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Antipsychotics: is it time to introduce patient choice?

  • Anthony P. Morrison (a1), Paul Hutton (a2), David Shiers (a3) and Douglas Turkington (a4)
Summary

Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice and reconsider whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.

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Corresponding author
Anthony P. Morrison, School of Psychological Sciences, University of Manchester, Manchester M13 9PL, UK. Email: tony.morrison@manchester.ac.uk
Footnotes
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Declaration of interest

A.P.M. and D.S. are both members of two National Institute for Health and Clinical Excellence guideline development groups: Psychosis and Schizophrenia in Children and Young People, and Psychosis and Schizophrenia in Adults (partial update).

Footnotes
References
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1 Leucht, S, Arbter, D, Engel, RR, Kissling, W, Davis, JM. How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials. Mol Psychiatry 2009; 14: 429–47.
2 Leucht, S, Kane, JM, Etschel, E, Kissling, W, Hamann, J, Engel, RR. Linking the PANSS, BPRS, and CGI: clinical implications. Neuropsychopharmacology 2006; 31: 2318–25.
3 Lepping, P, Sambhi, RS, Whittington, R, Lane, S, Poole, R. Clinical relevance of findings in trials of antipsychotics: systematic review. Br J Psychiatry 2011; 198: 341–5.
4 Leucht, S, Corves, C, Arbter, D, Engel, RR, Li, C, Davis, JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet 2009; 373: 3141.
5 Artaloytia, JF, Arango, C, Lahti, A, Sanz, J, Pascual, A, Cubero, P, et al. Negative signs and symptoms secondary to antipsychotics: a double-blind, randomized trial of a single dose of placebo, haloperidol, and risperidone in healthy volunteers. Am J Psychiatry 2006; 163: 488–93.
6 Moncrieff, J, Leo, J. A systematic review of the effects of antipsychotic drugs on brain volume. Psychol Med 2010; 40: 1409–22.
7 Ray, WA, Chung, CP, Murray, KT, Hall, K, Stein, CM. Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med 2009; 360: 225–35.
8 Weinmann, S, Read, J, Aderhold, V. Influence of antipsychotics on mortality in schizophrenia: systematic review. Schizophr Res 2009; 113: 111.
9 Foley, DL, Morley, KI. Systematic review of early cardiometabolic outcomes of the first treated episode of psychosis. Arch Gen Psychiatry 2011; 68: 609–16.
10 Álvarez-Jiménez, M, Hetrick, SE, González-Blanch, C, Gleeson, JF, McGorry, PD. Non-pharmacological management of antipsychotic-induced weight gain: systematic review and meta-analysis of randomised controlled trials. Br J Psychiatry 2008; 193: 101–7.
11 Marques, TR, Arenovich, T, Agid, O, Sajeev, G, Muthen, B, Chen, L, et al. The different trajectories of antipsychotic response: antipsychotics versus placebo. Psychol Med 2011; 41: 1481–8.
12 Perkins, D, Lieberman, J, Gu, H, Tohen, M, McEvoy, J, Green, A, et al. Predictors of antipsychotic treatment response in patients with first-episode schizophrenia, schizoaffective and schizophreniform disorders. Br J Psychiatry 2004; 185: 1824.
13 Harrow, M, Jobe, TH, Faull, RN. Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study. In Psychol Med 2012; Feb 17 (Epub ahead of print).
14 Morrison, AP, Hutton, P, Wardle, M, Spencer, H, Barratt, S, Brabban, A, et al. Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial. Psychol Med 2012; 42: 1049–56.
15 Day, JC, Bentall, RP, Roberts, C, Randall, F, Rogers, A, Cattell, D, et al. Attitudes toward antipsychotic medication: the impact of clinical variables and relationships with health professionals. Arch Gen Psychiatry 2005; 62: 717–24.
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Antipsychotics: is it time to introduce patient choice?

  • Anthony P. Morrison (a1), Paul Hutton (a2), David Shiers (a3) and Douglas Turkington (a4)
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eLetters

Overuse of Antipsychotics and Patient Choice

Vincent Riordan, Consultant Psychiatrist
10 October 2012

There can be little doubt that the mental health profession has, as Morrison et al clearly describe 1, overestimated the efficacy of antipsychotics and underestimated their toxicity. Unfortunately, this should not surprise us when we consider that for the six decades or so that these drugs have been in existence, the pharmaceutical industry has invested a great deal of resources in campaigns, targeting our profession, with the specific aim of creating and maintaining a culture ofbelief in that exact flawed risk benefit analysis described. This has involved not only direct marketing but also the manipulation of the published literature. 2

The authors fail to explain why we should expect their suggestion, ofincreasing patient choice, should improve matters. Shifting decision making away from professionals and towards patients would inevitably be accompanied by a similar shift in emphasis on the part of the pharmaceutical industry, with more marketing activity targeting patients and their carers. We professionals have indeed failed to use our training, as well as we should have done, in objectively evaluating the evidence base in order to protect our patients from the purveyors of dubious treatments. However, those who advocate greater patient choice need to explain why we should expect patients and carers (many of whom would be at a time of crisis or particular vulnerability) to be any less susceptible to such predatory and manipulative marketing activities.

