Antipsychotic treatments: who is really failing here?
Authors: Charles Heriot-Maitland, Stephanie Allan, Simon Bradstreet, Andrew Gumley
Journal: The Lancet Psychiatry (2018)

We have enormous respect for the group of René A Kahn and colleagues who recently published in The Lancet Psychiatry,1Kahn RS van Rossum IW Leucht S et al.Amisulpride and olanzapine followed by open-label treatment with clozapine in first-episode schizophrenia and schizophreniform disorder (OPTiMiSE): a three-phase switching study.Lancet Psychiatry. 2018; (published online Aug 13. https://doi.org/10.1016/S2215-0366(18)30252-9.)Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar many of whom are international leaders in psychiatric research, and among whom are some of our previous colleagues and collaborators. This is a high quality research study, which makes some important recommendations, and running such a project across 27 centres in 15 countries is an admirable achievement. However, we are not writing to comment on the study itself, but rather to draw attention to some of the language used in reporting these results. When treatments, whether biological, psychological, or social, are not helping or producing the desired outcomes of researchers, clinicians, or those in receipt of the treatments, this outcome is, without doubt, important. However, in a number of places throughout this Article, the authors refer to their patients as having failed at their antipsychotic treatment—eg, "patients fail a single antipsychotic trial" and "schizophrenia patients fail to remit to a single antipsychotic".1Kahn RS van Rossum IW Leucht S et al.Amisulpride and olanzapine followed by open-label treatment with clozapine in first-episode schizophrenia and schizophreniform disorder (OPTiMiSE): a three-phase switching study.Lancet Psychiatry. 2018; (published online Aug 13. https://doi.org/10.1016/S2215-0366(18)30252-9.)Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar Indeed, one of these remarks was chosen as the quote to publicise the Article on The Lancet Psychiatry's Twitter feed.2@TheLancetPsychiatry https://twitter.com/TheLancetPsych/status/1029137046055669761Date: Aug 14, 2018Date accessed: August 20, 2018Google Scholar So, let us be clear—this language is being used by world leading psychiatrists, and being put into the public domain by a leading psychiatric journal. In 2018. Can we please all just pause for a minute to think about what it would be like to read this statement as a person who has a received a diagnosis of schizophrenia. People with this diagnosis already experience considerable stigma and shame,3Brohan E Elgie R Sartorius N Thornicroft G Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: the GAMIAN-Europe study.Schizophr Res. 2010; 122: 232-238Summary Full Text Full Text PDF PubMed Scopus (350) Google Scholar whether in relation to trauma and adverse life experiences,4Varese F Smeets F Drukker M et al.Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies.Schizophr Bull. 2012; 38: 661-671Crossref PubMed Scopus (1500) Google Scholar or stereotyped views about people with psychosis that are still widely held in the general public,5Thornicroft G Brohan E Rose D Sartorius N Leese M Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey.Lancet. 2009; 373: 408-415Summary Full Text Full Text PDF PubMed Scopus (749) Google Scholar including those communicated by use of social media.6Robinson P Turk D Jilka S Cella M Measuring attitudes towards mental health using social media: investigating stigma and trivialisation.Soc Psychiatry Psychiatr Epidemiol. 2018; (published online Aug 1. DOI:10.1007/s00127-018-1571-5.)Crossref Scopus (72) Google Scholar As if this situation was not challenging enough, are these people now being told that if their symptoms do not improve with a treatment it is their failing? We would urge the psychiatric community to consider what is being communicated here, whether this language is helpful, and, indeed, whether this statement is even accurate. Is it really the patient's failure? Or a failure of the treatment? CHM is supported by a Medical Research Council Clinical Research Training Fellowship MR/L01677X/1, investigating the role of social factors in dissociation and threat processing in psychosis. AG is Chief Investigator of National Institute for Health Research Health Technology Assessment project 13/154/04, which is developing and testing digital technology to prevent relapse amongst individuals diagnosed with Schizophrenia. All other authors declare no competing interests. Antipsychotic treatments: who is really failing here? – Authors' replyWe thank Charles Heriot-Maitland and colleagues for their Correspondence about our Article.1 We agree that language used should reflect the reality that no one is to blame when an individual's symptoms of schizophrenia do not improve with treatment. Factors as diverse as perception of efficacy, doctor–patient relationship, and pathogenetic mechanisms all have a role. Although the good news from the OPTiMiSE trial1 is that 72% of participants with a first psychotic episode reached remission within 10 weeks of treatment, 28% of participants—a substantial minority—did not. Full-Text PDF Amisulpride and olanzapine followed by open-label treatment with clozapine in first-episode schizophrenia and schizophreniform disorder (OPTiMiSE): a three-phase switching studyFor most patients in the early stages of schizophrenia, symptomatic remission can be achieved using a simple treatment algorithm comprising the sequential administration of amisulpride and clozapine. Since switching to olanzapine did not improve outcome, clozapine should be used after patients fail a single antipsychotic trial—not until two antipsychotics have been tried, as is the current recommendation. Full-Text PDF