Critical debate 33.1

Possible answer to: Does antipsychotic medication damage physical health?

There are conflicting results from studies and reviews into the impact of prescribed medication on the risk of cardiovascular disease. There is certainly evidence of elevated risk linked to weight gain and metabolic side-effects as a result of prescribed antipsychotic medication, particularly for olan­zapine and clozapine (De Hert et al., 2012). It is also known that people with schizophrenia have an increased risk of metabolic diseases, such as type 2 diabetes, that predates the use of antipsychotic medication, indicating a possible genetic link between the two (Gough & O’Donovan, 2005). In clinical populations, the association is less clear because the majority of service users have had long expo­sure to a variety of medications, rarely take medications as the prescriber intended and have many other lifestyle and health behaviour risk factors.

Long-term exposure to any antipsychotic treatment was significantly associated with lower mor­tality than no prescribed medicine use in an important independently funded large cohort study in schizophrenia, with clozapine posing the lowest risk of all (Tiihonen et al., 2009). The reason for this result is hotly debated but it is possible that long-term exposure to medication could be a proxy measure for engagement and the receipt of care, or that medication is successfully targeting important risk factors such as symptoms, sleep problems and suicidality. In support of this, a recent systematic review found antipsychotic and antidepressant medications protected against mortality in SMI if the medication was taken as intended (Baxter et al., 2016).

Prescribing that takes account of individual responses by adjusting dosage and duration of treat­ment and adheres to guidelines is important. We know that people with SMI are prepared to continue taking medication if they believe the medicine is helping them with the problems they are experi­encing, and that there is some action they can take to help manage the negative effects. Recent research in early intervention services indicates that an intense structured exercise programme can reverse the weight gain and negative metabolic outcomes commonly seen in the first few months of antipsychotic medication treatment (Curtis et al., 2015). With a significant amount of support, it may be possible to maintain this improvement over time.