Adherence to psychiatric treatments and the public image of psychiatry

Accepting the idea that a person you love has a psychotic disorder is not easy. You will tend to deny the seriousness of the problem and to believe or hope that those experiences or behaviours will just go away, that this is only an existential crisis which will clear up spontaneously.

Accepting the idea that your loved one has to take an antipsychotic medication which is going to interfere with his mental processes and may have significant physical side effects is also not easy. You may prefer a less invasive treatment such as a talk therapy, or hope that a psychosocial approach providing friendship skills, job counseling and a supportive environment be sufficient. These sentiments may re-emerge periodically as the pharmacotherapy is ongoing.

Nowadays, consulting the Internet will be a common coping strategy under these circumstances. You will try to explore what scientists, or people who have faced the same situation, think about psychiatric diagnoses and pharmacological treatments.

Well, if you are a close relative or a friend of a person with a psychotic disorder who has been prescribed an antipsychotic medication, and you are navigating the Internet during these days, you will have a shocking experience. You will read on prominent websites that “psychiatric diagnosing is a kind of spiritual profiling that can destroy lives and frequently does” (1); that “psychiatry is a pseudoscience, unworthy of inclusion in the medical kingdom” (2); that “psychiatric drugs are toxins to the brain; they work by disabling the brain” (1); and that “psychiatric drugs increase the chronicity of major mental disorders over the long term” (3). You will read that “the way psychiatry is now practiced” is marked by “the frenzy of diagnosis, the overuse of drugs with sometimes devastating side effects, and widespread conflicts of interest” (4). You will learn that psychiatric diagnoses, contrary to those made by the other medical specialties, are not based on biological tests, being therefore invalid (e.g., 5), and that psychotropic drugs are not only useless, but “worse than useless”: their prescription explains why the incidence of mental disorders is continuously increasing worldwide (6).

One could argue that all this is not surprising, that we can find on the Internet all kinds of rubbish, and that psychiatry has always been under attack. But that appraisal would not be correct. In more than 30 years of work at the international level, I have never seen such a massive campaign in so many countries against the validity of psychiatric diagnoses and the efficacy of psychiatric treatments, especially medications, and I have never experienced such a weak and ambiguous response by our profession, with so many prominent figures in the field just arguing against each other and actually reinforcing the bad public image of psychiatry. We can be sure that patients and families are watching all this, and that the impact on the adherence to our treatments is going to be sensible.

Of course, everybody is free to say what he wants, even if driven by ideological acrimony or vested interests, and someone may believe in good faith that innovative ways of diagnosing and treating mental disorders will emerge in the medium or long term as an outcome of this quarrel. However, I think it is fair to our present-day patients and their families, as well as to the many thousands of psychiatrists who honestly exercise their profession worldwide, to emphasize some points which may help them swim against this current.

The first point is that the unavailability of laboratory tests does not invalidate psychiatric diagnoses. It is not true that psychiatry is unique in the field of medicine in making diagnoses which are not “based on biological tests”. There are, indeed, several non-psychiatric conditions (migraine and multiple sclerosis being good examples) which are diagnosed today without specific laboratory tests, and many others which have been correctly diagnosed for decades on the basis of their clinical picture before any laboratory test became available (7). Furthermore, most laboratory tests in medicine are “probabilistic, not pathognomonic, markers of disease” (8): they “will helpfully revise diagnostic probabilities, rather than conclusively rule in or rule out a diagnosis” (7), and their results will have to be interpreted using clinical judgment. Moreover, the availability of laboratory tests has not prevented some non-psychiatric diseases which lie on a continuum with normality – such as hypertension and diabetes – to be the subject of controversy as to the appropriate “threshold” for the diagnosis (e.g., 9). In fact, whether blood pressure or glycemic levels are normal or pathological depends on the clinical outcomes they predict, and the relevant evidence may under some circumstances (e.g., during pregnancy for glycemia) be unclear or controversial (e.g., 10). Indeed, “the lack of a gold standard against which to judge different claims around how to define disease” and the “highly subjective decisions” needed to evaluate “what constitutes sufficient distress or risk to warrant a definition of caseness” have been recently identified as general problems in medicine (see 9). So, assuming that the availability of laboratory tests automatically allows making “yes or no” diagnoses in the other branches of medicine is incorrect, and stating that psychiatric diagnoses are invalid because laboratory tests are not available is misleading.

The second point is that, although the boundaries between most mental disorders and the range of normality remain controversial (as for hypertension and diabetes, those boundaries do not “exist in nature”, but are fixed on the basis of clinical utility (11), there is now a reasonably wide agreement among psychiatrists about the prototypes of major mental disorders. The most significant contribution of the DSM-III has actually been the clear, explicit and precise delineation of those prototypes, which has been largely incorporated in the ICD-10, rather than the provision of thresholds in terms of number and duration of symptoms, whose empirical basis remains limited and which are rarely used in clinical practice. The prototypical forms of major mental disorders are a clinical reality, not a fiction, and patients and families can be confident that well-trained clinicians are able to recognize these forms in ordinary practice. There is indeed a “grey zone” between the prototypical forms of major mental disorders and the range of normality, but the skilled clinician will handle the cases falling in that zone with great caution, usually adopting a stepwise approach in which the first stage is watchful waiting. The characterization of earlier and milder forms of major mental disorders is currently an active research focus (see 12).

The third point is that psychiatric medications are not less effective, when prescribed for their target conditions, than those used by other medical specialties. Actually, according to a recent review of meta-analyses (13), the efficacy of antipsychotics in the acute treatment of schizophrenia, as assessed by the standardized mean difference from placebo, is similar to that of antihypertensives in the treatment of hypertension and of corticosteroids in the treatment of asthma. Even more, the efficacy of long-term antipsychotic treatment in preventing relapses in schizophrenia, as assessed by the same measure, is almost six times higher than the efficacy of angiotensin-converting enzyme (ACE) inhibitors in preventing major cardiovascular events in people with hypertension. One could argue that the effectiveness of psychiatric medications in ordinary clinical practice is lower than their efficacy as emerging from controlled trials, that those medications have significant side effects, and that researchers' financial conflicts of interests may have biased the results of trials, but all these arguments may also apply to medications used by other specialties (while psychiatry is unique among medical disciplines as to the impact of commentators' ideological conflicts of interests on the way the available evidence is presented). Of course, it is always important to emphasize that antipsychotic treatment has to be prescribed within the frame of a valid therapeutic alliance and complemented, whenever possible, by evidence-based psychosocial interventions.

These are some core facts on which, I believe, most psychiatrists could agree, mentioning them in their interactions with patients, families, students, residents and journalists, even if on the same occasion they deliver further messages which may reflect their own theoretical orientation, clinical experience or research interests, and which may be less widely shared by the profession.

We must keep the trunk of the tree, which all of us share, distinct from the branches, which we may share or not. Otherwise, we will have to blame ourselves if in the future the problem of adherence to psychiatric treatments will become even harsher and more widespread than it is today.