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Dr. Bob is Robert Hsiung, MD,
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Posted by SLS on January 6, 2007, at 7:51:14
In reply to Re: Patient paid to accept neuroleptic depot injection » med_empowered, posted by Phillipa on January 5, 2007, at 22:34:53
> Med I have to disagree as I saw so many schizophenics off their meds and miserable with voices and seeing things, and once stabalized they were productive in society again and happy and felt normal.
Yup. We might not like the story, but the outcome of medication seems to be much better than non-medication for those suffering with true schizophrenia.
Giving people a financial incentive to remain treatment compliant is an interesting idea. Ultimately, it might be both cost-effective and enhance the quality of life of the patient. It's something to think about, anyway. I won't debate the choice of neuroleptic. I know someone named Steve who will not accept treatment unless he is encouraged to come in once a month for his Prolixin injection. Any other modality fosters non-compliance and decompensation. The result of this is very expensive and drains public resources.
Steve had been a successful student studying to be a medical doctor. Real smart guy. He now drifts in and out of homeless shelters.
I don't think it is in anyone's best interest to leave schizophrenics alone.
- Scott
Posted by SLS on January 6, 2007, at 8:00:26
In reply to Re: Patient paid to accept neuroleptic depot injection, posted by laima on January 5, 2007, at 23:42:46
> Wow- it sounds very dicey ethically. Who is to say who must get shots?
Or any other treatment.
> What if someone is desperately broke and gets shots that are not quite exactly right for them for this reason?
Great point.
However, why were the shots chosen by the doctor in the first place?
I guess if the patient were aware of the injection program, they could purposely be non-compliant or "act" non-compliant to enter it.
What if the incentive were not contingent upon any particular treatment? What if compliance to any agent could be verified with lab tests?
- Scott
Posted by laima on January 6, 2007, at 9:24:55
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by SLS on January 6, 2007, at 8:00:26
You and Phillipa bring up valid points- but the program makes me feel uneasy to read about anyway. I am having a hard time putting my finger on why, precisely. Maybe it's because a psychiatrist once accused me of being psychotic when I told her zyprexa was making me feel strange and I extrapolated? (Ie- "You think this med makes you feel strange??!!") At the very least, I hope that more than one doctor makes the evaluation. But you're right, the same questions could be raised about other programs, hospitalizations, and such.
> > Wow- it sounds very dicey ethically. Who is to say who must get shots?
>
> Or any other treatment.
>
> > What if someone is desperately broke and gets shots that are not quite exactly right for them for this reason?
>
> Great point.
>
> However, why were the shots chosen by the doctor in the first place?
>
> I guess if the patient were aware of the injection program, they could purposely be non-compliant or "act" non-compliant to enter it.
>
> What if the incentive were not contingent upon any particular treatment? What if compliance to any agent could be verified with lab tests?
>
>
> - Scott
Posted by linkadge on January 6, 2007, at 9:39:23
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by laima on January 6, 2007, at 9:24:55
I think it was a good point that a patient with schizophrenia might make the decision for the wrong reasons. When you take a neuroleptic, you are taking a health risk. So you are paying someobdy to accept health risks. The asessment of what is safe and not safe, should not be based in any way on money.
Just like it was mentioned, selling blood, or selling organs. Money should not be a factor in a person accepting health risks. If a person gets TD, theres no amount of money they may have been recieved that make that deal fair.
It is clear that neuroleptics may help patients in the short term, but I don't know if the evidence exists that schizophrenic patients do any better long term on neuroleptics. Isn't the outcome for schizophrenia better in some countires without neuroleptic medications?
Linkadge
Posted by SLS on January 6, 2007, at 10:59:19
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by laima on January 6, 2007, at 9:24:55
> You and Phillipa bring up valid points- but the program makes me feel uneasy to read about anyway.
I'm pretty uncomfortable with the idea at this point, too. Your points are well taken.
- Scott
Posted by SLS on January 6, 2007, at 11:03:27
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by linkadge on January 6, 2007, at 9:39:23
> It is clear that neuroleptics may help patients in the short term, but I don't know if the evidence exists that schizophrenic patients do any better long term on neuroleptics.
How long does one have to remain on medication before you declare it "long term"?
> Isn't the outcome for schizophrenia better in some countires without neuroleptic medications?
