Some New Developments in Treatments
Third Generation Antipsychotics
The development of the new antipsychotics has proceeded apace in recent years (for the history of the first and second generation antipsychotic medicines see our information sheet on Treatments) and the new drugs are already being called by some: “third generation” antipsychotics although this term is not officially recognised.
Since their discovery in the 1950s the antipsychotic medications have gone through three distinct phases. First there were the first-generation (also known as typical antipsychotics) such as chlorpromazine (Thorazine or Largactil) developed between 1950 and 1990 which were very effective but suffered from some very unpleasant side effects. Then in the 1990s the second-generation antipsychotics (atypicals) such as risperidone (Risperdal) and clozapine came along. These were just as effective at treating the positive symptoms such as hallucinations and delusions but had less severe side effects. In 2002 the first of the third-generation antipsychotics aripiprazole (Abilify) was licensed for the treatment of schizophrenia in the US.
Competing claims have been made for aripiprazole. Some studies have found it to be more effective in treating hallucinations and delusions while others have found it be equally effective1. In truth the research evidence is still evolving and it will be some years before we know for certain whether the third-generation drugs are any better than the second or first. Furthermore we know from our experience of the previous antipsychotics that effectiveness is very specific to the sufferer: the medication that works well for one person may be not as effective in another. Aripiprazole may well follow that model as well. Nonetheless the advent of the new drugs is to welcomed. They give the doctors another tool in their toolbox and provide new hope to people who have not done well on antipsychotics before.
Omega 3 Supplements
Although some very promising early work indicated that supplements containing EPA (Eicosapentaenoic acid) an omega-3 fatty acid could be an effective addition to the antipsychotic medications in cases of hearing voices the later work has thrown some doubt on this and consequently the guidance from the National Institute of Health and Care Excellence (NICE) which previously recommended the use of Omacor in schizophrenia have now been changed. It is no longer believed that omega-3 supplements have the clear-cut benefits that was once thought2. With the change in NICE guidance to doctors Omega-3 supplements such as Omacor are no longer freely available on prescription in the UK: a private prescription would be needed if you wanted to continue with this supplement. In addition further evidence has emerged concerning the additional risk of cancer that this supplement poses. A study carried out by the Cancer Research Center at Ohio State University and reported on the NHS Choices website in 2013 found that men taking an omega-3 supplement had a higher risk of contracting prostate cancer3.
Repetitive Transcranial Magnetic Stimulation (RTMS)
In this method of treatment which was developed in the 1990s electromagnets are attached to the outside of the patient’s skull and thus a weak magnetic field is induced in the brain. It is painless and non-invasive and does not require sedation nor does it appear to have any significant side effects. This treatment should not be confused with electro convulsive therapy. Research work into the efficacy of this therapy for auditory hallucinations continues with some but not all studies indicating that it may be useful in reducing both the intensity and the frequency of voices. A recent study at the University of Caen in France and reported in the Daily Telegraph newspaper in the UK in 20174 indicated very favourable results in reducing voices albeit in a fairly small number of participants.
The American psychiatrist Edwin Fuller Torrey estimates that one RTMS treatment may be effective in reducing voices for up to three months following treatment5 however other studies have found that the effect may be much shorter-lived. This is another treatment that is currently showing some promise but requires much more extensive research before we can be sure about it.
Cognitive Behavioural Therapy (CBT)
This type of therapy has continued to gain in popularity in the UK in recent years when used in conjunction with antipsychotic medicines. Cognitive behavioural therapy is a type of psychotherapy which some people call a talking treatment. It was originally developed in the US to treat depression but in the UK has found popularity in the mental health field for the treatment of the positive symptoms (hallucinations and delusions) of schizophrenia. Interestingly it is not much used for this purpose today in America. It should be stressed that talking therapies alone cannot treat the positive symptoms of schizophrenia.
Although very popular at the moment it would be quite wrong to see CBT as a cure-all for voices. It works better for some people than for others and is not without its critics. Nonetheless there are many sufferers who would testify to its benefits.
