Medication for Psychosis: Myths and Truths Demian Rose, MD, PhD UCSF Assistant Professor PREP Medical Director PREP Prevention and Recovery of Early Psychosis

“Crazy” “Insane” “Out of touch with reality” “Mad” “Psycho” Language Matters Psychosis

“The opposite of neurosis” “Primary process” “Primitive defense mechanisms” “Something underneath”

Language Matters “The term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance…the term …varies to some degree across… categories.” -DSM-IV TR, pg. 297

Myth: Psychosis is “un-understandable” The “real or not” trap Psychosis is that for which we do not have a “good” explanation Image taken from abc.net.au

If you blindfold people for five days, 77% of them will develop visual hallucinations (2). 1. Tien (1991) Soc Psychiatr Epidemiology 2. Merabet (2004) Journal of Neuro-opthalmalogy Auditory verbal hallucinations occur in 10% to 15% of the population (1). Psychotic-like experience is common… …and easily induced Truth: Psychosis is on a continuum

Myth: Psychosis is a freight train The All-or-none trap Chronic Psychosis is a “cliff”: once you fall over it, there’s no coming back

# Months after treatment entry % Patients Relapse-Free Crow et al. (1986). Brit J. Psychiatry, 148, Truth: Treatment Makes a Difference

With proper medication treatment, about 40% of people with schizophrenia will have 2 or more years without significant symptoms (1) For comparison, about 40-80% of people with bipolar disorder treated with proper medication will have 2 or more years without significant symptoms (2) 1.Kane (2008) J Clin Psychiatry 2.Muzina (2005) Aust NZ J Psychiatry 40% without significant symptoms Truth: Remission is a Realistic Goal

Myth: Psychosis = medication deficiency The “if one med is good, then more are better” trap We need to find the “best combo”

Despite decades of trying, no one has found any combination of antipsychotics that outperforms one antipsychotic alone more meds = more side effects = less adherence A low dose regimen that minimizes side effects is effective One med = better adherence 1.Kane (2008) J Clin Psychiatry 2.Zipursky (2005) Truth: One medication is sufficient

Myth: Psychosis = medication deficiency The “if meds treat it well, then it’s Biological ” trap Psychosis “only responds to meds” Psychosis “can’t respond to psychotherapy”

Truth: Meds are one effective treatment But not the only effective treatment.. Cognitive Behavioral Therapy shows promise as an augmentation for schizophrenia (1) and possibly as a sole treatment for very early or prodromal symptoms (2) 1. Cochrane Review: “CBT for Schizophrenia” ( 2. Bechdolf (2006) Eur Arch Psychiatry and Clin Neurosci 3. McFarlane et al (2002) 4. Fisher et al (2009) Psycho-educational Multi-family Groups involve caregivers and peers and significantly reduce relapse(3) Computerized cognitive training shows promise as a safe treatment for symptoms that do not respond well to medications (4)

In Summary: Psychosis is not “fundamentally different” Psychosis responds well to treatment Medication can be effective at low doses There are many scientific treatments available PREP Prevention and Recovery of Early Psychosis