I don't know. Is it?
- Scott
Posted by linkadge on January 6, 2007, at 11:08:45
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by SLS on January 6, 2007, at 10:59:19
There is also the possability that a poor patient who may have otherwise recovered from schizophrenia, would still accept injections and compromise their health, just to get the $.
Linkadge
Posted by SLS on January 6, 2007, at 11:10:56
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by SLS on January 6, 2007, at 11:03:27
> > Isn't the outcome for schizophrenia better in some countires without neuroleptic medications?
>
> I don't know. Is it?Well, I'll be darned.
I Googled a bit and found some stuff to cooraborate your contention. This is interesting.
- Scott
Posted by SLS on January 6, 2007, at 11:26:23
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by linkadge on January 6, 2007, at 11:08:45
Cohen:
"Studies have shown that the outcome of schizophrenia is better in developing countries [10–12], and therefore the point prevalence in these countries should be lower. Despite this clear difference in the course of schizophrenia..."
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1140960#pmed-0020151-b10
These statements don't make sense to me. I wonder what exactly is being diagnosed.
- Scott
Posted by SLS on January 6, 2007, at 11:32:36
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by SLS on January 6, 2007, at 11:26:23
> Cohen:
>
> "Studies have shown that the outcome of schizophrenia is better in developing countries [10–12], and therefore the point prevalence in these countries should be lower. Despite this clear difference in the course of schizophrenia..."
>
> http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1140960#pmed-0020151-b10
>
> These statements don't make sense to me. I wonder what exactly is being diagnosed.
The one thing missing from the things I have read: Nowhere is there a statement indicating that the patients were not treated with neuroleptics.
- Scott
Posted by med_empowered on January 6, 2007, at 11:50:21
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by SLS on January 6, 2007, at 11:32:36
the studies are WHO studies...there were 2 of them, and I think the last one was done in the early 1990s. All the patients were DX'd by the same criteria--I think it was the ICD-10 definition of schizophrenia, not the DSM-IV--and followed up for a number of years. Apparently, in less developed countries, fewer patients were ever placed on neuroleptics, and very few were maintained on neuroleptics. Wealthy countries had low success rates in schizophrenia, as measured by continuing symptoms and more important things, like jobs and social integration. Poorer countries did much better in terms of relapse, social integration, and severity over the course of the study.
Since the countries involved had widely different cultures, I think the low use of neuroleptics has to be considered a possible factor. I think arguing that there was a problem in diagnosis reflects an unwillingness to find out what's going on here. The diagnostic criteria applied was quite sound and was applied uniformly; I think the problem is that in much of the world, schizophrenia is considered to have a very poor prognosis, so if a patient (or large group of patients) end up doing well, then the assumption is "well, it wasn't schizophrenia, after all". That is circular logic at its worst.
Apparently, there were studies early on in the days of neuroleptics that tended to show longer hospitalization times and more social dependency (welfare, etc.) in patients treated with and maintained on neuroleptics than with patients treated with non-neuroleptic methods (mainly psychosocial intervention). Also, Courtenay Hardening did a study in the 80s in which she tracked down patients (many backwards) who had been treated w/ psychosocial programs. Surprisinly, LOTS of them recovered fully or to a meaningful extent, and the ones who either stopped neuroleptics or never took them were among the best cases. Also, there was subgroup of patients who took very low doses of neuroleptics only when necessary, and they were also doing quite well.
Plus, there are shrinks now who are calling for looking at schizophrenia as a variant of bipolar, and using anticonvulsants and lithium in place of the neuroleptics. Some studies have also shown positive effects from high-dose diazepam and propranolol therapies.
Also, over the course of the illness, neuroleptics increase mortality. They increase seizures, obesity, liver problems, heart problems, and sudden deaths. Compared to patients not treated with neuroleptics, there may also be an increase in suicides, even with the atypicals. (Although clozapine is claimed to reduce suicide--I don't know if this is compared to older antipsychotics or to untreated schizophrenia, though).
Posted by linkadge on January 6, 2007, at 11:58:41
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by SLS on January 6, 2007, at 11:32:36
I don't know if one could assume that the rate of prescription of neuroleptic medications would be less in developing countries?
I think med empowered knows more about this information. I originally heard the point originally discussed by him/her.
