{"id":58449,"date":"2015-07-22T07:02:14","date_gmt":"2015-07-22T11:02:14","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=58449"},"modified":"2015-07-22T18:00:58","modified_gmt":"2015-07-22T22:00:58","slug":"wandering-wondering-wunderink","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/07\/22\/wandering-wondering-wunderink\/","title":{"rendered":"<strike>wandering, wondering,<\/strike> wunderink&#8230;"},"content":{"rendered":"<div align=\"justify\" class=\"small\">If you read the blogs, you&#8217;re likely familiar with the Wunderink Clinical Trial [<a href=\"http:\/\/archpsyc.jamanetwork.com\/article.aspx?articleid=1707650\" target=\"_blank\">Recovery  in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early  Dose Reduction\/Discontinuation or Maintenance Treatment Strategy<\/a>]. It has been reviewed by many including NIMH Director Tom Insel [<a target=\"_self\" href=\"http:\/\/www.nimh.nih.gov\/about\/director\/2013\/antipsychotics-taking-the-long-view.shtml\">Antipsychotics: Taking the Long View<\/a>], MedScape [<a target=\"_blank\" href=\"http:\/\/www.medscape.com\/viewarticle\/807894\">Antipsychotics in First-Episode Psychosis: Less Is More<\/a>], Sandra Steingard [<a href=\"http:\/\/www.washingtonpost.com\/national\/health-science\/a-psychiatrist-thinks-some-patients-are-better-off-without-antipsychotic-drugs\/2013\/12\/06\/547f5680-48aa-11e3-a196-3544a03c2351_story.html\" target=\"_blank\">A psychiatrist thinks some patients are better off without antipsychotic drugs<\/a>], me [<a href=\"http:\/\/1boringoldman.com\/index.php\/2015\/05\/14\/persistence-2\/\" target=\"_blank\">persistence&hellip;<\/a>], and many others [see <a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/08\/20\/well-worth-reading\/\">well worth reading&hellip;<\/a>]. These three editorials in BJPsych Advances offer somewhat differing views on this study and its meanings:             <\/div>\n<ul><span class=\"small\">                    <\/p>\n<li>\n<div align=\"justify\"><strong><font color=\"#200020\">Long-term effects of antipsychotics<\/font><\/strong><\/div>\n<div align=\"justify\">Joanna Moncrieff<\/div>\n<div align=\"justify\"><font color=\"#660033\"><em>BJPsych Advances<\/em><\/font> March 2015, 78-79. DOI: 10.1192\/apt.bp.114.012591<\/div>\n<\/li>\n<li>\n<div align=\"justify\"><strong><font color=\"#200020\">Early schizophrenia: skilful management of medication<\/font><\/strong><\/div>\n<div align=\"justify\">John Cookson<\/div>\n<div align=\"justify\"><font color=\"#660033\"><em>BJPsych Advances<\/em><\/font> March 2015, 80-84. DOI: 10.1192\/apt.bp.114.013359<\/div>\n<\/li>\n<li>\n<div align=\"justify\"><strong><font color=\"#200020\">Patients need reliable facts and figures about antipsychotics<\/font><\/strong><\/div>\n<div align=\"justify\">Stephen M. Lawrie<\/div>\n<div align=\"justify\"><font color=\"#660033\"><em>BJPsych Advances<\/em><\/font> March 2015, 85-87. DOI: 10.1192\/apt.bp.114.013375<\/div>\n<\/li>\n<p>                    <\/span><\/ul>\n<table width=\"95%\" cellspacing=\"0\" cellpadding=\"0\" border=\"0\" align=\"center\">\n<tr>\n<td>\n<div align=\"justify\"><sup><em>If I put the titles of these papers in Google&reg;, and select the BJPA link, I get full text. But if I try to use the link, it takes me to their pay wall. I suggest you try my <strong><font color=\"#200020\">title&middot;into&middot;Google&reg;<\/font><\/strong> method. The articles are short and make an interesting read as a trio.<\/em><\/sup><\/div>\n<\/td>\n<\/tr>\n<\/table>\n<p>         <\/p>\n<div align=\"justify\" class=\"small\"><font color=\"#200020\">Dr. Joanna Moncrieff<\/font> is the co-chairman of the <a href=\"http:\/\/www.criticalpsychiatry.co.uk\/\" target=\"_blank\">Critical Psychiatry Network<\/a>, a foreign correspondant on <a href=\"http:\/\/www.madinamerica.com\/author\/jmoncrieff\" target=\"_blank\">Mad in America<\/a>, and the author of <a target=\"_blank\" href=\"http:\/\/www.amazon.com\/Bitterest-Pills-Troubling-Antipsychotic-ebook\/dp\/B00FJYJTQI\/ref=sr_1_1?ie=UTF8&#038;qid=1382370105&#038;sr=8-1&#038;keywords=the+bitterest+pills\">The Bitterest Pills<\/a>, <a target=\"_blank\" href=\"http:\/\/www.palgrave.com\/products\/title.aspx?PID=283272\">The Myth of the Chemical Cure<\/a>, and <a target=\"_blank\" href=\"http:\/\/www.pccs-books.co.uk\/product.php?xProd=463&#038;xSec=1&#038;jssCart=951d6cfb50d466e4f830c58cadfd75d6\">A Straight Talking Introduction to Psychiatric Drugs<\/a>. Her writings are heavily referenced in the <em><font color=\"#200020\">British Psychological Society<\/font><\/em>&#8216;s Report, <a target=\"_blank\" href=\"https:\/\/www.bps.org.uk\/system\/files\/user-files\/Division%20of%20Clinical%20Psychology\/public\/understanding_psychosis_-_final_19th_nov_2014.pdf\">Understanding Psychosis and Schizophrenia<\/a> in the section on <a href=\"https:\/\/www.bps.org.uk\/system\/files\/user-files\/Division%20of%20Clinical%20Psychology\/public\/understanding_psychosis_-_final_19th_nov_2014.pdf#page=98\" target=\"_blank\">Medication<\/a>. She regularly writes of her concern that long term use of antipsychotic