In 2015, when the Norwegian Minister of Health ordered the country’s four regional health authorities to set aside beds for “medication-free treatment,” an initiative that user groups in Norway had lobbied for, many Norwegian psychiatrists spoke out in fierce opposition. They derided it as a “giant mistake,” which would lead to a lot of “very seriously ill people being deprived of the right to the best possible treatment.”
A recently published Norwegian study, which compared short-term outcomes for “medication-free treatment” (MFT) to “treatment as usual” (TAU), provides an evidence-based reason for the psychiatrists to drop their protests. There was little difference in short-term results between the two groups, and if anything, there was a hint that outcomes were slightly better for the MFT group, particularly for those diagnosed with psychotic or bipolar disorders. Patients in both groups “demonstrated substantial improvement” over the course of treatment.
“Our research contributes to the existing literature by providing further evidence that viable alternatives to TAU may exist, particularly regarding the role of medication in mental health care—a domain where evidence for the most severe disorders remains limited and contested,” the study authors wrote.
However, the term “medication-free treatment” is a misnomer, at least in terms of describing the care provided in such settings. As lead author Kari Standal and colleagues noted, the “medication-free” settings within Norwegian mental hospitals are designed “to enhance patient choice. These services place greater emphasis on psychosocial and psychotherapeutic interventions than traditional care. They aim to be free from coercion and pressure regarding medication, rather than totally absent of medication.”
The study was conducted in a university hospital in the greater Oslo area that serves a population of about 500,000, encompassing both urban and rural communities. The researchers compared outcomes for patients, who had a variety of psychiatric diagnoses, treated in a MFT setting or TAU setting at the hospital, without matching the patient groups in terms of age or history of medication use prior to admission.
They used the Outcomes Questionaire-45.2 (OQ) to assess outcomes. This 180-scale asks patients forty-five questions about how they are faring in three domains: symptom distress, interpersonal functioning, and satisfaction with social role. Each is scored on a scale of 0 to 4, with higher scores indicating greater severity of symptoms and social impairment.
The average age of the MFT patients was around 40 in the MFT group, and slightly older in the TAU group. Most were taking psychiatric drugs at baseline, with the MFT group having had a “much longer history of psychotropic use.” The baseline OQ scores for both groups were slightly less than 100, a number associated with moderately high to high levels of distress. The MFT program was expected to last 8 weeks, while TAU was expected to last 4 to 8 weeks.
The researchers had two data sets to analyze. One arose from a “research sample” that enrolled patients upon admission to the two different settings in the hospital, with 57 patients in the MFT cohort and 118 in the TAU group. The OQ scores for the MFT group dropped 14 points compared to a drop of 16.7 points in the TAU group, a small difference that was not seen by the researchers as “significant,” particularly given the small sample.
The second dataset was drawn from a registry of psychiatric patients who met eligibility requirements and had been treated at the hospital from 2017 to 2022. There were 140 in the MFT group and 238 in the TAU group, a sample size that was deemed adequately powered to assess effect sizes. The MFT OQ scores dropped 12.0 points compared to a drop of 6.7 points for the TAU group, a difference of 5.3 points that equated to an “effect size” difference of .30.
That is the same as the effect size for antidepressants that is found in placebo-controlled trials, which is regularly cited by psychiatrists as evidence of the efficacy of antidepressants. However, after assessing both data sets, the Norwegian researchers concluded “that any true difference in outcomes between MFT and TAU is likely negligible.”
There was one notable difference between the two groups at discharge related to usage of psychiatric drugs. The MFT participants “experienced a greater reduction in psychotropic medication dosages during treatment, and had lower doses of antidepressants and antipsychotics at discharge compared to TAU participants.” Even more to the point, at discharge the average daily antipsychotic dose for those in the MFT group with psychosis was less than one-third the dose for patients so diagnosed in the TAU group. Similarly, the average daily dose of mood stabilizers for those in the MFT group with a bipolar diagnosis was roughly half that of the bipolar patients in the TAU group.
The drug-use differential tells of how support for “cautious tapering” was a regular feature of the “medication-free” treatment. The researchers also reported they “found no evidence of significant withdrawal effects, as reductions in overall medication dosage were not associated with poorer outcomes.”
This study adds to the evidence base for providing drug-tapering support. In October, Dutch researchers reported that first-episode psychotic patients randomized to a drug-tapering protocol, compared to treatment as usual, had better long-term outcomes. This Norwegian study is complementary to that one, as it provides support for drug-tapering protocols in an older cohort of patients who have been using psychotropic medications for years. It showed that in an inpatient setting, “enhanced patient choice” could help them taper down to lower doses of their medications, and exit treatment seven weeks later in a better state, as measured by a patient questionnaire.
As Standal and colleagues noted, there is a need now to focus on the long-term outcomes with MFT care compared to TAU, a study that has yet to be done. They framed that question of assessing long-term outcomes in a novel way:
“In the Norwegian debate, it has been pointed out that learning to cope with feelings has important value for individuals and society. If one believes that feelings have a function and meaning, the way one deals with them has broader implications that merely alleviating symptoms . . . Feelings are linked to norms and morals; consequently, a liberal democratic society necessitates citizens with high affect consciousness. In our study, patients’ experiences with medication included emotional flattening, feeling ‘zombielike’ or ‘less human,’ feeling empty and tired, having suicidal thoughts, and misusing the medicine. One can imagine that these negative experiences have great costs for both individuals and society.”
That summary is a breath of fresh air in the psychiatric literature, as it tells of how drug-tapering for patients diagnosed with major psychiatric disorders can provide a benefit to society, which usually is primed to hear of how society benefits from forced treatment for people so diagnosed, as it (theoretically) helps protect public safety. Indeed, with that one paragraph, this Norwegian study sounded a call for Western psychiatry to rethink its assessments of the risks and benefits of antipsychotics and other psychiatric drugs, and not rely on symptom reduction for patients as the primary outcome measure.
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