A critical analysis of recent data on the long-term outcome of antipsychotic treatment

Examining the Long-Term Impacts of Psychotropic Drugs and Considerations for People Discontinuing Treatment

Psychotropic drugs dominate the mental healthcare landscape. This is despite contention over their proposed mechanism of action, concerns for their adverse effects, and questionable effectiveness, especially over the long term. Mental health nurses are routinely involved in administering psychotropic drugs, observing for and managing adverse effects, and providing information and support to people prescribed these agents. This critique explores the current understanding of the mechanism of action for psychotropic drugs, evidence for their effectiveness, adverse effect burden and implications for long term use. The role of mental health nurses in deprescribing and supporting people to discontinue treatment is considered.

The association between relapse and the outcome of schizophrenia and recurrent psychotic disorders

BACKGROUND

Having a relapse of schizophrenia or recurrent psychosis is feared by patients, can cause social and personal disruption and has been suggested to cause long-term deterioration, possibly because of a toxic biological process.

AIMS

To assess whether relapse affected the social and clinical outcomes of people enrolled in a 24-month randomised controlled trial of antipsychotic medication dose reduction versus maintenance treatment.

METHODS

The trial involved participants with a diagnosis of schizophrenia or recurrent, non-affective psychosis. Relapse was defined as admission to hospital or significant deterioration (assessed by a blinded end-point committee). We analysed the relationship between relapse during the trial and social functioning, quality of life, symptom scores (Positive and Negative Syndrome Scale) and rates of being in employment, education or training at 24-month follow-up. We also analysed changes in these measures during the trial among those who relapsed and those who did not. Sensitivity analyses were conducted examining the effects of 'severe' relapse (i.e. admission to hospital).

RESULTS

During the course of the trial, 82 out of 253 participants relapsed. There was no evidence for a difference between those who relapsed and those who did not on changes in social functioning, quality of life, symptom scores or overall employment rates between baseline and 24-month follow-up. Those who relapsed showed no change in their social functioning or quality of life, and a slight improvement in symptoms compared to baseline. They were more likely than those who did not relapse to have had a change in their employment status (mostly moving out of employment, education or training), although numbers changing status were small. Sensitivity analyses showed the same results for those who experienced a 'severe' relapse.

CONCLUSIONS

Our data provide little evidence that relapse has a detrimental effect in the long term in people with schizophrenia and recurrent psychosis.

[Long-term courses in schizophrenia : A review of current results and developments]

Despite classical conceptions of schizophrenia as a progressive illness with a high chronification, current long-term follow-up studies show a higher proportion of remission, possibly also a higher proportion of recovery than previously assumed. The heterogeneity of clinical courses is also reflected in different trajectories of cognitive and biological (e.g., imaging) variables, in which many of those affected show remission. Early clinical intervention during the first weeks and months following the onset of psychosis are decisive not only for early remission but also possibly for the long-term outcome. The treatment and reduction of somatic comorbidities are promising approaches in addition to a differentiated core treatment to positively influence the course of the illness even years after the disease. The identification of additional predictors, e.g., based on biological parameters, can together with machine learning approaches contribute to optimization of an individualized core treatment.

Does relapse cause illness progression in first-episode psychosis? A review

BACKGROUND

It is widely believed that relapse in first-episode psychosis (FEP) causes illness progression, with previous reviews suggesting that treatment non-response develops in one in six patients who relapse. This belief contributes to the primary treatment goal in FEP being relapse-prevention, often in favor of other recovery-oriented goals. However, previous reviews primarily reported on naturalistic studies in chronic schizophrenia and predated multiple major studies with higher-quality designs.

METHODS

We conducted a narrative review of studies of any design that examine the impact of relapse on medication response and other symptomatic and functional outcomes in FEP.

