognosis for schizophrenia has not really changed much over the years. The Merck Manual is a standard for medical information that has been around for over 100 years and is updated regularly. Albert Schweitzer carried one with him in Africa as did Admiral Byrd in his exploration of Antarctica. It says that "overall, one third of patients achieve significant and lasting improvement; one third improve somewhat but have intermittent relapses and residual disability; and one third are severely and permanently incapacitated. Only about 15% of all patients fully return to their pre-illness level of functioning."
Furthermore, the manual states that "when treated early, patients tend to respond more quickly and fully. Without ongoing use of antipsychotics after an initial episode, 70 to 80 per cent of patients have a subsequent episode within 12 months. Continuous use of antipsychotics can reduce the 1 year relapse rate to about 30 per cent. Drug treatment is continued for 1 to 2 years after a first episode. If patients have been ill longer, it is given for many years." And, the proper treatment also involves rehabilitation including community support services and psychotherapy.
So, if treated early, a patient will be on medication for a year or two and then may be able to be weaned off but should be followed for any signs of relapse. If there is relapse, then medication should be re instituted.
With Open Dialogue, individuals referred are seen within 24 hours of first contact and patients are seen, if possible, at the patient's home. Present at the meeting are members of the therapeutic team, the ill individual and all other relevant parties such as family, friends, and any other individuals considered to be important. These meetings can last up to an hour and a half and all decisions about treatment are made by all present. For an example of how a conventional early intervention program is run, visit the very extensive website of the PEPP program in London, Ont.
In order to determine if Open Dialogue provides better results than the standard approaches used in other early intervention programs common throughout North America, Europe and Australia, good quality research is required. One study (full text linked here) published in Psychotherapy Research in 2006 involved patients during two different time periods for a total of 75 patients who were followed for 5 years. Only 32 actually had schizophrenia. At the end of the 5 year follow up, 15 patients (20 per cent) were on medications so 80 per cent were not.
But, remember that only 32 had schizophrenia so it might be that 15 of the 32 were the ones on medication. We don't know as the researchers do not reveal the diagnoses for those on medications. But, if we assume that they were the ones with schizophrenia then only 53 per cent of those with schizophrenia were medication free. And this is roughly consistent with the Merck Manual and the definition that outcomes for a simple psychosis are better than for schizophrenia.
There is one other study on Open Dialogue on a two year follow up but its results may be included in the later 5 year study. There are no other evaluations of the program that I can find searching the medical literature and the number of participants they evaluated was very small.
Daniel Mackler, a filmmaker, produced a video on Open Dialogue and claims that the Finnish hospital he visited when making the film was almost empty because beds are not needed since the Open Dialogue program is so successful. People don't need hospitalization.
It does all sound wonderful so I decided to ask a Finnish expert about the program. I contacted Kristian Wahlbeck who is a Research Professor at the National Institute for Health and Welfare, Mental Health and Substance Abuse Services, in Helsinki.
His comment in an e-mail to me was "I am familiar with the Open Dialogue programme. It is an attractive approach, but regrettably there has been virtually no high-quality evaluation of the programme. Figures like "80 per cent do well without antipsychotics" are derived from studies which lack control group, blinding and independent assessment of outcomes."
He went on to say that "most mental health professionals in Finland would agree with your view that Open Dialogue has not been proven to be better than standard treatment for schizophrenia. However, it is also a widespread view that the programme is attractive due to its client-centredness and empowerment of the service user, and that good studies are urgently needed to establish the effectiveness of the programme. Before it has been established to be effective, it should be seen as an experimental treatment that should not (yet?) be clinical practise."
As for emptying hospital beds, he said "in our official statistics, the use of hospital beds for schizophrenia do not differ between the area with the Open Dialogue approach and the rest of the country."
My suggestion to the psychiatric contrarians is to can the hype on Open Dialogue until independent studies do confirm your views that it is vastly better than what currently exists. This view was given by Sandra P Thomas, the editor of Issues in Mental Health Nursing in a 2011 article entitled "Open Dialogue Therapy: Can a Finnish Approach Work Elsewhere?". She said that the "outcomes produced by Open Dialogue therapy deserves replication by researchers in other countries." If it is proved then let's expand that model.
In my opinion, their results do not seem to differ from those suggested by the Merck Manual. What I hope that we can all agree on is that there needs to be more early intervention and treatment programs employing treatment strategies that are evidence based so that those with psychotic symptoms can get help earlier in order to bring about better outcomes.
Holding up as a model a program that is not evidence-based serves no purpose.
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