There are ongoing ethical, moral, and legal challenges surrounding the prescription and discontinuation of antipsychotic medications—challenges that a new article suggests can be addressed through the lens of epistemic injustice.
Published in the Community Mental Health Journal, the article argues that epistemic injustice is a useful concept for understanding situations where clients and mental health professionals disagree about discontinuing or maintaining antipsychotic medications.
The lead author, Helene Speyer, a psychiatrist and associate professor at the University of Copenhagen, argues that understanding antipsychotic discontinuation through the lens of epistemic injustice could transform how clinicians and patients navigate decisions about medication. But Speyer’s perspective is not just academic—it is deeply personal.
Her lived experience with antipsychotics informs her critique of a system that often privileges clinical authority over patient voice. Speyer’s dual perspective as both a provider and someone who has “been there” lends unique weight to her call for change. The authors write:
“Decisions about long-term treatment with antipsychotic medication remain complex and emotionally charged, especially with the current priority on client rights, autonomy, and shared decision-making. We argue here that the current debate about risks and benefits associated with antipsychotic medication can be fruitfully analyzed through the lens of epistemic injustice.”
“In conclusion, we argue that both sides of the medication discontinuation debate should approach questions about medication with epistemic humility. There are no clear right or wrong answers, and people should be given the opportunity to make their own choices on their personal path to recovery, whether this involves choices to risk relapse or long-term medication.”
Miranda Fricker’s concept of epistemic injustice refers to the mistreatment of individuals as knowers or conveyors of knowledge. In psychiatry, this is often seen in harmful stereotypes of people with psychosis, such as labeling those with schizophrenia as dangerous or lacking “insight,” which leads to distrust in their ability to provide trustworthy and reliable knowledge.
The discussion focuses on how epistemic injustice manifests when unjustified biases or stereotypes about psychosis influence the decision-making process regarding the continuation or discontinuation of antipsychotic medication, often without shared decision-making.
The authors elaborate on Fricker’s two main categories of epistemic injustice—testimonial and hermeneutical—to highlight how these forms of injustice undermine patient voice and autonomy in the context of psychosis and medication management.
Testimonial injustice, in this case, is when a person diagnosed with schizophrenia is given lower credibility regarding their decision to discontinue medication due to a negative stereotype that the individual has a lack of insight. Historically, disagreements about diagnoses or treatment plans between clinicians and patients were labeled as a “lack of insight,” a term that devalues patients’ perspectives and creates testimonial injustice.
Despite guidelines recommending long-term adherence to antipsychotics, many individuals choose to stop taking their medication due to side effects and perceived risks. Healthcare professionals, however, are often reluctant to support this decision, viewing it as outside their clinical judgment, leaving patients to navigate this decision alone, and allowing clinicians to deny responsibility by framing the decision as being “against medical advice.”
This view contradicts current mental health movements that emphasize the importance of shared decision-making and prioritizing service users’ voices.
The authors write:
“The idea of epistemic injustice encourages clinicians to think in more nuanced ways and ask themselves if reluctance to support and supervise people during tapering could be based on unjustified negative stereotypes such as dangerousness, preconceptions about what a good life is like, or bias about chronicity. Another obscuring issue may be tensions between clients and medical professionals in their willingness to take risks. While running the risk of a relapse may be an important step in the path of personal recovery from a client’s perspective, being the treating clinician in a process that does not follow guidelines and could lead to clinical worsening may pose legal as well as moral issues.”
Hermeneutical injustice occurs when the failure to validate an individual’s desire to discontinue medication influences the dominant knowledge production surrounding antipsychotics and their use.
The authors identify the following three key gaps in the literature on antipsychotic discontinuation:
- The potentially severe consequences of long-term use of antipsychotics.
- The severity and frequency of withdrawal symptoms.
- The development of the safest tapering strategies.
There is a lack of guidance on safely tapering antipsychotic medications in clinical guidelines, an issue largely overlooked by the scientific community, which has instead focused on improving medication adherence. There have been no trials comparing tapering strategies; however, numerous studies on medication initiation exist.
The authors attribute this injustice to a biased research agenda that prioritizes medication adherence and maintenance, influenced by the dominance of the biomedical model and negative stereotypes about the chronicity of mental illness.
In conclusion, the authors argue that the ongoing debate about the risks and benefits of antipsychotic medication can be analyzed through the lens of epistemic injustice.
