Conventional antipsychotic prescription in unipolar depression, II: withdrawing conventional antipsychotics in unipolar, nonpsychotic patients

Abstract

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.