The 2010 publication of Robert Whitaker’s controversial book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness (a recent interview with Whitaker can be found here) caused some mental health professionals to second-guess what has for many become conventional wisdom: that effective treatment of mental health disorders is often based on early introduction and long-term use of psychiatric medications.
Among the professionals who paused to consider the “what ifs” raised by the book, there was a smaller group that began “discussing the research questions that needed to be explored in order to find the truth, one way or another,” said Gina Nikkel, PhD, the director of the Oregon Association of Community Mental Health Programs. She was among them.
After reading the book following its publication in the spring of 2010, one fact seemed clear to Nikkel and other like-minded professionals: “There was a whole lot of research needed to explore the meaning and the validity of the issues raised in the book, but it wasn’t research of the type that was going to be paid for by pharmaceutical companies.”
The reason, she explained, was that much of research would center on “medication optimization” strategies, which in general, emphasize the use of tools and therapies other than medications. Typically, these strategies aim at delaying first use, avoiding long-term use, and tapering or eliminating the use of medications.
Within a matter of months, Nikkel says that the and interest had grown to a point where “we thought it was important to engage private philanthropy as a means of engaging research, education, and others to ask, ‘what does this book really mean?’” In November 2010, she says that “a significant donor put up money,” spurring the group to create the Foundation for Excellence in Mental Health Care (FEMHC).
In February 2011, members of the newly-minted group met in Portland, Oregon, where they set an ambitious, two-year fundraising goal: $250 million. It is an ambition built on optimism: Nikkel maintained that the foundation’s goal—funding a broader range of mental health care research—appears to “match well with the goals of potential funders.” Further, she added, funders have been reassured by her “public sector credentials” as a professor, researcher and a former elected public official, since some of them lacked experience in that arena. These, she maintained, led to her selection as FEMHC’s first executive director.
Meeting participants also focused on developing four draft “position tracks”:
The first, policy-focused track, imagines “a future in which psychiatric medications are best utilized in the context of recovery supports,” guided by policies that “will progressively encourage and facilitate optimized use or non-use of medications combined with other clinical and social services and community supports with the primary goal of promoting recovery.”
The paper envisions a wide ranging, long-term collaboration that would unite physicians, consumers, government, and other stakeholders around consumer-focused recovery and wellness approaches and calls for a series of specific policy changes including protocol development, quality measurements, education and workforce changes.
The second track outlines guidelines and a preliminary process for individualized “medication optimization.” This process would, ideally, result in determining an individual’s minimum required medication dosage and guide the process for identifying and weaning appropriate individuals from medication altogether.
The third track considers guidelines for the treatment of schizophrenia. This track’s work highlights:
- concerns about the potential toxicity of neuroleptic medications
- the importance of risk-benefit analysis in their use
- manifestations of the disease that do, or do not, generally require the use of neuroleptic medications
- guidelines for engaging and supporting individuals in crisis, particularly those in initial or early psychotic episodes
- ongoing informed consent for the individual regarding treatment alternatives
- continuous engagement and support for families to assist them in understanding the symptoms and supporting the recovery process.
The group’s fourth “track” considers strategies for achieving positive long-term outcomes in depression treatment and the body of available evidence. This track’s effort considers protocols for appropriate antidepressant use and questions the recommended use of antidepressants as the initial treatment choice in all stages of the disorder.