Our antipsychiatry foes will read this as saying that people do better without antipsychotics, and that’s not what this says at all. But what it does say is that a subset of people, whom we can’t identify beforehand, will do better over the long term with lower doses, or no, medication. Although we can’t identify who will do better beforehand, this does totally change the risk-benefit discussion we have with our patients, especially the more compliant of those patients, and it completely disrupts the idea that prophylaxis for all patients with schizophrenia is the right and only thing to do.
Psychiatry seems to have its own leagues of critics. Certainly, assumptions are made in all areas of medicine, but there isn’t an outspoken group of antioncology patients who take to the streets with signs and megaphones. And being a cancer survivor is a good thing, while being a "psychiatry survivor" is not.
But psychiatry is not alone in being faced with challenges to assumptions we’ve taken as gospel. The food pyramid is one example of a frequently changing ideal about what we should be consuming. Is coronary artery stenting good, bad, or just oversold? The Institute of Medicine released a 169-page report this year discussing how the evidence that a sodium-restricted diet, which does lower blood pressure, is short on proof that it also lowers the risk of stroke and cardiac events. Knee jerk hormone replacement therapy for postmenopausal women proved to be a big mistake. But we have been prescribing long-term antipsychotics without question for more than 50 years, and I applaud Dr. Insel for asking us to at least reconsider the status quo, whether it’s how we establish our diagnostic criteria or the assumptions we make about what treatments best help all patients.
Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).