[aatd86]

I think you might miss the point slightly, moving too far the discussion on the other side.

It's perfectly normal to wonder how can one administrate something when one doesn't understand it. Especially when there can be such debilitating effects.

In clinical settings, things are way less clear than you make it seem. All psychosis are not equal and even all diagnostic of a same patient are not equal.

There is a lot more caution that should be advised. Including in the administration protocols instead of handwaving and just claiming that it should be taken life-long (which betrays that it's not a cure).

It does not even make sense in the first place that there is no attempt at finding the base neuro-transmitter levels in and out of psychotic phases for each patient before deciding on the posology of a treatment. Managing plasma concentration in a finer-grained way might avoid some (not all) of the issues with neuroleptics.

Some people even only have a few episodes every few years and are still put on life-long treatment with all the side-effects that can then be seen.

It needs to be way more fine-grained if not restudied.

[retrac]

> It's perfectly normal to wonder how can one administrate something when one doesn't understand it. Especially when there can be such debilitating effects.

A theoretical/principled understanding of how a drug works has never been required for useful medicine to happen. For example, we don't know how general anaesthesia works. We don't know why some people have extremely bad reactions to certain anaesthetics (and they do). And yet they are used every day, to enormous net benefit.

> finding the base neuro-transmitter levels in and out of psychotic phases for each patient before deciding on the posology of a treatment

Is it actually possible to measure that, non-invasively?

[aatd86]

The anaesthetic agent is not a drug that one is supposed to take for the remaining of their life and has no observed side-effects in general.

It's also treated with the utmost care and in most interventions, if there is a choice to do without, the patient is offered the choice. There is a lot more consent involved.

So it's not the same thing.

To answer your other question, yes, neurotransmitter levels can be measured in the blood or urine.

For someone under-treatment, it would only make sense to. Wait 4 or 5 times the half-life of the molecule. (that's the difficulty since once started, they are not even supposed to stop).

[horsawlarway]

> The anaesthetic agent is not a drug that one is supposed to take for the remaining of their life and has no observed side-effects in general.

This is notably untrue. General anaesthesia is associated with higher risks of dementia. Especially the older the person being treated.

While there's some disagreement here - short term cognitive decline is inarguable as a side-effect (called post-operative cognitive decline), and many suspect it's related to long term cognitive issues:

---

From: https://www.alzheimers.org.uk/about-dementia/risk-factors-an...

> There is a link between surgery and short-term changes in thinking and memory, called post-operative delirium or post-operative cognitive decline. This condition particularly seems to affect older people. Some studies have also found that these short term changes may be associated with higher risk of dementia later in life but other studies have found no association.

[aatd86]

I don't see how your link establishes that what I said is notably untrue.

[horsawlarway]

There are known side effects (short term cognitive decline). In addition - there are unresolved questions about whether those effects are persistent or not, and whether age plays a role.

What you said is: "[anaesthetic agent] has no observed side effects in general" and that's just not true.

As an aside - my grandmother had hip surgery at 86 and was never the same mentally afterwards. She could walk, but she couldn't remember who her family was. It was not particularly unexpected (she had an existing diagnoses of alzheimers) but the change post-surgery was notable enough that the entire family discussed it. It was like she had been slipping a bit, but the surgery threw her off a cliff. The difference between knowing who you are, but discussing the weather every half hour or so, to having no idea who the people around her were.

Personally - I would firmly place anesthetics into a fairly risky category of drug that we have a very poor understanding of. Which is decidedly not where you are placing it.

[MichaelZuo]

It has serious, observed, side effects for a sizable fraction of the population?

Yet your comment said "and has no observed side-effects in general."

[aatd86]

It's a well-known post-operation side effect that affects a few people transiently.

Maybe it's my fault for not being specific but in context, I was talking about long-term, possibly irreversible complications. While what you point out exists (every psychoactive drug has undesirable side-effects in general, even coffee can be dangerous), it is incomparable to the rate of occurences of side-effects such as tardive dyskinesia for neuroleptics for instance.

That's why I also added "in general" ...

[kbelder]

It isn't required for useful medicine, but it is useful for required medicine.

[whats_a_quasar]

The goal is to maximize the life outcomes and quality of life of people with schizophrenia. I think in the conversation here there are two questions: What should the public conversation on schizophrenia be like? And, how should the medical system use antipsychotics in the treatment of schizophrenia?

I think, on the first question, the public conversation about schizophrenia is not ideal for improving outcomes. In particular, people in their 20s who have a first psychotic episode need to be pushed by their friends and family to get medical care immediately. Schizophrenia treated early is associated with much better outcomes later in life, and long periods of untreated psychosis are associated with much worse outcomes. I think that poor quality articles like this one sustain that section of the population who distrust psychiatrists, which leads some schizophrenics to seek treatment too late or not at all.

On the second question, I think that doctors are doing about as well as they can with antipsychotics with the current state of knowledge. Though it sounds like your concern about overprescription is from experience, and my feelings about the right level of long-term antipsychotic use are much weaker than my feelings about the public conversation.

I agree that it would be better for antipsychotics to be better targeted. Measuring individual neurotransmitter levels sounds like a very interesting way to better target treatment, though I don't think it is straightforward to measure neurotransmitters in a living brain.

I agree that many patients are on antipsychotics for longer than is necessary. The challenge is distinguishing between patients who should discontinue antipsychotics and the patients who will immediately relapse into psychosis without meds.

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Other thoughts:

> It's perfectly normal to wonder how can one administrate something when one doesn't understand it.

This is a mischaracterization of the state of the science. Antipsychotics are well understood, though not fully understood. We at this point have decades of data on the efficacy of antipsychotics, the prevalence and severity of side effects. We know most of the interactions between the drug and the body. What is not well understood is the exact mechanism by which these interactions moderate psychosis.

> there is no attempt at finding the base neuro-transmitter levels in and out of psychotic phases for each patient before deciding on the posology of a treatment

To my non-expert ears this sounds like an interesting approach to make treatment more targeted. I am not aware of a technology that could currently be used to measure neurotransmitters in a living brain, and I worry that measurement would be invasive.

> Some people even only have a few episodes every few years and are still put on life-long treatment with all the side-effects that can then be seen.

[aatd86]

> This is a mischaracterization of the state of the science. Antipsychotics are well understood, though not fully understood

That's a very important distinction in the latter part. They are somewhat understood in their action mechanisms, whether VMAT1, VMAT2, D1, D2 receptors etc. But not really in their effectiveness (which is slightly more important, especially to determine administration protocols).

Which is also the point of the article.