Two pieces of research have been published over the last two years that should prompt a major reorientation of the treatment of schizophrenia and psychosis, and a fundamental reappraisal of the use of antipsychotic drugs in general. Put together, these studies suggest that the standard approach to treating serious mental health problems may cause more harm than good. Long-term treatment with antipsychotic drugs has adverse effects on the brain, and may impair rather than improve chances of recovery for some. Many people ask me how the psychiatric profession has responded to this data. Surely, they think, it must have stimulated a major debate within the profession, and some critical reflection about why it took so long to recognise these worrying effects? Sadly, this does not appear to be happening.
I have described both of these studies in detail in previous blogs. Briefly, in 2012 the research group led by Nancy Andreasen, the former editor of the American Journal of Psychiatry, published results of a brain scanning study of people diagnosed with schizophrenia or psychosis. The study found that people’s brains shrank over time in proportion to the amount of antipsychotic drugs they had been exposed to. The report concluded that ‘antipsychotics have a subtle but measurable influence on brain tissue loss over time‘ (1)(p 128). The study confirmed that the brain shrinkage observed in animals (2) also occurs in humans.
We don’t know whether these observed effects of antipsychotic treatment are temporary or permanent, and we don’t know whether they have any functional implications. In other words we don’t know whether the brain shrinkage is associated with intellectual decline or other brain-based abnormalities. The evidence is conflicting, with some studies suggesting there is no impact on mental ability (3), but worryingly, other studies, including Andreasen’s study, indicate that there may be an association between reduced brain volume and some cognitive or mental deterioration (4;5). It is obviously a worrying possibility.
The second game changing publication was the paper reporting the seven year follow up results of the Dutch antipsychotic discontinuation study (6). This study, conducted with people who had recovered from a first episode of psychosis, found that people randomised to a flexible and gradual antipsychotic discontinuation strategy were twice as likely to show a full social recovery than those who were allocated to continuous (maintenance) antipsychotic treatment. Moreover, relapses, which had been higher in the discontinuation group at 18 month follow up, had equalised.
As I have said elsewhere, I am not against the use of these drugs altogether, but these studies suggest that antipsychotics are bad for the brain and can reduce people’s social functioning when used continuously over long periods. When I present these findings to audiences of non-psychiatrists, they are shocked that the drugs can continue to be so freely used in the face of this evidence. ‘How can this be ethically justified?’ someone commented at a recent meeting I attended.
When people ask me how psychiatrists have responded, I have, up to now, tried to give my profession the benefit of the doubt. Some leading psychiatrists have been publicly critical of the overhyping of antipsychotics (7) and there are undoubtedly many others who are concerned about these research findings and trying to avoid antipsychotic drug treatment if possible, and use low doses for short periods where not. I have expressed the hope that as this research becomes more widely known, others will follow suit.
My illusions were recently shattered, however, by the Royal College of Psychiatrists’ conference planning committee. I proposed a symposium for the 2014 annual conference entitled ‘Re-evaluating antipsychotics- time to change practice?’ I invited Lex Wunderink, the first author of the Dutch study, to discuss his study, along with a leading British psychiatrist involved in brain scanning studies of people with schizophrenia. I was confident the symposium would be accepted, because obviously, I thought, the conference committee would recognise the importance of this research, and want to ensure it was widely publicised to, and debated by, members of the profession.
To my astonishment it was rejected. I wrote to the conference organiser to ask why, pointing out that patients, carers and the general public are wondering what the profession is doing about these research findings. They would be most surprised to know that the profession did not consider the results sufficiently interesting to merit discussion at the principal meeting of UK psychiatrists. She replied that there were too many competing suggestions. So I asked if any of the symposia selected covered these same areas of research. I did not get a reply.
Surely, these findings are so momentous they deserve a whole conference in themselves? Every department of psychiatry around the country should be considering the implications of these studies, and be thinking about how psychiatric practice should change as a result. Yet the representative body of UK psychiatrists feels the evidence is not worthy of an hour and a half’s discussion at its annual conference.
Although I would like to believe it is was an aberration, I fear that the conference committee’s view is a barometer of the profession’s general attitude. It seems not to be interested in discussing the serious harm its drugs can do to both physical and mental health, and in taking the steps necessary to minimise this harm. The profession appears to believe that if it keeps quiet about these inconvenient findings, and discusses them as little as possible, the fuss will blow over and nothing need change.
It is disgraceful that the profession is not taking these findings more seriously, but sadly not unprecedented. In the 1970s, the profession was accused of being ‘completely unconcerned’ about emerging evidence on the association between antipsychotic use and the syndrome of brain damage called ‘tardive dyskinesia’ (8).
At best psychiatry appears indifferent and complacent. At worst it is subconsciously attempting to hush up inconvenient data, so that, along with its partner, the pharmaceutical industry, it can continue ‘business as usual.’ Either way, it appears that the critics are right: the profession has its head firmly in the sand.
(1) Ho BC, Andreasen NC, Ziebell S, Pierson R, Magnotta V. Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia. Arch Gen Psychiatry 2011 Feb;68(2):128-37.
(2) Dorph-Petersen KA, Pierri JN, Perel JM, Sun Z, Sampson AR, Lewis DA. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. Neuropsychopharmacology 2005 Sep;30(9):1649-61.
(3) DeLisi LE, Hoff AL, Schwartz JE, Shields GW, Halthore SN, Gupta SM, et al. Brain morphology in first-episode schizophrenic-like psychotic patients: a quantitative magnetic resonance imaging study. Biol Psychiatry 1991 Jan 15;29(2):159-75.
(4) Gur RE, Turetsky BI, Bilker WB, Gur RC. Reduced gray matter volume in schizophrenia. Arch Gen Psychiatry 1999 Oct;56(10):905-11.
(5) Gur RE, Turetsky BI, Bilker WB, Gur RC. Reduced gray matter volume in schizophrenia. Arch Gen Psychiatry 1999 Oct;56(10):905-11.
(6) Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial. JAMA Psychiatry 2013 Jul 3.
(7) Tyrer P. From the Editor’s desk. British Journal of Psychiatry 2012;201:168.
(8) Crane GE. Clinical psychopharmacology in its 20th year. Late, unanticipated effects of neuroleptics may limit their use in psychiatry. Science 1973 Jul 13;181(4095):124-8.