An analysis of views about supported reduction or discontinuation of antipsychotic treatment among people with schizophrenia and other psychotic disorders.

BACKGROUND: Antipsychotic medication can reduce psychotic symptoms and risk of relapse in people with schizophrenia and related disorders, but it is not always effective and adverse effects can be significant. We know little of patients' views about continuing or discontinuing antipsychotic treatment. 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. METHODS: We collected quantitative and qualitative data by conducting semi-structured interviews in London, UK. Factors predicting a desire to discontinue medication were explored. Content analysis of qualitative data was undertaken. RESULTS: We interviewed 269 participants. 33% (95% CI, 27 to 39%) were content with taking long-term antipsychotic medication. Others reported they took it reluctantly (19%), accepted it on a temporary basis (24%) or actively disliked it (18%). 31% (95% CI, 25 to 37%) said they would like to try to stop medication with professional support, and 45% (95% CI, 39 to 51%) wanted the opportunity to reduce medication. People who wanted to discontinue had more negative attitudes towards the medication but were otherwise similar to other participants. Wanting to stop or reduce medication was motivated mainly by adverse effects and health concerns. Professional support was identified as potentially helpful to achieve reduction. CONCLUSIONS: This large study reveals that patients are commonly unhappy about the idea of taking antipsychotics on a continuing or life-long basis. Professional support for people who want to try to reduce or stop medication is valued.

Antipsychotic dose reduction and discontinuation versus maintenance treatment in people with schizophrenia and other recurrent psychotic disorders in England (the RADAR trial): an open, parallel-group, randomised controlled trial.

BACKGROUND: Maintenance antipsychotic medication is recommended for people with schizophrenia or recurrent psychosis, but the adverse effects are burdensome, and evidence on long-term outcomes is sparse. We aimed to assess the benefits and harms of a gradual process of antipsychotic reduction compared with maintenance treatment. Our hypothesis was that antipsychotic reduction would improve social functioning with a short-term increase in relapse. METHODS: RADAR was an open, parallel-group, randomised trial done in 19 National Health Service Trusts in England. Participants were aged 18 years and older, had a diagnosis of recurrent, non-affective psychotic disorder, and were prescribed an antipsychotic. Exclusion criteria included people who had a mental health crisis or hospital admission in the past month, were considered to pose a serious risk to themselves or others by a treating clinician, or were mandated to take antipsychotic medication under the Mental Health Act. Through an independent, internet-based system, participants were randomly assigned (1:1) to gradual, flexible antipsychotic reduction, overseen by treating clinicians, or to maintenance. Participants and clinicians were aware of treatment allocations, but assessors were masked to them. Follow-up was for 2 years. Social functioning, assessed by the Social Functioning Scale, was the primary outcome. The principal secondary outcome was severe relapse, defined as requiring admission to hospital. Analysis was done blind to group identity using intention-to-treat data. The trial is completed and has been registered with ISRCTN registry (ISRCTN90298520) and with ClinicalTrials.gov (NCT03559426). FINDINGS: 4157 people were screened, of whom 253 were randomly allocated, including 168 (66%) men, 82 (32%) women, and 3 (1%) transgender people, with a mean age of 46 years (SD 12, range 22-79). 171 (67%) participants were White, 52 (21%) were Black, 16 (6%) were Asian, and 12 (5%) were of other ethnicity. The median dose reduction at any point during the trial was 67% in the reduction group and zero in the maintenance group; at 24 months it was 33% versus zero. At the 24-month follow-up, we assessed 90 of 126 people assigned to the antipsychotic dose reduction group and 94 of 127 assigned to the maintenance group, finding no difference in the Social Functioning Scale (ß 0·19, 95% CI -1·94 to 2·33; p=0·86). There were 93 serious adverse events in the reduction group affecting 49 individuals, mainly comprising admission for a mental health relapse, and 64 in the maintenance group, relating to 29 individuals. INTERPRETATION: At 2-year follow-up, a gradual, supported process of antipsychotic dose reduction had no effect on social functioning. Our data can help to inform decisions about the use of long-term antipsychotic medication. FUNDING: National Institute for Health Research.

Randomised controlled trial of gradual antipsychotic reduction and discontinuation in people with schizophrenia and related disorders: the RADAR trial (Research into Antipsychotic Discontinuation and Reduction).