If we define the problem as being one with the power dynamics betweenprofessionals and patients we risk ignoring what is arguably a far greaterconcern, namely that we have, as described by Spielmans and Parry, allowedevidenced based medicine to be replaced by marketing based medicine.3

1.Morrison AP, Hutton P, Shiers D, Turkington D. Antipsychotics: is it time to introduce patient choice? B J Psych 2012; 201: 83 - 84.

2.Lexchin J. Those Who Have the Gold Make the Evidence: How the Pharmaceutical Industry Biases the Outcomes of Clinical Trials of Medications. Sci Eng Ethics 2012; 18: 247 - 261

3.Spielman GI, Parry PI. From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents. J Bioethic Inq 2010; 7: 13 - 29.

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Conflict of interest: The author is a practising consultant psychiatrist, in receipt of a public sector salary for same.

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There is no choice other than antipsychotics

K.A.L.A. Kuruppuarachchi, Professor of Psychiatry
10 October 2012

The editorial on Antipsychotics; is it time to introduce patient choice? (Morrison et al. BJP 2012) and From the Editor's desk ; The end of the psychopharmacological revolution( Tyrer BJP 2012) have been read with much concern as they are challenging some of the existing views of current psychiatric practice in many areas in the world.

There is evidence to support that various agents have been prescribed for mentally disturbed patients for centuries all over the world and Kraepelin also engaged in psychopharmacological experiments andprescribed various substances like opium, alcohol, chloroform, bromine salts etc. in the hope of ameliorating symptoms of his patients. It seems that the methods used in and the orientation of psychopharmacology haven'tundergone fundamental change since Kraepelin's work ( Spiegel 1989).

It is obvious that many practicing psychiatrists all over the world are so accustomed to psychotropic medication including the whole range of antipsychotics in their patient management that they may find it difficulteven to imagine patient care without those agents. As clinicians in developing countries such as Sri Lanka majority of psychiatrists tend to prescribe antipsychotics liberally as there is a limited choice in other therapeutic interventions. Many believe that this practice will benefit the patients and help to relieve/minimize the burden on the carers. Another area concerned in the management of our patients which is somewhat different from the west is that many patients depend on the clinicians to make decisions for themselves in many instances. Still therapists are playing a considerable role in decision making process in low-and middle- income countries(Kuruppuarachchi & Hapangama 2008).

The advantages of a "broader" medical model in psychiatry has also been highlighted. The implications of the assumption that the biological approach is reductionist, negative view of psychotropic medication, exclusive psychological approaches leading to "psychological reductionism"and causing harm to patients by denying them other effective forms of treatments have been highlighted. Also the importance of justifying treatment based on proper evidence rather than based on ideology has been emphasized(Shah & Mountain 2007).

On the other hand complex issues including capacity to make proper treatment decisions when concerned about patient choice in psychiatry has been addressed and limited willingness of many psychiatrists to collaborate on making decisions concerning medication has been discussed (Samele et al. 2007).

Since many psychotic patients are not responding adequately to antipsychotics many clinicians tend to seek help from several psychotropicmedications which is leading to polypharmacy and sometimes to irrational practice. In countries such as Sri Lanka one may encounter desperate carers who are administering medication surreptitiously to the patient. A lack of a comprehensive mental health act add to the problem. It is interesting to note that a more recent study with regard to antipsychotic switching from polypharmacy to monotherapy has shown that discontinuing one of two antipsychotics was followed by treatment discontinuation early and frequently and the two groups did not show a difference in symptom control or hospitalization even though there was a weight reduction in themonotherapy group. It has been suggested that the patients should have thechoice to return to antipsychotic polypharmacy if monotherapy is unsatisfactory ( Essock et al. 2011).

The complexity of the clinical presentation and the management of thefirst episode of psychosis has been highlighted and suggested early detection of "at- risk" mental states, early treatment of the first psychotic episode and interventions focusing on the early period of psychosis (the critical period) as three key elements of an early intervention strategy(Birchwood et al. 1997). In the therapeutic interventions of early intervention a clinical staging model has been suggested incorporating various therapeutic options depending on the stagealthough there are implications and problems in using in the prodrome as there is lack of specificity in many features and a wide variability in individuals(Yung et al. 2007).