Simpler socities perhaps, less information overload, less to be paranoid about. (I don't know if that would hold any water though).Vitamin D status of mothers might be higher in developing countries.
I just don't know what kind of information exists that says that neuroleptics imrpove the *long term* outcome of schizophrenia. They certainly aren't correcting the underlying disturbance.
Linkadge
Posted by Klavot on January 6, 2007, at 12:13:29
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by SLS on January 6, 2007, at 11:32:36
> > Cohen:
> >
> > "Studies have shown that the outcome of schizophrenia is better in developing countries [10–12], and therefore the point prevalence in these countries should be lower. Despite this clear difference in the course of schizophrenia..."
> >
> > http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1140960#pmed-0020151-b10
> >
> > These statements don't make sense to me. I wonder what exactly is being diagnosed.
>
>
> The one thing missing from the things I have read: Nowhere is there a statement indicating that the patients were not treated with neuroleptics.
>
>
> - ScottAnother important consideration: In developing countries, there is probably greater use of older, cheaper, typical antipsychotics, while in developed countries, there is probably greater use of more expensive, atypical antipsychotics. So in that sense, we are not even dealing with the same treatments for developing vs. developed countries.
Where I live (South Africa), drugs like Zyprexa are not available in state hospitals because it is too expensive. They only use drugs like chlorpromazine. Even drugs like Zoloft are not used in state psychiatric facilities - they use tricyclics, because it is cheaper.
Klavot
Posted by fca on January 6, 2007, at 12:30:59
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by Klavot on January 6, 2007, at 12:13:29
It seems to me that if you truly believe in patient choice and the right to refuse treatment ( sans dangerous to self or others)one is hard pressed to think that one can not choose treatment with compensation. If you can choose no treatment with the very real risk of negative and/or positive consequences why can one not choose treatment with compensation even though there might be positive and/or negative consequences. If one is resistant to taking medication because of a fear of negative consequences why is it any less a matter of autonomy to choose compensation even if other negative consequences may be experienced. Thanks fca
Posted by SLS on January 6, 2007, at 13:07:25
In reply to the case for neuroleptics is kind of weak, posted by med_empowered on January 6, 2007, at 11:50:21
Good post, M_E.
There are a few things that I would like to address, but I gotta run.
One thing that strikes me as funny, though, is that a statement like this: "I think arguing that there was a problem in diagnosis reflects an unwillingness to find out what's going on here." is so quickly made in a forum where so many people berate the ability of psychiatrists to properly diagnose patients - or even if there is really anything consistently reliable to diagnosis at all.
As you said, I do think something is wrong here, and I would like to know what it is.
- Scott
> the studies are WHO studies...there were 2 of them, and I think the last one was done in the early 1990s. All the patients were DX'd by the same criteria--I think it was the ICD-10 definition of schizophrenia, not the DSM-IV--and followed up for a number of years. Apparently, in less developed countries, fewer patients were ever placed on neuroleptics, and very few were maintained on neuroleptics. Wealthy countries had low success rates in schizophrenia, as measured by continuing symptoms and more important things, like jobs and social integration. Poorer countries did much better in terms of relapse, social integration, and severity over the course of the study.
>
> Since the countries involved had widely different cultures, I think the low use of neuroleptics has to be considered a possible factor. I think arguing that there was a problem in diagnosis reflects an unwillingness to find out what's going on here. The diagnostic criteria applied was quite sound and was applied uniformly; I think the problem is that in much of the world, schizophrenia is considered to have a very poor prognosis, so if a patient (or large group of patients) end up doing well, then the assumption is "well, it wasn't schizophrenia, after all". That is circular logic at its worst.
>
> Apparently, there were studies early on in the days of neuroleptics that tended to show longer hospitalization times and more social dependency (welfare, etc.) in patients treated with and maintained on neuroleptics than with patients treated with non-neuroleptic methods (mainly psychosocial intervention). Also, Courtenay Hardening did a study in the 80s in which she tracked down patients (many backwards) who had been treated w/ psychosocial programs. Surprisinly, LOTS of them recovered fully or to a meaningful extent, and the ones who either stopped neuroleptics or never took them were among the best cases. Also, there was subgroup of patients who took very low doses of neuroleptics only when necessary, and they were also doing quite well.
