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Questions and Answers
Super-sensitivity psychosis is a concept that has only recently gained attention.
False
Dopamine antagonists can potentially induce withdrawal psychosis even when used for non-psychiatric conditions.
True
The lowest possible dose of antipsychotics should be used consistently for all patients.
True
Long-term use of antipsychotics is guaranteed to improve outcomes for individuals with schizophrenia.
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There is no need to consider structural brain changes as a possible adverse outcome from antipsychotic use.
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Antipsychotics provide effective protection against relapse in the long term after the first episode of schizophrenia.
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In a study, almost 80% of patients experienced relapse after one year of being medication-free.
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A 2019 Swedish population study concluded that longer treatment with antipsychotics corresponded to a higher risk of hospitalization.
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Discontinuation of antipsychotics after the first episode is commonly recommended for the majority of patients.
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Positive symptoms are less likely to lead to hospitalization compared to cognitive and negative symptoms.
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Clozapine showed significantly better outcomes than chlorpromazine in the medium term for first-episode patients with non-refractory illness.
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Long-acting antipsychotic injections provide no significant advantages over oral antipsychotics.
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A meta-analysis found that 35% of treated patients relapsed while 61% of those who discontinued treatment relapsed at 18–24 months.
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Most individuals with schizophrenia who have experienced one episode are likely to have additional episodes.
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There is strong evidence supporting patient factors as reliable predictors of outcomes after antipsychotic discontinuation.
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The dose-reduction group in a follow-up study had better functional outcomes than those who remained on a consistent dose.
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The 10% suicide risk is highest in the last decade of illness.
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Regular use of targeted antipsychotics leads to better outcomes than prophylactic use.
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Continuing antipsychotic treatment is suggested to provide a better chance of successful withdrawal without issues.
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Patients with a negative attitude towards treatment face a reduced risk of relapse.
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Movement disorders occur in about 16% of patients using antipsychotics.
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Antipsychotics should be the only intervention used in treating schizophrenia.
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The number needed to treat (NNT) for relapse at 7-12 months with antipsychotics is 3.
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Depot preparations guarantee full medication delivery, contributing to a 30% lower risk of relapse compared to oral treatments.
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The risk of relapse is observed to be higher with newer antipsychotics than with older medications based on meta-analysis findings.
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A significant proportion of patients treated with olanzapine achieved remission for at least 6 months according to the CATIE Study.
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Adherence to antipsychotic treatment increases over time, reaching up to 75% by two years.
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Using very low doses of antipsychotic medications is associated with decreased risk of psychotic relapse.
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Non-adherence to antipsychotic treatment may lead to a four-fold increase in the risk of suicide attempts.
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There is data supporting lower standard doses of newer antipsychotic drugs used as prophylaxis.
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Patients discontinuing antipsychotics experience minimal relapse rates.
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The risk of relapse after abrupt withdrawal of antipsychotic drugs is half that of gradual withdrawal.
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Discontinuation symptoms such as headache and nausea may occur after the abrupt withdrawal of oral antipsychotic treatment.
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The recommended duration for gradual withdrawal of oral antipsychotics is at least 6 weeks.
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Patients with a history of aggressive behavior are often recommended for lifelong treatment.
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Social costs of relapse include factors such as the patient's stability in personal life and family responsibilities.
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The use of antipsychotics may potentially worsen outcomes by sensitizing patients to psychosis.
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Monitoring symptoms is unnecessary if the patient is considered stable.
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Patients who attempt dosage reductions should not consider the previous outcomes of those attempts.
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The effectiveness of targeted relapse treatment is equal to that of continuous prophylaxis.
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First-episode patients have shown better outcomes when treated with higher doses of antipsychotics.
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Study Notes
Super-Sensitivity Psychosis
- The concept of "super-sensitivity psychosis" has been discussed for decades and has recently seen a resurgence.
- Dopamine antagonists used for non-psychiatric conditions can induce withdrawal psychosis, suggesting a potential link to this concept.
- These theories emphasize the need for using the lowest possible dose of antipsychotics and balancing benefits against potential adverse effects, including those that may be less clinically apparent, such as structural brain changes.
First Episode of Psychosis
- Antipsychotics are effective in preventing relapse, particularly in the short to medium term.
- A meta-analysis showed a 26% relapse rate after 6-12 months for patients on maintenance antipsychotics compared to 61% on placebo.
- Current consensus suggests prescribing antipsychotics for 1-2 years after the first episode.
- A study indicated an 80% relapse rate after one year of being medication-free, increasing to 98% after two years.
- A 2019 Swedish study showed that longer treatment with antipsychotics led to lower hospitalization rates.
- Studies indicate that only a small minority of patients discontinue antipsychotics within 1-2 years.