RESULTS

We identified eight relevant studies, five of these published since the last major review on this topic. Observational studies show a clear association between relapses and worse response to medication, but poorly control for confounding. Three higher-quality studies (two randomized) generally do not find worse symptomatic or functional outcomes among medication reduction/discontinuation arms compared to maintenance controls, despite significantly higher initial rates of relapse.

CONCLUSION

While the social and psychological consequences of a relapse should not be dismissed, clinicians should demand high-quality evidence about the risks of relapse on long-term outcomes. The conventional notion that relapse leads to treatment non-response or worse long-term outcomes is generally not supported by the highest quality studies. These findings can help clinicians and patients weigh the risks and benefits of competing treatment strategies in FEP.

Combination of Two Long-Acting Antipsychotics in Schizophrenia Spectrum Disorders: A Systematic Review

BACKGROUND

Up to 34% of patients with schizophrenia are resistant to several treatment trials. Lack of continuous and adequate treatment is associated with relapse, rehospitalization, a lower effect of antipsychotic therapy, and higher risk of side effects. Long-acting injectables antipsychotics (LAI APs) enhance compliance and improve clinical outcomes and quality of life in patients with schizophrenia, and thus it may be advisable to administer two LAI APs at the same time in cases of treatment-resistant schizophrenia. The purpose of this review is to summarize the available literature regarding the combined use of two LAI APs in patients with schizophrenia or other psychotic spectrum disorders.

METHODS

An extensive literature search for relevant articles regarding any combination of two long-acting injectable antipsychotics has been performed from inception up to 9 February 2024, on PubMed, Scopus and APA PsycInfo, according to the PRISMA statement. Only studies reporting combination of two LAI APs and its clinical outcome in patients with schizophrenia and related disorders were selected.

RESULTS

After the selection process, nine case reports, four case series and two observational retrospective studies were included in the final analysis. All patients treated with dual LAI APs reported a good response, and no new or unexpected adverse effects due to the combination of two LAIs were reported. Different drug combinations were used, and the most frequent association resulted in aripiprazole monohydrate + paliperidone palmitate once monthly (32 times).

CONCLUSIONS

Our review highlights that the treatment regimen with two concurrent LAI APs is already widely used in clinical practice and is recognized as providing a promising, effective, and relatively safe therapeutic strategy for treating the schizophrenia spectrum disorders.

Targeted Treatment of Schizophrenia Symptoms as They Manifest, or Continuous Treatment to Reduce the Risk of Psychosis Recurrence

Current pharmacological treatment of schizophrenia employs drugs that interfere with dopamine neurotransmission, aiming to suppress acute exacerbation of psychosis and maintenance treatment to reduce the risk of psychosis recurrence. According to this treatment scheme, available psychotropic drugs intended to treat negative symptoms, cognitive impairment, or anxiety are administered as add-ons to treatment with antipsychotics. However, an alternative treatment scheme proposes a targeted or intermittent treatment approach, by which antipsychotic drugs are administered upon psychosis exacerbation and discontinued upon remission or stabilization, while negative symptoms, cognitive impairment, or anxiety are treated with specific psychotropics as monotherapy. Along these lines, antipsychotics are renewed only in the event of recurrence of psychotic symptoms. This 50-year-old debate between targeted and continuous treatment schemes arises from disagreements about interpreting scientific evidence and discordant views regarding benefit/risk assessment. Among the debate's questions are: (1) what is the percentage of individuals who can maintain stability without antipsychotic maintenance treatment, and what is the percentage of those who exacerbate despite antipsychotic treatment? (2) how to interpret results of placebo-controlled 9- to 18-month-long maintenance trials in a life-long chronic disorder, and how to interpret results of the targeted trials, some of which are open label or not randomized; (3) how to weigh the decreased risk for psychotic recurrence vs the almost certainty of adverse effects on patient's quality of life. Patients' profiles, preferences, and circumstances of the care provision should be considered as the targeted vs continuous treatment options are considered.

