A common practice when antipsychotics are found to be ineffective for schizophrenia is to prescribe a second, additional psychoactive medication. Now, a new study suggests that this practice is not supported by the research.The study, published in the top-tier psychiatry journal JAMA Psychiatry, examined all the meta-analyses of this treatment approach to determine the evidence base for add-on medications in schizophrenia.
According to the researchers, “None of the 42 combinations of an antipsychotic drug treatment with a second psychotropic medication had consistent support for its recommendation.”
The researchers, led by Stefan Leucht from the Department of Psychiatry and Psychotherapy at Technische Universität München in Munich, also found that the original studies were very poorly designed and at high risk for bias. More specifically, “Meta-analyses of 21 interventions fully or partially recommended their use, with recommendations being positively correlated with the effect sizes of the pooled intervention. However, the effect sizes were inversely correlated with meta-analyzed study quality, reducing confidence in these recommendations.”
That is, 21 of the 42 potential combination treatments were recommended by previous authors.
These previous meta-analyses were more likely to recommend this strategy if they found a large effect size for the intervention. A large effect size implies that the treatment was substantively better than the control. However, the likelihood of finding a large effect size was related to the quality of the original studies. When the meta-analysis authors found a large effect size, the studies tended to be of poor quality and at high risk of bias. For well-designed studies, the meta-analysis authors tended to find minimal effect sizes.
To put it more plainly, according to the researchers, all of the recommendations for augmenting with a second medication were based on poor quality evidence from studies at high risk of bias. The researchers measured design/bias of studies using the AMSTAR-Plus Content measure. This scores studies on a scale of 1-8, with 1 being poorly designed and 8 indicating well-designed studies. Studies are scored on a number of areas, including sample size, publication bias, and other sources of bias in trial design.
The studies included in the meta-analyses averaged a score of 2.8 out of 8. That indicates that they are very poorly designed, with high risk of bias. Only 1 out of the 37 possible augmentation strategies scored as high as 4.
The researchers also write that “There were 12 strategies that were at least partially recommended by authors of the meta-analyses despite their lack of significant differences between combination treatments and controls.” This means that 12 augmentation treatments were recommended despite the finding that they were no better than the first medication alone.
The researchers also reviewed other potential medication treatments when an initial antipsychotic does not have the desired effect, and concluded that “Dosage escalation is advised against in all treatment guidelines of national and international psychiatric societies given its limited evidence of success. Switching to another antipsychotic drug has not been supported by conclusive evidence, except for switching to clozapine.” They note that even switching to clozapine has been questioned in recent meta-analyses.
This research suggests that when initial antipsychotic treatment for schizophrenia is ineffective, additional pharmaceutical interventions are not supported by good evidence. Additionally, the evidence for the effectiveness of initial antipsychotic treatment has itself been questioned in the research literature. However, alternative approaches are being studied, including exercise, CBT, and trauma-focused therapy.
Correll, C. U., Rubio, J. M., Inczedy-Farkas, G., Birnbaum, M. L., Kane, J. M., & Leucht, S. (2017). Efficacy of 42 pharmacologic cotreatment strategies added to antipsychotic monotherapy in schizophrenia: Systematic overview and quality appraisal of the meta-analytic evidence. JAMA Psychiatry, 74(7). 675-684. doi:10.1001/jamapsychiatry.2017.0624 (Link)
If one hammer doesn’t work in treatment then let’s use a whole bunch of hammers! When all you have in your toolbox for treatment is hammers then everything looks like a nail. And when one hammer doesn’t work then obviously three or four hammers will do a better job!
That’s the psychiatrist’s theology, it’s insane. They do say insanity is doing the same thing over and over again and expecting a different result, after all.
Speaking of which, I’ll mention once again that combining the antipsychotics causes “psychosis,” via anticholinergic intoxication syndrome, so combining the antipsychotics is morally repugnant.
But absolutely, the psychiatrists do need to be taught this, “This research suggests that when initial antipsychotic treatment for schizophrenia [or “bipolar”] is ineffective, additional pharmaceutical interventions are not supported by good evidence. Additionally, the evidence for the effectiveness of initial antipsychotic treatment has itself been questioned in the research literature.” Because the psychiatrists who claim to “know everything about the meds” either know nothing about the drugs they prescribe, or they are satanic attempted murderers.
