The drugs we call “antipsychiatric drugs”, “neurological inhibitors” or “main sedatives” were introduced into psychiatry in the 1950s. While they have always been closely related to the treatment of mental illness, schizophrenia and dual emotional disorders, they have also been widely applied in other situations where they can have a chilling effect, including dementia and learning difficulties, as well as anxiety, depression and insomnia。
When they were introduced in the 1950s, they were hailed as a panacea. Most experts at the time also felt that, despite the side effects of anti-psychiatric drugs, they undoubtedly had a “advanced risk ratio” for those suffering from schizophrenia. Long-term, indefinite treatment should therefore be recommended for all those in such situations. Some anti-psychiatric drugs are recommended for long-term treatment for the prevention of dual emotional disorders, which is one of the most common adaptations of these drugs today。
Why stop using antipsychotics?
If anti-psychiatric drugs are generally considered to be so effective, why is it decided to discontinue their use, and should the clinician support or encourage such a decision?
While it is recognized that many people with long-term illnesses are not well equipped to take medications, when people with severe mental disorders stop taking drugs, they are often considered to be a result of their lack of “insight” about their disease. However, we know that anti-psychotic drugs can produce severe physical reactions, induce psychological and behavioural changes, such as sedatedness, emotional depression and sexual dysfunction, which are often very unpleasant experiences for users。
In addition to previously recognized serious adverse reactions, such as delayed motor disorders, malignant syndrome of anti-psychiatric drugs, weight gain, diabetes and sudden heart death, recent evidence suggests that anti-psychiatric drug treatment is associated with brain atrophy. Numerous qualitative studies have shown that some users experience the debilitating and harmful effects of anti-psychotic drugs and are sceptical or contradictory about whether they bring any overall benefit。
Therefore, the decision to stop taking anti-psychotic drugs is not necessarily irrational. This may be an understandable and reasonable response to a series of adverse events arising from these drugs。
In addition to the burden of side effects, some long-term test evidence suggests that the benefits usually attributed to such treatment are not as safe as we believe。
The maintenance of treatment is recommended on the basis of detoxification tests, in which patients already taking anti-psychotic drugs are randomly assigned to continue to take or change to placebos. While these tests suggest that continuous drug treatment can reduce relapse rates, it is important to note that they are stop drug trials rather than tests that test differences between long-term continuing treatment and placebos. They all concern patients who have already been treated with anti-psychiatric drugs, who in fact have often been treated for years before treatment。
Thus, in these studies, the benefits of continued anti-psychiatry treatment may come from the prevention of side effects associated with “anti-psychiatric abstinence”, rather than from long-term treatment itself。
In fact, the cessation of anti-psychiatric drugs can lead to typical signs of abstinence, including agitation, anxiety, irritation, insomnia and irritation, as well as occasional psychiatric symptoms. Discontinuation symptoms are important because they may be mistaken for relapse in random experiments。
A number of case studies have shown that the interruption of anti-psychiatric drugs may occasionally give rise to psychiatric symptoms for those who have never had such symptoms, including those who had previously had no mental health problems. These cases have been reported to include new psychosis during the suspension of d2 receptor retardants, such as methylenedioxychloropamine and dopanone, which can be used for other medical adaptations. In random trials of long-term treatment, psychiatric symptoms caused by interruption are also classified as relapse。
In addition to the cessation symptoms, there is some evidence that detoxification increases the susceptibility to potential relapses. For example, we have learned from animal studies that antipsychotic drugs cause changes in brain dopamine systems, which can last for some time after treatment has ceased. Consistent with this assumption, the risk of relapse due to the discontinuation of anti-psychiatric drug treatment has increased to the highest level in weeks and months after the cessation of treatment and has decreased with prolonged follow-up. For example, in one study, 50 per cent of the relapse to the placebo group occurred within the previous three months。
