Blindingly obvious, yet somehow newsworthy.

When you give sick people intensive wraparound treatment they do better!!!

Yeah, stunning.

I was listening to NPR a couple of days ago discussing the results from the RAISE trial.

The title on their website is:

Study Suggests Talk Therapy Eases Symptoms Of Schizophrenia.

Which is not what the study does at all. Though talk therapy does help with schizophrenia; that’s not at all what this was about. If you get right down to the nitty gritty, the outcomes for many of the core symptoms of schizophrenia, like hallucinations and delusions, didn’t differ much, if at all. What changed mainly was overall quality of life and some things related to mood and organization.

Another bit that struck me, which doesn’t come across very well in print, was this:

Until now, the standard prescription was powerful drugs, which sometimes have intense side effects. Now researchers recommend a range of interventions, including low dosage drugs, talk therapy, family involvement and supported employment or education.

What doesn’t come out in print was the verbal emphasis on powerful drugs and intense side effects.

Strangely, this is simultaneously not news and all wrong.

  1. These patients were still using antipsychotic medicines (you know, those “powerful drugs” with “intense side effects”). Hopefully they got away with lower doses, but that isn’t reported in the study at all, so you couldn’t conclude that. The symptoms that antipsychotic medicines are best at treating didn’t really differ between groups, and neither did hospitalizations.
  2. It’s no secret at all that talk therapy helps schizophrenia.
  3. This was a comparison of intensive, team-based, multidisciplinary treatment with “community care.” It wasn’t a comparison of talk therapy vs. high dose powerful medicines with intense side effects.
  4. We know these kinds of comprehensive treatment models work better. There have been several trials with similar results, and plenty of clinical programs involving such interventions that clearly work. In this neck of the woods, we have Chesapeake Connections and Creative Alternatives. These models even go one step further and involve integrating the payment model into the treatment system; and they probably look after sicker patients than those in the RAISE trial.

I have a sneaking suspicion. The sneaking suspicion is that under all this is a set of biases that medicines are dangerous and talk therapy is some kinder, gentler, all-natural, GMO-free, organic alternative. So when there is a study that involves both, there is some ingrained tendency to find a way that it is either/or.

Antipsychotic medicines aren’t lots of fun, for certain. Neither is psychosis. Between the two, antipsychotic medicines are probably better, particularly for people with full-blown chronic schizophrenia. Getting the same results with lower doses would be a laudable goal.

Psychotherapy, real psychotherapy, is no damn joke, though. It takes lots of time. You have to talk a lot about things that are really uncomfortable. Folks with severe psychoses can be quite overwhelmed with such interactions, and they often have major trouble communicating. It requires a lot of conscious effort, and homework. Progress tends to be slow and incremental, over many months. Sometimes it actually makes people worse, and it is very, very operator dependent.

This study is a really, really big deal. It is not a really big deal because it showed that lower doses of medicines to get the same result is better. It didn’t, but we knew that already.

It is not a really big deal because it showed that a comprehensive approach to treatment works better than the 15-minute-med-check model of psychiatry that our system presses us into. Everybody knows that.

Why it’s a big deal is that they implemented it in multiple community-based sites; and that there was continued evidence that catching people earlier may prevent deterioration.

That last part, really, was the most important one. I am afraid that point is lost in the overall squickiness people feel about treating psychiatric symptoms with medicines. That is particularly sad.

So long as everything about psychiatry is reported with an implicit dichotomization of “scary psychiatry” vs. “gentle, healing psychiatry” the reality of the thing is lost. It’s really just psychiatry, which really is just medicine. There’s what works, and what doesn’t work. For what works, there’s how much it works, and the risks. Then there’s the cost.

We’re starting to see that getting to people early with a comprehensive strategy for patient care, rather than just symptom mitigation, could save people from years of disability and deterioration.

It would be nice if the media figured that out. Powerful medicines vs. psychotherapy was, and is, settled. The solution is you substitute & for vs.  Is it any wonder the public is so weirded out by psychiatry, when the media is still talking about the psychiatry of 1959?


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