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Does Treatment of Schizophrenia with Antipsychotic Medications Eliminate Or Reduce Psychosis? a 20-Year Multi-Follow-Up Study

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Does Treatment of Schizophrenia with Antipsychotic Medications Eliminate Or Reduce Psychosis? a 20-Year Multi-Follow-Up Study Psychological Medicine, Page 1 of 10. © Cambridge University Press 2014 ORIGINAL ARTICLE doi:10.1017/S0033291714000610 Does treatment of schizophrenia with antipsychotic medications eliminate or reduce psychosis? A 20-year multi-follow-up study M. Harrow*, T. H. Jobe and R. N. Faull Department of Psychiatry, University of Illinois College of Medicine, Chicago, IL, USA Background. This research assesses whether multi-year treatment with antipsychotic medications reduces or eliminates psychosis in schizophrenia. It provides 20 years of longitudinal data on the frequency and severity of psychotic activity in samples of schizophrenia patients (SZ) treated versus those not treated with antipsychotic medications. Method. A total of 139 early young schizophrenia and mood-disordered patients were assessed at index hospitalization and then reassessed six times over 20 years for psychosis and other major variables. Results. At each follow-up assessment over the 20 years, a surprisingly high percentage of SZ treated with antipsycho- tics longitudinally had psychotic activity. More than 70% of SZ continuously prescribed antipsychotics experienced psychotic activity at four or more of six follow-up assessments over 20 years. Longitudinally, SZ not prescribed antipsychotics showed significantly less psychotic activity than those prescribed antipsychotics (p<0.05). Conclusions. The 20-year data indicate that, longitudinally, after the first few years, antipsychotic medications do not eliminate or reduce the frequency of psychosis in schizophrenia, or reduce the severity of post-acute psychosis, although it is difficult to reach unambiguous conclusions about the efficacy of treatment in purely naturalistic or observational research. Longitudinally, on the basis of their psychotic activity and the disruption of functioning, the condition of the majority of SZ prescribed antipsychotics for multiple years would raise questions as to how many of them are truly in remission. Received 6 August 2013; Revised 30 October 2013; Accepted 2 November 2013 Key words: Antipsychotic medications, longitudinal, psychosis, schizophrenia, treatment. Introduction antipsychotics are important for continued stability and keep SZ on antipsychotics indefinitely. Does continuous multi-year treatment with antipsy- A major issue is the lack of evidence of long-term chotic medications reduce or eliminate psychosis and (>3 years) treatment with antipsychotic medications are the results superior to a non-medicated sample? and whether, as ’antipsychotics’, they reduce or elimin- Despite these medications being viewed as ’antipsycho- ate psychosis. Optimistic views by the World Psychiatric tics’, their long-term effectiveness in eliminating psy- Association (WPA) Pharmacopsychiatry Section note chosis in schizophrenia patients (SZ) is still unknown. that: ’Antipsychotic treatment has a significant impact Antipsychotic medications are seen as the cornerstone on the long-term course of schizophrenic illness and for the short- and long-term treatment of SZ, based on can significantly facilitate recovery’ (Tandon et al. 2008, their action reducing the period of intense psychosis p. 31). However, in a comprehensive review of the very during acute hospitalization, and on the numerous many double-blind studies, Leucht et al. (2012) noted 6-month to 2-year double-blind studies of schizo- that ’nothing is known about the effects of antipsychotic phrenia out-patients (Gilbert et al. 1995; Davis et al. drugs compared to placebo after three years’. 2003; Buchanan et al. 2010). American Psychiatric Research by us and other investigators has begun to Association (APA) guidelines (Lehman et al. 2004) indi- question the long-term effectiveness of antipsychotics. cate clinicians should consider discontinuing anti- This research has produced clear evidence of subsam- psychotics for SZ who are symptom free for a year ples of SZ who, on a long-term basis, show favorable or longer. However, many clinicians assume that outcomes without prolonged antipsychotic treatment (Bleuler, 1978; Fenton & McGlashan, 1987; Harding et al. 1987; Harrow et al. 2005, 2012; Harrow & Jobe, * Address for correspondence: M. Harrow, Ph.D., Department of Psychiatry, University of Illinois at Chicago, 1601 W. Taylor Street 2007, 2013; Jablensky & Sartorius, 2008). (M/C 912), Chicago, IL 60612, USA. The current multi-follow-up research used 20-year (Email: [email protected]) longitudinal data, collected prospectively, at multiple 2 M. Harrow et al. times, at systematic intervals for treated and untreated Table 1. Schizophrenia patients (SZ) prescribed antipsychotic SZ, and focused on psychosis, assessing: (1) How fre- medications at each follow-up over the 20 years of assessments quently over a 20-year period do SZ treated with anti- psychotics experience psychosis? (2) For those SZ Antipsychotic No experiencing psychosis while being treated with anti- medications Other psychiatric psychotics, how severe are the psychotic symptoms? with or without psychiatric medications (3) Is the psychosis less severe than that of SZ not in Follow-up other medications prescribed treatment? (4) How effective is antipsychotic treatment Year medications (%) (%) (%) over time for mood-disordered patients who were psychotic at the acute phase? 