How do we, as clinicians, assess the benefits and harms of any medication, including but not limited to psychiatric medications? More specifically, how do we decide whether long-term antipsychotic treatment does more good than harm—or vice versa, as some critics of psychiatry have claimed? Certainly, a careful examination of the literature on relapse and remission rates in schizophrenia spectrum disorders is an important part of the answer.
However, we reject the notion that this is the only criterion for judging the risks and benefits of long-term antipsychotic use. Equally, we do not believe that armchair analyses of the literature by non-clinicians will answer the risk to benefit question in a humane and judicious manner. On the contrary, we believe that working with psychotic patients, and appreciating their often profound suffering, is an essential part of the equation. Critics of psychiatry who have never spent time with patients and families coping with the ravages of schizophrenia simply do not grasp the human tragedy of this illness. These critics also miss the deep-seated satisfaction that comes from seeing severely impaired patients achieve remission, and even recovery—in which antipsychotic medication usually plays an important role.
As clinicians with many years of experience in treating patients with schizophrenia, our views on antipsychotic medication are shaped not only by our understanding of the scientific literature, but also by our personal care of many hundreds of patients over several decades. Recent studies that pointed to the benefits of long-term antipsychotic use in schizophrenia, including reduction of relapse rates and the risk of suicide, were examined previously.1,2 Here we examine the concept of quality of life (QOL) and what we know about its relationship to antipsychotic use. We focus primarily on placebo-controlled studies, despite the paucity of such investigations in the published literature.
What is meant by “quality of life”?
As Berlim and Fleck3 noted in their 2003 review, the concept of QOL is relatively new in the psychiatric literature and “embraces a whole spectrum of uses and meanings.” In general, however, QOL refers to “. . . how patients feel and how satisfied they are with treatment, besides the traditional focus on disease outcomes.” In 1998, the World Health Organization described QOL in these terms: “It is a broad-ranging concept affected in a complex way by . . . physical health, psychological state, level of independence, social relationships and their relationship to salient features of their environment.”4 Berlim and Fleck list nearly a dozen instruments or scales designed to measure QOL, including the Quality of Life Scale (QLS), the Wisconsin Quality of Life Index (W-QLI), and the Medical Outcomes Study Short Form-36 Items (SF-36). The main items on the original (21-item) version of the QLS are shown in the Table.5
QOL and antipsychotic medication
Bobes and colleagues6 provide a comprehensive review of QOL in schizophrenia, based mainly on open-label and/or naturalistic studies. Only 2 studies compared QOL of patients who received an antipsychotic (either olanzapine or long-acting risperidone) with QOL of patients in the placebo group. Hamilton and colleagues7 evaluated patients (N = 76) over a 6-month period; Nasrallah and colleagues8 evaluated patients (N = 369) over 3 months. In both studies, patients who received the antipsychotic showed significantly greater improvement in QOL than those treated with placebo. Indeed, Nasrallah and colleagues found that long-acting risperidone (25 mg q 2 weeks) improved QOL to levels “not significantly different from normal,” based on the SF-36.
To be sure, Bobes and colleagues6 acknowledge the “wide range of adverse [antipsychotic drug] effects that may negatively affect the quality of life” in patients with schizophrenia, and they observe that atypical antipsychotics may not improve QOL more than typical agents. Nevertheless, the authors conclude that “. . . the longer the length of the illness, the worse the quality of life . . . the combination of psychopharmacological and psychotherapeutic treatment improve quality of life.” They also observed that “. . . patients integrated in community support programs demonstrate a better quality of life than those who are institutionalized.” (Unfortunately, adequate outpatient and community supports are sadly lacking in many if not most parts of the US.)
Dr Pies is Professor of Psychiatry and Lecturer on Bioethics at SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor-in-Chief Emeritus of Psychiatric Times. Dr Pierre is Associate Director of Residency Education, UCLA Semel Institute for Neuroscience and West Los Angeles VA Medical Center; Acting Chief, Inpatient Psychiatry, West Los Angeles VA Medical Center; and Health Sciences Clinical Professor, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA. The authors report no conflicts of interest concerning the subject matter of this article.