There is some evidence that CBT can help people who suffer from hearing voices, for instance a large review of previous studies was carried out at the University of Amsterdam in 20136. A further review of previous studies was published in the Clinical Psychology Review in 20167 which also found benefits of CBT but this time the study looked at psychotic symptoms in general rather than voices in particular. According to Torrey in the US8 CBT is only effective if the sufferer has insight into their condition and has its best effect with those who have had only limited benefits from medication over a long period and who are distressed by their voices.
CBT is carried out in an individual setting involving a single therapist and the patient rather than in groups. Consultations, are of course, confidential and their content will not be shared with relatives or carers. CBT is unlike psychoanalysis as it is not preoccupied with past life events but instead tries to help the sufferer develop skills for coping with their daily symptoms now. Nor does CBT seek to challenge the patient but instead tries to help the patient to understand their symptoms better by collecting and analysing evidence and to give back some degree of control over the symptoms..
Within the National Health Service access to CBT is via the psychiatrist and will only be made available following an additional assessment by a clinical psychologist. Like treatment with medicines the effectiveness of CBT depends greatly on the cooperation of the sufferer in the treatment. Active participation in the therapy sessions along with the homework in between sessions is necessary and in the end its success depends greatly on the patient’s motivation in applying the lessons learnt to their daily life.
Some recent work has been carried out into the possibility of delivering CBT on-line which would clearly have great benefits to people living in remote rural areas where access to face-to-face CBT may be difficult. The early work on this, such as the study carried out by Freeman at Oxford University9, shows some promise but it is very early days and clearly more research is necessary on this subject .
In the UK standards of treatment and care for people with schizophrenia who are being cared for within the National Health Service are laid down by the National Institute for Health and Care Excellence commonly known as NICE. NICE guidelines still recommend treating schizophrenia with antipsychotic medication as a first resort although in recent years the guidance has been widened to additionally include the provision of individual cognitive behavioural therapy over at least 16 sessions. Although this is the prescribed standard the availability of this therapy in practice depends on local resources and provision across the country whilst markedly better than a decade ago is still patchy in some areas.
One new development in the field of treating voices was made in the UK in 2017 by a team of researchers from Kings College and University College in London10 and involved the use of Avatar therapy for people who still hear voices despite their medication. In this method computer technology was used to enable the study participants to create a visual representation of the entity represented by their voices. This entity could be human or non-human. Using feedback from the patient the technology is able to mimic fairly closely the gender, tone and accent of the person’s voices. The participant can then use this image on the screen to practice interacting with the voice and with the aid of a therapist develop ways of resisting them; ultimately if possible gaining the upper hand.
A number of the patients in this study found that after this therapy their voices became less frequent and they experienced less distress caused by their voices. This was a fairly small study of only 142 participants but the research team included eminent scientists in this field and it did indicate that further work to explore this method would be justified.
1. Keltner N, Johnson V, Aripiprazole: A Third Generation of Antipsychotics Begins? Published in Perspectives in Psychiatric Care, 2002.
2. Schizophrenia: When Clozapine Fails, 2015, Miyamoto S, Jarskog L, Fleischhacker W. published in Current Opinions in Psychiatry 2015.
3. Brasky TM, Darke AK, Song X, et al. Plasma Phospholipid Fatty Acids and Prostate Cancer Risk in the SELECT Trial. Journal of the National Cancer Institute. Published online July 10 2013
4. Scientists identify part of the brain that makes schizophrenia sufferers hear ‘voices’, Daily Telegraph 5th September 2017, viewed on line 3rd August 2018 at https://www.telegraph.co.uk/news/2017/09/05/scientists-identify-part-brain-makes-schizophrenia-sufferers/.
5. 2013, Edwin Fuller Torrey, Surviving Schizophrenia, p204
6. Van der Gaag M, Valmaggia L, Smit F, The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: A meta-analysis, published in Schizophrenia Research June 2014.
7. Hazell C, Hayward M, Cavanagh K,Strauss C, A systematic review and meta-analysis of low intensity CBT for psychosis, published in Clinical Psychology Review 2016.
8. 2013, Edwin Fuller Torrey, Surviving Schizophrenia, p207.
9. Sleep therapy eases depression and paranoia, New Scientist, 16 Sept 2017
10. Craig T, Rus-Calafel M, Ward T, Leff J, Howarth E, Emsley H, Garety P. AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial, published in Lancet Psychiatry January 2018.