Schizophrenia Research Forum - A Catalyst for Creative Thinking


Morrison AP, Hutton P, Shiers D, Turkington D. Antipsychotics: is it time to introduce patient choice? Br J Psychiatry. 2012 Aug ; 201():83-4. Pubmed Abstract

Comments on News and Primary Papers


Primary Papers: Antipsychotics: is it time to introduce patient choice?

Comment by:  Nev Jones
Submitted 1 October 2012
Posted 2 October 2012
  I recommend this paper

Morrison and colleagues’ commentary raises a number of points worthy of serious consideration. Essentially, the authors question the reflexive use of antipsychotics as the primary, and sometimes only, ongoing treatment for schizophrenia and psychosis, in light of recent research regarding efficacy, toxicity, and the availability of non-pharmacological alternatives.

If we were to take these issues seriously in the context of research, what might the logical next steps be? The disconnect between long-term outcome studies (e.g., Harding et al., 1987a; Harding et al., 1987b; Harrow et al., 2012), in which a substantial percentage of individuals in functional recovery or remission report no longer taking antipsychotics, and shorter-term efficacy studies (e.g., Emsley et al., 2012; Gaebel et al., 2011), suggesting a generalized global benefit to continuous pharmacotherapy, underscores the many important unanswered questions regarding antipsychotic use over the lifespan. What, for example, are the neural and behavioral mechanisms and correlates of periods of recovery and/or remission occurring in the absence of medication? Are there important differences between early-course (i.e., 0-4 years post-onset) and middle or later-course schizophrenia vis-à-vis medication efficacy, necessity, and risk/benefit tradeoffs? Aside from the relatively limited individual-level variables suggested by Harrow and colleagues, what biological, social, and structural factors predict "successful" medication discontinuation? What are the best "treatments" for individuals at any stage of illness who refuse antipsychotics (and how do they "work" in the absence of medications)?

Although the ethics of randomization to a longer-term medication discontinuation condition remain questionable, it seems unambiguous that researchers could be doing more to investigate "naturalistic" long-term trajectories of medication (dis)use and recovery, examine differences between subgroups (utilizing, e.g., latent class growth curve modeling), make better use of matched control designs, and actively recruit and include individuals who have discontinued antipsychotics and/or disengaged with the mainstream mental health system as research participants.

Such efforts would not only help elucidate issues of obvious importance to psychiatric researchers, but also demonstrate a sensitivity to issues that mental health activists and advocates have long emphasized.

References:

Emsley R, Oosthuizen PP, Koen L, Niehaus DJ, Martinez G. Symptom recurrence following intermittent treatment in first-episode schizophrenia successfully treated for 2 years: a 3-year open-label clinical study. Journal of Clinical Psychiatry. April 2012;73(4):e541-7. Abstract

Gaebel W, Riesbeck M, Moller H, et al. Relapse prevention in first-episode schizophrenia—Maintenance vs. intermittent drug treatment with prodrome-based early intervention: Results of a randomized controlled trial within the German research network on schizophrenia. Journal Of Clinical Psychiatry. February 2011;72(2):205-218. Abstract

Harding C, Brooks G, Ashikaga T, Strauss J. The Vermont longitudinal study of persons with severe mental illness: II. Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. The American Journal Of Psychiatry. June 1987a;144(6):727-735. Abstract

Harding C, Brooks G, Ashikaga T, Strauss J. The Vermont longitudinal study of persons with severe mental illness: I. Methodology, study sample, and overall status 32 years later. The American Journal Of Psychiatry. June 1987b;144(6):718-726. Abstract

Harrow M, Jobe TH, Faull RN. Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study. Psychological Medicine. February 2012;17:1-11. Abstract

View all comments by Nev Jones