Antipsychotic medication, mortality and neurodegeneration: The need for more selective use and lower doses

How important are informed consent, informed choice, and patient-doctor relationships, when prescribing antipsychotic medication?

BACKGROUND

Antipsychotic medications (APs) are used for people with psychosis diagnoses and, increasingly for other problems and groups.

AIMS

This study examines how APs are prescribed, from the perspective of recipients.

METHODS

757 people, from 30 countries, responded to questions about their experiences with APs, in an online survey.

RESULTS

Most (70%) were told nothing about adverse effects. Fewer than 2% recalled being told about the risks of diabetes, suicidality, sexual dysfunction, or reduced life span. None recalled being told about reduced brain volume or withdrawal effects. Only 28% recalled being offered other treatments; with only 14% offered talking therapies. 46% were not told how long to take the APs; and, of those who were told something, 48% were told to take them forever. Most respondents (76%) were not told how APs work. Only 19% were satisfied with the prescribing process, and only 25% reported a good, or very good, relationship with the prescriber. Information, satisfaction with the process, and the prescriber relationship were all positively related to three self-reported outcomes: reduction of problems the drugs were prescribed for, general helpfulness, and quality of life.

CONCLUSIONS

Steps need to be taken to ensure people prescribed antipsychotics are fully informed, especially about adverse effects and alternatives.

A high-fat diet, but not haloperidol or olanzapine administration, increases activated microglial expression in the rat brain

This study examined the effects of chronic treatment of the antipsychotic drugs, haloperidol and olanzapine, on microglial activation in the brain. In addition, we explored the interaction of these antipsychotic drugs with normal and high-fat diet. In order to measure activated microglial expression, we used [³H] PK11195 in vitro autoradiography. Male Sprague Dawley rats were given a diet of either regular chow diet or a high-fat diet, and assigned either water, haloperidol drinking solution (1.5 mg/kg), or olanzapine drinking solution (10 mg/kg) for four weeks. Following treatment, rats were euthanized and brains extracted for [³H] PK11195 autoradiography. Rats on 4 weeks of a high-fat diet showed increased [³H] PK11195 binding compared to rats on a normal diet in the temporal association cortex (19 %), ectorhinal cortex (17 %), entorhinal cortex (18 %), and perirhinal cortex (18 %), irrespective of drug treatment. These are regions associated with memory, sensory, and visual processing. Rats treated with either haloperidol or olanzapine showed no differences in [³H] PK11195 binding compared to the control group. However, there were differences between the 2 different antipsychotic medications themselves. Haloperidol increased [³H] PK11195 binding in the amygdala (23 %), ectorhinal cortex (24 %), and perihinal cortex (29 %), compared to olanzapine. These results corroborate a known role of a high-fat diet and central inflammatory changes but suggest no role of these antipsychotic drugs in promoting neuroinflammation across 4 weeks compared to normal control rats.

Plasma β-III tubulin, neurofilament light chain and glial fibrillary acidic protein are associated with neurodegeneration and progression in schizophrenia

Schizophrenia is a progressive disorder characterized by multiple psychotic relapses. After every relapse, patients may not fully recover, and this may lead to a progressive loss of functionality. Pharmacological treatment represents a key factor to minimize the biological, psychological and psychosocial impact of the disorder. The number of relapses and the duration of psychotic episodes induce a potential neuronal damage and subsequently, neurodegenerative processes. Thus, a comparative study was performed, including forty healthy controls and forty-two SZ patients divided into first-episode psychosis (FEP) and chronic SZ (CSZ) subgroups, where the CSZ sub group was subdivided by antipsychotic treatment. In order to measure the potential neuronal damage, plasma levels of β-III tubulin, neurofilament light chain (Nf-L), and glial fibrillary acidic protein (GFAP) were performed. The results revealed that the levels of these proteins were increased in the SZ group compared to the control group (P < 0.05). Moreover, multiple comparison analysis showed highly significant levels of β-III tubulin (P = 0.0002), Nf-L (P = 0.0403) and GFAP (P < 0.015) in the subgroup of CSZ clozapine-treated. In conclusion, β-III tubulin, Nf-L and GFAP proteins may be potential biomarkers of neurodegeneration and progression in SZ.

