Medication-Free Treatment: An Alternative in Psychiatry?
Updated: Sep 17
It's been over two years since the world witnessed the inauguration of its first modern non-pharmacological treatment clinic in Tromsø, Norway. Since then, the debate has been fervent regarding the legitimacy of this initiative by the Ministry of Health.
The roots of this movement trace back to 2010. A coalition of Norwegian civic groups, some of which held anti-psychiatric views, demanded the adoption of non-pharmacological treatments in psychiatry. They saw it as a viable alternative to drug-based methods within the state's mental health services. According to their demands, daily drug-free treatment should be available for psychiatric patients, including those suffering from severe psychotic disorders. As part of the state program's implementation, the proposal was to establish non-pharmacological therapy wards over several years. The initial requirements for these wards were minimal: safety, a bed to sleep in, regular meals, and staff to converse with.
It's crucial to highlight that this decision was made despite existing recommendations for treating psychiatric patients at the time. This divergence ignited a significant conflict between health authorities, the psychopharmaceutical industry, trade unions, and civic groups.
Nevertheless, the initiative eventually swayed policymakers. In November 2015, Norway's Ministry of Health mandated four regional health bodies to establish non-pharmacological therapy departments for patients with severe mental disorders, including those within the psychotic spectrum.
This shift in healthcare policy has profound implications for the structure of psychiatric care in Norway. Notably, it essentially revokes the mandate to prescribe antipsychotic drugs to patients in psychotic states.
On February 8, 2017, the first public debate on this topic took place, featuring active participation from researchers, clinicians, representatives of civic groups, and politicians:
Public Debate: "Evidence Base for the Efficacy of Therapy in Psychiatry" Litteraturhuset, Oslo, Norway, 2017-02-08.
Has Society Reached a Consensus on the Implemented Reform?
As of now, the answer leans more towards "no" than "yes". Civic groups continue to emphasize the importance of offering a choice in treatment methods. They reference the lack of clear data regarding the long-term efficacy of antipsychotic pharmacotherapy. On the other hand, clinicians highlight the potential dangers of allowing non-pharmacological options for patients in psychotic states. They remind us that a psychotic state inherently involves a fundamental distortion of reality perception, where an individual may not be capable of making rational decisions, including about optimal therapeutic methods.
Regardless of which side of the debate one leans towards, it's worth noting that the mere existence of this discussion is a positive indicator for our specialty, which is undoubtedly undergoing a crisis. The raised issues touch upon some of the most complex and sensitive topics in theoretical and clinical psychiatry: the lack of objective criteria in diagnosing psychoses (and the general absence of biomarkers for mental disorders), the freedom of choice versus the right to mandate treatment methods, and the efficacy of treatments which is increasingly being questioned in large-scale studies. Open debates and dialogue are always preferable to blindly following dogmas. However, maintaining a neutral tone in discussions can be challenging, especially given that psychiatric debates remain among the most polarizing in medicine. Engaging in these discussions, we should frequently remind ourselves of our primary objectives: alleviating the suffering of patients and their families, whose opinions should undoubtedly be prioritized. Norway's experience has showcased the potential for productive dialogue in this direction, allowing each side to listen and clarify each other's arguments, gradually finding common ground. Critics of the reform note that attempts to minimize pharmacological therapy have long been actively pursued by researchers, yielding intriguing, albeit preliminary, results. Many experts have long pointed out the real issue of over-reliance on psychopharmacotherapy. In defense of the government's decisions, it's worth noting the relatively small scale of the changes in clinical practice. Currently, several programs have been implemented: in Northern Norway, a project to reduce psychopharmacological load for various patients; in the central region, non-pharmacological alternatives for patients with depressive states are offered; in the southwest, attempts to minimize pharmacotherapy for psychotic spectrum patients are underway.
In any case, the critics' argument about the lack of systematic data on the safety of non-pharmacological management of psychiatric patients will soon be tested experimentally. In the meantime... What do you think?
Update from 2019-07-12:
In July, I had the opportunity to chat with Dr. Magnus Hald. The live stream of the interview (in English) is available on the Youtube channel #HouseOfOuroboros.
© Alexander Lebedev
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