Journal Reading

dr. Wijaya aji, M.Sc., Sp.Kj

Publisher

Title

Creator
 Table Of content
01 02 03
Abstract Introduction Result

04 05 06
Discussion Conclusion Critical appraisal
 01
Abstract
 Result
269 patients interviewed; 33% (95% CI, 27 to 39%) taking long term antipsychotic
medication. Other 19% reluctantly, accepted in temporary basis 24%, actively dislike 18%.
31% want to support with professional support, who want to discontinue have a negative
attitudes toward medications. Motivation to stop → adverse effect and health concern,
professional support helpful to achieve reduction

Conclusion
Patient are commonly unhappy about the idea of taking
antipsychotic, professional support has valued.
 Background

Antipsychotic → reduce psychotic symptoms

Adverse effect Patients view, to reduce/ discontinue

Aims
To explore the views of people with schizophrenia and other
psychotic disorders about continuing their antipsychotic
medication or attempting to reduce or discontinue this medication
with clinical support.
 02
Introduction
 INTRODUCTION
Long-term antipsychotic
medication is recommended
for people with recurrent
episodes to reduce the risk
of relapse

ADVERSE EFFECT OF
ANTI PSYCHOTIC :
Antipsychotic medication is considered • Diabetes
the primary treatment for people with a • Tardive dyskinesia
diagnosis of schizophrenia and related • Heart disease
disorders due to its efficacy • Sedation
• Emotional blunting
• Akathisia
• Sexual dysfunction
 INTRODUCTION

Due to the
The balance between the benefits and harms of
adverse effect of
long term antipsychotic treatment requires
antipsychotic drug careful consideration

The low adherence rates amongst patients with schizophrenia are linked to increased
risk of relapse and rehospitalization because people stopping medication abruptly
without clinical supervision, which may increase withdrawal-related adverse effects
including ‘supersensitivity’ psychosis and withdrawal-induced relapse
 AIM

• explore the views of people with diagnoses of schizophrenia and other

psychotic disorders towards taking antipsychotics on a long-term basis, and
attitudes towards reducing or stopping these drugs with clinical support.
• explore the characteristics of people who want to discontinue antipsychotic
medication compared to those who do not.
 METHOD

STUDY DESIGN SETTING

Face-to-face interviews with • Place : Community mental

people with a diagnosis of health services and primary
schizophrenia in randomised trial care practices across areas of
of supported antipsychotic London
reduction • Time : April 2016 till
August 2017.
 Inclusion criteria
• A clinical diagnosis of schizophrenia,
schizoaffective disorder, delusional
disorder or other psychotic disorder
(excluding bipolar disorder and psychotic
depression) as recorded in participants
medical notes
• A history of either more than one episode
of psychosis or schizophrenia, or a single
episode that lasted more than a year
• Taking antipsychotics
• Being stable for a period of at least 3
months (e.g. not requiring acute care by
the crisis team or inpatient unit)
exclusion criteria
• Lack of capacity to consent to the
research
• Being legally compelled to take
antipsychotic medication
• The potential to present a serious risk
of harm to self or others in the view of a
treating clinician
• inability to speak or comprehend
• spoken English such that an interpreter
is required.
03
Result
 Sample
Characteristics
269 patient
s

The mean age of the sample

was 46 years, 65% were male.
Nearly all participants had a
diagnosis of either schizophrenia
or schizoaffective disorder.
The majority of participants had long term
involvement with services, 36% of
participants being in contact with mental
health services for >20 years.
183/265 were taking a second
generation antipsychotic (including
clozapine), and 133/264 were prescribed
a long-acting antipsychotic depot
injection.
 Most were recruited through
secondary mental health
services, mainly from
community mental health teams

The mean length of time taking

antipsychotic medications was
16.5 years

Most patients were taking only

one antipsychotic medication
at the time of the interview.
 Most participants were
single, living alone, and
unemployed.
The analysis of potential predictors of wanting to discontinue antipsychotic medication

DAI score showed a statistically

significant association, people with
more negative attitudes towards
taking medication being more likely
to want to discontinue.
No demographic factors, illness or
treatment characteristics were
associated with wanting to
discontinue medication and neither
was coming from primary or
secondary care services.
 132 participants provided reasons : valued or accepted continuing antipsychotic medication

● The most common reason : fear of relapse

● Other common reasons : antipsychotic helps to maintain stability or produce a general improvement,
that it reduces positive symptoms, particularly hallucinations, the sedative or calming efects of
antipsychotics, and the reduction of other symptoms (agitation and suicidal thoughts)
● Some of them said that the doctors told them to take it.
 121 participants provided data on reasons for wanting to reduce or discontinue antipsychotics

● 90/121 participants concerns about the adverse efects of antipsychotic medication and/or its actual and
potential impact on their physical health.
● The commonly specifc adverse efects : sedative efects, weight gain and neurological efects (shaking,
twitching, stifness).
● Impairment of general functioning, cognitive and emotional capacities, and sexual functioning
● Some respondents felt they no longer needed medication, and disliked the idea of taking medication
long-term
 61 participants, they thought would be helpful if they were to consider reducing or
discontinuing antipsychotics.

