The option of drug-free/drug withdrawal is the minimum that all

Sami Timimi
Consultant Psychiatrist, Visiting Professor Psychiatry University Lincoln, UK
Interessekonflikt:  Nei

Neuroleptics are highly toxic drugs that cause a variety of physical harms, many of them permanent. These iatrogenic effects contribute significantly to the decreased life expectancy of people with mental illness. Long-term use of neuroleptics is associated with grey and white matter shrinkage over time that is dose related and associated with a worsening of negative symptoms, functioning and cognitive abilities. With such a terrible safety record, neuroleptics would have to establish that the benefits of taking it, particularly long-term, far outweigh the risks.

The evidence provides little reassurance that this is the case. Efficacy studies are highly misleading as many of them rely on a ‘cold turkey’ comparison – a comparison between those maintained on a neuroleptic and those abruptly withdrawn and put on a placebo, who are thus susceptible to acute withdrawal effects including dopamine supersensitivity psychosis. Despite this limitation, gains of using neuroleptics are surprisingly small (1).

With regards real world effectiveness, the literature is even less encouraging.  Research carried out by the World Health Organisation (WHO), found that patients outside the United States and Europe are significantly more likely to make a ‘full’ recovery and show lower degrees of impairment when followed up over several years, despite most having limited or no access to ‘anti-psychotic’ medication (2). Outcomes from treatment in real world mental health settings in the developed world are disappointing with as little as 20-25% of those in routine clinical care recovering (3).

Evidence is accruing that, particularly in terms of functional outcomes, those who come off ‘anti-psychotics’ have better long term outcomes than those who stay on them (4,5). Klingberg and Wittorf (6) conclude that psychosis psychotherapy does not have an evidence problem but an implementation problem.

Patients rely on us having the ethical courage to try innovations such as this that may improve this picture of poor outcomes.

1. Lepping P, Sambhi R, Whittington R, et al. Clinical relevance of findings in trials of antipsychotics: systematic review. Br J Psychiatry 2011; 198: 341–345.
2. Hopper K, Harrison G, Janka A, et al. Recovery from schizophrenia: An international perspective. Oxford: Oxford University Press, 2007.
3. Lambert MJ. Prevention of Treatment Failure: The use of measuring, monitoring, and feedback in clinical practice. Washington DC: APA, 2010.
4. Harrow M. Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications. J Nervous Mental Dis 2007; 195: 406-414.
5. Wunderink L., Nieboer R, Wiersma D, et al. (2013) Recovery in remitted first-episode psychosis at 7 years of follow-up. J Am Med Association Psychiatry 2013; 70: 913-920.
6. Klingberg S, Wittorf A. Evidence­based psychotherapy for schizophrenic psychosis. Nervenarzt 2012; 83: 907-918.

Published: 07.04.2017
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