If psychiatry wants to align with the values of shared decision-making and recovery-oriented mental health, then there must be safer tapering processes established, safer ways to identify those who do not need medication without jeopardizing the health of those who do, and educating doctors on the difference between relapses and withdrawal symptoms.
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Speyer, H., Eplov, L. F., & Roe, D. (2024). Antipsychotic Discontinuation through the Lens of Epistemic Injustice. Community Mental Health Journal. https://doi.org/10.1007/s10597-024-01274-7 (Link)
What is this absolutely insipid nonsense about? It’s the heavily conformist, socially conditioned thinking. As if an intellectual argument around the best conceptual approach to antipsychotic reduction is of any value whatsoever compared to an experience based monitoring and understanding of the actual psychological, subjective and physiological process people go through when discontinuing. You say the debate about when medication should be used has no right or wrong answers, but if you were completely clear about the actual research on the long-term outcomes of antipsychotics, and also the comparison of outcomes between those that were treated chronically with antipsychotics and those which for various reasons weren’t (this is done through historical, cross-cultural and domestic comparative analysis famously the two multi-national studies from the World Health Organization), then you would see without a shadow of a doubt that there is no case for antipsychotic medication besides having an expensive solution to a very difficult problem, which is the hundreds of millions of people the world over who are becoming unwell psychologically, emotionally and spiritually in this meat mincer of a social process through which we feed our children to the craven vampires who destroy our world. So in light of all imagine how one experiences your article which doddles around trivial issues in a vague attempt to be critical of psychiatry but missing all the most important facts and thereby actually producing something that affirms psychiatry by giving it, again, too much intellectual and moral credit. I’m afraid that for me articles like this, which are over half on MIA I feel, actually just give the impression of the over all poverty of the critical discussion which is too often based on intellectual posturing with no sense of the factual terrain whatsoever. The above is a clear case in point posted by people who need to learn how to differentiate the merely theoretical from the real. I hope you catch my drift. If not you may as well take your brain out, put it in the bread slicer and eat it for dinner. Hopefully being thus broken down and reconstituted it’ll work better for you, and if not, oh well – no loss.
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“I’m afraid that for me articles like this, which are over half on MIA I feel, actually just give the impression of the overall poverty of the critical discussion which is too often based on intellectual posturing with no sense of the actual terrain whatsoever. The above is a clear case in point posted by people who need to learn how to differentiate the merely theoretical from the real.”
Agree 100%. Insipid crap like the above article reminds me why I hated studying philosophy as much as I did, although I did get an “A” in it.
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“Imagine how one experiences your article which doddles around trivial issues in a vague attempt to be critical of psychiatry but missing all the most important facts and thereby actually producing something that affirms psychiatry.”
Brilliant! Thank you, No-one.
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But there ARE wrong answers! Forcing people capable of reasoning to go against their own wishes IS wrong, whatever might be “right.” The choice of “justice” as a focus implies without question that stopping unjust or “wrong” actions is the main thrust of the effort!
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Psychiatry has a historical tendency to distance itself from the principles of “shared decision-making and recovery-oriented ‘mental health’.” For decades, psychiatrists, along with major pharmaceutical companies, governments, and other corrupt institutions, have been complicit in administering neuroleptics to intentionally incapacitate and control people. Research has shown that these drugs lead to progressive shrinkage or loss of brain tissue, resulting in brain atrophy that is consistent with dementia. This process can both induce and exacerbate various symptoms and accelerate cognitive and neurobehavioral decline (Jackson, G., 2008, Psychrights.org). Why are we engaged in debates over the forced consumption of neurotoxins for quasi-diagnoses when they, and the ‘professionals’ who prescribe them should be prohibited?
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Why are we engaged in such a debate? Now THAT’S a good question the answer of which should be obvious to anyone with half a brain. However, the reality seems to suggest that the vast majority of those who practice psychiatry are strangely satisfied administering Chemical Lobotomies to a woefully uninformed public.
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Dear Birdsong,
I would like to seek clarification on whether you are suggesting that I have a diminished capacity for reasoning (“should be obvious to anyone with half a brain”) by questioning the rationale behind the examination of prescriptions for neurotoxins, instead of advocating for their outright prohibition, along with that of psychiatry. It seems to me that prioritizing complete bans would be a more logical approach than pursuing regulation.
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Dear Cat,
I didn’t mean to suggest that your reasoning capacity is diminished in any way. My comment was posed rhetorically to all readers.
What I’m saying is that it should be obvious to anyone that there’s no debating the very real harm caused by neuroleptics.
