Study Shows Success With Reduced Antipsychotic Use

People who reduced antipsychotic use by tapering were doing just as well after five years as those who continued using the drugs.

Peter Simons
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A new study by Sandra Steingard at the University of Vermont found that many patients in a community mental health center were able to reduce their antipsychotic drug use by tapering. After five years, these patients were doing just as well as those who did not reduce their antipsychotics, in terms of both the number of hospitalizations and employment status.

The article, published in Community Mental Health, concluded that patients were able to reduce their dosage of antipsychotics effectively, and were able to maintain at least the same level of functioning as those who did not reduce their dosage.

Dr. Sandra Steingard serves as Medical Director at HowardCenter, a community mental health center in Burlington, Vermont. She is also Clinical Associate Professor of Psychiatry at the University of Vermont College of Medicine.

According to Steingard, patients are often on higher dosages of antipsychotics than necessary. For instance, in an emergency setting, doctors may prescribe a high dosage of antipsychotics that other treatment providers are reluctant to reduce, even after patients are stable and doing well in the community.

Long-term antipsychotic use (even with the newest medications) has been linked to many dangerous adverse effects, such as extreme weight gain, metabolic problems, and tardive dyskinesia. The drugs have even been linked to worsening long-term outcomes for people with psychotic disorder diagnoses.

Steingard explains that critics of tapering believe that informing patients about risks and giving patients control over their care are dangerous propositions. These critics suggest that patients are likely to discontinue their medications abruptly and to have far worse outcomes. However, this new research finds otherwise, suggesting that patients are more capable than these critics believe.

“These discussions did not lead to a wholesale abandonment of drug treatment,” she writes. In fact, “Most patients were cautious.” Additionally, those that did reduce their medication use had similar outcomes, indicating that their treatment did not suffer because of tapering.

Steingard writes that patients should be given more information, be allowed to discuss risks and benefits of antipsychotic treatment with their doctors and that patients should be enabled to make informed decisions about their mental health care.

“There are many clients in a typical community mental health center setting who can participate in a discussion about the risks of antipsychotic drugs, including some of the current controversies regarding long-term use, and make individualized decisions about their care.”

 

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Steingard, S. (2018) Five-year outcomes of tapering antipsychotic drug doses in a community mental health center. Community Mental Health Journal. https://doi.org/10.1007/s10597-018-0313-1 (Link)

8 COMMENTS

  1. Too fast weaning is not reasonable, but too slow weaning is not reasonable either.

    Suppose a dose of 3mg of haldol per day. How long does it take to reach 0.25mg per day, by reducing the dose by 30% every 3 months, the most “rapid” weaning proposed in the study?

    21 months.

    But the author sometimes speaks of reducing the dose by only 25%, or waiting more than 3 months … or even to re-increase the dose to the initial value.

    In the end, only 3 people managed to stop neuroleptics after 5 years. 3 out of 129! This is a very bad result (2%).

    According to Harrow, Wunderink, Moilanen, Wils and others, we should expect great benefits with the total cessation of the drug. So we must stop being scared, stop frightening patients who want to stop the drug!

    1) The therapist must have confidence in total weaning. Admittedly, there will be more relapses in the weaning group, but only for ~14 weeks! (Viguera, 1997, pdf p. 4, fig. 3) After that, there will probably be no relapse in the weaning group, while the maintenance group will continue to relapse forever. It takes maximum support especially at the beginning to put the client back on track (social relations, employment …), ideally daily, by phone.

    2) The client should not be encouraged to decrease only, and still less to re-increase: if he wants to stop, you must stop! And in a reasonable time. If the weaning is too slow, it may encourage him to stop abruptly, which happened in this study! The best, in my opinion, is to stop depot injection, with some tablets in security, and with the possibility to call someone often.

    2% of total cessation is too little: it is the proof that the therapist did not have enough confidence in the weaning, which led patients to decrease too slowly or to wean themselves brutally (in a spirit of contradiction). A therapist with reasonable self-confidence could hope for a result of:

    _ 33% total weaning,
    _ 33% decrease,
    _ 33% maintenance.

    and maybe even better depending on the clientele.

    If you have confidence in weaning, and you are weaning rationally (ie gradually and adapted to the needs), it will greatly increase the chances of success by mere effect of suggestion and autosuggestion.

    Viguera AC, Baldessarini RJ, Hegarty JD et al. (1997) Clinical Risk Following Abrupt and Gradual Withdrawal of Maintenance Neuroleptic Treatment Arch Gen Psychiatry. 1997;54:49-55

  2. Since the antipsychotics/neuroleptics actually create both the negative and positive symptoms of “schizophrenia,” the negative symptoms being created via NIDS and the positive symptoms being created via anticholinergic toxidrome, it’s not remotely surprising that “Study Shows Success With Reduced Antipsychotic Use.”

    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome
    https://en.wikipedia.org/wiki/Toxidrome

    I absolutely agree “that patients should be given more information, be allowed to discuss risks and benefits of antipsychotic treatment with their doctors and that patients should be enabled to make informed decisions about their mental health care.” I got nothing but lies from my “mental health professionals,” and/or they are the most delusional people on the planet.

    By the way, Sandra, you look like you’ve lost weight, you look great. Thanks for trying to educate your profession about the dangerous effects of the antipsychotics.