Lack of Clear Guidelines Prevent Clinicians from Reducing Antipsychotics

Despite severe side effects and questionable efficacy, clinicians often balk at reducing or eliminating antipsychotic medication.

Gavin Crowell-Williamson
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A recently published study from noted critical psychiatry expert Joanna Moncrieff explored the barriers that prevent clinicians from helping service users in discontinuing or reducing antipsychotics.

The team of London-based researchers investigated mental health professionals’ opinions and experiences regarding the reduction and discontinuation of antipsychotics. While the established treatment for psychosis is antipsychotics, many people either stop taking them on their own or request different treatment. Despite this, and despite concerns about adverse effects of continued consumption of antipsychotics, there are no professional guidelines to reduce or eliminate antipsychotic treatment.

The researchers conducted focus groups with psychiatrists and other members of community mental health services. They discovered a wide range of opinions and experiences regarding antipsychotics. Most professionals mentioned that the drugs can have negative effects, and were supportive of prescribing the lowest effective dose–though eliminating antipsychotics was seen as less acceptable. These opinions were due to organizational and knowledge barriers, as well as the result of prior experience with relapse following antipsychotic discontinuation.

“These systemic barriers are concerning as they may be hindering good practice,” write the authors. “For example, pressure to discharge means that service users may be stabilized quickly through high dose antipsychotics and then discharged to GPs (primary care physicians), who are unlikely to alter this medication. This situation reduces patient choice and may result in the long-term use of potentially unnecessarily high doses.”

A box of Zyprexa pills.
(Photo Credit: Raining/Wikimedia Commons)

The authors cite constraints such as limited time with service users and limited organizational support, as well as limited access to non-medication treatments. These factors force clinicians to rely on medication stabilization alone.

“This may mean that maintenance treatment is favored over reduction for organizational rather than clinical reasons, and that service users may miss out on opportunities to minimize the adverse effects of long-term treatment, or to manage their illness in other ways.”

While antipsychotics are often first-line treatment for psychosis, there are a number of side effects and adverse effects of antipsychotics, especially after long-term use. In addition, a third of patients don’t respond at all to antipsychotics, which causes many to discontinue medication on their own volition. Most research on discontinuation of antipsychotics has investigated sudden rather than gradual discontinuation; one study that compared maintenance treatment to gradual reduction found a short-term risk of relapse in the reduction group, but no long-term difference and higher rates of social recovery. The dearth of research has contributed to the lack of professional guidelines for reducing antipsychotics, necessitating clinicians to make intuitive decisions that are affected by their personal attitudes on antipsychotics.

In the current study, the researchers conducted seven focus groups, each of which contained 3-8 participants: a total of 35 psychiatrists, mental health nurses, social workers and clinical team managers. There were four main areas of emphasis: experiences and views regarding reducing/discontinuing antipsychotics, the process of reduction and discontinuation (such as facilitators and barriers), detection and definition of relapse and support for antipsychotic reduction. Data were analyzed with thematic analysis.

All participants recognized that antipsychotics can have some benefits as well as severe adverse effects, and some noted a perceived overreliance on medication in the industry. Adverse effects discussed included weight gain, diabetes, heart problems, sedation, impaired function, sexual dysfunction and shortened life-span, and concern and empathy were shown for individuals who experienced these adverse effects.

Critique of medication overreliance pointed to a pattern of polypharmacy and sudden dose escalation to stabilize and discharge quickly. A small group of psychiatrists firmly believed that antipsychotic medication, when considered holistically, was absolutely the best course of long-term treatment. These individuals were wary of discontinuation-related relapse.

All psychiatrists noted the importance of reducing antipsychotics in certain instances, with some pointing to a ‘minimally effective dose’ as ideal, aiming to avoid relapse and maximize quality of life. While some nurses and psychiatrists had positive experiences with reducing medication, most pointed to experiences of relapse and other adverse outcomes. These professionals often preferred “maintenance treatment” rather than reducing antipsychotics, accepting over-medication as a risk. As such, discontinuing these drugs was not usually seen as an option. They expressed additional concern that patients might end up on a higher dose of antipsychotics following relapse.