Using Open Questions to Understand 650 People's Experiences With Antipsychotic Drugs

Studies of antipsychotic medication, which are increasingly prescribed for a broad range of problems and circumstances, rarely ask the people who take them to describe their experiences with the drugs. In this study, 650 people, from 29 countries, responded, in an online survey, to "Overall in my life antipsychotic medications have been _____?" and "Is there anything else you would like to say, or emphasise, about your experiences with antipsychotic drugs?" Of the total participants, 14.3% were categorized as reporting purely positive experiences, 27.9% had mixed experiences, and 57.7% reported only negative ones. Negative experiences were positively correlated with age. Thematic analysis identified 749 negative, 180 positive, and 53 mixed statements. The 2 positive themes were "symptom reduction" (14) and "sleep" (14), with the majority (153) unspecified. The 4 negative themes (besides "unspecified"-191) were: "adverse effects" (316), "interactions with prescriber" (169), "withdrawal/difficult to get off them" (62), and "ineffective" (11). The adverse effects included: weight gain, emotional numbing, cognitive dysfunction, sedation, akathisia, effects on relationships, and suicidality. "Interactions with prescriber" included lack of information about withdrawal effects, support, or discussion of alternatives. The only mixed theme was "short-term good, long-term bad" (28). Open questions can add to findings from methodologies focused on symptom reduction. Clinicians should pay more attention to the need for respectful and collaborative patient-prescriber relationships. At the point of prescription, this must include providing the full range of information about antipsychotics, including potential benefits and harms, difficulties withdrawing, and information on alternatives treatments such as psychological therapies.

Positive and Negative Effects of Antipsychotic Medication: An International Online Survey of 832 Recipients

Background:

Antipsychotic medication is currently the treatment of choice for psychosis, but few studies directly survey the first-hand experience of recipients.

Objective:

To ascertain the experiences and opinions of an international sample of users of antipsychotic drugs, regarding positive and negative effects.

Methods:

An online direct-to-consumer questionnaire was completed by 832 users of antipsychotics, from 30 countries – predominantly USA, UK and Australia. This is the largest such sample to date.

Results:

Over half (56%) thought, the drugs reduced the problems they were prescribed for, but 27% thought they made them worse. Slightly less people found the drugs generally ‘helpful’ (41%) than found them ‘unhelpful’ (43%). While 35% reported that their ‘quality of life’ was ‘improved’, 54% reported that it was made ‘worse’. The average number of adverse effects reported was 11, with an average of five at the ‘severe’ level. Fourteen effects were reported by 57% or more participants, most commonly: ‘Drowsiness, feeling tired, sedation’ (92%), ‘Loss of motivation’ (86%), ‘Slowed thoughts’ (86%), and ‘Emotional numbing’ (85%). Suicidality was reported to be a side effect by 58%. Older people reported particularly poor outcomes and high levels of adverse effects. Duration of treatment was unrelated to positive outcomes but significantly related to negative outcomes. Most respondents (70%) had tried to stop taking the drugs. The most common reasons people wanted to stop were the side effects (64%) and worries about long-term physical health (52%). Most (70%) did not recall being told anything at all about side effects.

Conclusion:

Clinical implications are discussed, with a particular focus on the principles of informed consent, and involving patients in decision making about their own lives.

Personal Accounts of Discontinuing Neuroleptic Medication for Psychosis

We conducted this study to explore personal accounts of making choices about taking medication prescribed for the treatment of psychosis (neuroleptics). There are costs and benefits associated with continuing and discontinuing neuroleptics. Service users frequently discontinue neuroleptics; therefore, we specifically considered these decisions. We used a grounded theory approach to analyze transcripts from interviews with 12 participants. We present a preliminary grounded theory of the processes involved in making choices about neuroleptic medication. We identified three tasks as important in mediating participants' choices: (a) forming a personal theory of the need for, and acceptability of taking, neuroleptic medication; (b) negotiating the challenges of forming alliances with others; and (c) weaving a safety net to safeguard well-being. Progress in the tasks reflected a developmental trajectory of becoming an expert over time and was influenced by systemic factors. Our findings highlight the importance of developing resources for staff to facilitate service user choice.

Antipsychotic polypharmacy in psychotic disorders: a critical review of neurobiology, efficacy, tolerability and cost effectiveness

OBJECTIVE

The purpose of this study was to review the scientific evidence for neurobiological rationale, efficacy, tolerability and cost effectiveness of antipsychotic polypharmacy (APP).

DATA SOURCES

A systematic literature search of Medline, Embase, Ovid and the Cochrane Database of Systematic Reviews until April 2012 was carried out.

RESULTS

Theories behind APP have only modest pre-clinical and clinical evidence. We found limited statistical evidence supporting modest efficacy of APP in patients with psychotic symptoms refractory to clozapine. APP is associated with increased mortality, metabolic syndrome, decreased cognitive functioning, high dose prescription and non-adherence. It brings up extra costs, lacking evidence for cost-effectiveness.

CONCLUSIONS

Pre-clinical studies underpinning neurobiological hypotheses in APP are lacking. Evidence supporting efficacy of APP is limited with modest beneficial clinical relevance. APP is associated with several serious adverse effects and increased health costs. In the absence of more convincing pre-clinical support and clinical evidence we advise adherence to existing guidelines and limiting combinations of antipsychotics (in consideration with other pharmacotherapeutic, somatic and psychotherapeutic options) to patients with clozapine-refractory psychosis in well-evaluated individual trials that might need 10 weeks or more.