medication can cause brain damage [see <a href=\"http:\/\/joannamoncrieff.com\/2013\/12\/13\/antipsychotics-and-brain-shrinkage-an-update\/\" target=\"_blank\">Antipsychotics and brain shrinkage: an update<\/a>], a point she also emphasized in this editorial. After summarizing the results of the Wunderlink Trial, she concludes:<\/div>\n<blockquote>\n<div align=\"justify\">Antipsychotics can effectively reduce acute psychotic symptoms in many people, but evidence on the benefits of long-term treatment is more equivocal, and recent evidence underlines their potentially negative effect on brain volume, alongside other serious physical complications. NICE [2014] recommends more research into long-term outcomes of antipsychotic discontinuation. In the meantime, recent evidence suggests that a trial of supported antipsychotic discontinuation should be considered as one option in the routine treatment of people with psychotic conditions. This strategy may help some people to improve their functioning and quality of life, and reduce the risks to their physical health.<\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\"><font color=\"#200020\">Dr.. Stephen Lawrie<\/font> is a Neuro-Imaging researcher at thr University of Edinburgh who has done some industry-funded research. After reviewing the known risk\/benefit profile of the antipsychotics and countering some of Dr. Moncrieff&#8217;s points, he presented a close reading of the Wunderink study, noting among other things that&#8230;<\/div>\n<blockquote>\n<div align=\"justify\">Only about 20% of those in the dose reduction\/discontinuation group actually managed to discontinue their antipsychotic medication at all. There were no actual differences between the dose reduction\/discontinuation and maintenance treatment groups in social function or quality of life, and the mean dose of antipsychotic over the previous 2 years was only about 1.5 mg different in haloperidol equivalents [~2 mg v. ~3.5 mg daily]. In the final analysis, only 8 individuals in the dose reduction\/discontinuation group and 3 in the maintenance treatment group had sustained antipsychotic discontinuation during the 7-year follow-up.<\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\">He goes on to conclude&#8230;<\/div>\n<blockquote>\n<div align=\"justify\">What it actually shows is that antipsychotic discontinuation is rarely feasible and that slow tapering of the dose down to an average of about 2 mg haloperidol equivalents is associated with some measures of functional improvement. Indeed, the results are entirely in keeping with treatment guidelines which suggest that antipsychotic medication should be maintained for 2 years and then phased withdrawal attempted. What the trial suggests we really need is not new strategies for managing antipsychotic treatment after a first episode, but a way of identifying the small number of patients who can manage without antipsychotics.<\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\"><font color=\"#200020\">Dr. John Cookson<\/font> is a Consultant Psychiatrist at the The Royal London Hospital. He begins with&#8230;<\/div>\n<blockquote>\n<div align=\"justify\">The enthusiastic embrace by Moncrieff of Wunderink et al&rsquo;s 7-year follow-up of a 2-year randomised controlled trial of treatment for first-episode psychosis is understandable. But any eagerness to dismiss the usefulness of long-term treatment with antipsychotics is premature. The results are counter-intuitive and seem to have puzzled the authors themselves and to invite speculative explanations.       <\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\">He reviews the history of the studies supporting long term maintenance and Wunderink&#8217;s paper. I found this article&#8217;s logic harder to follow and summarize and leave it for&nbsp; you to reach your own conclusions. He ends with&#8230;<\/div>\n<blockquote>\n<div align=\"justify\">The main finding of the Wunderink et al study is that after 7 years, 30 people from the original 128 with a first episode of non-affective psychosis were identified as being in recovery, with symptomatic and functional remission; of these, 25 were on no medication at that time. This group represented about half of the patients eligible for the study. The findings tell us that skilful management of medication is important in helping patients to achieve more complete remission of functional impairments after a diagnosis of schizophrenia-like illness.<\/div>\n<p>      <\/p>\n<div align=\"justify\">It remains advisable for  patients with a first episode of schizophrenia or other non-affective  psychosis to continue on medication for at least 1 year after remission  of the episode and\/or discharge from hospital. A proportion of patients  who remain well 1 year later may not require further antipsychotic  medication, but there is no reliable way of identifying these, other  than by a gradual discontinuation of medication. Those with a longer  initial DUI or with comorbid substance misuse are less likely to remain  well for long without medication. For those requiring medication to  remain well, adherence is important; the medication is not effective  unless it is taken, and side-effects must be recognised. The management  of dosage, choice of antipsychotic and achievement of adherence require  close clinician&ndash;patient relationships with skilful clinical management,  as does advice to the families and carers.