2 67 5 28 4.5 66 9 25 7.5 63 14 23 10 62 10 28 Method 15 66 3 31 Sample and 20-year follow-up schedule 20 62 9 29 At a relatively early phase in their disorder, 139 young patients were assessed prospectively at the acute phase of hospitalization as part of the Chicago Follow-up scale (1958) for socio-economic status (SES), 53% Study, a prospectively designed, longitudinal, multi- were from households with SES of 1–3 (higher follow-up research program (Harrow et al. 1990, 1994, SES) and 47% were from households with SES of 4–5 2005, 2012; Harrow & Jobe, 2010, 2013; Jobe & (lower SES). The research received Institutional Harrow, 2010). These patients were then reassessed Review Board approval from the University of Illinois at five or six subsequent follow-ups over the next at Chicago, and informed consent was obtained from 20-year period by trained interviewers who were not all participants. informed of their diagnosis or of the results of previous follow-ups. The assessments, which included struc- Antipsychotic medications tured research interviews [the Schedule for Affective Disorders and Schizophrenia (SADS); Endicott & Table 1 presents data on the percentage of SZ pre- Spitzer, 1978] and a functioning interview, occurred scribed antipsychotics and those not prescribed medi- at index hospitalization, and at 2, 4.5, 7.5, 10, 15 and cations at each follow-up assessment. Typically, as 20 years post-index hospitalization. occurs in the natural course of psychotic patients, The sample of 139 DSM-III-diagnosed patients in- there was no single uniform treatment plan that ap- cluded 70 patients with schizophrenia spectrum disor- plied to all patients. ders (61 SZ and nine schizo-affective patients). After At the 20-year assessments, 62% of SZ were prescribed structured research interviews at index hospitalization, antipsychotics with or without other medications and satisfactory inter-rater reliability for diagnosis was another 9% were prescribed other medications. For obtained for the SZ sample (k=0.88). We also assessed those SZ prescribed antipsychotics, the median dose a control sample of 69 patients with mood disorders, prescribed at the 10-year follow-ups was 575 chlorpro- all of whom were psychotic at index hospitalization. mazine (CPZ) equivalent units, and at the 15-year All SZ met the 6-month duration of illness criteria follow-ups 500 CPS equivalent units for first- and (none were schizophreniform patients). From among second-generation antipsychotics (Gardner et al. 2010), the 70 SZ, 59 were assessed at the 20-year follow-ups. which is consistent with the Schizophrenia Patient Out- The other 11 SZ were assessed at all of the first five comes Research Team (PORT) guidelines (Buchanan follow-ups, including the 15-year follow-ups. The 69 et al. 2010). At the 20-year assessments, 28% of the non-schizophrenia patients included 38 psychotic bi- mood-disordered patients were prescribed antipsycho- polar patients and 31 psychotic unipolar depressives. tics and 37% were prescribed other medications but Within the limits of studying relatively young patients not antipsychotics. (mean age at index hospitalization was 23 years), the In addition, 25 of the SZ were prescribed antipsycho- sample comprised consecutive admissions to two tic medications at every one of the follow-up assess- Chicago hospitals (a private hospital and a state hospi- ments (group 1), and another 24 SZ were prescribed tal). At index hospitalization, 41% of the patients were antipsychotic medications at some, but not all, follow- first admissions and another 25% had only one previous ups (group 2). Another 15 SZ were not on antipsycho- hospitalization. The median level of education at index tics at any of the follow-up assessments (starting at hospitalization was 13 years. Fifty-one per cent of the the 2-year follow-ups) over the 20 years (group 3). sample were males. Using the Hollingshead–Redlich Six other SZ had a 20-year follow-up but had less Continuous antipsychotic treatment of psychosis 3 100 76% 78% 71% 75 56% 50 27% 24% 25 20% 17% % SZ with psychotic activity 0 4.5 yr 10 yr 15 yr 20 yr Fig. 1. Longitudinal comparisons of psychosis in medicated (▪) and unmedicated ( ) schizophrenia patients (SZ). than four follow-up assessments
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