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How Antipsychotic Medication May Save Lives

How Antipsychotic Medication May Save Lives

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COMMENTARY

One way anti-psychiatry groups trivialize psychosis and marginalize psychiatry is by emphasizing the adverse effects of antipsychotic medications while denying or minimizing their benefits.1 To be sure, the well-recognized metabolic, neurological, and cardiovascular risks associated with many antipsychotic medications must be taken very seriously. Moreover, antipsychotics (APs) are often used when they are not needed; eg, for the treatment of anxiety disorders2; for “agitation” in nursing home patients; and for “acting out” in adolescent populations. (I spent many years as a psychopharmacology consultant trying to get doctors to reduce their over-reliance on antipsychotics.) On the other hand, there is convincing evidence that in patients with chronic schizophrenia, APs play a crucial role in maintaining remission, averting relapse, improving quality of life, and—importantly—reducing overall mortality.3-5

But even many psychiatrists may not realize that APs reduce the risk of suicide in patients with schizophrenia.

To back up a bit: an estimated 20% to 40% of those with schizophrenia attempt6—and 5% complete—suicide7—a risk at least 10 times that of the general public. Suicides are concentrated early in the illness course and are associated with a number of risk factors, ie:

“Risk factors with a strong association with later suicide included being young, male, and with a high level of education. Illness-related risk factors were important predictors, with number of prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight all having a strong evidential basis. A family history of suicide and co-morbid substance misuse were also positively associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment.”8 [italics added].

This last point, of course, is crucial. Indeed, the authors add that,

“. . . efforts at prevention should focus on optimizing adherence to medication, and possible earlier use of clozapine, as the only antipsychotic medication with demonstrated efficacy . . . for the management of suicidality in schizophrenia.”8

Indeed, the first FDA-approved medication with an anti-suicide indication was clozapine for schizophrenia. The regulatory approval in 2003 was largely based on the International Suicide Prevention Trial (InterSePT), a randomized trial that compared clozapine with olanzapine in patients with schizophrenia and schizoaffective disorder who were at high risk for suicide.9 Suicidal behavior (measured by suicide attempts, hospitalizations, and rescue interventions) was significantly decreased in patients treated with clozapine, which is associated with a substantially lower risk of suicide than any other antipsychotic.10

There is little question that, for patients suffering the chronic, debilitating symptoms of schizophrenia, antipsychotic medication is a critical component of treatment—and may literally be life-saving.

But while clozapine provides the best evidence of anti-suicidal properties in schizophrenia, there is accumulating evidence that antipsychotic medication in general is associated with decreased risk of suicide in this population. For example, Tiihonen and colleagues11 performed an observational study of antipsychotic treatment in patients with schizophrenia and schizoaffective disorder (N = 2230, average length of follow-up =3.6 years). Excess mortality was seen mostly in patients not taking antipsychotic drugs, for whom the risk of suicide was high. There were 26 suicides in patients not taking antipsychotics compared with 1 in patients taking medication (adjusted relative risk 37.4).11

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