● The most commonly was support from psychiatrists and other professionals.
● Reducing medication gradually and a stable situation or having a ‘healthy lifestyle’ at the time of
reduction were important.
● To be independent or obtain employment was a motivation to reduce or stop antipsychotics
● Access to a supply of medication to take ‘as required,’ family support, psychological therapy and
alternative therapies were being potentially useful by some participants.
04
Discussion
 Long Term antipsychotic
medication
● ⅓ participants were satisfied taking it Character of participants
● ⅓ participants want to stop with medical Negative attitude toward medication
professional support
●
There’s no character distinguished between them
Almost ½ want to reduce medication
●
Consistent with
●
Others : reluctantly, accepted in temporary basis,
●
● ○ Qualitative research : accepted
actively dislike it ambivalently as the least worst option
○ quantitative research : Patient with
schizophrenia felt more harm than
good

Why do people take the
antipsychotic drug?
● Prevent relapse
● Reduction of positive symptoms
● Sedative properties
● Their doctor told them
Why do people want to stop
medication
● Adverse effect
Support from healthcare professional is helpful
to reduce or discontinue medication (gradual
tapering)
 Strength & Limitation
+ -
Largest survey about
Can’t generalize to population study
●
discontinuing or reduce
●
antipsychotic medication
● People who consent to take a part in
research to take a part in research
maybe more adherent and accepting the
treatment than other patients
● People with long histories of medication
use, may also contact and have bias
response
 Interpretation and implications
● Patients lack to make a collaborative decision about taking antipsychotic and reduce or discontinue
● clinicians can be reluctant to help people reduce or discontinue because they are focus on risk and lack training and
official guide to management this

● Mental health service need to support informed decision making and patients choice, and to this end service should
provide support for patients who wis try to reduce or discontinue antipsychotic
● Need for guidance to the best approach, current evidence “reduction must be gradually, to minimize relapse.
● Routine discussion with patients→ reveal the dissatisfied patient
● Patient may wish to switch to a different medication to lessen the impact of the adverse effect
 Conflict of interest
● Clarify what patients want and how might it best be offered
● People who have a short history and qualitative work could help to explore
patient attitudes in more depth including across different sub group ex
ethnicity
 05
Conclusion
 Patient diagnosed with schizophrenia or

1
related disorders are unhappy to taking
medicine on continuing or life long basis,
and would like to reducing their
medication

Guidance on how to support people to

2
make informed decision about long term
antipsychotic treatment and to reduce/
discontinue if they wish
 CRITICAL
APPRAISAL
 CRITICAL APPRAISAL
NO. KRITERIA YES (+) NO (-)
Abstract
1. Abstract 1 paragraph (-)
2. Overall informative (+)
3. No abbreviation other than the standard (+)

4. Less than 250 words (+)

Introduction
1. Consists of 3 paragraphs (+)
2. The first paragraph sets out the reasons (+)
for the research
3. The first paragraph states the (+)
hypothesis or research objectives
4. Supported by relevant libraries (+)
5. Less than 1 page (-)
No Criteria Yes (+), No (-)

1 Type and design of research +

2 Study time and place Time +/Place +

3 Population source +

4 Sampling technique -

5 Inclusion criteria +

6 Exclusion critria +
7 Large sample estimation -
No Criteria Yes (+), No (-)

8 Step of the study explanation -

9 Blind -

10 Statistical test +

11 Computer program +

12 Subjective consent +
No. Criteria Yes (+), No (-)

1 Number of subjects (+)

2 Characteristics Table (+)

3 Research Results Table (+)

4 Comments and Opinions of Authors about (+)

results

5 Data Analysis Table with Test (+)

No. Kriteria Yes (+), No (-)
1 Separate discussions and conclusions (+)

2 Discussions and conclusions are clearly (+)

present
3 Discussion refers to previous research (+)

Limitations of research (+)

5 Conclusion based on research (+)
6 Research Advice (+)
7 Write a list of references according to the (+)
rules
VALIDITY
No criteria result

Are the results applicable to the

1 Yes
selected sample?

Are the results applicable to the

2 Yes
reachable population?
Are the results applicable to the
3 NO
target population?
 Importancy
No. criteria result
Was the sample allocation in this study done
1. -
randomly?
Was the sample observation carried out sufficiently
2. +
long and complete?

3. Were all samples in the randomized analysed? -

4. Do the sample and researcher remain blind? -

 Applicable
No Criteria Result
Are there any differences in our patients compared to Yes
those in previous studies so that these results cannot be
1 applied to our patients?

Is it possible to apply this research to our patients? Yes

2

Does the patient have the potential to benefit if the Yes

3 study is applied?