The Association of Antipsychotic Postponement With 5-Year Outcomes of Adolescent First-Episode Psychosis

Background and Hypothesis

Based on the need-adapted approach, delaying antipsychotics could help identify first-episode psychosis (FEP) adolescents who might not require them. However, some individuals might need antipsychotics, and postponing could harm their prognosis. This nationwide register-based follow-up aimed to test these two hypotheses.

Study Design

All adolescents aged 13-20 with a psychotic disorder (ICD-10 codes: F20-F29) in Finland between 2003 and 2013 were identified (n = 6354) from national registers. For each case, a fixed 1825-day follow-up period was established from the onset of psychosis or until death. The outcome was considered "good" if adolescents did not die and had not received psychiatric treatment and/or disability allowances during the final year of follow-up. Testing the first hypothesis involved all antipsychotic treatment-naïve adolescents with FEP (n = 3714). The second hypothesis was tested with a sub-sample of only those who had received antipsychotics during follow-up (n = 3258). To account for baseline confounders, hypotheses were tested via a stabilized inverse probability of treatment weighted generalized linear models with logit link function.

Study Results

Immediate antipsychotic treatment after the onset of psychosis was associated with poor 5-year outcome (adjusted odds ratio [aOR]: 1.8, 95% CI: 1.6-2.1). There was no statistically significant association between antipsychotic postponement and treatment outcome in those who eventually received antipsychotic treatment (aOR: 1.02, 95% CI: 0.7-1.2, P: .8), thus not providing support for second hypothesis.

Conclusions

There is a significant subgroup of adolescent with psychosis who do not require immediate antipsychotic treatment. A more robust design is needed to evaluate the causality of the observed association.

An analysis of views about supported reduction or discontinuation of antipsychotic treatment among people with schizophrenia and other psychotic disorders

BACKGROUND

Antipsychotic medication can reduce psychotic symptoms and risk of relapse in people with schizophrenia and related disorders, but it is not always effective and adverse effects can be significant. We know little of patients' views about continuing or discontinuing antipsychotic treatment.

AIMS

To explore the views of people with schizophrenia and other psychotic disorders about continuing their antipsychotic medication or attempting to reduce or discontinue this medication with clinical support.

METHODS

We collected quantitative and qualitative data by conducting semi-structured interviews in London, UK. Factors predicting a desire to discontinue medication were explored. Content analysis of qualitative data was undertaken.

RESULTS

We interviewed 269 participants. 33% (95% CI, 27 to 39%) were content with taking long-term antipsychotic medication. Others reported they took it reluctantly (19%), accepted it on a temporary basis (24%) or actively disliked it (18%). 31% (95% CI, 25 to 37%) said they would like to try to stop medication with professional support, and 45% (95% CI, 39 to 51%) wanted the opportunity to reduce medication. People who wanted to discontinue had more negative attitudes towards the medication but were otherwise similar to other participants. Wanting to stop or reduce medication was motivated mainly by adverse effects and health concerns. Professional support was identified as potentially helpful to achieve reduction.

CONCLUSIONS

This large study reveals that patients are commonly unhappy about the idea of taking antipsychotics on a continuing or life-long basis. Professional support for people who want to try to reduce or stop medication is valued.

M.6Saiz-RuizJ.418León-QuismondoL.31NacherJ.323334ContrerasF.3536De-la-CámaraC.42037GutiérrezM.43839SáizP. A.40. A longitudinal study of gene expression in first-episode schizophrenia; exploring relapse mechanisms by co-expression analysis in peripheral blood

