Conventional Antipsychotic Prescription in Unipolar Depression, II: Withdrawing Conventional Antipsychotics in Unipolar, Nonpsychotic Patients. [CME]
J Clin Psychiatry 2003;64(6):668-672
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Background: In a Hull and Holderness Community
NHS Trust audit of prescribing in unipolar depression, 55
patients were identified as taking a redundant conventional
antipsychotic with no apparent diagnostic indication. Concerns
regarding these patients' polypharmacy, duration of treatment,
and risk of long-term or undetected side effects led to their
being contacted with a view to the discontinuation of
conventional antipsychotic treatment.
Method: All case notes were scrutinized to
validate, as far as possible, the diagnosis of unipolar
depression without psychotic features. Patients were invited for
a review of their medication. Ratings of symptoms (Brief
Psychiatric Rating Scale), depression (Hamilton Rating Scale for
Depression), motor side effects (Abnormal Involuntary Movement
Scale), and personal function (Independent Living Skills Survey)
were made before and after conventional antipsychotic
discontinuation. The study was conducted Autumn 1999-Spring 2000.
Results: None of the 55 patients were deemed to
present comorbid depression secondary to any other diagnosis. One
patient could not be contacted; 14 patients, who tended to be
older, refused the review. Of the remaining 40 who were seen, 25
had already discontinued antipsychotic treatment; their
chronicity of illness was half that of the 15 patients continuing
antipsychotic treatment. However, only 11 of these 25 patients
had their medications discontinued under consultant psychiatrist
supervision following the audit; 14 patients had stopped
medication of their own volition, or for unclear reasons. Of the
remaining 15 patients, 13 had their conventional antipsychotic
discontinued by us. There were clinically and statistically
significant improvements in symptoms and side effects after
antipsychotic treatment was discontinued, and a statistically
significant improvement in personal health care function.
Conclusion: In this small sample,
discontinuation of nonindicated conventional antipsychotic
treatment was associated with clear benefits. Conventional
antipsychotics should be used with caution in nonpsychotic
depressed patients, particularly in the long term. Reluctance to
discontinue medication in more chronic patients may be misplaced.