{"id":62289,"date":"2015-12-16T06:00:44","date_gmt":"2015-12-16T11:00:44","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=62289"},"modified":"2015-12-16T13:02:34","modified_gmt":"2015-12-16T18:02:34","slug":"again-2","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/12\/16\/again-2\/","title":{"rendered":"[again]…"},"content":{"rendered":"
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Clinical Outcome After Antipsychotic Treatment Discontinuation in Functionally Recovered First-Episode Nonaffective Psychosis Individuals: A 3-Year Naturalistic Follow-Up Study<\/font><\/strong><\/div>\n
by Jacqueline Mayoral-van Son, MD; Victor Ortiz-Garcia de la Foz, VTE; Obdulia Martinez-Garcia, PhD; Teresa Moreno, MD; Maria Parrilla-Escobar, MD; Elsa M. Valdizan, MD, PhDc; and Benedicto Crespo-Facorro, MD, PhD<\/div>\n
Journal of Clinical Psychiatry.<\/font><\/strong> Published online 12\/08\/2015<\/div>\n

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Objective:<\/font><\/strong><\/em> The timing of antipsychotic discontinuation in patients who have fully recovered from their initial episode of psychosis is still open to discussion. We aimed to evaluate the risk of symptom recurrence during the 3 years after antipsychotic discontinuation in a sample of functionally recovered first-episode nonaffective psychosis [FEP] patients [DSM-IV criteria] with schizophrenia spectrum disorder.<\/div>\n
Method:<\/font><\/strong><\/em> Participants in this open-label, nonrandomized, prospective study were drawn from an ongoing longitudinal intervention program of FEP from a university hospital setting in Spain. From July 2004 to February 2011, functionally recovered FEP individuals were eligible if they met the inclusion criteria of [1] a minimum of 18 months on antipsychotic treatment, [2] clinical remission for at least 12 months, [3] functional recovery for at least 6 months, and [4] stabilization at the lowest effective doses for at least 3 months. Forty-six individuals who were willing to discontinue medication were included in the discontinuation group [target group]. Twenty-two individuals opted to stay on the prescribed antipsychotic medication and therefore were included in the maintenance group [control group]. Primary outcome measures were relapse rate at 18 and 36 months and time to relapse.<\/div>\n
Results:<\/font><\/strong><\/em> The rates of relapse over the 3-year period were 67.4% [31 of 46] in the discontinuation group and 31.8% [7 of 22] in the maintenance group. The mean time to relapse was 209 [median = 122] days and 608 [median = 607] days, respectively [log rank = 10.106, P = .001]. The resumption of antipsychotic medication after the relapse occurred was associated with clinical stability and lack of further relapses. When the overall group of relapsed individuals from the 2 conditions [N = 38] was compared to those who remained asymptomatic after 3 years [N = 30], there were significant differences [P < .05] in total scores on the Scale for the Assessment of Negative Symptoms, the Clinical Global Impressions scale, and the Disability Assessment Schedule.<\/div>\n
Conclusions:<\/font><\/strong><\/em> Antipsychotic treatment discontinuation in individuals who had accomplished a functional recovery after a single psychotic episode was associated with a high risk of symptom recurrence. Relapsed individuals had a greater severity of symptoms and lower functional status after 3 years.<\/div>\n
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Trial Registration:<\/font><\/strong><\/em> ClinicalTrials.gov identifier: NCT02220504<\/a><\/div>\n
Author contributors:<\/font><\/strong><\/em> Drs Mayoral-van Son, Parrilla-Escobar, and Moreno collected clinical data. Dr Mayoral-van Son interpreted the results and drafted the manuscript. Mr Ortiz-Garcia de la Foz performed the statistical analyses and drafted the manuscript. Dr Crespo-Facorro interpreted the results and reviewed the manuscript. Drs Valdizan and Martinez-Garcia helped in the interpretation of clinical data and reviewed the manuscript. The corresponding author had access to all study data. All authors approved the final version of the manuscript.<\/div>\n
Potential conflicts of interest:<\/font><\/strong><\/em> Dr Crespo-Facorro has received honoraria for his participation as a speaker at educational events from Otsuka, Lundbeck, and Johnson & Johnson. Drs Mayoral-van Son, Valdizan, Parrilla, Moreno, and Martinez-Garcia and Mr Ortiz-Garcia de la Foz report no additional financial or other relationship relevant to the subject of this article.<\/div>\n
Funding\/support:<\/font><\/strong><\/em> The present study was conducted at the Hospital Marqu\u00e9s de Valdecilla, University of Cantabria, Santander, Spain, under the following grant support: SENY Fundaci\u00f3n<\/a> Research Grant CI 2005-0308007 and Fundaci\u00f3n Marqu\u00e9s de Valdecilla<\/a> API07\/011.<\/div>\n

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The issue of maintenance antipsychotics following the recovery from the first episode of psychosis is surrounded by a layer of controversy overdetermined by guild, commercial, and ideological biases that pervade the interpretation of almost everything said or written about it. This study from Spain just out will surely be looked at through those same lenses that make things so hard to evaluate. Since it will surely be compared to the Wunderink et al study [see persistence…<\/a>], I thought I’d post them side by side…<\/div>\n