Little is known about the pathophysiological mechanisms of relapse in first-episode schizophrenia, which limits the study of potential biomarkers. To explore relapse mechanisms and identify potential biomarkers for relapse prediction, we analyzed gene expression in peripheral blood in a cohort of first-episode schizophrenia patients with less than 5 years of evolution who had been evaluated over a 3-year follow-up period. A total of 91 participants of the 2EPs project formed the sample for baseline gene expression analysis. Of these, 67 provided biological samples at follow-up (36 after 3 years and 31 at relapse). Gene expression was assessed using the Clariom S Human Array. Weighted gene co-expression network analysis was applied to identify modules of co-expressed genes and to analyze their preservation after 3 years of follow-up or at relapse. Among the 25 modules identified, one module was semi-conserved at relapse (DarkTurquoise) and was enriched with risk genes for schizophrenia, showing a dysregulation of the TCF4 gene network in the module. Two modules were semi-conserved both at relapse and after 3 years of follow-up (DarkRed and DarkGrey) and were found to be biologically associated with protein modification and protein location processes. Higher expression of DarkRed genes was associated with higher risk of suffering a relapse and early appearance of relapse (p = 0.045). Our findings suggest that a dysregulation of the TCF4 network could be an important step in the biological process that leads to relapse and suggest that genes related to the ubiquitin proteosome system could be potential biomarkers of relapse.

Do DSM classifications help or hinder drug development?

Development and regulatory approval of psychotropic drugs targets individuals with syndromes described in the current Diagnostic and Statistical Manual of Mental Disorders (DSM). This helps drug developers and regulators to communicate with prescribers, and prescribers to match a specific psychotropic with the individual patient(s) most likely to benefit from it. However, this practice has been criticized on the grounds that DSM syndromes are too heterogenous biologically, and the effects of psychotropics are too nonspecific to allow for an effective match. This review considers the advantages and disadvantages of the current practice and the possible alternatives. It concludes that efforts should be made to explore psychotropic development transdiagnostically, free of the DSM boundaries. However, currently there exists no alternative diagnostic system that is clearly superior to the DSM in terms of communications between the stakeholders in drug development.


Perspective on medication decisions following remission from first-episode psychosis

While antipsychotics (APs) could provide rapid relief of positive symptoms in psychotic disorders, their usage is often associated with side effects, stigma and inconveniences. For these and other reasons, many psychosis patients, particularly those of first-episode psychosis (FEP) in remission, wish to discontinue maintenance treatment. The current review aims to discuss the strategies of AP treatment following remission from FEP, with particular emphasis on the evaluation of outcomes following AP discontinuation. Upon review of relevant literature, three potential strategies are put forth for treatment-responsive, remitted FEP patients: a) life-long maintenance treatment, b) AP discontinuation during second year of treatment, or c) AP discontinuation after three years of treatment. In theory, the first strategy presents the safest option for maximal symptom control. However, a rigorous RCT indicates that if AP discontinuation is to be attempted, the third strategy best prevents poor long-term clinical outcomes. Further data is needed to address the costs and benefits of each treatment strategy, compare AP-free patients with those on different types of APs, as well as explore even longer-term outcomes.

Five-Year Cumulative Exposure to Antipsychotic Medication After First-Episode Psychosis and its Association With 19-Year Outcomes

Background

The long-term effectiveness of antipsychotic maintenance treatment after first-episode psychosis (FEP) is contested. In this real-world observational study, we examined how cumulative exposure to antipsychotics within the first 5 years from FEP was associated with the 19-year outcome.

Methods

Finnish national registers were used to detect all patients who were hospitalized due to non-affective psychosis in the mid-1990s, and who were treatment naïve prior to the inclusion period (N = 1318). Generalized linear models with logit link function were used to estimate how cumulative exposure to antipsychotics within the first 5 years from onset was associated with mortality, work capability, and the use of psychiatric services at the end of the 19-year follow-up. To adjust for confounding by indication, the primary outcome analyses implemented stabilized inverse probability of treatment weighting using propensity scores.

Results

Persons with a higher cumulative exposure to antipsychotics within the first 5 years from FEP were more likely to still be receiving antipsychotics (adjusted odds ratio [OR] = 2.1; 95% CI: 1.5−2.8), psychiatric treatment (OR = 1.4; 95% CI: 1.1−1.7), and disability allowances (OR = 1.3; 95% CI: 1.01−1.6) at the end of the 19-year follow-up, as compared to low/zero-exposure. Higher cumulative exposure was also associated with higher mortality (OR = 1.5; 95% CI: 1.1–2.1).