Combination of pharmacological and psychological methods seems to be used in the interventions of cognitive dysfunction in schizophrenia in theforeseeable future despite psychological interventions such as cognitive remediation show promise and there is evidence that pharmacogenetics iscontributing to some positive outcomes in therapeutics although psychopharmacological research has been slow to translate to clinical practice during the recent times. It has been suggested that favourable attitudes towards psychological therapies in the management of psychosis could partly be due to the perception that there will be a lesser risk of harm from similar approach, better acceptance of psychological therapies ,relative shortage of translational work in biological therapies and unwillingness to collaborate with industries (Gaughran & Kapur 2011).

Many clinicians and relatives feel guilty about not treating their patients early and adequately believing that they may have poor outcomes and end up with residual symptoms unless intervened promptly.

It is worthwhile adhering to rational prescribing of antipsychotics rather than feeling negative about them while paying attention to the other therapeutic approaches/models when indicated.

References;

Morrison AP, Hutton P, Shiers D, Turkington D. Antipsychotics: is it time to introduce patient choice?. British Journal of Psychiatry 2012; 201:83-84.Tyrer P. From the Editor's desk -The end of the psychopharmacological revolution. British Journal of Psychiatry 2012; 201:168.

Spiegel R. Psychopharmacology : an introduction - 2nd ed. John Wiley& Sons Ltd, 1989.

Kuruppuarachchi KALA, Hapangama A. Patient choice in psychiatry in low- and middle- income countries. British Journal of Psychiatry 2008; 192(3): 233-234.Shah P, Mountain D. The medical model is dead - long live the medical model. British Journal of Psychiatry 2007; 191:375-377.

Samele C, Lawton-Smith S, Warner L, Mariathasan J. Patient choice in psychiatry. British Journal of Psychiatry 2007; 191: 1-2.

Essock SM, Schooler NR, Stroup ST, McEvoy JP, Rojas I et al. Effectiveness of Switching From Antipsychotic Polypharmacy to Monotherapy . Am J Psychiatry 2011; 168: 702-708.

Birchwood M, McGorry P, Jackson H. Early intervention in schizophrenia. British Journal of Psychiatry 1997; 170: 2-5.

Yung AR, McGorry PD. Prediction of psychosis: setting the stage. British Journal of Psychiatry 2007;191(Suppl. 51): s1-s8.

Gaughran F, Kapur S. How change comes: translating biological research into care. The Psychiatrist 2011; 35: 321-324.

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Conflict of interest: None declared

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DISINFECTING PSYCHOSES

Bob Johnson, Consultant Psychiatrist
10 October 2012

DISINFECTING PSYCHOSES

Psychiatry hobbled itself in 1968 (DSM*-II). DSM-V (March 2013) offers worse. Every non-psychiatrist knows, as DSM-I did in 1952, that personal disasters foment 'breakdowns'. Not so DSM-II. To claim, as DSM-II did, that psychiatric disorders are never a REACTION to anything, disables medical practice more severely than denying smoking triggers diseases. The real surprise is that this self-defeating nostrum, hailed in 1994 (DSM-IV, page xvii) as an "important methodological innovation", has commanded such medical and governmental adulation for so long.

All doctors, with the sole exception of those labouring under this DSM anomaly, work on the assumption that disease is indeed a REACTION to adverse events - nothing else works nearly as well, medically. DSM-IV however is chillingly unmistakeable: "DSM-II was similar to DSM-I but eliminated the term REACTION" (page xvii). This has unwelcome consequences, from which DSM-IV does not flinch. The one medical item which is always 100% REACTION is 'stress', whose toxic tentacles permeate medical practice and all mental disease. DSM-IV however explicitly eliminates from psychiatric practice the most stressful event of them all - "death of a loved one" (page xxi). DSM-IV's medical myopia extends further. "The term 'organic mental disorder' is no longer used in DSM-IV because it incorrectly implies that other mental disorders in the Manual do not have a biological basis" (page 10). Any medical student who similarly failed to differentiate, clinically, between say, alcoholic delirium and acute psychosis, would instantly be disqualified. Shouldn't DSM?