One consulting psychiatrist was quoted as saying, “Unfortunately what we do see in people who against our advice stop their medicines is that they get into a terrible lot of trouble before they get back into the service; you know, they lose their relationships, they lose their jobs, they lose their housing, get involved in drug misuse, criminality.”

Participants identified a number of organizational barriers, such as lack of resources to support the reduction of antipsychotics, including access to and funding for alternative treatment, as well as resource cuts which led to increased pressure to discharge to primary care. This practice leads to over-prescription in order to quickly stabilize individuals. This creates a challenge, as primary care physicians tend not to adjust antipsychotics, lacking the knowledge and clinical support to do so. Thus, people often remain on excessively high doses of antipsychotics for quite some time.

A consulting psychiatrist was quoted as saying, “People get put on high levels of medication often they are put on polypharmacy, and then as soon as they are not acute enough to need the home treatment team they are discharged, often straight back to the GP, so there is never the opportunity for stability and there is never the opportunity for de-escalation, and the GPs very reasonably do not reduce medication because they do not want to particularly when it is antipsychotic polypharmacy.”

Participants further noted the challenge of prescribing or reducing antipsychotics in a system that shuttles people to different services without providing clinical context about medication decision to their new providers, as well as knowledge barriers surrounding clinical guidelines to reduce antipsychotics and who is suitable for antipsychotic reduction.

All focus groups mentioned the importance of communication between clinicians and patients; participants stressed a desire to sustain a good relationship with their patients, and emphasized the importance of respecting and engaging with patients’ requests. Some psychiatrists felt that their professional expertise gave them more authority to make decisions, and as such used a range of strategies to discourage the request to stop taking antipsychotics. All focus groups emphasized the importance of family and caregiver relationships during the reduction process.

There are a host of clinical implications to the information provided from the focus groups, including reduced patient choice as a result of overmedication due to the desire to stabilize and discharge, a prevalent power dynamic leading to reduced patient choice in treatment and a desire for risk aversion in clinicians. Many of these fears may rest in the firm belief in the medical model of psychosis, which suggests that antipsychotics eliminate a chemical imbalance and are thus necessary for recovery. This model may lead clinicians to believe that their patients have diminished decision-making capacity. Given this, involving patients in treatment decisions becomes both more challenging and more vital to eliminate the power disparities between clinician and patient.

“Relapse following reduction or discontinuation is not inevitable, and some service users reasonably wish to reduce their side-effect burden, or consider options other than continuous maintenance treatment,” conclude the authors. “However, when service users stop antipsychotics covertly and abruptly (which may be more likely if support or options to reduce are not offered) their risk of relapse and negative or coercive service experiences may increase.”

The authors hope that future research on gradual antipsychotic discontinuation could inform guidelines to help clinicians engage in discussions of reduction/discontinuation with service users.

“Further support for engaging patients meaningfully and constructively in decision making would be useful, and financial constraints that encourage the prioritization of short-term stability to enable rapid discharge, with long term high-dose antipsychotic prescribing need to be debated.”

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Cooper, R.E., Hanratty, É., Morant, N., & Moncrieff, J. (2019). Mental health professionals’ views and experiences of antipsychotic reduction and discontinuation. PLoS ONE, 14(6): e0218711. https://doi.org/10.1371/journal.pone.0218711 (Link)

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Gavin Crowell-Williamson
MIA Research News Team: Gavin Crowell-Williamson is a Research Assistant at the University of Washington studying addiction-related suicide prevention. He is interested in researching how to provide opportunities for mental health care in communities that lack access, as well as understanding systemic factors that either facilitate or prevent getting help for mental health. He is currently pursuing a graduate degree in Community Development and Action from Vanderbilt University.

