Category Archives: Psychiatry

Effectiveness of Antipsychotics – Schizophrenia Vs Psychiatric Medicines

During my medical training I did three months of community psychiatry.

It was valuable time.

Among the most shocking experiences in that time was the visit I made to a share house for people with severe mental illness, often schizophrenia.

These were the type of people whom you could tell were mentally ill. They just looked the part.

Many had clear-cut cigarette stains on their fingers – even the younger ones.

They were listless with vacant stares. Some mumbled as they walked or sat.

But worst of all was their slow, staggering walking, and the regular twitches and twists of their faces and tongues.

It was this last sign that struck me the most, because this was not in fact a sign of mental illness, but rather a sign of being on anti-psychotic medication, often at high-dose, and long-term. A tragic, visible and socially awkward side-effect with the polite medical term, dystonia.

Many were on court-ordered injections of their anti-psychotic medication. They would never get off it.

Even those people that somehow came off this medication, would find that the dystonias would be permanent, marking them out as ‘different’ forever.

Now this was in the 1990s when there were new anti-psychotics coming out that were meant to cause less of these side-effects. Less, but not zero. They all had some sort of problems.

So in trying to come to grips with this iatrogenic (doctor-caused) damage I did ask myself the key question, “Did they need this medication, or could we reduce it or even stop it altogether?”

I can’t say I cut back their medication much at all.

However it set me to thinking and research, and the answers I found back then disturbed me. They were part of my deliberate decision to avoid psychiatry when I looked at becoming a counsellor.

So now in 2012 a friend sent me an article that brings these memories back to me and revives that question:

“Did those people need that anti-psychotic medication?”

Well here is an official answer:

The British Journal of Psychiatry (2012) 201: 83-84 doi: 10.1192/bjp.bp.112.112110

Recent evidence from systematic reviews and meta-analyses suggests that the efficacy and effectiveness of antipsychotics to produce clinically meaningful benefits for people with psychotic disorders have been overestimated. A meta-analysis showed that although there may be demonstrable effects of antipsychotics in comparison with placebo, the improvements over placebo are not as great as previously thought:1 the average change in symptoms rated with the Positive and Negative Syndrome Scale (PANSS) attributable to antipsychotics did not meet an empirically derived threshold for minimal clinical improvement,2 and only 17–22% experienced an important benefit (significant improvement or prevention of relapse) which could be attributed to the drugs rather than to placebo effects or natural recovery. A subsequent systematic review concluded that the improvements claimed for antipsychotics, old and new, are of questionable clinical relevance,3 with most trials failing to demonstrate even minimal improvement measured using the PANSS. There is also growing recognition that there is no discernible difference in effectiveness between first- and second-generation antipsychotics, supported by evidence from a recent meta-analysis.4 It is also relevant that there is evidence from double-blind trials in healthy volunteers that antipsychotic medication can result in secondary negative symptoms.5″

Or when put into non-medical jargon:

“Recent evidence from systematic reviews and meta-analyses suggests that the efficacy and effectiveness of antipsychotics to produce clinically meaningful benefits for people with psychotic disorders have been overestimated.”

Translation: Ooops. We goofed.

A meta-analysis showed that although there may be demonstrable effects of antipsychotics in comparison with placebo, the improvements over placebo are not as great as previously thought: …

Translation: These are not the ‘cures’ we claimed they were.

… the average change in symptoms rated with the Positive and Negative Syndrome Scale (PANSS) attributable to antipsychotics did not meet an empirically derived threshold for minimal clinical improvement …

Translation: The drugs are largely useless – but the research papers look good!

… and only 17–22% experienced an important benefit (significant improvement or prevention of relapse) which could be attributed to the drugs rather than to placebo effects or natural recovery.

Translation: 80% of people were wasting their time taking these.

A subsequent systematic review concluded that the improvements claimed for antipsychotics, old and new, are of questionable clinical relevance,3 with most trials failing to demonstrate even minimal improvement measured using the PANSS.

Translation: The fact that these drugs are close to useless is so important/surprising/horrifying, we had to find a way to say it again.

There is also growing recognition that there is no discernible difference in effectiveness between first- and second-generation antipsychotics, supported by evidence from a recent meta-analysis.

Translation: Forget the hype. The newer drugs are just as useless as the older ones.

It is also relevant that there is evidence from double-blind trials in healthy volunteers that antipsychotic medication can result in secondary negative symptoms.

Translation: The drugs can even CAUSE the same problems they were meant to treat!

I learned my psychiatry in the 1990s during what was called the “Decade of the Brain”: a big time for research into neurology, neurochemistry and putting psychiatry onto a proper medical footing.

Unfortunately what that decade should have taught us instead was … humility.