Does everybody respond to antipsychotic medication? If people don’t respond, how are they treated?

Professor David Taylor: Not everyone responds to antipsychotic medication, it depends on the stage of the illness.

If we look at people who have a first episode of schizophrenia, and we look at the effect of treatment with medication over a year, most studies show that about 90 per cent of people will show a response. That doesn’t mean that 90 per cent of people will get completely better and be as well as they were before they started having symptoms, but 90 per cent of people will be effectively treated, let’s say. So at the beginning only about 10 per cent of people don’t respond to medication.

As the illness goes on and people have it for longer, the rate of response goes down substantially. So if we look at someone who is having their fifth episode of schizophrenia, they are hospitalised for the fifth time, then you might expect somewhere between 20 and 50 per cent of people to respond to antipsychotic medication.

If we go to the situation where someone has tried 2 or more medications and has found that none of them has worked, then one’s chances of finding a medication that works are quite slim. Unless you use clozapine, and clozapine is effective for the majority of people who don’t respond to other medications, and by the majority I mean about 50 or 60 per cent of people who don’t respond to their antipsychotics will respond to clozapine.

Maybe 40 per cent of people don’t show a response to clozapine. Some of those will respond if clozapine is given for a bit longer, so there is one school of thought that suggests that you really need to take clozapine for a year to see whether it’s going to work. Other people will show a slightly better response if another antipsychotic is added to clozapine. This is one of the few areas where using 2 antipsychotics together is evidence-based and acceptable.

This is a group of patients who we struggle to treat effectively. They’ve usually tried a great number of antipsychotics sometimes as many as 10 or 15, including clozapine.

Generally speaking a drug history will be taken to see if there is any particularly drug or combination in the patient’s time of their illness that has been more effective than any other. There are also attempts to introduce non-drug measures, such as psychological therapies, and also sometimes having somebody in a hospital, in a ward where they feel comfortable and at home, their therapeutic milieu can make a big difference to people’s condition.

So although drug treatment may not work there are other things that can be tried to improve matters. And for most people drug treatment works at least a little bit, but there are definitely a group of people for whom drug treatment does not work sufficiently well and they remain ill despite various attempts at effective drug treatments.