The August issue of the British Journal of Psychiatry offers an editorial stating that, as “mental health services appear to have overestimated the strength of the evidence base for antipsychotic medication, while underestimating the seriousness of the adverse effects, it seems sensible to re-evaluate the risk–benefit ratio of such drugs.” The authors cite Martin Harrow’s 20-year study of schizophrenia outcomes (among other research) in concluding that “It may be time to reappraise the assumption that anti-psychotics must always be the first line of treatment for people with psychosis; rather, this should be a collaborative decision that is balanced with provision of informed choices and the offer of evidence-based alternatives.”
Morrison, A., Hutton, P., Shiers, D., Turkington, D; “Antipsychotics: is it time to introduce patient choice?” British Journal of Psychiatry. 2012 (201) 83-84
From the conclusion:
“Given that mental health services appear to have overestimated the strength of the evidence base for antipsychotic medication, while underestimating the seriousness of the adverse effects, it seems sensible to re-evaluate the risk–benefit ratio of such drugs. This risk–benefit profile may be a factor in the high rates of non-adherence and discontinuation of medication found in patients with psychosis; thus, some decisions to refuse or discontinue antipsychotic medication may represent a rational informed choice rather than an irrational decision due to lack of insight or symptoms such as suspiciousness. Given accurate and honest assessments of both risks and benefits, it should be possible to prescribe antipsychotics in a more thoughtful and collaborative way, and these considerations should involve explicit discussion of the possibility of not prescribing at all. Provision of such choices may help to engage people who might otherwise reject services; for example, patients with low levels of insight and/ or high levels of internalised stigma might resist medication but consider that talking to someone is acceptable.
“To facilitate informed choice and decision-making, we require a much better evidence base to help address questions such as how and when medication might be required, who is most likely to respond and what alternatives exist. There is some evidence for different trajectories of response, with a small proportion of patients demonstrating a rapid and dramatic favourable response to certain antipsychotics,11 but more research is clearly required to inform our ability to predict those most (and least) likely to respond to antipsychotics. Shorter duration of untreated psychosis has been shown to be a predictor of response to antipsychotics,12 which could be employed as an argument against offering no medication as a choice. However, any additional benefits of early treatment would still need to be evaluated against the long-term risks, and the traditional assumption that ‘untreated psychosis’ can only be treated by prescribing antipsychotics (and therefore not by psychosocial therapies) has yet to be comprehensively tested. It is relevant to this assumption that 20-year outcome data from the Chicago Follow-Up Study suggest that service users who decide not to take antipsychotics (often against medical advice) do relatively well, if not better, in comparison with service users who take such medication continuously.13
“In addition to research regarding predictors of response to antipsychotics, research is also required to inform evidence-based alternatives to antipsychotic medication, since the most likely candidates (such as psychosocial treatments including cognitive therapy and family interventions) have almost exclusively been evaluated as an adjunct to medication. There are a few exceptions, such as a recent trial of cognitive therapy for people who chose not to take antipsychotics;14 however, more clinical trials with greater methodological rigour are clearly needed.
“It may be time to reappraise the assumption that anti- psychotics must always be the first line of treatment for people with psychosis; rather, this should be a collaborative decision that is balanced with provision of informed choices and the offer of evidence-based alternatives. These decisions should be negotiated with service users on the basis of the likely positive and negative consequences and the prioritisation of their goals and values; such a collaborative approach might also result in better response for those who choose to take antipsychotics, since the quality of relationship with the prescribing clinician is associated with attitudes and adherence to medication.”
Note from Kermit Cole, “In the News” editor:
The authors of this editorial are encouraging readers to reply to it, saying “We (Tony Morrison, myself, David Shiers, Doug Turkington) are trying to start a debate around antipsychotic treatment and choice, drawing attention to what we perceive as a changing cost-benefit ratio … Whether you agree with our arguments or not, please do consider contributing to the debate: http://bjp.rcpsych.org/letters/submit/bjprcpsych;201/2/83.”
They add: “Service-user opinions will be particularly important here.”