Treating Psychosis — A Lost Cause?
So is the treatment of psychosis and schizophrenia a lost cause? Can we not offer any hope to people suffering from these illnesses or their families of living a normal life? Not at all. While recovery from the most severe forms of psychosis such as schizophrenia is unusual, it does happen but the stars have to align just right.
If we can catch the illness at an early stage before it becomes chronic (and the brain begins to decay), if the medicine we use effectively treats the symptoms, if the person afflicted stays compliant with treatment and follow up (the hardest part in many cases-generally, once the acute symptoms subside, both patients and families become lackadaisical about treatment leading to relapse), then in many cases we can expect a good outcome.
An interesting aspect of my work though is that as a person’s condition improves, both their own and their family’s expectations about what they can accomplish rise proportionately. When a young person develops psychosis and is first brought to see me, all the family wants is for them to calm down, not be aggressive and start sleeping properly. Once that is accomplished, they want the person to then resume normal daily activities, then to resume education or job duties etc.
In the best case scenario, this then progresses to the family’s (and the patient’s) expectation that they can study, work, get married and do all of those things that ‘normal’ people do. As mental health professionals, we support these expectation while trying to temper hopes about the future since, unlike the family, we know how fragile the recovery is, especially in the early stages and how quickly it can be derailed.
This does not even take into account the pressures of our particular culture which leads families to make decisions like try to marry off an acutely ill person because ‘shaadi k baad sab theek ho jaye ga’. I cannot even begin to describe the disastrous outcomes I have seen in my practice to families marrying off acutely ill patients in the hope that things will resolve automatically after marriage and/or kids.
Thankfully, some families do ask my opinion about this before they proceed which allows us to make an informed decision.
Luckily, we do have some effective medicines now which, combined with educated, compliant patients and families can give us some happy endings and we can end this series on psychosis with a few such stories.
Some Happy Endings
A physician friend in the USA called me about his sister in law who had spent several years studying in the US but had to return to Pakistan because of visa issues. She had not adjusted well to being back in Pakistan and gradually got depressed and then psychotic.
Local hospitals in her city had tried her on several medicines, to no avail. Her family was frantic and took her to well-known hospital in Karachi where I had some friends in the Psychiatry department. I called them and recommended one particular medicine that is reserved for the most severe cases of psychosis and after some persuasion they started her on that medicine. Fast forward three years to last summer and while visiting the USA, my friend told me that his sister in law has recovered nicely, is working full time and apparently symptom free. She is still taking the medicine without any apparent problems.
A young doctor in Lahore calls me about his younger brother, a senior medical student who has been psychotic and aggressive off and on for at least a year. I meet the brother in my hospital and he breaks down crying while describing his younger brother who had been a brilliant student but suffered a psychotic break in senior year of medical college. He shows me a video of the patient in which he is rambling loudly about conspiracies, secret agencies and the like. We admit the patient to our hospital and after trying a couple of medicines which seem to have no effect, we start him on the same ‘last resort’ anti-psychotic medicine to which he has an immediate good response.
We also discover during the course of his hospitalization that the patient had been using marijuana (‘charas’) heavily in the months preceding his illness and had continued using until he was admitted to the hospital. In some cases, his doctor brother had been supplying him with charas to try and calm him down. We have a meeting with his brother where we review the patient’s progress and my hope that he will be able to resume his medical studies. I also tell the brother in no uncertain terms that the patient can never ever use ‘charas’ or any illicit drug again unless he wants to remain psychotic for the rest of his life and have no meaningful chance of recovery. If the patient and his family will comply with our instructions, I remain hopeful that he can have a meaningful recovery.
And a post-script to the patient ‘Farhat’ (not her real name) that we met in the last article. She showed up in my clinic with her husband a few days ago after more than a year. She has continued to be symptom free from her psychosis and, pleasantly enough, her husband says even her apathy and unmotivated state has improved very slightly to where she is now beginning to take an interest in her home and her children. This demonstrates the inherent resilience of the brain (and the body).
If we can prevent repeated attacks of the illness, even in the most chronic cases, the brain can, in limited ways heal itself and recover some of its lost functions. The person may never recover to the state prior to the illness but they can certainly hope for more than they could when the illness struck. In certain selected cases then, when everything aligns just right, happy endings do happen and, in those cases, instead of mourning the illness, I, and the people I am fortunate enough to work with, can give thanks for what we still have.
The writer is a psychiatrist practicing in Lahore. He taught and practiced Psychiatry in the United States for 16 years. He tweets @Ali_Madeeh