In 2010, five users’ and interest organisations took the initiative for the ‘Joint Campaign for Drug-Free Treatment Programmes in the Mental Health Services’ (1), and in 2015 the Ministry of Health and Care Services instructed the regional health trusts to establish treatment programmes that were drug-free. The objections raised by the psychiatric profession have been vehement and polarised (2, 3).
At Jæren District Psychiatric Centre (Jæren DPS) we decided to identify the patients’ wishes for a drug-free treatment option and whether the groups of patients who wanted this option shared any special characteristics.
Material and method
Starting in November 2016, patients admitted to inpatient wards at Jæren DPS were consecutively recruited for the study. The recruitment continued until October 2017 when 100 patients had consented to participate. The inclusion criteria were a hospitalisation period of at least one week and that the patient was competent to provide informed consent. The consent encompassed participation in interviews and permission to retrieve information on diagnoses and use of medication from the patient records. These data were retrieved from the discharge record pertaining to the hospitalisation period in question and included the diagnosis upon discharge (ICD-10) (4) and all types of drugs used and their dosages at the time of discharge. Drugs prescribed for somatic diseases were also recorded to find out whether this patient group had a more accepting attitude to psychoactive drugs. The dosages of the drugs in question were recalculated into defined daily doses (DDD) (5).
The participants were interviewed according to a structured questionnaire with pre-defined response alternatives (appendix). In addition to the demographic information, the form encompassed questions about the duration of the mental disorder and the drug use period, diagnosis and perceived benefit of various elements of the treatment (individual and group counselling, activities, drugs etc.). The benefit was ranked into five categories ranging from 0 = ‘no benefit at all’ to 4 = ‘extremely high benefit’. Finally the questionnaire included a question on whether the patient would want a drug-free treatment programme if this were available (yes/no) and what alternatives the patient might consider.
None of the four interviewers were involved in the treatment of the patients. Two interviewers had user experience, with a background as teacher and nurse respectively. The two others were nurses employed in the training unit. All personally identifiable data were anonymised. The study was submitted to the Regional Committee for Medical and Health Research Ethics (REK Western Norway, reference no. 2016/1581) and approved by the Data Protection Officer at Jæren DPS.
The frequency and percentage calculations of data were made in Excel.
Results
Of 156 patients who were asked to participate, 56 (36 %) declined. Of those 100 who were included, 25 were interviewed by the two interviewers with user experience. In this group, seven (28 %) patients would want a drug-free option if available, versus 45 (60 %) of the remaining 75 patients, but the difference was not significant. Patient characteristics and perceived benefit of psychoactive drugs among the 100 included patients are shown in Table 1. Altogether 64 of the patients had a history of psychiatric illness with a duration of more than five years, and 41 patients had been using psychoactive drugs for more than five years. Thirteen of the patients had been sectioned under the provisions on coercive mental health care at the time of their interviews.
Table 1
Patient characteristics and perceived benefit of psychoactive drugs among 100 hospitalised patients at Jæren District Psychiatric Centre, included consecutively in the period November 2016–October 2017
|
Variable
|
n
|
|
Sex, women
|
57
|
|
Age, years
|
|
|
|
18–29
|
33
|
|
|
30–45
|
32
|
|
|
46–60
|
21
|
|
|
> 60
|
14
|
|
Main diagnosis, ICD-10
|
|
|
|
F3 Affective disorders
|
51
|
|
|
F2 Psychosis disorders
|
25
|
|
|
F4 Anxiety disorders
|
9
|
|
|
F6 Personality disorders
|
6
|
|
|
Other1
|
9
|
|
Psychoactive drugs upon discharge
|
90
|
|
Perceived benefits of psychoactive drugs
|
|
|
|
Good / very good / extremely good
|
63
|
|
|
Little
|
19
|
|
|
None
|
7
|
|
|
No response
|
112
|
Status for drug use
Ninety of the patients used drugs for mental disorders upon discharge, and the average number of drugs was 1.9 (range 1–5). Use of six different generic types of antipsychotics and ten different antidepressants was registered. Of the 100 patients, 67 used antipsychotic drugs, 41 used antidepressants and 30 used mood stabilisers. In seven patients, antipsychotics were administered as injections in depot form. The perceived benefits of psychoactive drugs are shown in Table 1.
A total of 42 patients also used drugs to treat somatic diseases. The most frequent types were medications for cardiovascular disease, diabetes, gastrointestinal disease, allergies, asthma and hypometabolism.
Desire for a drug-free treatment option
Altogether 52 of the 100 patients examined answered ‘yes’ to the question of whether they would want a drug-free treatment programme if this were available. A total of 45 patients gave a negative answer, while three patients had no opinion. The latter have been excluded in Table 2, which shows the proportion of affirmative answers in different patient groups.