Conclusions

After adjustment for confounders, moderate and high cumulative exposure to antipsychotics within the first 5 years from FEP was consistently associated with a higher risk of adverse outcomes during the 19-year follow-up, as compared to low or zero exposure. Due to potential unmeasured confounding, controlled trials are needed.

Barriers to stopping neuroleptic (antipsychotic) treatment in people with schizophrenia, psychosis or bipolar disorder

Most guidelines recommend long-term, indefinite neuroleptic (or antipsychotic) treatment for people with schizophrenia, recurrent psychosis or bipolar disorder, on the basis that these medications reduce the chance of relapse. However, neuroleptics have significant adverse effects, including sexual dysfunction, emotional blunting, metabolic disturbance and brain shrinkage, and patients often request to stop them. Evidence for the benefits of long-term treatment is also not as robust as generally thought. Short-term randomised trials show higher rates of relapse among those whose neuroleptic treatment is discontinued compared with those on maintenance treatment, but they are confounded by adverse effects associated with the withdrawal of established medication. Some longer-term studies show possible advantages of medication reduction and discontinuation in terms of improved social functioning and recovery. Therefore, there is a good rationale for supporting patients who wish to stop their medication, especially given the patient choice agenda favoured by The National Institute for Clinical Excellence (NICE). The major barrier to stopping antipsychotics is an understandable fear of relapse among patients, their families and clinicians. Institutional structures also prioritise short-term stability over possible long-term improvements. The risk of relapse may be mitigated by more gradual reduction of medication, but further research is needed on this. Psychosocial support for patients during the process of reducing medication may also be useful, particularly to enhance coping skills. Guidelines to summarise evidence on ways to reduce medication would be useful. Many patients want to try and stop neuroleptic medication for good reasons, and psychiatrists can help to make this a realistic option by supporting people to do it as safely as possible, with the best chance of a positive outcome.

The association between family dysfunction and admission to an acute mental health inpatient unit: a prospective study

OBJECTIVES

With the shift from deinstitutionalization to community care in mental health services, relatives of persons with severe and enduring mental illnesses have had to take over the role as primary caregivers. Disturbed family dynamics have been observed within families with an 'ill' member. Although schizophrenia and related mental illnesses are biologically based disorders, environmental stress (including stress within family relationships) plays a major role in the onset and maintenance of symptoms. With this study, we assume that family dynamics play a central role in the course of severe psychiatric illness and hypothesized that dysfunction within family systems is a prognostic indicator of hospitalization in the course of schizophrenia/bipolar and schizoaffective disorders.

METHODS

Prospective, observational cohort study evaluating family functioning of 121 patients (schizophrenia/bipolar and schizoaffective disorder) from community at baseline and followed-up over 12-month period after recruitment. Measurements included demographics, diagnosis, Family Assessment Device - General Functioning, Perceived Criticism Scale, Brief Psychiatric Rating Scale, Global Assessment of Functioning and Social Support Questionnaire-6.

RESULTS

Significant differences found between patients admitted and not admitted during the 12-month time period for age (p = 0.003), Brief Psychiatric Rating Scale (BPRS; p = 0.026), Family Assessment Device - General Functioning (FAD-GF; p = 0.007) and Social Support Questionnaire total satisfaction level (p = 0.042) at baseline. Bivariate analysis showed that those admitted into hospital were younger with a higher BPRS score, less social satisfaction and disturbed family dynamics. FAD-GF (p = 0.006) and age (p = 0.022) were significant independent predictors for admission.

CONCLUSION

This provides further evidence supporting importance of promoting better family functioning through modified family dynamics, integrating and involving family into the care of such patients.