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… and then again in a scaled-and-colored-to-match version to show the difference in parallel. For review, Wunderink et al’s initial report after two years found what has traditionally been reported – that maintenance medication had a significant positive effect on relapse rates. However, in a later follow-up, they found that the relapse rates equalized [from about three years on], and on functional testing, the patients who were not on a fixed maintenance schedule actually came out better by a respectable margin at about seven years. This new study from Spain did not replicate Wunderink’s findings:<\/div>\n
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A systematic review of studies exploring the recurrence of psychotic symptoms with antipsychotic discontinuation in first-episode nonaffective psychosis reported a weighted mean recurrence rate of 77% during the first year and more than 90% at 2 years.33 In contrast, the 1-year risk of recurrence within the medication continuation group was estimated at 3%. These estimates differed considerably from the 1-year rates of relapse in FEP patients of 61% in the discontinuation group and 26% in the continuation medication group reported by Leucht and colleagues.1 Methodological discrepancies in the study design; inclusion criteria; and duration of follow-up, diagnosis, and hospitalization rates make comparability between studies problematic. Wunderink and colleagues, exploring remitted psychotic patients, observed that relapse rates were 2 times higher in individuals who gradually tapered or discontinued medication, and that only 20% of patients could be successfully discontinued. Strikingly, those patients with an earlier reduction or discontinuation treatment strategy appear to have long-term functional gains compared with individuals who maintained treatment. Stopping antipsychotic medication has been repeatedly demonstrated as the biggest predictor of relapse in schizophrenia. It is of note that, despite most relapsed patients’ responding promptly to resuming antipsychotics, our data herein indicate that patients who suffered a relapse had a decreased functional status and a greater severity of symptomatology at 3 years compared with those patients who did not relapse.<\/font><\/strong><\/p><\/blockquote><\/div>\n

There are some real differences in the way these two studies were conducted, but the goal of the research was the same, and their take home messages were strikingly different. This study was independently funded and conducted in a single university hospital setting, getting around some of the concerns that confound this kind of clinical trial. Like most of the European Social Democracies, Spain has a National Health Service and it’s ranked as one of the more effective. As best I can tell, this was a well-conducted study. It certainly mirrors my own [admittedly limited] experience. <\/div>\n

But the general tone of the discussions about maintenance medications in psychotic illness has been so contentious for so long that it would be naive to think that any one study will bring things to any resolution. The dialog has been too divisive to expect anything to be that simple. The issues of maintenance antipsychotics, involuntary hospitalization, forced drugging<\/font><\/em>, commercialization, conflicts of interest, the medical model<\/font><\/em>, guild vs guild, the recovery<\/font><\/em> and survivor movements<\/font>, etc. have gotten all glommed up together and made productive dialog difficult at best and, at times, impossible [see persistence…<\/a>]. But the resolution between the implications of those two graphs, these two studies, isn’t a polemic difference – it’s science, a science that needs to be worked out scientifically<\/font>. <\/p>\n

As I’ve said before, I started out believing that aiming to be medication-free was the best of ideas following a psychotic episode, but my experience was different. I had believed that working together, the patient and I could identify triggers and incipient symptoms, and prevent or outrun relapses. But that was the exception rather than the rule in my [again<\/font><\/em>] limited experience. In this study, they found what I saw – that the onset of relapse occurred with little or no prodrome, and the relapse itself was more than just disruptive – it was destructive. My perspective is [again<\/font><\/em>] anecdotal, but theirs comes from a more scientific observational frame. <\/p>\n

My hope would be that this report will help isolate the practical from the ideological\/polemic battles that plague us. It would be [again<\/font><\/em>] naive to suggest all the differences would be resolved. But this one needs to be separated and thoroughly studied. One study [left graph] says maintenance antipsychotics cause harm. The other study [graph right] says maintenance antipsychotics prevent harm. That’s the kind of difference we can only work out with careful longitudinal observations…<\/font><\/em> <\/div>\n","protected":false},"excerpt":{"rendered":"

Clinical Outcome After Antipsychotic Treatment Discontinuation in Functionally Recovered First-Episode Nonaffective Psychosis Individuals: A 3-Year Naturalistic Follow-Up Study by Jacqueline Mayoral-van Son, MD; Victor Ortiz-Garcia de la Foz, VTE; Obdulia Martinez-Garcia, PhD; Teresa Moreno, MD; Maria Parrilla-Escobar, MD; Elsa M. Valdizan, MD, PhDc; and Benedicto Crespo-Facorro, MD, PhD Journal of Clinical Psychiatry. Published online 12\/08\/2015 […]<\/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-62289","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/62289","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=62289"}],"version-history":[{"count":21,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/62289\/revisions"}],"predecessor-version":[{"id":62310,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/62289\/revisions\/62310"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=62289"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=62289"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=62289"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}