How do we, as clinicians, assess the benefits and harms of any medication, including but not limited to psychiatric medications? More specifically, how do we decide whether long-term antipsychotic (AP) treatment does “more good than harm”–or vice versa, as some critics of psychiatry have claimed?
Certainly, a careful examination of the literature on relapse and remission rates in “schizophrenia spectrum” disorders** is an important part of the answer.
But we reject the notion that this is the only criterion for judging the risks and benefits of long-term AP use. Equally, we do not believe that armchair analyses of the literature by non-clinicians will answer the risk/benefit question in a humane and judicious manner.
On the contrary, we believe that the working with psychotic patients, and appreciating their often profound suffering, is an essential part of the equation.
Critics of psychiatry who have never spent time with patients and families coping with the ravages of schizophrenia simply do not grasp the human tragedy of this illness. These critics also miss the deep-seated satisfaction that comes from seeing severely impaired patients achieve remission, and even recovery—in which antipsychotic medication usually plays an important role.
As clinicians with long experience treating patients suffering with schizophrenia, our views on antipsychotic medication are shaped not only by our understanding of the scientific literature, but also by our personal care of many hundreds of patients, over several decades.
In two previous pieces, one of us (RP) examined some recent studies pointing to the benefits of long-term AP use in schizophrenia, including reduction of relapse rates and the risk of suicide.1,2 In this piece, we examine the concept of “quality of life” (QOL) and what we know about its relationship to antipsychotic use.
We focus primarily on placebo-controlled studies, despite the paucity of such investigations in the published literature.
What is Meant by “Quality of Life”?
As Berlim and Fleck noted in their 2003 review, the concept of “quality of life” is relatively new in the psychiatric literature and “embraces a whole spectrum of uses and meanings.”3
In general, however, QOL refers to “…how patients feel and how satisfied they are with treatment, besides the traditional focus on disease outcomes.”3
In 1998, the World Health Organization described QOL in these terms:
“It is a broad-ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships and their relationship to salient features of their environment.”4
Berlim and Fleck list nearly a dozen instruments or scales designed to measure QOL, including, for example, the Quality of Life Scale (QLS), the Wisconsin Quality of Life Index (W-QLI), and the Medical Outcomes Study Short Form – 36 Items (SF-36).
The main items on the original (21-item) version of the QLS5 include such factors as interpersonal relations, social initiative, work functioning, motivation, sense of purpose and emotional interaction.