Long-Term Use of Medication is Based on Myths and Lack of other Skills to Help People in Most Severe Crises: Commentary to the Article of Peter Goetzsche.

Peter Goetzsche summarized the point of origin to his register-based research as follows: “This suggests that factors other than the drugs’ pharmacological properties and the natural course of untreated disease are decisive for their usage.” (Goetzsche, 2020, 281). He claims that the huge increase of use of antidepressants and neuroleptics is not based on the clinical factors but commercial purposes. The increase of the use of the drugs is related to the increase of disability allowance in all countries studied.

He wanted to investigate the same concerns about the use of benzodiazepines and stimulants agents. His design was to compare the curve of redeemed prescriptions of the drugs over a decade, e.g. 2007-2017, He found the curve being mostly similar, with some more decline of the use of benzodiazepines. He also noticed the more rapid decline in the number of redeemed prescriptions in first time prescriptions. This would mean that once a medicine has become part of the treatment culture, it will be more likely to remain at he same level for ten years.

He makes a conclusion that: “These findings are disturbing. No matter which psychiatric drug people take or what their problem is, roughly one-third of the patients will still be in treatment with the same drug or a similar one ten years later.” (Goetzsche, 2020, 282).

These results, deriving from this simple register-based study, are interesting. What they indicate is that it does not matter the question about the specific drug being used to specific patients with specific diagnosis, but it does matter the automatic care culture without considering if there really is need to use these drugs. Of course, in this type of study there is no information about real-life cases. In real life, each situation is a unique one meaning that the medication prescribed should also be adopted in every ones’ needs. No we do not know, which variables are related to the treatment culture staying the same without consideration of new interventions if one intervention has not been helpful. The everyday clinical observations for psychiatrists and other clinicians are that these drugs do not help in the way expected, but they are still used. Unfortunately, for me this hypothesis means that the psychiatrists prescribing the bills have no other tools to provide their care to their patients.

What really surprise me is that the curve of use for ten years is the same for every drug irrespective of the problems of the patients whom they are prescribed to. In my clinical background and in my studies, I focused mainly on developing new approaches for psychosis and major depressions. In one research project in Finnish Western Lapland, we followed for 19 years what happened with the first episode psychotic patients in the Open Dialogue care and compared this to usual treatment in the rest of Finland. The outcome differences were significant (Begrström, 2018). In Open Dialogue care at the outset 20 % of the patients were prescribed neuroleptic medications. During the first five years altogether 33% had been prescribed, but half of them also stopped neuroleptics. Approximately 19 years after, among those patients who started the treatment in Open Dialogues care, 33% were still using the neuroleptics. After the first two years, the patients could have had mainstream psychiatric treatment and most probably prescribed neuroleptics, if they would have had psychotic symptoms. Howver, it seemed that the Open Dialogue interventions at the outset had helped them to avoid more new (psychotic) crises and thus even being within the main stream treatment they showed less symptoms that would have required neuroleptics’ prescribing.

The difference with the mainstream treatment in Finland was enormous. At the outset, 70% of the patients were prescribed neuroleptics and after 19 years 80% were still using. 50% of them were still in psychiatric treatment after 19 years compared to 28% in Open Dialogue care. In common treatment 61% patients were living on a disability allowance compared to 33% among those who 19 years ago had participated on Open Dialogue treatment.

These statistics concerning the usual treatment are alarming. They indicate that in 30 years no improvement has occurred in the outcomes of treatment of psychoses. Psychotic patients are expected to retire in two thirds of the cases, they are in need for services for 20 years and they are using neuroleptics for decades with no real help, and they suffer from armful effects of medications. I suppose that this is the case because of the overemphasis on medications as the primary response in any crisis.

In another study of our research team we made a nationwide register-based comparison between patients who had been using or not neuroleptics (Begrstöm et al., 2020). These drugs resulted to be continued in the next five years, patients were more likely to take medications after 19 years ( 80% vs. 60%), to be retired (61% vs 50%), to be still in need for psychiatric services (54% vs. 64%), and to show a higher mortality (16% vs. 11%). This research was not a comparison between Open Dialogue and usual treatment, but comparison among all patients who had received psychiatric treatment in all parts of Finland. This indicates that, although the treatment is traditional, avoiding neuroleptic medications in psychotic crises seems to be related to better long-term outcomes.

Peter Goetzsche makes the important observation in his register-based study. Even if some of his conclusions could be considered mere hypotheses, they are important. Why is it the case that the use of any kind of medication seems to follow the same line regardless of the problem? The use of drugs really is not evidence based, as it seems more as a myth that is followed in psychiatry. Our studies supported this notion and they also indicate that there might be some alternatives, if the system would be willing to adopt more human way of coping with people during the most severe crises. The human ways of response would mean that (1) people are met immediately at the outset of crises in their natural settings as homes; (2) all involved are invited to open meetings to discuss about their situation to understand it more and (3) the decision of medications is based on the unique needs instead of starting the medication automatically in all cases. As in the Open Dialogue approach, the prescribed neuroleptics or antidepressants are withdrawn as early as possible, at the same time as the other part of the process is continuing as long time as needed. If this is done, at the end patients need much less medications and recover much better. And I suppose psychiatrists would be much more satisfied with their own work.