Antipsychotic medication, sedation and mental clouding: An observational study of psychiatric consultations

Abstract

Sedation and mental clouding are of concern to people on antipsychotic medication and are implicated in social withdrawal but their severity may be underestimated by psychiatrists. Existing studies of communication about adverse effects of medication are based on reports made by doctors or patients. This study is based on audiotapes of 92 outpatient consultations in two UK mental health trusts involving nine consultant psychiatrists where antipsychotic medication was discussed. When interviewed, these doctors and their colleagues had expressed a commitment to ‘patient-centred’ practice as well as recording concerns about the difficulties involved in the discussion of medication side effects. The study focuses on the ways in which sedation and mental clouding are presented and engaged with. Analysis of audiotape transcripts showed that patients raise these issues more often than doctors, contrasting with other adverse effects (such as blood changes) where doctors are more frequently the initiators of discussion. Sleepiness is sometimes presented by both patients and doctors as a part of normal experience and therefore to be welcomed. When presented as troublesome, patients’ reports were sometimes met by doctors offering no response, changing the subject, or disagreeing with the patient's interpretation of the experience. Equally, there were some attempts by doctors to engage with patients’ troubles and seek solutions. These could be unsuccessful where they involved challenges to the patients’ medication-taking rationale, or more successful where they involved sympathetic and supportive listening. We speculate that the capacity to avoid addressing these problems is linked to the informal conversational style of these consultations, which means that concerns raised by one party can remain unaddressed without offending conversational norms. Doctors in these consultations are able to exercise considerable discretion over whether to define reports of sedation and mental clouding as medication-related problems.

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.