>
> Plus, there are shrinks now who are calling for looking at schizophrenia as a variant of bipolar, and using anticonvulsants and lithium in place of the neuroleptics. Some studies have also shown positive effects from high-dose diazepam and propranolol therapies.
>
> Also, over the course of the illness, neuroleptics increase mortality. They increase seizures, obesity, liver problems, heart problems, and sudden deaths. Compared to patients not treated with neuroleptics, there may also be an increase in suicides, even with the atypicals. (Although clozapine is claimed to reduce suicide--I don't know if this is compared to older antipsychotics or to untreated schizophrenia, though).
>
>
Posted by ed_uk on January 6, 2007, at 13:14:37
In reply to Re: Patient paid to accept neuroleptic depot injection, posted by med_empowered on January 5, 2007, at 19:32:28
Hello Med,
If someone tried to force me to have a Haldol depot, I would pay NOT to have it. I certainly wouldn't be interested in the offer of being paid to accept it though.......even if it was a lot of money. Thankfully, I am not in the position where anyone is trying to give me neuroleptics.
It's interesting that even some of the most ill patients with schizophrenia are well aware that their depot makes them feel worse.
Regards
Ed
Posted by ed_uk on January 6, 2007, at 13:22:54
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by SLS on January 6, 2007, at 7:51:14
Hi Scott
One of the main problems with depot neuroleptics is that only a limited range of high-potency neuroleptics are available in depot form. The recent addition of Risperdal as a depot may have made treatment more tolerable for some. The side effects of high-potency depots can be severe and very prolonged. In the UK, a lot of people take daily procyclidine tablets to reduce the extrapyramidal side effects of their depot.
I know someone on Clopixol depot (zuclopentixol). Even though he has little awareness of most things (!), he does know that the depot makes him feel very restless. Given his mental state, it seems that his complaints about Clopixol have been completely ignored. This is something that worries me.
Regards
Ed
Posted by linkadge on January 6, 2007, at 13:38:33
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by fca on January 6, 2007, at 12:30:59
But money can change things. Sure a person can always refuse the incentive, but say that person has a hungry family to feed, then the person might make such sacrifices.
Its like prostitution. It is outlawed because we do not think it is right that a person sell their body for money. Now, the prostitute has the decision not to sell their body, but when it comes down to it the fact that there is money in it can change a decision that somebody might not otherwise make.
Linkadge
Posted by ed_uk on January 6, 2007, at 13:39:21
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by Klavot on January 6, 2007, at 12:13:29
Hi Klavot
>Where I live (South Africa), drugs like Zyprexa are not available in state hospitals because it is too expensive. They only use drugs like chlorpromazine. Even drugs like Zoloft are not used in state psychiatric facilities - they use tricyclics, because it is cheaper.
It's interesting to hear about South Africa. The UK was much slower to accept the use of atypicals than the US but things have changed a lot in recent years. Atypicals are now more widely used than typicals in the UK. Chlorpromazine and haloperidol have decreased in popularity. What you said about Zoloft was interesting. The situation in the UK is that some of the generic SSRIs are now even cheaper than the TCAs. Fluoxetine 20mg caps are the cheapest of all, the cost to the health service being about £2 per month!
Ed
Posted by ed_uk on January 6, 2007, at 13:41:41
In reply to Re: Patient paid to accept neuroleptic depot injec » fca, posted by linkadge on January 6, 2007, at 13:38:33
You make good points Link. Some patients have very valid reasons for not accepting depots.
Ed
Posted by fca on January 6, 2007, at 15:14:03
In reply to Re: Patient paid to accept neuroleptic depot injec » fca, posted by linkadge on January 6, 2007, at 13:38:33
Sure money can change things and so can no money change things--even if you believe these meds are a crap shoot regarding outcomes then they are also a crap shoot if you choose to not do it. It is essentially the same argument regarding the legalization of prostitution. Whose body is it? To assume that someone will make a bad decision because of economic vulnerability also assumes they can not or will not factor that vulnerability into their decision making. BTW, That is true of many life choices. I really do not think you can have it both ways.
Also, regarding the efficacy of antipsychotics. I have been in MH since the mid sixties and at that time worked in an institution with 4,000 plus patients. I saw the population go down to 150 in the same institution and have spent the last 30 years running Community Mental health Centers. If anyone seriously thinks that antipsychotics (new and old) have not improved the quality of life for persons with mental illness they just do not have an historical perspective. There are abuses and excesses from all perspectives and it is certain the APs are very very far from perfect. But I can assure you that stepping back 40 years there is simply no comparison regarding the quality of life for persons whether in or out of institutions. This is not a subject that one in anyway wants to romanticize the past or the present.