Stress, especially from earlier trauma, though contradicting DSM, sheds welcome light on that most challenging psychiatric symptom - psychotic speech - of the "shoes AND ships AND sealing-wax" variety. Listen to this carefully, and it is readily apparent that its incoherence and impenetrability are as puzzling to the sufferer as to the hearer. It makes most sense to trace this cognitive pathology back to earlier trauma,thus the sufferer can be seen to be tentatively picking his or her way through a verbal minefield, ducking and diving from half-topic to half-topic - an understandable coherent pathway being judged far too dangerous to contemplate, initially. Mind-numbing drugs exacerbate this fog. But trustworthy emotional support and guidance, in the right hands, produces delightful results, the classic remedy of "rest the patient - rest the part".

Unhappily this DSM anomaly erodes the law - a point that has so far escaped legal notice, both governmental and judicial. The practical reality is that 'REACTION' is vitally linked not only to 'CONSENT', but also to 'INTENT'. Again these links may puzzle scientific theorists, but they remain nevertheless of vital importance, since due legal process simply cannot function healthily without 'intent', any more than medical and psychiatric practice can without 'reaction'. Here clinical and legal objectives fruitfully reinforce one another, since Human Rights are themselves therapeutic. The 'Healing Hand Of Kindness' a process which harms no one and which everyone can understand, encourages clinical wonders to blossom. According to Robert Whitaker (2002), the York Quakersused it 1796-1850 to achieve mouth-watering success rates inconceivable today. Disinfecting trauma, disinfects psychoses. Time to revert?

[*DSM: Diagnostic And Statistical Manual Of Mental Disorders, AmericaPsychiatric Association, USA, various editions.Whitaker, Robert, 2002, chapter 2, "Mad in America", Basic Books, New York, ISBN 0738203858]

Dr Bob Johnson

Consultant Psychiatrist, P O Box 49, Ventnor, Isle of Wight, PO38 9AA UK

Tel for messages 07976 228 444e-mail DrBob@TruthTrustConsent.com www.TruthTrustConsent.com GMC speciality register for psychiatry reg. num. 0400150formerly Head of Therapy, Ashworth Maximum Security Hospital, Liverpool

Consultant Psychiatrist, Special Unit, C-Wing, Parkhurst Prison, Isleof Wight.

MRCPsych (Member of Royal College of Psychiatrists),

MRCGP (Member of Royal College of General Practitioners).

Diploma in Psychotherapy Neurology & Psychiatry (Psychiatric InstNew York),

MA (Psychol), PhD(med computing), MBCS, DPM, MRCS.

Author Emotional Health ISBN 0-9551985-0-XAuthor Unsafe at any dose ISBN 0-9551985-1-8Ref Anthony P. Morrison, Paul Hutton, David Shiers, and Douglas TurkingtonAntipsychotics: is it time to introduce patient choice? BJP August 2012 201:83-84; doi:10.1192/bjp.bp.112.112110

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Conflict of interest: None declared

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Re:Antipsychotics: is it time to introduce patient choice?

anthony p morrison, professor of clinical psychology
10 October 2012

We have been pleasantly surprised by the positive tone of the responses to our editorial, as we had envisaged that it would attract criticism as well as support. However, this support has been very welcome,and we have been particularly impressed by the number of eloquent and authoritative responses from service users. As Felicity Callard points out, the ability of service users to have a voice in academic and clinicaljournals is often missing, and the publication of several letters from service users in the British Journal of Psychiatry represents an importantstep in the right direction. We share her regret that the voice of serviceusers, who have for years been making similar arguments to those in our editorial, but from a position of lived experience rather than scientific research, is often unheard or viewed as less legitimate. Nev Jones, as onesuch service user voice, draws our attention to the often negative subjective effects that accompany antipsychotic medication, which is another important factor to consider in the cost-benefit profile. She alsoshares experiences of service users being discharged from services if theychoose not to take medication, which is a situation we have encountered many times, especially in recruiting for our recent clinical trial; this is clearly not to the benefit of anyone, and is only likely to result in crises that could have been avoided by a more collaborative approach to service provision. She also notes the lack of opportunities for guided discontinuation of antipsychotics; hopefully this is a situation that willchange, given recent encouraging evidence from clinical trials that demonstrate that at least a proportion of people can be successful in their choices to discontinue medication 1. Irene Campbell-Taylor provides a compelling argument in support of autonomy and the importance of the ability to make decisions about our life, regardless of whether others agree with those decisions or not; we would agree that service users should have the right to make such choices as long as there is no immediate risk of significant harm to self or others. However, even in such difficult circumstances, there may be other ways to manage risk, including alternative pharmacological approaches such as the use of benzodiazepines in order to reduce arousal, which can still accommodate peoples' wishes and respect their autonomy. Magenta Simmons suggests shared decision making (SDM) as a way forward in the promotion of choice, and we would agree that this approach has great potential to enhance the involvement of service users in decisions about their care. However, we would also suggest a note of caution, as there may be risks if this is delivered in isolation from the system that service users have to negotiate, given that the wider cultural context within services may discourage autonomy and involve coercion; indeed, as Hamann and colleaguesreported 2, service users who received the SDM intervention 'were perceived as more "difficult" by their psychiatrists'. Thus, interventionsshould also aim to change the wider service context. Shona Francey and colleagues discuss the relevance of a staging approach to the issues of choice regarding antipsychotics, which may certainly influence the relative cost-benefit profiles for service users at a particular phase of their mental health problems. However, we consider the issue of informed choice to be important regardless of whether it is an early phase or a more long-term condition. They also discuss their innovative clinical trial, which is a welcome development that will undoubtedly inform the evidence base regarding the possible costs and benefits of alternatives incomparison with antipsychotic medication, especially in first episode psychosis, which is sorely needed 3. Finally, Fiona Lobban asks for a strategy for translating the emerging evidence into changes to routine practice, which we can only endorse. It can be hoped that the increasing influence of recommendations such as those contained in the NICE guidelines 4, in combination with an associated programme of audit and incentives to perform in accordance with them, will promote such collaborative evidence-based practice. Similarly, we would hope that widespread provision of such information for service users and carers willfacilitate them in demanding change and ushering in genuinely collaborative care that embraces patient choice.

