Better Off Without Antipsychotic Drugs?

To those of us who have practiced psychiatry for many years, the recent public attention to antipsychotic maintenance issues is a surprise. For example, on December 9, 2013, The Washington Post published the article “A Psychiatrist Thinks Some Patients Are Better Off Without Antipsychotic Drugs,”¹ as if this were a novel idea. As Yogi Berra famously put it, it’s like déjà vu all over again.

It has been known for a century that some individuals with schizophrenia recover and do not need ongoing treatment. As early as 1939, Dr Harry Stalker at the University of Edinburgh published outcome data on 3551 patients with schizophrenia. He reported that 21% were in complete remission or social remission and another 5% had improved and were living at home.²

In 1978, Dr Joseph Stephens at the Maryland Psychiatric Research Center summarized the results of 25 schizophrenia outcome studies in which the patients had been followed for at least 10 years.³ On average, 29% of the patients were in complete remission, although this varied widely among studies and depended on whether the initial sample had included large numbers of individuals with acute-onset symptoms (good outcome) or individuals with a slow onset and negative symptoms (poor outcome).

How long should patients with first-onset schizophrenia be treated? It is known, as Stalker and many other early psychiatrists noted, that some of these patients will fully recover with no treatment at all, although antipsychotic drugs appear to hasten this recovery. And there is no reason to maintain such patients on regimens of antipsychotic medication. Since we have no way of predicting for sure which first-episode patients will or will not relapse, it is generally-although not universally-accepted that such patients should be treated with antipsychotics until symptom remission, and then the medication can be slowly withdrawn. I reflected that practice in my book Surviving Schizophrenia: A Family Manual, published in 1983. I wrote: “Thus, in someone who has been diagnosed and treated for schizophrenia for the first time, it is usually safe to discontinue the drugs a few weeks after the person has recovered.”⁴

The above scenario views the glass as half full, but it is equally important to look at it as half empty. In Dr Stalker’s 1939 study, before antipsychotic drugs had been introduced, 67% of his patients were rated as “unimproved” and another 5% had died. In the later study by Stephens, the average number of patients who were rated as unimproved (“active, chronic psychosis”) 10 years later was 44%, although this varied depending on the original sample.

Antipsychotic medications improve the quality of life for most, but not all, patients with chronic schizophrenia, and most of them will require medications for many years-even for life. Thus, in Surviving Schizophrenia, I wrote that for many patients with chronic schizophrenia, “I advise them to continue taking the antipsychotic drugs for the rest of their lives, just as many diabetics have to take insulin for the rest of their lives.”

Dosage, however, is a critical issue. It seems to be sometimes forgotten today that there are huge differences in how individuals metabolize antipsychotic medication. For example, a study published in 1982 reported that when a group of patients with schizophrenia were each given 20 mg of fluphenazine, the difference between the highest and lowest blood level of the drug was 40-fold.⁵ Thus, a very low dose of an antipsychotic is sufficient to control the symptoms of many patients with schizophrenia, even if it does not produce full recovery, whereas other patients may require much higher doses to achieve the same effect.

So yes, it has been clearly established for many years that “some patients are better off without antipsychotic drugs.” However, in recent years, advocates have interpreted this to suggest that most individuals with schizophrenia are better off without antipsychotic drugs. Some have even argued that the antipsychotic drugs themselves cause many of the psychotic symptoms.

For the past half century, we have been witnessing a grand, unplanned experiment on the outcome of untreated schizophrenia. Since we began deinstitutionalizing patients from state mental hospitals in the 1960s, studies have shown that approximately half of all individuals with serious mental illness are untreated at any given time.⁶ According to the NIMH, there are approximately 2.6 million adults with active schizophrenia in the US, which means that approximately 1.3 million are not being treated. The results of this grand, unplanned experiment to ascertain the outcome of untreated schizophrenia are now available in homeless shelters, on the streets, in public libraries and bus stations, and in the jails and prisons where many of these untreated individuals have ended up. The experiment, to say the least, has not been a success.

There is general agreement that some individuals with schizophrenia are better off without antipsychotic drugs. But, there should also be general agreement that many other individuals with schizophrenia are better off taking antipsychotic drugs long-term. As Dr Darold Treffert⁷ put it:

It is not “freedom” to be wandering the streets, severely mentally ill, deteriorating and getting warmth from a steam grate or food from a garbage can; that’s abandonment. And it is not “liberty” to be in a padded jail cell instead of a hospital, hallucinating and delusional, without treatment because that is all the law will allow.

Disclosures:

Dr Torrey is a research psychiatrist who specializes in schizophrenia and bipolar disor-der. He is founder of the Treatment Advocacy Center and Associate Director of the Stanley Medical Research Institute, which supports research on schizophrenia and bipolar disorder, and he is Professor of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md. He is the author of American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Steingard S. A psychiatrist thinks some patients are better off without antipsychotic drugs. Washington Post. December 9, 2013.

2. Stalker H. The prognosis in schizophrenia. J Mental Sci. 1939;85:1224-1240.

3. Stephens JH. Long-term prognosis and followup in schizophrenia. Schizophr Bull. 1978;4:25-47.

4. Torrey EF. Surviving Schizophrenia: A Family Manual. New York: Harper and Row; 1983:116.

5. Fluphenazine levels: long and short. Biol Ther Psychiatry Newslett. 1981;4:33-34.

6. Kessler RC, Berglund PA, Bruce ML, et al. The prevalence and correlates of untreated serious mental illness. Health Serv Res. 2001;36(6, pt 1):987-1007.

7. Treffert DA. 1995 Wisconsin Act 292: finally, the fifth standard. Wis Med J. 1996;95:537-540.