Antipsychotic medication, sedation and mental clouding: An observational study of psychiatric consultations☆
Introduction
Sedation and mental clouding have long been of concern to patients on antipsychotic medications (Estroff, 1981; National Schizophrenia Fellowship (2001a), National Schizophrenia Fellowship (2001b)). These experiences are commonly described as feeling ‘tired’, ‘sleepy’ or ‘like a zombie’ and contribute to social withdrawal (Rogers et al., 1998; Usher, 2001). One of the respondents in the study by Rogers et al. (1998) illustrates this:
Well you just sort of, you’re walking around like a zombie and you’re like sort of you can’t join in with things, I wouldn’t be talking to you like what I’m talking now. I know I might seem a bit high, but when you’re on [the antipsychotic drug] you can’t even be bothered holding a conversation you know, you’re just sat there saying yes or no, so I won’t take it I’m sorry but I’m not taking it. (1998: 1317)
Psychiatrists differ from patients in their judgements of the distress caused by adverse effects of antipsychotic medication (Day, Kinderman, & Bentall, 1998; Rettenbacher, Burns, Kemmler, & Fleischhacker, 2004). Psychiatric perspectives on sedation and mental clouding may suffer particularly from this. For example, in their study of the information given by psychiatrists to patients about the side effects of antipsychotic drugs, Smith and Henderson (2000) listed 23 experiences that the authors (both psychiatrists) considered to be common adverse effects of these medications, without including sedation, drowsiness or mental clouding. Yet in a survey of patients reported by the National Schizophrenia Fellowship (2001a) where 2222 respondents were asked ‘What is the worst thing about taking medication for mental illness?’ ‘Sedation and lethargy’ was the most commonly mentioned ‘worst thing’ (22% of respondents).
Other studies indicate that communicating about adverse effects is variable in psychiatric practice (Laugharne, Davies, Arcelus, & Bouman, 2004) with surveys of patients suggesting that insufficient information is given (Mind, 1998; National Schizophrenia Fellowship, 2000; Olofinjana & Taylor, 2005). But all of these studies are based on self-reports, either by doctors or by patients. Such study designs are subject to recall bias. Patients may forget what they have been told. Doctors may be optimistic in their estimates of how much information they provide. Observational studies of communication behaviour in psychiatry are rare. One exception is a study of the extent to which psychiatrists engage with patients who choose to talk about their psychotic symptoms during consultations (McCabe, Heath, Burns, & Priebe, 2002). This study found that doctors exhibited reluctance and discomfort in engaging with these concerns. Thus in this study, when a patient asked ‘why don’t people believe me when I say I’m God’ a psychiatrist responded with a question: ‘what should I say now?’ and laughter. This, the authors argue, is a typical response, although they also warn against generalising from a few selected cases (anecdotalism).
Having searched the published literature we have been unable to discover any studies reporting similar direct observations of how the adverse effects of medication are discussed in psychiatric consultations. We therefore report here a naturalistic observational study of communication about sedation and mental clouding during outpatient consultations in which antipsychotic medications are reviewed. We assess the ways in which psychiatrists either engage with or avoid these issues. We present our data both by means of simple counts (to guard against the charge of anecdotalism) and by means of detailed commentaries on selected extracts.
Section snippets
Method
Nine consultant psychiatrists working in two adult mental health service trusts in the UK agreed to audiotape consultations with consenting patients participating in outpatient consultations where antipsychotic medications were discussed. The psychiatrists had been interviewed about their perceptions of such consultations for an earlier study (Seale, Chaplin, Lelliott, & Quirk, 2006) which had identified the discussion of side effects as an area of particular concern to respondents. Respondents
Results
Sedation and mental clouding were raised as topics in 39 of the 92 consultations, more often by patients than by doctors. In relation to typical antipsychotics, patients attributed sedation or mental clouding to the medication 21 times in 14 consultations. A doctor raised the issue independently in relation to typicals on just one occasion (in two others the doctor referred to a past consultation where the patient had complained of this effect). In relation to atypical antipsychotics patients
Discussion
In these consultations patients initiate discussion of sedation and mental clouding quite frequently and do so more often than doctors. By marking the experience of sleepiness and lethargy as positive both doctors and patients are responding to the ambiguous status of sleepiness, in that it can be understood as part of normal experience rather than a medical condition. This can contribute to a lack of ‘hearability’ of the issue as a complaint and stands in marked contrast to evidence from
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The study was funded by Eli Lilly who did not influence the conduct of this research.