7 Advances in Schizophrenia

Bret S. Stetka, MD; Christoph U. Correll, MD


January 16, 2014

In This Article

Editor's Note:
2013 saw many important advances in the understanding and management of schizophrenia and psychotic symptoms. Below, we look back at these developments, as well as at their potential impact on the practice of psychiatry in 2014 and beyond.

The Evolution of Antipsychotic Prescribing

As addressed in Medscape's 2013 psychiatry practice changers, the use of antipsychotic medications is continually under scrutiny and refinement. When used properly, these agents can be very effective; when misused or overused, they put patients at unnecessary risk for potentially serious long-term side effects.

A number of recent studies and recommendations have informed and helped optimize the use of antipsychotics. Perhaps most notable among these is the 5 recommendations[1] put forth by the American Board of Internal Medicine Foundation's Choosing Wisely® campaign. The initiative is intended to reduce unnecessary or potentially harmful medical practices. Regarding antipsychotic prescribing, it recommends the following:

1. Don't prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

2. Don't routinely prescribe 2 or more antipsychotic medications concurrently.

3. Don't use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia.

4. Don't routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

5. Don't routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

Whereas the first 4 recommendations have generally been accepted as valid and relevant, the fifth recommendation has been challenged. Although it is clearly important to avoid overuse of antipsychotics in the vulnerable pediatric population, the recommendation to restrict routine use of antipsychotics to patients with psychotic disorders neglects to acknowledge that 2 second-generation antipsychotics are approved by the US Food and Drug Administration (FDA) for the treatment of irritability and aggression in pediatric patients aged 5 or 6-17 years with autism -- the only FDA approval for any symptoms in autism -- and that 4 second-generation antipsychotics are FDA-approved for the use of mania in youth aged 10-17 years. Moreover, in meta-analyses of placebo-controlled trials[2] and in several head-to-head studies,[3] second-generation antipsychotics were significantly more effective than lithium or antiepileptic mood stabilizers for the treatment of pediatric mania.

The over- and misprescribing of psychotropic drugs needs to be addressed where present. However, data continue to support the proper use of pharmacotherapies in mental health care. Findings[4] published in 2013 in JAMA Psychiatry suggest that when used appropriately, psychotropic medications can be very effective.

The study authors analyzed FDA Summary Basis of Approval reports on over 92,000 patients with mental illness and found that although severe psychiatric illnesses, including schizophrenia and major depression, are associated with an increased mortality risk, psychotropic medication prescribed for these disorders appears to reduce this risk. Moreover, overall mortality was lower among patients with schizophrenia who were assigned to receive antipsychotics, including haloperidol and second-generation antipsychotics, compared with patients with schizophrenia who were assigned to receive placebo. The same was true for patients with depression and bipolar disorder. Altogether, treatment with modern psychotropic drugs decreased mortality risk by 25%-70%.

These results highlight the need for clinicians to (1) carefully select patients who are truly in need of treatment with antipsychotics; (2) consider psychosocial interventions instead of or in addition to antipsychotic treatments; (3) carefully select the antipsychotics -- ideally in a shared decision-making process -- for the treatment of patients' symptoms and disorders, considering their past treatment experiences, attitudes, and preferences; (4) use the lowest effective dose and shortest necessary duration of treatment, but also keep patients with relapsing conditions on appropriate long-term maintenance therapy as needed; (5) consider nonadherence as one reason for suboptimal response, worsening, relapse, or refractoriness; and (6) routinely and proactively monitor and manage antipsychotic adverse effects in order to maximize the benefit/risk ratio.


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