15 COMMENTS

  1. “Despite severe side effects and questionable efficacy, clinicians often balk at reducing or eliminating antipsychotic medication”
    This is not true, if the doctor sees that the patient is not taking and does not want to take the pills, he will offer to cancel antipsychotics. Because it’s silly to give antipsychotics when there is no risk of psychosis (unless the patient himself wants to repeat such psychedelic experience).

    • In my experience, this is very much the norm – it takes an act of Congress to get a doctor to support withdrawing from psychiatric drugs, and the desire to do so is often regarded as a “symptom of the illness” rather than a rational decision based on the pros and cons of the situation. Many docs seem to believe that being “mentally ill” eliminates the ability to think and reason and make decisions.

      It is true that it is getting easier to find clinicians to help someone wean, but such professionals are still the exception rather than the rule. And even when one does find someone “willing” to help them taper safely, there is an almost constant message that it’s a bad idea and will probably go wrong soon. Plus a lot of the “supporters” don’t appear to understand how to taper safely anyway. So it’s not really a very easy process, and some people can’t find anyone willing to help at all.

  2. “Many of these fears may rest in the firm belief in the medical model of psychosis, which suggests that antipsychotics eliminate a chemical imbalance and are thus necessary for recovery.”

    The antipsychotics can create psychosis, via anticholinergic toxidrome.

    https://en.wikipedia.org/wiki/Toxidrome

    Withdrawal from the antipsychotics can also create psychosis, via a drug withdrawal induced “super sensitivity manic psychosis.”

    So the antipsychotics create a “chemical imbalance” in people’s brains, which creates “psychosis.”

    Will the BS “chemical imbalance theory” of “mental illness” etiology ever die? And isn’t this evidence that the psychiatrists do, in fact, still believe in the “chemical imbalance theory?” Thus, proving Dr. Pies wrong about his fellow psychiatrists?

    “In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. On the other hand, the ‘chemical imbalance’ trope has been tossed around a great deal by opponents of psychiatry, who mendaciously attribute the phrase to psychiatrists themselves.2 And, yes—the ‘chemical imbalance’ image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding.3 In truth, the ‘chemical imbalance’ notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists.”

    The “chemical imbalance theory of “mental illness” causation is a lie. Stop lying to your clients, DSM deluded “mental health” minion.

  3. I admire much of what Dr. Moncrief has written in the past, but this ‘study’ seems to be mired in a time-warp of insistent denial, intentional foot-dragging and slow-walking what has been reported, ‘studied’, and proven for a decade or more (See Whitaker’s scathing article this week).

    I was intentionally, falsely diagnosed in 2004, riding the tidal wave of the ‘bipolar goldrush’ following the disgraceful, criminal DSM IV (thx Allen!) and experienced 2 Neuroleptic Malignant Syndrome ‘events’, bradycardia that required a week of hospitalization (surgical floor), tardive dyskinesia in both eyes, micrographia caused by brain lesions, gulping air like a goldfish, inability to hold my head erect, drooling and palsy (of course), and all the other VISIBLE grotesqueries…with the ‘invisible’ effects far worse.

    My point is that sloppy prescribing resulting in anaphylaxis (documented in the ER) ‘CURED’ my “lifelong” bipolar disorder nearly overnight(!), as the cost and liability algorithms suggested they agree with me to get me out…. and get me out safely…and (hopefully) quietly.
    Of course, I am SHOCKED they aren’t broadcasting this miracle ‘cure’ for bipolar on the front page of the New York Times. Or at the annual APA convention. Or anywhere at all.

    It took 2 1/2 years as the only client of the new VP/CMO (who had been the clinic director during the clusterf*ck) to titrate and withdraw completely and he was available to me 24/7, by phone, text-he traveled a lot, or appointment. That last year was a white-knuckle ordeal WITH his guidance. Things got worse before they got better and it was a challenge to believe that I would emerge resembling ‘myself’.