In addition, some studies have shown that the phasing out of drugs is less likely to lead to relapse than a sudden stoppage. Discontinuation of long-term drugs may lead to the risk of relapse, which is clearly demonstrated in the case of lithium treatment for patients with dual emotional disorders: the risk of relapse after the patient stops lithium treatment is higher than before it is taken. No similar study has been carried out on the use of anti-psychiatric drugs for psychiatric treatment。
Thus, evidence derived from the benefits of long-term anti-psychiatric treatment may not necessarily prove the benefits of long-term treatment and may at least at least reflect the difficulty of eliminating anti-psychiatric drugs. It shows that the risk of recurrence of anti-psychiatric drugs in the short term need not be interpreted as chronic illness and deteriorating conditions, but as a temporary obstacle to be overcome in the process。
Two random comparative tests of anti-psychiatry drug maintenance have reported long-term results, all of which involve initial psychiatric patients. One is an open trial, which assesses the decrease in progressive and supportive anti-psychiatry treatment compared to maintenance treatment. The results show that while people in the reduction group are more likely to deteriorate in the short term than those maintaining the treatment group, in the long run their social functioning and resilience are twice as likely to improve. The rate of relapse, although initially rising, has gradually stabilized as the duration of follow-up visits has been extended。
Another test included a placebo control test for the maintenance of thorium sulphate. Ten years of follow-up data indicate that people randomly assigned to the placebo group initially showed poor results, including suicide or chlorazine treatment or deterioration of symptoms. However, there are no differences in individual outcome indicators between random groupings. It is worth noting that, unlike the wunderink study, in the latter case, there was no difference in the dose of drugs that stopped and maintained the drug at the end of the long follow-up. Therefore, the study does not necessarily assess the effects of long-term dose reductions. The result may be a relatively short period (6 weeks) of sulfur tablets, which triggers relapses or withdrawals, leading to the re-introduction of anti-psychotics。
Thus, in some cases, it may be reasonable to help people try and stop using anti-psychiatric drugs and be consistent with the selection framework recommended by the national institute of health and clinical optimization (nice). It can reduce the burden of adverse reactions and, despite the increased risk of short-term relapse or deterioration, can reflect patient preferences and improve functionality over the long term。
Moreover, evidence of the benefits of long-term treatment is not as strong as usual. Even if people do not succeed in completely eliminating anti-psychiatric drugs, the phase-down process may result in lower doses, which will mitigate some of the adverse effects and make treatment more tolerant and achieve a reasonable quality of life. In the event of disagreement between the patient and the doctor, support for a gradual reduction in the use of drugs would avoid the risk of hidden and abrupt withdrawals。
Overcoming obstacles and stopping anti-psychotic treatment
Any intervention to reduce the risk of relapse can help those who want to try to stop. It will reduce the anxiety of patients, caregivers and professionals in the course of drug treatment。
There is evidence that the gradual reduction of anti-psychotic drugs before withdrawal reduces the risk of relapse. An analysis by viguera et al. Found that the patients had relapsed earlier than the slow stoppage. A study also found a link between gradual reduction over a period of four weeks or longer and self-reported successful stoppage and non-recurrence. However, another detoxification study did not reveal any difference in the overall relapse rate between sudden and phaseout. This suggests that this reduction may not be sufficiently gradual。
Studies of hyperbolic receptor occupation patterns indicate that reduction needs to be carried out in a similar hyperbolic manner. This involves a proportional reduction of doses at each stage, resulting in a smaller reduction in absolute doses. At lower doses, the reductions are becoming smaller and may therefore last for many years. A five-year study of mini-naturalism showed that a reduction in doses could do without increasing hospitalization rates。
It is also important to recognize that at least some of the relapses or deteriorations following the discontinuation of anti-psychiatric drugs may have been caused by the process of withdrawal. If some relapses are the result of a stoppage, this means that stability can be achieved once the body is readjusted to the point where there are no drugs。
