Better Outcomes Off Medication for Those Recovered from First-Episode Schizophrenia

A new study has found that of 10 people who were fully recovered from their first episode of schizophrenia (FES), those not taking antipsychotics did better in terms of cognitive, social, and role functioning—and reached full recovery more quickly. The research was led by Susie Fu at the University of Oslo, Norway. It was published in Psychiatry: Interpersonal and Biological Processes.

According to Fu, “The findings challenge some of the views about medication treatment of FES patients. For a subgroup of FES patients, continuous medication treatment is not necessary for maintaining low levels of symptoms. These patients show sustained good functioning once fully recovered.”

The participants came from the Oslo Schizophrenia Recovery Study. 31 people were referred to the researchers after their first episode of schizophrenia was diagnosed, and the researchers followed their progress for seven to eight years. At the last follow-up, 10 of the participants were considered “fully recovered.”

The study goes on to examine the differences amongst those 10 who were fully recovered. By the last follow-up, six of the 10 were no longer on antipsychotic medications. Two of them had never started, and the others discontinued their medication throughout the eight years of the study (most often with the help of their prescriber).

The six who were not taking medication recovered more quickly than those who continued taking the medication. That is, they were more likely to have recovered early in the study, while those who continued taking medication took longer to reach the goal of “full recovery.”

The researchers also found that being on antipsychotic drugs actually increased the likelihood of psychotic relapse—a finding which has been shown in other studies as well. All four participants who were still on antipsychotics experienced relapses, while none of the participants who were not taking the drugs relapsed.

To refute findings such as these, supporters of antipsychotic medications often argue that perhaps people who stopped taking the medications did so because they were doing better.

However, the researchers give two reasons that this is unlikely. First, they compared people’s functioning at the beginning of the study. Here’s what the researchers say about that:

“The unmedicated participants were not evidently healthier than medicated participants at baseline. Quite the opposite: The unmedicated participants had the largest impairments in role functioning and highest symptom level at baseline.”

Second, the researchers asked why people stopped taking the medication. The most common reason was adverse effects. That is, people stopped taking their medication because it was affecting their lives negatively due to side effects, not because they were doing better.

The researchers also note that recovery can look different for each individual. Although all 10 of the participants met criteria for full recovery, “the changes were significantly larger when individuals were off antipsychotic medications than on medications for processing speed and work functioning.”

Current guidelines, such as those released by the American Psychiatric Association, suggest that there is a high danger of relapsing after discontinuation of antipsychotic treatment; therefore, they suggest “maintenance” treatment—continuing antipsychotic use after recovery from initial psychosis.

However, Fu cites the evidence that the largest danger of relapse may be due to withdrawal effects of antipsychotic medications. According to Fu, antipsychotic medications dysregulate the dopaminergic system, leading to withdrawal and relapse when they are removed from the system.

The study was limited in its small sample (only 10 participants). Additionally, there were 28 people who did not meet the criteria for full recovery, and their data was not included in the study.

What this study shows, though, is that of the 10 people who became fully recovered seven or eight years after initial treatment (out of a cohort of 31), six were not taking medication. Those six, moreover, had recovered more quickly than the drug takers, didn’t have relapses during the eight years (whereas those on the drugs did), and they had more robust recoveries, in that they had larger improvements in cognition, social, and role functioning. Moreover, quite remarkably, the six off medications had more severe symptoms and were more impaired at baseline.

 

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Fu, S., Czajkowski, N., & Torgalsbøen, A. (2019). Cognitive, work, and social outcomes in fully recovered first-episode schizophrenia: On and off antipsychotic medication. Psychiatry: Interpersonal and Biological Processes. doi: 10.1080/00332747.2018.1550735 (Link)