1. Wunderink L, Nienhuis FJ, Sytema S, Slooff CJ, Knegtering R, Wiersma D. Guided discontinuation versus maintenance treatment in remittedfirst-episode psychosis: relapse rates and functional outcome. J Clin Psychiatry 2007;68(5):654-61.2. Hamann J, Mendel R, Meier A, Asani F, Pausch E, Leucht S, et al. "How to speak to your psychiatrist": shared decision-making training for inpatients with schizophrenia. Psychiatric Services 2011;62(10):1218-21.3. Bola JR, Kao DT, Soydan H. Antipsychotic Medication for Early-Episode Schizophrenia. Schizophrenia Bulletin 2012;38(1):23-25.4. National Institute for Clinical Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care. UK: NICE, 2009.

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Conflict of interest: None declared

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Not just for psychosis anymore?

Johanna Ryan, paralegal
05 September 2012

My personal experience of antipsychotic drugs has consisted of tryingto avoid them. Lately, it's getting difficult. I am a middle-aged American who has struggled with major depression for most of my life. I have been in treatment, largely pharmaceutical, for most of the past thirty-odd years, with very mixed results. Nonetheless, I can count up afew blessings: I've been able to continue working for almost all that time. I've never been gripped by impulses that would land me in jail. And I've never had "psychotic" symptoms. No voices, no visions, no delusions.

In spite of that, virtually every physician or counselor I've spoken to in the past five years has urged me to try antipsychotic drugs for my "treatment resistant depression." Since aripiprazole was approved for this a few years ago, the pressure has really grown. According to the ads now running on American TV, anyone who takes an SSRI for six weeks butstill has some depressive symptoms should "ask their doctor about..." [this atypical antipsychotic]. No one can legally force me to take it, thank goodness. But if I don't lose what's increasingly seen as my neurotic fear of these drugs, I will have to find a new psychiatrist soon - and finding one who will respect my choice in this matter will be tough.

My qualms are largely based on the research I've seen. Most of it isthird-rate, pharma-directed and designed to play up these drugs, as far as I can tell. And it's still alarming. In some studies the majority of thosewho enroll drop out, and no one explains why. Study monitors are allowed to ladle out lorazepam as needed, and no one explains why. And akathisia rates run as high as 25%, even after the data are fully massaged. Meanwhile, the alleged improvements people experience are minimal. There's also weight gain, cardiac problems, movement disorders ... Some of these commercials debuted during NBC's Saturday Night Live comedy show, and the contrast between the shiny happy people on the screen and the announcer's litany of scary side effects was so surreal, many viewers assumed it was a satire put on as part of the show.

What would I ask of you good folks at BJP? Please stand up to these infomercials disguised as research (by no means limited to aripiprazole). Don't publish the dodgy stuff. Demand to see the raw data. Ask hard questions, the sort you would ask if your son or daughter were to be put on this stuff. If the answers you get warrant it, raise a public stink. Better yet, maybe organize some research on terms not controlled by the drug companies. You guys are on the inside, and we need you to speak up for consumers if we are someday to trust the profession again. Thank you so much for opening up this discussion.

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Conflict of interest: None declared

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