Thursday, August 29, 2013

For the Rest of Your Life -- Or Perhaps Not

Over on 1 boring old man (who actually is not all that boring), Mickey is writing about a post of Thomas Insel's blog yesterday --  Insel writes about how some patients do better without long-term anti-psychotic treatment.  Dr. Insel is the Director of the National Institute of Mental Health.  

So perhaps you've heard that people with certain mental disorders need to stay on their medications forever.  Certainly, some do -- they stop their medicines and each time they try that experiment they end up sick --- in the hospital, in jail, on the street, or simply festering in the basement.  But some people stop their medicines and they don't get sick, so clearly, not everyone with a given diagnosis must stay on medicines for life, but we don't have a way of knowing who needs them and who doesn't.  We know risks for populations (maybe, to read Dr. Insel's blog, we don't know them as well as we thought), yet we know nothing about a given individual until a doc stops the meds or the patient goes off them on their own.  We also know that the medicines have risks.  How much risk?  Who knows.  Here, one figure sticks: of those who remain on an older generation antipsychotic (Haldol, thorazine, prolixin) for 25 years, 68% will get tardive dyskinesia.  And that figure doesn't say anything about dose.

So read Dr. Insel's post: Antipsychotics: Taking the Long View.
And read 1 boring old man's post: surprise...

And I'll copy a part of Dr. Insel's post here:

After six months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering-off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by seven years, the discontinuation group had achieved twice the functional recovery rate: 40.4 percent vs. only 17.6 percent among the medication maintenance group. To be clear, this study started with patients in remission and only 17 of the 103 patients—21 percent of the discontinuation group and 11 percent of the maintenance group—were off medication entirely during the last two years of follow-up. An equal number were taking very low doses of medication—meaning that roughly one-third of all study patients were eventually taking little or no medication.
For me, there were three remarkable results in this study. First, the groups did not ultimately differ in their experience of symptoms: about two-thirds of each group reported significant improvement in symptoms at seven years. Second, 29 percent of the discontinuation group reported that they had also achieved a healthy outcome in work and family life—a number that should give hope to those struggling with serious mental illness. And finally, antipsychotic medication, which seemed so important in the early phase of psychosis, appeared to worsen prospects for recovery over the long-term. Or, as Patrick McGorry said in an accompanying editorial, “less is more.”2 At least for these patients, tapering off medication early seemed to be associated with better long-term outcomes.