How important are informed consent, informed choice, and patient-doctor relationships, when prescribing antipsychotic medication?

What is helpful and unhelpful when people try to withdraw from antipsychotics: An international survey

OBJECTIVE

Antipsychotics remain the first-line treatment for people diagnosed with psychotic disorders despite adverse effects which lead many people to stop their medication. Many stop without the support of the prescriber, who may fear relapse. The objective of this study is to better understand the process of withdrawal from antipsychotics, from the perspective of people taking antipsychotics.

DESIGN

Online survey.

METHODS

An international online survey elicited quantitative responses about pre-withdrawal planning (560) and qualitative responses about what was helpful and unhelpful when withdrawing from antipsychotics (443). Responses came from users of antipsychotics in 29 countries.

RESULTS

Forty-seven per cent did not consult their psychiatrist before discontinuing. Only 40% made preparations, most commonly making a plan, gathering information and informing family. The most frequently reported helpful factors were focussing on the benefits of getting off the drugs (including ending adverse effects and feeling more alive), information about withdrawal symptoms and how to withdraw safely, withdrawing slowly, and support from psychologists, counsellors and psychotherapists. The most common unhelpful factor was the psychiatrist/doctor, largely because of their lack of knowledge, refusal to support the patient's wishes and the threat or use of coercion.

CONCLUSIONS

Evidence-based, respectful, collaborative responses to patients' concerns about adverse effects and desires to withdraw would probably reduce relapse rates and improve long-term outcomes. It would definitely help end pervasive breaching of the principle of informed consent and human rights legislation.

Strategies and Management for Psychiatric Drug Withdrawal: A Systematic Review of Case Reports and Series

In recent years, an increasing number of case reports on psychiatric drug withdrawal have emerged, offering detailed clinical insights and valuable real-world evidence on the withdrawal process. The objective of this review was to evaluate the strategies and management for withdrawing psychiatric drugs, as detailed in case reports and series. A systematic review of case reports and series published between 2013 and 2023 was conducted to capture the latest trends in psychiatric drug withdrawal. Cases were identified following the PRISMA guidelines by searching electronic databases Medline and Scopus. Finally, 47 case reports and series were included. The primary reason for drug withdrawal was attributed to the emergence of adverse events, followed by medication dependence or abuse, and clinical decision-making or symptom resolution. Gradual reduction of doses was implemented through various management approaches as the primary strategy for drug withdrawal, and drug substitution emerged as the second most employed strategy. Also, patients were mostly undergoing polypharmacy. Favorable treatment outcomes were reported in the majority of cases, suggesting that psychiatric drug withdrawal is feasible - though quite challenging in some situations. However, the remarkably low number of unsuccessful cases may create a misleading impression of the significant difficulty associated with withdrawing psychiatric drugs.

Supported decision-making interventions in mental healthcare: A systematic review of current evidence and implementation barriers

BACKGROUND

There is a growing momentum around the world to foster greater opportunities for the involvement of mental health service users in their care and treatment planning. In-principle support for this aim is widespread across mental healthcare professionals. Yet, progress in mental health services towards this objective has lagged in practice.

OBJECTIVES

We conducted a systematic review of quantitative, qualitative and mixed-method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning, to understand the current research evidence and the barriers to implementation.

METHODS

Seven databases were searched and 5137 articles were screened. Articles were included if they reported on an intervention for adult service users, were published between 2008 and October 2023 and were in English. Evidence in the 140 included articles was synthesised according to the JBI guidance on Mixed Methods Systematic Reviews.

RESULTS

Research in this field remains exploratory in nature, with a wide range of interventions investigated to date but little experimental replication. Overarching barriers to shared and supported decision-making in mental health treatment planning were (1) Organisational (resource limitations, culture barriers, risk management priorities and structure); (2) Process (lack of knowledge, time constraints, health-related concerns, problems completing and using plans); and (3) Relationship barriers (fear and distrust for both service users and clinicians).

CONCLUSIONS

On the basis of the barriers identified, recommendations are made to enable the implementation of new policies and programs, the designing of new tools and for clinicians seeking to practice shared and supported decision-making in the healthcare they offer.

PATIENT OR PUBLIC CONTRIBUTION

This systematic review has been guided at all stages by a researcher with experience of mental health service use, who does not wish to be identified at this point in time. The findings may inform organisations, researchers and practitioners on implementing supported decision-making, for the greater involvement of people with mental ill health in their healthcare.