- A relapse rate of 94% was observed within two years and 97% within three years after stopping risperidone long-acting injection.
- A 2018 meta-analysis found relapse rates of 35% for treated patients and 61% for those discontinued at 18-24 months.
- A 5-year follow-up of a 2-year RCT showed a diminishing benefit of maintenance treatment in the medium term.
- Dose reduction and discontinuation groups showed better functional outcomes.
- There are various interpretations of results, but dose reduction is a viable option in first-episode psychosis.
- No reliable patient factors are linked to outcomes following antipsychotic discontinuation except for cannabis use.
- Evidence favors continued antipsychotic use over stopping.
- Prolonged discontinuation regimens using hyperbolic tapering may offer the best chance of successful withdrawal.
- Relapse definitions generally focus on severity of positive symptoms, while cognitive and negative symptoms may worsen with antipsychotic treatment.
- In an RCT, clozapine did not offer an advantage over chlorpromazine for first-episode patients.
- In a naturalistic study, clozapine and olanzapine showed better outcomes compared to other treatments.
Antipsychotic Treatment and Schizophrenia
- Long-acting antipsychotic injections offer advantages over oral antipsychotics, particularly in preventing readmission.
- Significant benefits are suggested for long-acting risperidone over oral risperidone in first-episode patients and paliperidone LAI over other oral antipsychotics in recently diagnosed schizophrenia.
Importance of Diagnosis and Management
- Schizophrenia diagnosis is often delayed.
- Carers and healthcare staff should be aware of early signs of relapse and how to access support.
- Antipsychotics should not be the sole intervention, psychosocial and psychological support is crucial.
Multi-Episode Schizophrenia
- Most individuals with one episode will experience additional episodes.
- Patients with residual symptoms are at higher risk of relapse and functional deterioration.
- Suicide risk is 10%, concentrated in the first decade of illness.
- Regular use of antipsychotics protects against relapse but targeted use may have worse outcomes.
Summary of Benefits and Harms
- Antipsychotics significantly reduce relapse, re-admission, and violent/aggressive behavior.
- Antipsychotics can cause movement disorders, anticholinergic effects, sedation, and weight gain.
How and When to Stop
- Stopping antipsychotics requires a thorough risk-benefit analysis.
- Withdrawal should be gradual and monitored.
- Abrupt withdrawal leads to a doubled relapse rate compared to gradual withdrawal.
- Abrupt withdrawal can also cause discontinuation symptoms like headache, nausea, and insomnia.
Factors to Consider
- Patient’s symptom-free duration.
- Severity of adverse effects.
- Previous illness pattern.
- Outcomes of previous dose reduction attempts.
- Current social circumstances.
- Social cost of relapse.
- Patient/carer’s ability to monitor symptoms and seek help.
- Early signs of relapse.
- Effectiveness of targeted relapse treatment compared to continuous prophylaxis.
- Life-long treatment is considered for those with a history of aggression, suicidal behavior, and residual psychotic symptoms.
Alternative Views
- Antipsychotics might sensitize patients to psychosis, leading to relapse as a discontinuation reaction.
- This might explain better outcomes in first-episode patients receiving lower doses and poor outcomes with abrupt discontinuation.
- This raises questions about the validity of long-term studies with abrupt treatment stops, as rebound phenomena and withdrawal reactions may contribute to high relapse rates.
Depot Preparations and Antipsychotic Treatment
- Depot preparations offer advantages over oral maintenance due to guaranteed drug delivery.
- Meta-analyses suggest lower relapse risks associated with depot maintenance.
- Long-acting antipsychotic preparations are preferred by both prescribers and patients.
Meta-Analysis Findings
- Relapse risk with newer antipsychotics is similar to that with older drugs.
- The proportion of multi-episode patients achieving remission is small and varies among drugs.
- The CATIE study found limited remission rates with olanzapine, quetiapine, and risperidone.
Adherence to Antipsychotic Treatment
- Non-adherence rates are high in schizophrenia.
- Non-adherence increases relapse risk, severity, duration of hospitalization, and risk of suicide attempts.
Dose for Prophylaxis
- Many patients receive higher doses than necessary.
- Lower doses of older drugs are associated with less severe side effects, better subjective state, and community adjustment.
- Very low doses increase psychotic relapse risk.
- There is no data supporting lower standard doses of newer drugs for prophylaxis.
- Effective doses should be continued as prophylaxis, particularly after a first episode, with careful dose reduction being considered.
Conclusion
- Ongoing trials are refining treatment approaches, supporting dosing strategies, and enhancing adherence to treatment.
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Description
Explore the intricacies of super-sensitivity psychosis and its implications in psychiatry. This quiz delves into the effects of antipsychotic medications, their dosages, and the management of first episodes of psychosis. Understand the balance between effective treatment and potential adverse effects.
