Thursday, March 4, 2010

Rethinking relapse

For every psychiatrist and patient who thinks believes that schizophrenia is a chronic biological disease that causes people to invariably relapse because of their "disease" after discontinuing their medication I am thrilled to present the following excerpt from the recent New York Times magazine article, Depression's Upside

Consider a 2005 paper led by Steven Hollon, a psychologist at Vanderbilt University: he found that people on antidepressants had a 76 percent chance of relapse within a year when the drugs were discontinued. In contrast, patients given a form of cognitive talk therapy had a relapse rate of 31 percent. And Hollon’s data aren’t unusual: several studies found that patients treated with medication were approximately twice as likely to relapse as patients treated with cognitive behavior therapy. “The high relapse rate suggests that the drugs aren’t really solving anything,” Thomson says. “In fact, they seem to be interfering with the solution, so that patients are discouraged from dealing with their problems. We end up having to keep people on the drugs forever. It was as if these people have a bodily infection, and modern psychiatry is just treating their fever.”

I, too, relapsed the first time I tried to go off an antidepressant. I got back on the medication for a few months, rethought my exit strategy, looked further into homeopathic substitutes, and the next time I attempted to get off them, I was successful. For a while during this ordeal, I almost had myself convinced I was chronic. So what, then, is so special about coming off medications when the person is diagnosed with schizophrenia? The difference, I suspect, is stigma. Many doctors just can't get out of their heads the idea that schizophrenia is chronic and that medications prevent someone from relapsing. They are afraid of the lurking beast. Rather than revert to treating the patient with understanding and empathy, they pile on drugs to prevent the scarier aspects of psychosis from rearing their heads. The meaningful but hard work of psychiatry is avoided in favor of prescription writing.

Coming off schizophrenia drugs should involve exactly the same thinking that this study has shown. In other words, you analyze the situation, you add more non-drug therapies (like CBT or other therapies I write about in this blog) and you resist the conclusion that most doctors are only too willing to hand you, that people with schizophrenia will always need their drugs because they just can't function without them.

Relapse can mean that you are simply not there yet, that you haven't yet developed the coping strategies and the self-awareness that is needed for a steadier toe-hold on life. It doesn't mean that you are a chronic case. Relapse can occur while on the drugs or off the drugs but has a lot to do with your particular circumstances at the time. People often relapse witin a year of getting off their drugs. Relapse at this stage should not be attributed solely to the fact that the person is off the drugs. It is a dangerous connection to make. A far better way to look at it is to reason that maybe there are other things that you should be doing to develp your life coping skills, to make you more emotionally resilient. This is a strategy coming out of strength, not weakness. The weaker response is to succumb to the fear that there is nothing you can do to change, to admit that you are chronic and forever dependent on your drugs.


  1. Problems, psychological or other, have the annoying habit to come bouncing back until a true solution is found. You can only find a true solution, if you acknowledge the true nature of the problem.

    Psychiatry offers solutions to problems that do not exist, while the problems that do exist go unrecognized: relapse is predetermined.

    Once again, The Hitchhiker's Guide to the Galaxy comes to mind: you have to ask the right question to get the right answer.

    A couple of blog entries on the article by its author, Jonah Lehrer: "The Upside of Depression", and "Critiques" (with some "interesting" comments, like this one for instance - not to mention the one right below, OMG!)

  2. The administration of drugs contributes to relapse. In addition to varnishing over the underlying issues that are not being addressed the withdrawl of the drugs induces the condition that the drugs intended to address.

    Antidepressants induce depression, and suicidal idealogue, when withdrawn. Antipsychotics induce psychosis when withdrawn.

    In addition to the lobbying influences of pharmaceutical companies in establishing policy, policy makers get fixed on the short term cost of treatment when considering psychotherapy and because the short term direct treatment costs are higher they do not sanction them. Most policy makers and hospital administrators fix their attention on health care costs within the 3-5 year time frame and then steer away from more expensive treatments. If these individuals undertook a cost benefit analysis over a 20 or 30 year time frame considering the direct costs of treatment and the effects on productivity, without even giving rise to the consequences in terms of personal happiness and satisfaction they would opt for psychotherapeutic over pharmacological treatments.

    Unfortunately, it's not likely to change any time soon.

  3. Agreed. I am touching on this in tomorrow's post.

  4. Anonymous: the influence of the pharmaceutical industry is a huge factor, yes. Anyhow, I also see sociopolitical interests at work in this:

    If it were all about financial profit for the pharmaceutical companies, it would probably be easier to bring about change. Unfortunately, Big Pharma's interests correspond perfectly with a thoroughly narcissistic society's needs.

  5. Anonymous - There are two ways at least, if not more, of looking at the problem of why people often relapse after coming off the meds. I used to think that the drugs caused dependency and therefore relapse was inevitable when coming off them, but I also think that maybe what is happening is that the drugs just paper over the problem, like wallpaper. Remove the wallpaper and you've get to see what has been there all along. The drugs don't fix the problem. Dr. Abram Hoffer always referred to them as major tranquillizers. Remove the tranquillizers and naturally the same old problems surface. Doctors claim this is chronicity when really, it is not. Until most doctors "get this", they will continue to push medication. It helps them avoid doing the real work of getting to the bottom of someone's pain.
    But it's also true that abrupt withdrawal from drugs throws the body into chaos. We got Chris off the drugs slowly and methodically, and he relapsed six months later. I don't connect this with the drugs, I link it to his reverting to his natural defense mechanisms that he was still unwilling to give up.


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