Long-Term Effects of Antipsychotics

Should antipsychotics be used long term for illnesses other than schizophrenia?

Posted Nov 15, 2017

Donald Goff, Jeffrey Lieberman, and colleagues recently published a review article entitled “The Long-Term Effects of Antipsychotic Medication on Clinical Course in Schizophrenia” in the American Journal of Psychiatry. In this paper, the authors review the use of antipsychotics for initial treatment of psychosis associated with schizophrenia as well as the effects of long-term use, including clinical outcomes and relapse prevention. The benefits of antipsychotics in the initial treatment of psychotic symptoms are clear. Data also support long-term use of these medications to minimize the occurrence of relapse. The authors note that up to 20% of individuals with schizophrenia may “maintain remission or partial remission for extended periods off medication.” However, it is difficult to identify this subset of individuals who might do well without long-term “maintenance” treatment. 

Although antipsychotic medications are effective, some have substantial side effects, including several types of movement disorders, weight gain, and effects on sugar and lipid regulation. They may increase the risk of stroke and are associated with higher rates of death in the elderly.

We agree with the authors that for many patients with schizophrenia, the long-term use of antipsychotics, together with lifestyle changes, can be very helpful. However, what about the long-term use of these medications for symptoms other than the psychotic symptoms associated with schizophrenia? These agents are increasingly being used to treat symptoms associated with a variety of conditions, including bipolar disorder, depression, dementia, borderline personality disorder, and autism. Some health care providers even prescribe these drugs to help with sleep or anxiety.

For these other indications, there are limited data demonstrating long-term benefit. Antipsychotic medications may help some patients for weeks or months, but longer-term use may lead to unwanted side effects. It is difficult to evaluate the risk-to-benefit ratio when long-term benefit hasn’t been demonstrated.

We teach our psychiatry residents to prescribe medications based on evidence that they work, and there are limited data supporting the long-term use of antipsychotic medications for conditions other than schizophrenia. Nevertheless, it is common to encounter patients who do not have schizophrenia but have been prescribed antipsychotics for long periods of time. Unfortunately, some of these patients are taking two or more such drugs simultaneously. It is often necessary for patients with schizophrenia to continue antipsychotics, but patients with other psychiatric disorders may be able to be weaned off these medications.

Antipsychotics are often prescribed by non-psychiatrists. It is important for non-psychiatric physicians and other prescribers such as nurse practitioners and physician assistants to review their use of antipsychotics each time they see a patient for whom these drugs are prescribed. Antipsychotics are important and powerful weapons against certain illnesses, but like any powerful treatment they need to be used carefully.

This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.

References

Goff, D.C., Falkai, P., Fleischhacker, W.W., Girgis, R.R., Kahn, R.M., Uchida, H., Zhao, J., & Lieberman, J.A. (2017). The long-term effects of antipsychotic medication on clinical course in schizophrenia. Am J Psychiatry. 174:840-849.