&nbsp;<\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\"><img decoding=\"async\" width=\"90\" border=\"0\" hspace=\"4\" align=\"right\" src=\"http:\/\/1boringoldman.com\/images\/rorschach.gif\" \/>Wunderink is one of those studies that gets discussed and analyzed over and over &#8211; something of a <em><font color=\"#200020\">Rorschach ink&middot;blot<\/font><\/em> for the pre-existing opinion of the reader. Those who&nbsp; are opposed to maintenance antipsychotic treatment point to the greater functional recovery in the group of patients in the reduction\/discontinuation group at seven years. Those who support maintenance antipsychotic treatment note that very few patients could actually get off of antipsychotics entirely in either group of this study. The patients in the reduction\/discontinuation group were on a lower mean dose in the years following the original 18 month study, suggesting that the improved functional recovery might be related to the lower dosing regimens.<\/div>\n<p align=\"justify\" class=\"small\">I must say that my own limited and anecdotal experience mirrors these results somewhat. I left training with the attitude that lower<em><font color=\"#200020\">&middot;<\/font><\/em>dose or better-yet, medication<em><font color=\"#200020\">&middot;<\/font><\/em>free, was the laudable goal, but wasn&#8217;t altogether able to bring it off. Getting people medication<em><font color=\"#200020\">&middot;<\/font><\/em>free was invariable followed by relapse, and I settled for the  lower<em><font color=\"#200020\">&middot;<\/font><\/em>dose route unless directed otherwise by the patient&#8217;s choice. Those selecting medication<em><font color=\"#200020\">&middot;<\/font><\/em>free either restarted medication or relapsed and ended up on a higher dose. In theory, perhaps, relapse is not necessarily a bad thing, but in practice, it was a major disruption in the interpersonal and vocational lives of the patients I followed. A couple sustained medication<em><font color=\"#200020\">&middot;<\/font><\/em>free<em><font color=\"#200020\">&middot;<\/font><\/em>ness, but it was way late in the game.  <\/p>\n<div align=\"justify\" class=\"small\">Wunderink&#8217;s study raises questions, but doesn&#8217;t  necessarily answer them. It&#8217;s partially the reason I found that section  [Section 12 on Medication] of the <em><font color=\"#200020\">British Psychological Society<\/font><\/em>&#8216;s Report, <a target=\"_blank\" href=\"https:\/\/www.bps.org.uk\/system\/files\/user-files\/Division%20of%20Clinical%20Psychology\/public\/understanding_psychosis_-_final_19th_nov_2014.pdf#page=98\">Understanding Psychosis and Schizophrenia<\/a> and Dr. Moncrieff&#8217;s editorial as more polemic than science-based. While I might share their sentiment, we don&#8217;t treat patients by sentiment. And one thing about Wunderink&#8217;s cohort &#8211; they were patients who came for follow-up unlike most other studies. By my reckoning, the studies that report on psychotic patients continuing on medications invariably show that most don&#8217;t [eg CATIE], in spite of what the various guidelines recommend. So while so many papers end with a call for further research, Wunderink&#8217;s final words are, in this case, mandatory in my book to adequately anchor any conclusions from this trial:<\/div>\n<blockquote>\n<div align=\"justify\">Of  course, only one study indicating advantages of a DR strategy in  patients with remitted FEP is not enough evidence in such an important  matter. However, these results merit replication by other research  groups.<\/div>\n<\/blockquote>\n","protected":false},"excerpt":{"rendered":"<p>If you read the blogs, you&#8217;re likely familiar with the Wunderink Clinical Trial [Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction\/Discontinuation or Maintenance Treatment Strategy]. It has been reviewed by many including NIMH Director Tom Insel [Antipsychotics: Taking the Long View], MedScape [Antipsychotics in First-Episode Psychosis: Less Is [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","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_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-58449","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58449","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=58449"}],"version-history":[{"count":40,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58449\/revisions"}],"predecessor-version":[{"id":58492,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58449\/revisions\/58492"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=58449"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=58449"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=58449"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}