Table 2
Number of patients who gave an affirmative answer to the question of whether they would want a drug-free treatment programme if this were available among 100 patients hospitalised at Jæren District Psychiatric Centre. Selected categories with the highest proportion of affirmative answers, ranked in descending order. Patients who had no opinion have been excluded from the dataset (n = 3).
|
Patient group
|
Affirmative answers, n (%)
|
|
Sectioned (n = 13)
|
10 (77)
|
|
No/little benefit from psychoactive drugs (n = 25)
|
17 (68)
|
|
No/little benefit from counselling1 (n = 26)
|
17 (65)
|
|
Men (n = 41)
|
25 (61)
|
|
Diagnosed with psychosis (F20) (n = 24)
|
13 (54)
|
|
Has used psychoactive drugs > 5 years (n = 41)
|
22 (54)
|
|
Age > 45 years (n = 35)
|
19 (54)
|
|
Age 18–45 years (n = 62)
|
33 (53)
|
|
Disease history > 5 years (n = 64)
|
34 (53)
|
|
Has used psychoactive drugs < 1 year (n = 19)
|
10 (53)
|
|
Good2 benefit from counselling1 (n = 68)
|
34 (50)
|
|
Uses somatic drugs on a regular basis (n = 41)
|
20 (49)
|
|
Women (n = 56)
|
27 (48)
|
|
Good2 benefit from psychoactive drugs (n = 58)
|
24 (41)
|
|
Disease history < 1 year (n = 15)
|
6 (41)
|
Discussion
The examined patient group was quite heavily burdened by mental disorders: more than one-half had a disease and treatment history of more than five years, and nine out of ten used more than one type of psychoactive drug. The discrepancy between the number of patients who used antipsychotic drugs (n = 67) and the number of patients diagnosed with psychosis (n = 25) is due to the fact that this group of drugs is also used for treatment of manic disorders and in smaller doses as a tranquilising medication, usually less than 0.5 defined daily doses. A total of 63 patients reported to have good, very good or extremely good benefit from psychoactive drugs. A total of 52 patients nevertheless wanted an option for drug-free treatment.
Among patients who were also taking medication for somatic disorders we expected to find a higher acceptance for the use of psychoactive drugs. This was not so, however. One-half (49 %) of this group would want an option for drug-free treatment.
The public debate on psychoactive drugs is not of recent date, but has become more vocal in recent years. Antipsychotic and antidepressant drugs in particular have received a negative focus. The criticism is associated with inadequate evidence of efficacy, long-term adverse effects (6) and that antipsychotics are claimed to sustain symptoms of psychosis (7).
Many patients are treated with psychoactive drugs for many years, often with multiple drugs and with uncertain effect (8). However, in light of clinical experience it is difficult to envisage treatment of serious psychoses and manic conditions entirely without the use of antipsychotic drugs; this view is supported by historical experience from the time prior to the introduction of antipsychotic drugs in the 1950s. In the prevailing guidelines for treatment of psychosis disorders, drugs still occupy a key position (9). The paradoxical clinical experience is that patients with conditions for which there is best evidence that drugs are effective – psychoses and manic conditions – tend to have the greatest reservations regarding the use of medication.
The relatively high number of patients who would want a drug-free option if it were available may be an expression of disappointment, since many of them continued to struggle with persistent symptoms or unpleasant adverse effects. It could also be an expression of a wish to avoid the daily reminder of the disorder that the drug intake may represent. An alternative interpretation is that many of the patients had an insufficient understanding of their own need for preventive treatment or treatment as such. On the other hand, we may wonder why far more patients would not want a drug-free option, since the health authorities have backed the establishment of such treatment programmes.
One strength of the study is that it is based on a patient sample that had personal experience of relatively severe mental disorders, where all commonly used psychoactive drugs were used in the treatment. Another advantage is that persons with user experience have participated in the project group, including the discussion and implementation of patient interviews.
The reason for using a hospitalisation period of at least one week as an inclusion criterion was that the study also identified the benefits to the patients of therapeutic interventions other than drugs. When compared to background variables from the 2016 national study of patient experiences in mental health care (10), our patient sample is reasonably representative of hospitalised Norwegian psychiatric patients in terms of sex, age, diagnoses and disease burden.
For the key question in this study, ‘would you want a drug-free treatment programme if this were available?’, only two response alternatives were given: yes or no. This may represent a methodological weakness, because the response alternatives fail to leave sufficient room for nuances and doubts. The patients were asked during hospitalisation, i.e. during an active stage of the disorder, where we may assume that the need for alleviation and drugs is at its highest. It is therefore possible that the proportion that would have favoured a drug-free option might have been larger during a less intense phase of the disorder.
The reasons for the patients’ views on the use of drugs have not been identified, and this ought to be followed up through a qualitative study.