And while I agree that prioritizing complete bans would be a more logical approach than pursuing regulation, I’m sorry to say I also don’t think it’s the most realistic one at this point.
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prohibited?
its high time they were prosecuted!
(imho)
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“The idea of epistemic injustice encourages clinicians to think in more nuanced ways and ask themselves if reluctance to support and supervise people during tapering could be based on unjustified negative stereotypes such as dangerousness, preconceptions about what a good life is like, or bias about chronicity.”
Absolutely, epistemic injustice, and avarice, does encourage clinicians to NOT withdrawal people from the antipsychotics. But thankfully for me, my psychiatrist finally realized – once he finally stopped believing my psychologist’s lies – I was not a “dangerous person” and had a “good life.” So, according to my my medical records, he blamed my psychologist’s “invalid” DSM misdiagnosis on that non-medically trained psychologist.
And my psychiatrist finally weaned me off his anticholinergic toxidrome inducing neurotoxic drug cocktails. But I will say, medically unnecessarily anticholinergic toxidrome poisoning people forever, for profit, is highly profitable for the psychiatrists. But it is also highly unethical.
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Why should so-called mental health professionals be granted the ultimate authority to judge what properly constitutes a “good life?” The very notion is meaningless outside of a specific culture and social milieu, which are guided by a generally accepted system of moral values that evolve over time.
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Oh my dear Ms. Riddle… and Speyer, H., Eplov, L. F., & Roe,
Your effort to “reframe the way we think about different mental states and experiences” is a tired fail.
Where’s the call-to-action?
Reading this theoretical discussion regarding the ‘correctness of intent’ and ‘possibilities that may result’, is an asinine, tired waste of time to the veterans w/PhD’s from Psychotropic Gladiator School.
How precious, how antiseptic an intellectual exercise you’ve all presented.
Allow me to cut to the blood & guts on the despair-soaked floor for the oh-so-delicate & academic minded authors.
*I was diagnosed a lifelong bipolar for ‘presenting’ anxiety & insomnia following my small business closing.
*I was prescribed an antipsychotic (with an anticonvulsant, benzo, & ‘mood stabilizer’) every 24 hours for the following decade.
*The ADDICTION WITHDRAWALS (seizure/coma/death) prevented my acting to save myself by stopping.
Liability and my revenue-stream (in oh-so-many ways and levels) prevented the prescribers from stopping.
*THAT prescribing caused (documented) Cardiomyopathy (non-theoretical heart failure), TWO Neuroleptic Malignant Syndromes, nerve damage to both eyes, a prefrontal brain lesion, alarming kidney, liver, & thyroid labs, & muchmuchmuch more.
60 days FOLLOWING the doctor-guided (oh yes) 2.5 year titration & withdrawal, I ‘experienced’ 3 years of ‘seizure-like’ events…met by the ER, my neurologist, and the specialists at Barrow Neurological Institute/Phoenix…with a nervous shrug…after being informed of my extensive psychiatric prescribing medical history.
Had I been a street addict, things would have been so much more linear…’easier’ to ‘explain’.
It didn’t matter that the false lifetime bipolar diagnosis had been wiped, in writing.
They ALL viewed me as a dangerous, possibly messy legal liability…in the dangerous, messy ‘specialty’ train wreck that is Psychiatric Drug ‘Treatment’-and they were NOT going to become an ‘expert witness’ for my attornies, if that was my goal. (It wasn’t: I just wanted to live).
And whoever heard of an SMI diagnosis being expunged anyway? Impossible.
The Thin White Line holds fast for the medical guild….too.. (Think priests & police)
Academic arguments regarding how client’s credibility should be honored is laughable here on Earth 1. It’s the very first casaulty of the diagnosis….silently smothered as a baby in a crib. One isn’t even aware of it’s absence, until you say “No” the first time.
The Psychiatric Industry is based on Plato’s Noble Lie.
No one gives a second thought to sacrificing a patient…after all, it’s for the greater good.
You folks clearly have no idea or understanding of the eye-ball deep feces being slung every single second of every single day in ANY appointment that is even remotely touched by psychiatry, but especially the prescribing end of the game.
It’s where YOU’RE drugged & addicted…and they’re (ostensibly) NOT….& THEY have a close, personal relationship with the judiciary…& YOU don’t.
There…I cleared it up for you.
Either present a Call-to-Action with your publishing…& ACT, save some lives… or stop writing these empty exercises in word counts.
READ THE ROOM (Comments). It’s insulting to people who bear the scars…that are NOT theoretical.
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