Posted by laima on January 6, 2007, at 15:19:33
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by linkadge on January 6, 2007, at 11:08:45
...especially if they are unemployed and pretty broke. I mean, even me- if I was a touch broker than I am- it would be awfully tempting to get a zyprexa shot for a chunk of cash- and I hate the stuff! And I keep mulling over my experience with the prima-donna psychiatrist who genuinely believed that if I felt zyprexa was making me feel bizarre, it was evidence of a developing psychosis and indicated that I needed even MORE. Meanwhile, I noticed she had a zyprexa pen and notepad. One problem to be reckoned with: in some circles- unfortuneately, sometimes even in the mental health world- once one is a "mental patient"- one's credibility goes out the window. I think the term "schizophrenic" maybe even carries the ultimate in stigma. I mean, think honestly- how do would we feel about a person we meet if we were informed ahead of time, "This person coming to see you-is a schizophrenic- just so you know, just to warn you". Oh- and then such a person doesn't like their medication? What about looking into why, rather than dismissing the fact that they don't want to comply and blaming it on their mental disorder? Why not look into WHY, what the problem is. If one feels better with a med, I imagine one would look forward to it and seek it out. Perhaps some individuals are too messed up to make the connection though- I just don't know, but it definately seems possible. If someone gets involved with criminal behavior, the ethical balance shifts again for me. Ie, if someone hears instructions to hurt people, and the medication turns off those voices, then perhaps such a program is 100% valid.
I remember that last fall there was a news story about how some experts wanted to do away with the term "schizophrenia" altogether, and this was one of their reasons. I'm sure all cases are different, but the more I think about it, the more troubled I feel about this sort of program overall.
> There is also the possability that a poor patient who may have otherwise recovered from schizophrenia, would still accept injections and compromise their health, just to get the $.
>
>
> Linkadge
Posted by laima on January 6, 2007, at 15:25:33
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by SLS on January 6, 2007, at 11:26:23
I've read that "schizophrenia" is so complex, it may not even be valid to to put all of the variations under one umbrella term, "schizophrenia". Causes vary, symptoms vary widely. One thing I think about is what if someone gets so stressed out that they snap? No one believes them when they describe what troubles them, treats them condescendingly and dismissively? I can imagine the shere frustration and desperation such a person must feel. Another person might slip into having symptoms due to too much drug abuse or genetics. Meanwhile, they are treated the same?? I hope doctors take such histories into account, but I never saw any such differentation discussed in my zyprexa insert. Again, I know I am extrapolating.
> Cohen:
>
> "Studies have shown that the outcome of schizophrenia is better in developing countries [10–12], and therefore the point prevalence in these countries should be lower. Despite this clear difference in the course of schizophrenia..."
>
> http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1140960#pmed-0020151-b10
>
> These statements don't make sense to me. I wonder what exactly is being diagnosed.
>
>
> - Scott
>
Posted by laima on January 6, 2007, at 15:28:24
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by fca on January 6, 2007, at 12:30:59
I think desperation can be a strong factor. Waving money in front of a desperate, maybe hungry, person seems manipulative to me.
>If one is resistant to taking medication because of a fear of negative consequences why is it any less a matter of autonomy to choose compensation even if other negative consequences may be experienced. Thanks fca
Posted by laima on January 6, 2007, at 15:29:53
In reply to Re: Patient paid to accept neuroleptic depot injection » med_empowered, posted by ed_uk on January 6, 2007, at 13:14:37
Might you be tempted if you lived on the street and had no money for the homeless shelter or for food?
> Hello Med,
>
> If someone tried to force me to have a Haldol depot, I would pay NOT to have it. I certainly wouldn't be interested in the offer of being paid to accept it though.......even if it was a lot of money. Thankfully, I am not in the position where anyone is trying to give me neuroleptics.
>
> It's interesting that even some of the most ill patients with schizophrenia are well aware that their depot makes them feel worse.
>
> Regards
>
> Ed
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Dr. Bob is Robert Hsiung, MD,
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