How can medication help?
Many people find neuroleptic medication helpful, particularly in acute crises when experiences can feel overwhelming. They can reduce the intensity of experiences and help make them less distressing. Some people also find them helpful for a period afterwards, or even long-term, to make the experiences feel more manageable and reduce the likelihood of them increasing in severity or intensity.
Whilst there is no doubt that many people find neuroleptic drugs helpful, there is some controversy over how they work. Many appear to affect the neurotransmitter (brain chemical) dopamine, and they are sometimes thought of – and often promoted by pharmaceutical companies – as specific treatments for specific illnesses, perhaps by correcting some sort of chemical imbalance. However, this idea is contested, and it has been suggested that the term ‘antipsychotic’ is rather misleading. In practice what they do appears to be more general, exerting a ‘damping down’ effect on thoughts and emotions in a comparable way to other psychoactive drugs such as diazepam (Valium). This can of course be very useful, particularly when someone is very agitated or is experiencing many distressing thoughts. Some psychiatrists are now suggesting adopting a ‘drug-centred’ rather than a ‘disease-centred’ approach. What this means is that medication can sometimes be helpful for people who are in distress, but that is not the same as curing an illness or putting right a biochemical abnormality or imbalance.
As with psychological therapies, some people benefit massively from taking medication and others not at all. With both types of treatment, professionals should provide information about what is available and about what research suggests others have found helpful. Then we need to support people to try things and see what works for them.
Problems with ‘antipsychotic’ medication
Until recently the ‘received wisdom’ has been that everyone who experiences psychosis should take medication long-term to reduce the likelihood of ‘relapse’. However, opinion on this is changing. An editorial in the British Journal of Psychiatry has suggested that the general effectiveness of ‘antipsychotic’ medication may have been over-estimated. A meta-analysis (which pools results from many studies) suggested that many people experience only slight benefits and only about 20 per cent experience a significant improvement or prevention of reoccurrence. There appears to be little difference in this regard between ‘old’ and the ‘new’ types of medication. Recent studies which followed people’s recovery over seven to 20 years found that although in the short term they had more relapses, in the longer term people who reduced their dose or were able to cope without taking medication tended to do better.
Most drugs have unwanted effects (also called adverse effects or side effects) as well as desired ones. Common unwanted effects of ‘antipsychotic’ medication include stiffness, weakness and tremor (‘parkinsonism’), tension and restlessness (‘akathisia’) and muscle spasms. Trials with healthy volunteers have suggested that neuroleptic medication can also cause the tiredness, apathy and lethargy which are sometimes considered ‘negative symptoms of schizophrenia’. Indeed, in a recent study of people’s experiences of taking both ‘old’ and ‘new’ types of neuroleptic, the predominant effects that people reported were ‘sedation, cognitive impairment and emotional flattening or indifference’. Different drugs have slightly different side effects.
An issue that has caused controversy recently is that of the likely effects of neuroleptics when they are taken – as they often are – for many years. Some people find it helpful to take them long-term, and in the past services have often recommended that people should do so if they have had a significant ‘psychotic’ episode. However, recent research suggests that long-term use can sometimes lead to health problems such as decreased brain volume or heart problems. This has created a dilemma for prescribing clinicians. A leading researcher has recently concluded that clinicians should prescribe them at the ‘lowest possible dosages’. Many people gain weight, and of course being overweight brings its own problems and risks such as diabetes. Recent evidence suggests when used long-term, unwanted effects can outweigh positive effects for many people. This is particularly important in view of the increasing evidence that people with a diagnosis of schizophrenia have a significantly lower average life expectancy than others. The likely reasons for this are complex, including increased suicide risk, frequent poverty and poorer physical health care (there is evidence that health care workers can be prejudiced and sometimes miss problems). Whilst one study found that taking psychiatric medication appeared to increase average life expectancy, for many people the opposite may be true. Science journalist Robert Whitaker has drawn attention to these issues in his books Mad in America and Anatomy of an Epidemic.
Being on medication can also have psychological effects. For example, the idea that it is medication that makes things better can give the misleading message that there is little that people can do to help themselves. It is important that workers think of, and present, medication as only one of many things that might help.
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