No doubt, we’ve got the inmates running the asylums.
Oh the poisoning works, it stops the patient/slabe from exhibiting any unwanted behaviour. The outside person such as the family is happy for the control. Who pays the psychiatrist? The schizophrenic is not paying the supposed doctor.
“People labelled by institutional psychiatrists as mentally ill are concurrently defined by the courts as less than human, in much the same way ‘Negroes’ in America were once defined as three-fifths persons. This is how Black people were, and people with mental illnesses are, deprived of liberty and justice by the state. Labelling of anyone as less than human is legal fiction, something false that is asserted as true, that the courts will not allow to be disproved. Just as defining Negroes as three-fifths persons served to maintain the institution of slavery, defining people as mentally ill serves to maintain the institution of psychiatry.
A person has a right to refuse treatment for cancer. A person does not have a right to refuse treatment for mental illness. If institutional psychiatrists are deprived of their power by the state to deprive mentally ill persons of their liberty, that is, if the state did not allow psychiatrists to enslave their patients in the name of liberating them, institutional psychiatry would go the way of slavery, as well it should.” wrote J. A. Schaler.
Absolutely, the psychiatrists turn peoples’ medical records into “fiction.” On my second to last appointment with my psychiatrist I confronted him with all his delusions written in his medical records. Some decent and disgusted nurses at my PCP’s office had handed over all my family’s medical records to me, just before forcing my PCP and her malpractice prone husband out of the practice, due to their complete and total lack of ethics.
I learned my psychiatrist believed one of the universities I graduated from is “fictional.” He believed the town I grew up in is “fictional,” despite it being all over the newspapers at the time since some famous people had just moved there. He had delusions my parents lived in state. He was a Holy Spirit blasphemer, despite claiming to be a member of an Abrahamic religion. He thought contractions in one’s private parts were “voices” in one’s head. He thought dreams were “psychosis.” I could go on and on about the “fictional” crap written in his delusional medical records.
Was I supposed to assume someone with a medical degree is too stupid to know the difference between one’s head and other parts of one’s body? I had no idea psychiatrists were so insanely stupid and/or unethical. I used to believe doctors had brains in their heads, how embarrassing.
I remember researching legal fiction just after leaving that insanely delusional psychiatrist. But you are correct, “Labelling of anyone as less than human is legal fiction, something false that is asserted as true, that the courts will not allow to be disproved.” I couldn’t find a lawyer, but I did eventually find a doctor with a brain in his head who took the lunatic’s misdiagnosis off my medical records.
“… if the state did not allow psychiatrists to enslave their patients in the name of liberating them, institutional psychiatry would go the way of slavery, as well it should.” Absolutely.
Maybe his knowledge was fictional.
Took the words right out of my mouth!
You’ve heard the story-“get a bigger hammer!”
Stephen, Thank you for summing up these findings.
This meta analysis confirms what psychiatric survivors, their loved ones and allies have been saying for years, but our voices have been silenced as we have been systematically shut out of the decision making process, shamed, shushed, and ridiculed.
These ridiculous prescribing algorithms, created by industry and used shamelessly by practitioners of medical ‘science — people who should know better because of their supposed respect for empirical evidence—-‘ have resulted in over medication and great harm to our children.
It’s time to turn the tables on the epistemic authorities within this corrupted harmful mental health system and demand better alternatives for our loved ones, friends, clients, and neighbors. These people who have been harming our children with impunity, especially those precribers in ER’s, acute care facilities, state hospitals, and secure psychiatric facilities need to be exposed for their abusive practices. Augmenting one worthless dopamine binding anti-psychiatric when it is clearly causing akathesia and other horrific psychiatric symptoms ( aka adverse drug reactions) with another dopamine binding agent of equally dubious value will not help someone experiencing an adverse drug reaction or a paradoxical worsening of symptoms.
How many decades will it take for these shameful unscientific prescribing practices to be suspended and amends made to those who were deeply harmed through years of over drugging?? A complete turn over in the field of psychiatry via aging out and retirement of everyone in the field of psychiatry? The emancipation of all medical colleges and medical journals from big Pharma funding?
“When something doesn’t work very well, let’s do more of it.”
That’s what the psychiatrists say!
“Top tier psych journal = PULP FICTION”……
How do you stop such idiots?
And the title of the movie was? Get a Bigger Hammer!