RESEARCH WEEKLY: Risks, rewards and long–term antipsychotics

(Mar. 22, 2016) Given the stakes involved with antipsychotic medication – the side effects that can result either from taking or not taking them for psychotic conditions can be life-changing – it should come as no surprise that they are a recurring source of controversy in the mental health community.

Two psychiatrists with long careers in treating psychotic disorders have recently analyzed the literature and controversies around the long-term use of antipsychotics, in light of criticiism that antipsychotics worsen psychosis and the clinical outcomes in schizophrenia.

Ronald W. Pies, MD, professor of psychiatry at SUNY Upstate Medical and Tufts universities, comments on recent studies and their interpretations in “Long-term antipsychotic treatment: Effective and often necessary, with caveats” in Psychiatry Times.

Allen Frances, professor emeritus and former chair of the department of psychiatry at Duke University School of Medicine and chair of the DSM-IV task force, examines the topic in Psychology Today and mass media.

Here is a brief summary of what the authors say. Links to complete versions are provided in the references below.

What the Literature Says
“It is important to understand that only a portion of people with a first psychotic episode have schizophrenia, which is usually a very chronic illness,” Pies writes in Psychiatry Times. “Many have quite brief bouts of psychosis that never return, making long-term antipsychotic treatment unnecessary.” He suggests that some confusion about long-term antipsychotics usage results when this population is inappropriately conflated with the population living with chronic psychotic disorders.

According to Pies’s review of related psychiatric literature, “There is no convincing evidence that maintenance treatment causes worsening of schizophrenia or related psychotic illnesses, or leads to poorer outcomes, when compared with discontinuation of the antipsychotic.”  To the contrary, he says, “the preponderance of evidence points to the net benefits of long-term (antipsychotic) use in patients with schizophrenia,” including lower overall mortality.

“We need to make modest claims – not sweeping generalizations – about the literature on long-term use of antipsychotic medication,” says Pies. “Indeed, these medications are almost certainly over-used – without substantial evidence for their efficacy – in patients with ordinary anxiety disorders or insomnia; for adolescent ‘acting out’; and for ‘agitation’ in geriatric or nursing home populations.”

That said, Pies continues, while “‘gold-standard,’ randomized, placebo-controlled studies are fewer than we would like” and subject to different interpretations, “most randomized, long-term studies of schizophrenia support the net benefit of antipsychotics in preventing relapse of the illness. Some data also show better ‘quality of life’ with maintenance antipsychotic treatment, compared with drug discontinuation.”

Risks vs Benefits
In the end, Pies says, “Discussion of long-term (antipsychotic) use must be placed in the larger perspective of general medical care, in which physicians are constantly struggling with the perennial ‘risk vs. benefit’ equation. Many life-saving treatments in other medical specialties – from cancer chemotherapy to cardiac surgery – are associated with significant risks. But we must also consider the risks of absent or inadequate treatment, and the inherent morbidity and mortality of the illness itself.”

Pies’s reader-friendly analysis of the literature examining long-term antipsychotic use is available online in its entirety from Psychiatry Times.

Psychiatrist Allen Frances of Duke University describes his own research and clinical experience with long-term antipsychotic medications and quotes from an interview with Pies in “Setting the record straight on antipsychotics,” published in Psychology Today, where he authors the column Saving Normal. “The misleading idea that antipsychotic medications cause or worsen psychosis legitimizes the incorrect view that long-term medication is bad for everyone,” Frances concludes. “A minority of people with chronic, severely impairing psychotic symptoms may eventually do fine off meds, but the majority will have relapses that are always disruptive and often dangerous.”

Frances offers further analysis of the antipsychotic controversy in a Huffington Post blog, “Do antipsychotics help or harm psychotic symptoms?”

The Treatment Advocacy Center has long decried the overuse and misuse of psychotropic medications, especially for off-label applications and children. At the same time, the preponderance of evidence continues to document the usefulness of antipsychotic medications in saving and improving the lives of at-risk individuals with severe and persistent psychotic disorders.

References:
Pies, Ronald W. (22 February 2016). “Long-term antipsychotic treatment: Effective and often necessary, with caveats.” Psychiatry Times.
Frances, Allen J. (16 February 2016). “Setting the record straight on antipsychotics.” Psychology Today.
Frances, Allen J. (1 February 2016). “Do antipsychotics help or harm psychotic symptoms?” Huffington Post.