Anatomy of an Epidemic (51 page)

No mention is made of antipsychotics in the first few meetings. If the patient begins sleeping better and bathing regularly, and in other ways begins to reestablish societal connections, the therapists know that the patient’s “grip on life” is strengthening, and that medication will not be needed. Now and then, Alakare may prescribe a benzodiazepine to help a person sleep or to dampen the patient’s anxiety, and eventually she may prescribe a neuroleptic at a low dose. “Usually I suggest that the patient use it for some months,” Alakare said. “But when the problems go away, after six months or a year, or maybe even after three years, we try to stop the medication.”

From the outset, the therapists strive to give both the patient and family a sense of hope. “The message that we give is that we can manage this crisis. We have experience that people can get better, and we have trust in this kind of possibility,” Alakare said. They have found that it can take a long time—two, three, or even five years—for a patient to recover. Although a patient’s psychotic
symptoms may abate fairly quickly, they are focused on the patient’s “grip on life” and repairing his or her relationship to society, and that is a much bigger task. The team continues to meet with the patient and family, and as this process unfolds, teachers and prospective employers are asked to attend too. “It’s about restoring social connections,” Salo said. “The ‘in-between’ starts working again, with family and with friends.”

Over the past seventeen years, open-dialogue therapy has transformed “the picture of the psychotic population” in western Lapland. Since the 1992–93 study, not a single first-episode psychotic patient has ended up chronically hospitalized. Spending on psychiatric services in the region dropped 33 percent from the 1980s to the 1990s, and today the district’s per-capita spending on mental-health services is the lowest among all health districts in Finland. Recovery rates have stayed high: From 2002 to 2006, Tornio participated in a multinational study by Nordic countries of first-episode psychosis, and at the end of two years, 84 percent of the patients had returned to work or school, and only 20 percent were taking antipsychotics. Most remarkable of all, schizophrenia is now disappearing from the region. Families in western Lapland have become so comfortable with this gentle form of care that they call the hospital (or one of the outpatient clinics) at the first sign of psychosis in a loved one, with the result being that today first-episode patients typically have had psychotic symptoms for less than a month and, with treatment initiated at this early stage, very few go on to develop schizophrenia (the diagnosis is made after a patient has been psychotic for longer than six months). Only two or three new cases of schizophrenia appear each year in western Lapland, a 90 percent drop since the early 1980s.
¹⁵

Tornio’s success has drawn the attention of mental-health-care providers in other European countries, and during the past twenty years, two or three other groups in Europe have reported that the combination of psychosocial care and limited use of neuroleptics has produced good outcomes.
¹⁶
“This really happened,” Seikkula said. “It’s not just a theory.”

• • •

On my way back to Helsinki, I kept puzzling over this one thought: Why are the group meetings in Tornio so therapeutic? Given the outcomes literature for neuroleptics, I could understand why selective use of the drugs had proven to be so helpful. But why did open-dialogue therapy help psychotic patients heal?

During my two days in Tornio, I sat in on three group sessions, and although I don’t speak Finnish, it was nevertheless possible to gain a sense of the meetings’ emotional tenor and to observe how the conversation flowed. Everyone sat in a circle, in a very relaxed and calm manner, and before anyone spoke, there often was a split-second moment of silence, as if whoever was going to speak next was gathering his or her thoughts. Now and then someone laughed, and I couldn’t identify a time when anyone was interrupted, and yet no individual seemed to go on speaking too long, either. The conversation seemed graced by gentility and humility, and both family members and patients listened with rapt attention whenever the therapists turned and spoke to each other. “We like to know what they really think, rather than just have them give us advice,” said the parents in one of the meetings.

But that was the sum of it. It was all a bit mystifying, and even the staff at Keropudas Hospital hadn’t really been able to explain why these conversations were so therapeutic. “The severe symptoms begin to pass,” Salo said with a shrug. “We don’t know how it happens, but [open-dialogue therapy] must be doing something, because it works.”

In the early 1800s, Americans regularly turned to a book written by Scottish physician William Buchan for medical advice. In
Domestic Medicine
, Buchan prescribed this pithy remedy for melancholy:

Two centuries later, British medical authorities rediscovered the wisdom of Buchan’s advice. In 2004, the National Institute for Health and Clinical Excellence, which acts as an advisory panel to the country’s National Health Service, decided that “antidepressants are not recommended for the initial treament of mild depression, because the risk-benefit ratio is poor.” Instead, physicians should try non-drug alternatives and advise “patients of all ages with mild depression of the benefits of following a structured and supervised exercise programme.”
¹⁸

Today, general practitioners in the UK may write a
prescription
for exercise. “The evidence base for exercise as a treatment for depression is quite good,” said Andrew McCulloch, executive director of the Mental Health Foundation, a London-based charity that has been promoting this alternative. “It also reduces anxiety. It’s good for self-esteem, control of obesity, et cetera. It has a broad-spectrum effect.”
¹⁹

In terms of its short-term efficacy as an antidepressant, studies have shown that exercise produces a “substantial improvement” within six weeks, that its effect size is “large,” and that 70 percent of all depressed patients respond to an exercise program. “These success rates are quite remarkable,” German investigators wrote in 2008.
²⁰
In addition, over time, exercise produces a multitude of “side benefits.” It enhances cardiovascular function, increases muscle strength, lowers blood pressure, and improves cognitive function. People sleep better, they function better sexually, and they also tend to become more socially engaged.