Acknowledgments—The authors wish to thank Dr. Dieter Naber and Dr. A. George Awad for their helpful correspondence.
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http://www.psychiatrictimes.com/blogs/couch-crisis/how-antipsychotic-medication-may-save-lives. Accessed August 5, 2016.
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5. Heinrichs DW, Hanlon TE, Carpenter WT Jr. The Quality of Life Scale: an instrument for rating the schizophrenic deficit syndrome. Schizophr Bull. 1984;10:388-398.
6. Bobes J, Garcia-Portilla MP, Bascaran MT, et al. Quality of life in schizophrenic patients. Dialog Clin Neurosci. 2007;9:215-226.
7. Hamilton SH, Revicki DA, Genduso LA, Beasley CM. Olanzapine versus placebo and haloperidol: quality of life and efficacy results of the North American double-blind trial. Neuropsychopharmacol. 1998;18:41-49.
8. Nasrallah HA, Duchesne I, Mehnert A, et al. Health-related quality of life in patients with schizophrenia during treatment with long-acting, injectable risperidone. J Clin Psychiatry. 2004;65:531-536.
9. Beasley CM Jr, Sutton VK, Taylor CC, et al. Is quality of life among minimally symptomatic patients with schizophrenia better following withdrawal or continuation of antipsychotic treatment? J Clin Psychopharmacol. 2006;26:40-44.
10. Vothknecht S, Schoevers RA, de Haan L. Subjective well-being in schizophrenia as measured with the Subjective Well-Being Under Neuroleptic Treatment scale: a review. Aust N Z J Psychiatry. 2011;45: 182-192.
11. Leucht S, Tardy M, Komossa K, et al. Maintenance treatment with antipsychotic drugs for schizophrenia. Cochrane Database Syst Rev. 2012;5:CD008016.
12. Witte MM, Case MG, Schuh KJ, et al. Effects of olanzapine long-acting injection on levels of functioning among acutely ill patients with schizophrenia. Curr Med Res Opin. 2012;28:315-323.
13. Isitt JJ, Nadipelli VR, Kouassi A, et al. Health-related quality of life in acute schizophrenia patients treated with RBP-7000 once monthly risperidone: an 8-week, randomized, double-blind, placebo-controlled, multicenter phase 3 study. Schizophr Res. 2016;174:126-131.
14. Sohler N, Adams BG, Barnes DM, et al. Weighing the evidence for harm from long-term treatment with antipsychotic medications: a systematic review. Am J Orthopsychiatry. December 14, 2015; Epub ahead of print.
15. Memon MA, Bienenfeld D. Brief psychotic disorder. Medscape. November 17, 2015. (Updated). http://emedicine.medscape.com/article/294416-overview. Accessed August 5, 2016.
16. Frances A. Setting the record straight on antipsychotics. Psychiatric Times. February 17, 2016. http://www.psychiatrictimes.com/couch-crisis/setting-record-straight-antipsychotics. Accessed August 5, 2016.
For further reading
Awad AG, Voruganti LN. The impact of newer atypical antipsychotics on patient-reported outcomes in schizophrenia. CNS Drugs. 2013;27:625-636.
Cortesi PA, Mencacci C, Luigi F, et al. Compliance, persistence, costs and quality of life in young patients treated with antipsychotic drugs: results from the COMETA study. BMC Psychiatry. 2013;13:98.
Pies R. Trivializing the suffering of psychosis. Psychiatric Times. 2014. http://www.psychiatrictimes.com/schizophrenia/trivializing-suffering-psychosis. Accessed August 5, 2016.
Staring AB, Mulder CL, Duivenvoorden HJ, et al. Fewer symptoms vs more side-effects in schizophrenia? Opposing pathways between antipsychotic medication compliance and quality of life. Schizophr Res. 2009;113:27-33.
Strakowski SM, Johnson JL, Delbello MP, et al. HGDH Research Group: quality of life during treatment with haloperidol or olanzapine in the year following a first psychotic episode. Schizophr Res. 2005;78:161-169.