    I have experienced 16 ‘partial seizures’ (I had no history) in the three years subsequent to the taper and end of drugs. Some have lasted 15 hours. After my GP suggested I should “talk to somebody’ (code for therapist), I insisted on being completely vetted medically; cardio, basic neuro scans for ‘masses’ or bleeds, testing inner ear, finally ending up at the Barrow Neurological Institute in Phoenix. The knew, they didn’t know, they were uncomfortable with the Andreason proof (SHORT-term antipsychotics) regarding pre-frontal shrinkage. As Barrow is the top of the ‘food chain’ but not specializing in THIS (psychotropic) stuff, they stayed officially ‘non-committal’, but “concerned”. The neurologist mentioned on my way out, ‘We’re seeing more and more of this” and “Stay in touch”. Oh, OK.

    I can ‘sense’ these events coming now (like some epileptics) and can reach a therapist who does 30 minutes of Epley Maneuvers, bilateral, front and back. She finds THAT odd as her experience informs her this is HIGHLY irregular, extremely rare for BPV.
    Yeah, me too.
    I’ll take ANY prevention or relief.

    I won’t live long enough to see this addressed, but I’m (almost) 6 months clear and optimistic.

    My poor brain took a beating. And I watch my kidney and liver function like a hawk.

    This article overstates the re-treaded obvious and never seriously challenges the job security/revenue stream ‘elephant’ in the room….”organizational” pressures.
    The responses lacked insight (oh, the irony!), critical thinking, and sincere evaluation of the status quo. They sound like politicians.

    Describing THEIR “challenges in prescribing” antipsychotics is a bitter read. Damp hand-wringing and mewling about the”importance of communication” and “respecting…patient’s requests” made me throw up in my mouth a little.

    I want Dr. Moncrief to DEMAND a bigger platform and raise an angry voice, using her visibility to help FORCE change….she has all the right intentions, references, studies, credentials…..it’s not working so far.
    When the likes of a criminal such as Allen Frances can commandeer the NYT, The Atlantic, and the Post, still regarded as some kind of leader and expert in modern psychiatry…despite the trail of tears and shattered lives he has stepped over and profited handsomely from…it’s time for a real scientist to develop some whistleblowing swagger and never stop until things change.

    Exactly when is enough… enough?

    Regarding “….future research on antipsychotic discontinuation”….Well, I’m right here.
    Hit me up, Dr. Moncrief..
    I can answer that for you.

  4. Psychiatrists have a vested interest in keeping everybody their profession “diagnoses” “medicated” till they die alone, crippled, and miserable in a HUD slum or institution before their fifty-third birthday. Why? So these professionals can enjoy the glory and honor of Real Scientists and honest-to-gosh doctors and live lavish lifestyles on seven digit incomes.

    It’s obvious who benefits the most from neuroleptics.

    And the bare idea of survivors who escape and lead good lives despite mainstream psychiatry’s best efforts must stick in their craw.

  5. Yes, ’till they die alone, crippled, and miserable. Destroying the political organizing powers of survivors is part of the plan.

    These drugs should be off the market, psychiatry should not exist.

    Money spent sending survivors to psychotherapists should be spent sending them to law school.

  6. Anytime therapists are saying that you need them, that we need their new diagnostic manual, then they are saying that there is something wrong with you, and so the more you let them do that, the more likely you will die alone, crippled, and miserable.

    Thanks again to ThereAreFourLights for suggesting that we send survivors to law school. That is the most promising thing I have ever seen posted on this forum.

  7. A survivor is one who is having to live without public honor.

    Actually the term “survivor” comes from the Recovery Movement, and I do not agree with it. What they call a survivor is no different from a victim.

    Rather than survivors, we need to be finding ways to achieve victory.

    But Psychiatry, Psychotherapy, and the Recovery and Salvation Industries will stand in your way.