A systematic review of comparative time to all cause discontinuation of antipsychotic medications in first episode psychosis

Alice Brooke,Richard Whale,Mihaela Bucur

doi:10.1192/bjo.2021.642

Abstract

AimsPrompt treatment with medication and intensive psychosocial support are interventions that have been shown to improve function and prognosis in patients with First Episode Psychosis. NICE guidelines state that patients with a first episode of Psychosis should remain on an antipsychotic medication for 1–2 years to reduce risk of relapse, yet most patients stop long before 2 years. This systematic review explores the comparative time to all cause discontinuation of antipsychotics, often used as a marker of real-world treatment effectiveness, in First Episode Psychosis patients.MethodA literature search was performed across multiple healthcare databases from 1980 to present day in the English Language. Inclusion criteria covered patients with a First Episode of Psychosis aged 14 years and over, and studies that were randomised controlled trials or observational in nature. The primary outcome measure was time to discontinuation of antipsychotic medication. Bias was assessed using the GRADE approach.Result11 studies and 3840 patients were included in the review. Seven studies were randomised clinical trials; three were blinded, and four open-label. The remaining four were observational studies. All but one of the studies had a minimum follow-up period of one year (with a maximum of three years). Due to significant methodological heterogeneity across studies, it was not possible to perform meta-analysis. Narrative analysis of the results showed that Olanzapine performed ranked best, and wasbeing taken for the longest time period by patients, followed by Risperidone.ConclusionMultiple reviews exist on the efficacy of antipsychotics in First Episode Psychosis, but this is the first one to focus on time to discontinuation as a distinct outcome measure. The review encompasses a large sample size across North America, Eastern Asia and Europe. The interaction of time to discontinuation of antipsychotics with associated symptom levels and medication doses remains an area for further research. The review highlighted the significant differences in statistical methodology across studies in this emerging field, and the need for standardisation in ongoing research. Whilst effectiveness may therefore be greatest for olanzapine, this is outweighed in current guidance by its least favourable metabolic adverse effects profile.

Highlights

This recognises that medical students require a range of interventions at multiple levels to reduce stress, promote wellbeing and manage the spectrum of mental health difficulties they may encounter
Full text studies included 41: ‘Curriculum and Grading’ (n = 4); ‘Mindfulness and Yoga’ (n = 11); ‘Stress Management/Relaxation’ (n = 13); ‘Behavioural Interventions’ (n = 3); ‘Cognitive & Selfawareness Interventions’ (n = 2); Mentorship (n = 3); ‘Education, Screening and Access to care’ (n = 3); ‘Multifaceted Interventions’ (n = 2). Effective interventions include those that reduce academic stress through grading changes and supporting transition to clinical training; resilience enhancing interventions such as mindfulness, yoga, CBT, group based exercise and relaxation; peer mentorship; faculty mentorship when actively engaged by the mentor; reducing stigma; improving detection; and improving access to treatment
We propose a framework for implementing these effective interventions through ‘Ecological and Preventative’ paradigms

Summary

Introduction

This recognises that medical students require a range of interventions at multiple levels to reduce stress, promote wellbeing and manage the spectrum of mental health difficulties they may encounter. A framework for nurturing doctors: systematic review of wellbeing interventions in medical students UK medical students report high levels of stress, in particular within the coronavirus pandemic: 46% have a probable psychiatric disorder; almost 15% consider suicide; 80% describe support as poor or moderately adequate.

Results

Conclusion