{"id":58316,"date":"2015-07-11T13:25:08","date_gmt":"2015-07-11T17:25:08","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=58316"},"modified":"2015-07-13T23:04:57","modified_gmt":"2015-07-14T03:04:57","slug":"after-the-fact","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/07\/11\/after-the-fact\/","title":{"rendered":"after the fact…"},"content":{"rendered":"\n

The place of antipsychotics in the treatment of Psychosis remains clouded in controversy in spite of more than a half century of study, experience, and debate. Neither Kraepelin’s Dementia Praecox, a progressive deteriorating illness leading to an early death, nor Bleuler’s Schizophrenia, a defined syndrome<\/em> with multiple types<\/em>, survives as the dominant model for predicting the course of illness. We now tend to see episodes of psychosis punctuating a variable level of functional impairment over time. While traditional guidelines call for maintenance medication based on relapse prevention, long term studies document that many patients regularly discontinue the treatment. And others feel strongly that maintenance medication itself interferes with recovery. Both of these opposing recommendations are backed by studies, anecdotal case reports, passionate ideologies, and interpretations of the bias of the opposing view. Since these medication have now been around now for a lifespan we’re seeing large population surveys that bear on this controversy. This one’s from Scandanavia, a traditional resource for this big population studies: <\/p>\n

\n
Antipsychotic treatment and mortality in schizophrenia<\/a>.<\/div>\n
by Torniainen M, Mittendorfer-Rutz E, Tanskanen A, Björkenstam C, Suvisaari J, Alexanderson K, and Tiihonen J.<\/div>\n
Schizophrenia Bulletin<\/font><\/strong>. 2015 41[3]:656-663.<\/div>\n

<\/p>\n

BACKGROUND<\/font><\/strong><\/em>: It is generally believed that long-term use of antipsychotics increases mortality and, especially, the risk of cardiovascular death. However, there are no solid data to substantiate this view.<\/div>\n
METHODS<\/font><\/strong><\/em>: We identified all individuals in Sweden with schizophrenia diagnoses before year 2006 [N = 21 492], aged 17-65 years, and persons with first-episode schizophrenia during the follow-up 2006-2010 [N = 1230]. Patient information was prospectively collected through nationwide registers. Total and cause-specific mortalities were calculated as a function of cumulative antipsychotic exposure from January 2006 to December 2010.<\/div>\n
RESULTS<\/font><\/strong><\/em>: Compared with age- and gender-matched controls from the general population [N = 214920], the highest overall mortality was observed among patients with no antipsychotic exposure [hazard ratio [HR] = 6.3, 95% CI: 5.5-7.3], ie, 0.0 defined daily dose [DDD]\/day, followed by high exposure [>1.5 DDD\/day] group [HR = 5.7, 5.2-6.2], low exposure [<0.5 DDD\/day] group [HR = 4.1, 3.6-4.6], and moderate exposure [0.5-1.5 DDD\/day] group [HR = 4.0, 3.7-4.4]. High exposure [HR = 8.5, 7.3-9.8] and no exposure [HR = 7.6, 5.8-9.9] were associated with higher cardiovascular mortality than either low exposure [HR = 4.7, 3.7-6.0] or moderate exposure [HR = 5.6, 4.8-6.6]. The highest excess overall mortality was observed among first-episode patients with no antipsychotic use [HR = 9.9, 5.9-16.6].<\/div>\n
CONCLUSIONS<\/font><\/strong><\/em>: Among patients with schizophrenia, the cumulative antipsychotic exposure displays a U-shaped curve for overall mortality, revealing the highest risk of death among those patients with no antipsychotic use. These results indicate that both excess overall and cardiovascular mortality in schizophrenia is attributable to other factors than antipsychotic treatment when used in adequate dosages.<\/div>\n
<\/div>\n<\/blockquote>\n
The conclusions are relatively straight-forward. In this large cohort study, there was shortened lifespan associated with Schizophrenia, no matter how it was treated. Antipsychotic medication decreased that effect in any dose, but more·so in the low·to·moderate dose ranges [the data-set they had couldn’t address the possibility that the high dose patients had more severe illness than the others].<\/div>\n

While the implications of this study may seem to conflict with other oft·quoted papers [eg Wunderink, Harrow, etc] the outcome parameters are different – functional improvement there vs overall mortality here. Further, all of these reports can’t possibly factor in the most confounding variable of all – the unique clinical field that the patient, the clinician, and the family face at any given moment in time. So reading the blogs, the individual case reports, and the various commentaries on this topic can be confusing as they often discuss these decisons as if they fall into the domain of morality – using maintenance medication is good<\/font><\/em> as opposed to using maintenance medication is bad<\/font><\/em>.<\/p>\n

Like so many decisions in clinical medicine, there really isn’t yet an over-riding guiding principle here that I can see – no solid one-size fits all. The best advice in these circumstances is to be as informed as possible, to live with the intrinsic ambiguities, to take your best shot given the particulars of the given case,  and then be careful to follow up on the impact of the intervention. Frequently, if there is to be clarity, it will become apparent after the fact. That’s just how clinical medicine works…<\/div>\n","protected":false},"excerpt":{"rendered":"

The place of antipsychotics in the treatment of Psychosis remains clouded in controversy in spite of more than a half century of study, experience, and debate. Neither Kraepelin’s Dementia Praecox, a progressive deteriorating illness leading to an early death, nor Bleuler’s Schizophrenia, a defined syndrome with multiple types, survives as the dominant model for predicting […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-58316","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58316","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=58316"}],"version-history":[{"count":14,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58316\/revisions"}],"predecessor-version":[{"id":58350,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58316\/revisions\/58350"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=58316"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=58316"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=58316"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}