INTRODUCTION: Antipsychotic medication is effective in reducing acute symptoms of psychosis, but it has a range of potentially serious and debilitating adverse effects and is often disliked by patients. It is therefore essential it is only used when benefits outweigh harms. Although multiple trials conducted with people with schizophrenia indicate an increased risk of relapse in the short-term following abrupt antipsychotic discontinuation, there is little evidence about the long-term outcome of a gradual process of reduction and discontinuation on social functioning, relapse and other outcomes. METHODS AND ANALYSIS: This is a multicentre, randomised controlled trial involving people with schizophrenia and related disorders who have had more than one episode. Participants are randomised to have a clinically-supervised, gradual reduction of antipsychotic medication, leading to discontinuation when possible, or to continue with maintenance treatment. Blinded follow-up assessments are conducted at 6, 12 and 24 months and the primary outcome is social functioning, measured by the Social Functioning Scale at 24 months. A minimum of 134 evaluable participants provides 90% power to detect a five-point difference, and 206 to detect a four-point difference. Secondary outcomes include severe relapse (admission to hospital) and the study is also intended to detect a minimum 10% difference in severe relapse, which requires 402 participants, assuming a 15% loss to follow-up. Other secondary outcomes include all relapses, as identified by an independent and blinded endpoint committee, symptoms measured by the Positive and Negative Syndrome Scale, quality of life, adverse effects, self-rated recovery and neuropsychological measures. Enrolment started in 2016. The trial is scheduled to finish in June 2022. ETHICS AND DISSEMINATION: Ethical approval was initially obtained on 27 October 2016 (UK Research Ethics Committee reference 16/LO/1507). Results will be published in peer-reviewed journals and disseminated to the public. TRIAL REGISTRATION NUMBER: ISRCTN90298520. EudraCT: 2016-000709-36. Pre-results.

Mental health and arts participation: the state of the art in England.

Although participation in arts activity is believed to have important mental health and social benefits for people with mental health needs, the evidence base is currently weak. This article reports the first phase of a study intended to support the development of stronger evidence. Objectives for the first phase were to map current participatory arts activity, to identify appropriate indicators and to develop measures for use in the second phase of the research. A survey of participatory arts projects for people with mental health needs aged 16 to 65 in England, identified via the Internet and relevant organizations, was carried out to map the scale and scope of activity and to establish the nature of current approaches to evaluation. The results indicate that the scope of activity, in terms of projects' settings, referral sources, art forms and participation is impressively wide. In terms of scale, however, projects reported low funding and staffing levels that may have implications for the feasibility of routine evaluation in this field. Current approaches to evaluation were limited, but entailed considerable effort and ingenuity, suggesting that projects are keen to demonstrate their benefits. The survey has enabled us to build on the best evaluation practice identified to develop a measure for assessing the mental health, social inclusion and empowerment outcomes of arts participation for people with mental health needs. For the second phase of the study we will work with arts and mental health projects, using the measure alongside qualitative work in a realistic evaluation design, in order to identify the characteristics of effective projects.

Evaluation of personality disorder workshops in Essex, England: reported impacts on clinical practice.

In this paper we examine the background and context for training related to working with people with personality disorders in England. People with a diagnosis of personality disorder often feel excluded from mainstream health, social and employment contexts, and sometimes experience negative and stigmatizing attitudes from people, including health and social care workers. An evaluation of a program of workshops for forensic nurses and other practitioners was carried out to ascertain how effective the workshops were in challenging attitudes and also in potentially promoting better practice in working with this client group. The evaluation was designed utilizing the principles of illuminative evaluation and involved an analysis of workshop evaluation forms and telephone interviews with course participants. The course received very positive evaluations and participants described how it challenged their beliefs, promoting therapeutic optimism, understanding, and more positive partnerships. Key factors in achieving this were adopting a team approach to the training and service user participation in the workshops. Drawing on our experiences and a wide range of literature, we illustrate the importance of service user involvement in teaching and promoting more positive attitudes, and we outline further areas for investigation.

Evaluating the impact of participatory art projects for people with mental health needs.

Participatory art projects for people with mental health needs typically claim outcomes such as improvements in confidence, self-esteem, social participation and mental health. However, such claims have rarely been subjected to robust outcome research. This paper reports outcomes from a survey of 44 female and 18 male new art project participants attending 22 art projects in England, carried out as part of a national evaluation. Outcomes were quantified through self-completed questionnaires on first entry to the project, during January to March of 2006, and 6 months later. The questionnaires included three measures: empowerment, mental health [Clinical Outcomes in Routine Evaluation (CORE)] and social inclusion. Paired t-tests were used to compare overall change, and mixed model repeated measures analysis of variance to compare subgroups, including age, gender, educational level, mental health and level of participation. Results showed significant improvements in empowerment (P = 0.01), mental health (P = 0.03) and social inclusion (P = 0.01). Participants with higher CORE scores, no new stress in their lives and positive impressions of the impact of arts on their life benefited most over all three measures. Positive impressions of the impact of arts were significantly associated with improvement on all three measures, but the largest effect was for empowerment (P = 0.002) rather than mental health or social inclusion. This study suggests that arts participation positively benefits people with mental health difficulties. Arts participation increased levels of empowerment and had potential to impact on mental health and social inclusion.