Do not view relapse as a necessary evidence of lifetime anti-psychiatric drugs, but rather as a small episode in the process of reaching a state of lack of medication. While relapses may require the resumption of drug treatment, further attempts at drug reduction can be made, perhaps more slowly, once symptoms stabilize. Just as addictions may undergo several detoxification attempts, the process of getting rid of neurostatics may be prolonged and interrupted by setbacks, but this does not mean that they should be abandoned whenever they encounter obstacles. Even if people are unable to successfully completely stop the drug, it is worthwhile to try to stop it at lower doses and less side effects。
It was also important to address the causes of fear of recurrence. The plan should include detailed contingency arrangements to intervene in early signs of recurrence, help to reduce the fear of patients and relatives, monitor closely and provide assistance and advice during appointments. It is important to educate patients about the reasonable motivation to stop using anti-psychiatric drugs, as well as about the adverse effects of long-term treatment and interruption。
Increased patient education to deal with unpleasant symptoms may also be useful during periods of withdrawal or reduction. Response mechanisms, including psychological, behavioural and drug-based strategies, can be learned to prepare for cessation. Support could also be sought from various sources, including clinical doctors, friends and acquaintances。
Some non-pharmacological clinical interventions or strategies can also improve their prognosis. A recent overview of the system found that, as an alternative to routine anti-psychiatry treatment, patients with mental illness who were randomly assigned to certain psycho-social projects had the same or in some cases better effects than patients who were randomly assigned to routine anti-psychiatry treatment. Strengthening individual coping mechanisms or providing other psychosocial interventions may therefore help to reduce the risk of relapse or instability associated with detoxification。
Support from friends, families and professionals also helps patients to stop drugs, especially for people at risk of relapse into anti-psychotic drugs。
Despite significant changes in general attitudes towards drug treatment and the fact that patients are no longer passive recipients, many psychiatrists remain disturbed to help patients stop using anti-psychotic drugs, fearing that they will be blamed if problems arise. However, there are others who support the patient's initiative to stop or reduce drugs and even encourage patients who have not done so before to consider this option。
When conducting relevant investigations, professionals generally reflect a lack of guidance and wish to determine which patients may have good results after the reduction or discontinuation of anti-psychiatric drugs. Unfortunately, although individualized studies have identified various patient and treatment characteristics for predicting relapse or functional outcomes, the analysis failed to identify any consistent predictive factors for relapse。
There is little guidance available on how to help patients stop. Standard evidence on how to reduce and discontinue the use of anti-psychiatric drugs is also scarce, but there is ample evidence from communities and experienced clinicians on different approaches to detoxification. This information shows that a flexible approach, including constant self-reflection and adjustment of declining plans based on individual success stories, is likely to be successful and acceptable。
Official guidance based on this experience will encourage clinicians to support those who wish to try and stop their anti-psychiatry treatment. Nice is currently developing guidelines to end the use of benzodiazepines, opioids and antidepressants, and hopes that in the future nice or similar institutions will also provide guidelines for antipsychotic drugs。
Conclusions
Anti-psychiatric drugs can mitigate acute symptoms of mental illness and in the long term may help prevent relapse or inhibit persistent symptoms in some people. However, they have serious and unpleasant side effects, and some studies have shown that if some people attempt to stop using drugs and avoid or minimize long-term use, they may have better overall long-term healing effects。
Based on current evidence, it is not possible to predict the specific characteristics of these populations. Helping people reduce or discontinue the use of anti-psychiatric drugs is therefore a reasonable treatment option. However, fear of recurrence is a realistic and significant obstacle, and short-term stability is often given priority by professionals, associated personnel and service providers, which can undermine long-term benefits。
With the support of professionals, the risk of relapse can be reduced by gradually reducing drug treatment. Even if the increased risk of relapse cannot be mitigated, the patient should in most cases have the right to decide whether to take an anti-psychiatric drug of his or her own, after full discussion of its pros and cons. If they decide to reduce or stop using anti-psychiatric drugs, they should be supported; if they wish to live a better life free of the burden of anti-psychiatric drugs, they should not be blamed or considered irrational。