A 2000 study by James Blumenthal at Duke University also revealed that it is unwise to combine exercise with drug therapy. He randomized 156 older depressed patients into three groups—exercise, Zoloft, and Zoloft plus exercise—and at the end of sixteen weeks, those treated with exercise alone were doing as well as those in the other two groups.
²¹
Blumenthal then tracked the patients for another six months, with the patients free to choose whatever treatment they wanted during this period, and at the end the patients treated initially with exercise alone were doing the best. Only 8 percent of those who had been well at the end of sixteen weeks had relapsed during the follow-up, and by the end of ten months 70 percent of the exercise-only group were asymptomatic. In the two Zoloft-exposed groups, more than 30 percent of the patients who had been well at the end of sixteen weeks relapsed, and fewer than 50 percent were asymptomatic by the study’s end. The “Zoloft plus exercise” group had fared no better than the “Zoloft alone” patients, which suggested that exposure to Zoloft
negated
the benefits of exercise. “This was an unexpected finding, because it was assumed that combining exercise with medication would have, if anything, an additive effect,” Blumenthal wrote.
²²

The Long-Term Benefit of Exercise for Depression

In this study by Duke researchers, older patients with depression were treated for 16 weeks in one of three ways, and then followed for another six months. Patients treated with exercise alone had the lowest rates of relapse during the following six months, and as a group, they were much less likely to be suffering from depressive symptoms at the end of ten months. Source: Babyak, M. “Exercise treatment for major depression.”
Psychosomatic Medicine
62 (2000): 633–38. 100–11.

In 2003, when Britain’s Mental Health Foundation launched its exercise-for-depression campaign, it took advantage of the fact that general practitioners in Britain were already “prescribing” exercise to patients with diabetes, hypertension, osteoporosis, and other physical conditions. The delivery of this medical care requires physicians to collaborate with local YMCAs, gyms, and recreational facilities, with these collaborations known as “exercise-referral schemes,” and thus the foundation simply needed to get the GPs to start prescribing exercise to their depressed patients too.
Today, more than 20 percent of the GPs in the UK prescribe exercise to depressed patients with some frequency, which is four times the percentage who did in 2004.

A “prescription” for exercise typically provides the patient with twenty-four weeks of treatment. An exercise professional assesses the patient’s fitness and develops an appropriate “activity plan,” with the patient then given discounted or free access to the collaborating YMCA or gym. Patients work out on exercise machines, swim, and take various exercise classes. In addition, many exercise-referral schemes provide access to “green gyms.” The outdoor programs may involve group walks, outdoor stretching classes, and volunteer environmental work (managing local woodlands, improving footpaths, creating community gardens, etc.). Throughout the six months of treatment, the exercise professional monitors the patient’s health and progress.

As might be expected, patients have found “exercise-on-prescription” treatment to be quite helpful. They told the Mental Health Foundation that exercise allowed them to “take control of their recovery” and to stop thinking of themselves as “victims” of a disease. Their confidence and self-esteem increased; they felt calmer and more energetic. Treatment was now focused on their “health,” rather than on their “illness.”

“The fathers of medicine wouldn’t be surprised about what we are doing,” McCulloch said. “They would say, ‘Hasn’t science gone any further? Diet and exercise? This is what is new?’ If they could travel in a time machine, they would think we were mad, because people have been saying these things for thousands of years.”

The children who end up living at Seneca Center in San Leandro, California, have come to the last stop for severely disturbed youth in the northern part of the state. The children, five to thirteen years old, have usually cycled through several foster homes and have had multiple hospitalizations, and their behavior has been so difficult
that there are no foster homes or hospitals left that want to see them again. In bureaucratic terms, they are “level-14” kids, which is the designation given to the most troubled kids in California, but since these children have flunked out of other level-14 facilities, they are better described as “level-14-plus-plus” youth. Counties pay Seneca Center $15,000 a month to shelter a child and, not surprisingly, when the children arrive at the center, most are on heavy-duty drug cocktails. “They are so drugged up that they are asleep most of the day,” said Kim Wayne, director of the residence program.
²³

And then their lives begin to change dramatically.

I visited one of Seneca Center’s two residences for younger children in the summer of 2009, and when I entered, here is what I saw: a young African American girl wearing headphones singing along to a Jordin Sparks song; a second slightly older African American girl sitting at the kitchen table, leafing through photos of their recent group trip to Disneyland; and two African American boys at the table goofing around with each other and racing to see who could drink a glass of water the fastest. A Caucasian girl sat on the couch, and the sixth resident of the house, I later learned, was off at a swimming lesson. Within a short while, the girl with the headphones was singing a cappella (and quite well), and the girl huddled over the photo album had started calling me Bob Marley, apparently because I knew who Jordin Sparks was. Now and then, one of the children erupted into laughter.

“The kids are so grateful to be off the drugs,” said therapist Kari Sundstrom. “Their personalities come back. They are people again.”

The two Seneca Center homes may be the last residential facilities in the United States where severely troubled children under county or state control are treated without psychiatric drugs. Indeed, in most child-psychiatry circles, this would be considered unethical. “I’ve been told, ‘If your child had a disease, would you deny your child medication that helped him get better?’” said Seneca Center founder and CEO Ken Berrick. And even within the agency, which has a staff of around seven hundred and provides a variety of services to two thousand troubled children and youth in northern California, the residence program is an anomaly.