Controversies in Psychiatry: Coercive measures and medication

The field of psychiatry is in crisis. Developments in pharmacology and psychotherapy, reforms in services, increased spending and reduced treatment-gap have not substantially improved prognosis for patients in psychiatry. Mental disorder remains lethal short-term and disabling long term. In comparison, prognosis has improved dramatically in oncology and cardiology. Controversies in psychiatry are causing variation in clinical practice between hospitals, even within single-provider health systems. There is, for example, great variation in rates of coercive measures including involuntary admission and involuntary outpatient pharmacotherapy. There is also great variation in medication in severe mental disorder, both in preferred drugs, dose, duration of medication, and treatment alternatives beyond pharmacotherapy. Current empirical methods are incapable of solving the major controversies in psychiatry. Ethics committees will be reluctant to approve randomization in trials addressing the controversies. If approved, studies would require statistical power beyond what can be realistically funded. Follow-ups in RCTs in psychiatry are usually some few weeks, whereas the controversial questions regard prognosis over years. Epidemiology struggles with residual confounding, bias and reverse causality. However, the variability in these controversies causes a lottery-like situation for the individual patient, who is generally unaware of the crisis and blinded to the local practice. We will use this natural randomization in a cohort of all Norwegian patients in 2010-11 with a 12-year follow-up in registries of mortality, accidents, crime, employment and welfare, and health service use. Update December 12, 2023: The project is much delayed due to delayed data delivery. We have no empirical findings to report yet. Data is expected to arrive shortly.

The field of psychiatry is in crisis. Developments in pharmacology and psychotherapy, reforms in services, increased spending and reduced treatment-gap has not substantially improved prognosis for patients in psychiatry. Mental disorder remains lethal short-term and disabling long term. In comparison, prognosis has improved dramatically in oncology and cardiology. Controversies in psychiatry are causing variation in clinical practice between hospitals, even within single-provider health systems. There is, for example, great variation in rates of coercive measures including involuntary admission and involuntary outpatient pharmacotherapy. There is also great variation in medication in severe mental disorder, both in preferred drugs, dose, duration of medication, and treatment alternatives beyond pharmacotherapy. Current empirical methods are incapable of solving the major controversies in psychiatry. Ethics committees will be reluctant to approve randomization in trials addressing the controversies. If approved, studies would require statistical power beyond what can be realistically funded. Follow-ups in RCTs in psychiatry are usually some few weeks, whereas the controversial questions regard prognosis over years. Epidemiology struggles with residual confounding, bias and reverse causality. However, the variability in these controversies causes a lottery-like situation for the individual patient, who is generally unaware of the crisis and blinded to the local practice. We will use this natural randomization in a cohort of all Norwegian patients in 2010-11 with a 12-year follow-up in registries of mortality, accidents, crime, employment and welfare, and health service use. Statistical methods for causal modelling in observational data established in economics will be applied. This innovation in research design has merit to change how we investigate effects of treatments in psychiatry, and eventually improve the prognosis for patients and society.