Antipsychotic Medications, Schizophrenia and the Issue of Quality of Life

  • A. George Awad
  • Lakshmi N.P. Voruganti


Schizophrenia as a long term disabling illness generally runs a chronic course with acute psychotic relapses that frequently requires hospitalizations. Antipsychotic medications have emerged as the cornerstone in treatment of the disorder in addition to other important interventions such as rehabilitation, psychosocial and economic support. Unfortunately antipsychotic medications has presented a number of significant limitations in terms of inconveniencing or serious side effects as well as there inability to improve certain symptoms at different stages of the illness. 30{%} to 50{%} of patients on antipsychotic medications develop serious dislike to medication as a result of becoming dysphoric, a situation that lead to compromised adherence to medications and subsequent relapse and compromised quality of~life. ∈dent Reviewing published studies involving both new and old antipsychotic medications reveal a good deal of methodological limitations that make it difficult to reach any definitive conclusion about the impact of antipsychotic medications on quality of life. However, the weight of the evidence so far can only suggest a trend favouring the new antipsychotics in terms of their positive impact on quality of life. On the other hand it is clear that medications by themselves can not directly improve quality of life but certainly can improve the potential for patients to benefit from other important interventions such as rehabilitation and psychosocial support that can have direct impact on quality of life. A number of methodological and conceptual issues are proposed to improve the quality of quality of life studies. Finally, though quality of life by itself is an important outcome it is time for the field to look beyond quality of life measurements. In addition to being an outcome, quality of life improvement can be also construed as mediator of other important outcomes such as decreased relapse rate, re-hospitalization and medical resources utilization. Similarly, improvement in quality of life can enhance strategies for improving adherence to medications and other therapeutic regimens as well as better and longer tenure in the community

Key words

Schizophrenia Antipsychotics Quality of life Conceptual models Quality of life scales Dopamine Neurobiological correlates 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Davies L.M., Drummond M.F. The Economic Burden of Schizophrenia. Psychiat. Bull 1990; 14: 522–555.CrossRefGoogle Scholar
  2. 2.
    Awad A.G., Voruganti L.N.P., Heselgrave R.J. The Aim of Antipsychotic Medications: What Are They and Are They being Achieved? CNS Drugs 1995; 4: 8–16.Google Scholar
  3. 3.
    Arana G.W. An Overview of Side Effects Caused by Typical Antipsychotics. J. Clin Psychiatry; 2000; 61 (Suppl 8): 5–11.PubMedGoogle Scholar
  4. 4.
    Awad A.G. Antipsychotic Medications: Compliance and Attitudes Towards Treatment. Curr. Opin. Psychiatry. 2004; 17: 75–80.CrossRefGoogle Scholar
  5. 5.
    Awad A.G., Masty V., McDonnell D. The Link Between Drug Attitudes, Compliance Behaviour and Resource Use Among Individual with Schizophrenia. Poster Presented at the 150 2nd American Psychiatric Association Meeting 1999; (Washington, D.C.).Google Scholar
  6. 6.
    Kerwin R.W., Taylor D. New Antipsychotics: A Review of their Current Status and Clinical Practice. CNS Drugs 1996; 6: 71–82.Google Scholar
  7. 7.
    Awad A.G., Voruganti L.N.P. New Antipsychotics, Compliance, Quality of Life, and Subjective Tolerability – Are Patients Better Off? Can J Psychiatry 2004; 49: 297–302.PubMedGoogle Scholar
  8. 8.
    Lieberman J., Stroup T.S., McEvoy J.P., Swartz M.S., Rosenheck R.A., Perkins D.O., Keefe, R., Davis C., Severe J., Hsiao J., and the Catie Investigators. Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia. The New England J. MED; 353: 1209–1223.Google Scholar
  9. 9.
    Voruganti L.N.P., Cortese L., Owyeumi L., Kotteda V., Cernovsky Z., Zirul S., Awad A.G. Switching from Conventional to Novel Antipsychotic Drugs: Results of a Prospective Naturalistic Study. Schizophr. Res 2002; 57: 201–208.PubMedCrossRefGoogle Scholar
  10. 10.
    Wirshing D.A., Spellberg P.J., Erhart S.M., Marder S.R., Wirshing W.C. Novel Antipsychotic and New Onset Diabetes. Biol. Psychiatry 1998; 44: 778–783.PubMedCrossRefGoogle Scholar
  11. 11.
    Newcomer J.W. Second Generation (atypical) Antipsychotic and Metabolic Effects: A Comprehensive literature Review. CNS Drugs 2005; 19: 1–93.PubMedCrossRefGoogle Scholar
  12. 12.
    De Nayer, DeHert M., Scheem A., Van Gaal L., Peuskins J., Conference Report: Belgain Consensus on Metabolic Problems Associated with Second Generation Antipsychotics. Int J. Psychiatry Clin Pract. 2005; 9: 130–137.CrossRefGoogle Scholar
  13. 13.
    Rothbard A., Murrin M.R., Jordon N., Kuno E., McFarland B., Stroup T.S., Morrissey J.P., Stiles P., Boothroyd R., Merwin E., Shern D. Effects of Antipsychotic Medication on Psychiatric Service Utilization and Cost. J Ment Health Policy Econ 2005; 8 : 83–93.Google Scholar
  14. 14.
    Awad A.G. Voruganti L.N.P., Heselgrave R.J., Preliminary Validation of a Conceptual Model to Assess Quality of Life in Schizophrenia. Quality of Life Res, 1997; 6: 21–26.CrossRefGoogle Scholar
  15. 15.
    Lambert M., Naber D. Current Issues in Schizophrenia: Overview of Patient Acceptability, Functioning Capacity and Quality of Life. CNS Drugs 2004; 18: 5–17.PubMedCrossRefGoogle Scholar
  16. 16.
    Norman R.M., Malla A.K., McLean T., The Relationship of Symptoms and Level of Functioning in Schizophrenia to General Wellbeing and the Quality of Life Scale. Acta Psychiatr Scand 2000, 102: 303–309.PubMedCrossRefGoogle Scholar
  17. 17.
    Barowne S, Clarke M, Gervin M., Waddington J.L., Larkin C., O’Callaghan B., Determinants of Quality of Life at First Presentation with Schizophrenia. Br. J. Psychiatry 2000; 176: 173–176.CrossRefGoogle Scholar
  18. 18.
    Karow A., Naber D., Subjective Wellbeing and Quality of Life under Atypical Antipsychotic Treatment. Psychopharmacology 2002; 162: 3–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Ritsner M., Kurs R., Impact of Antipsychotic agents and their Side Effects on the Quality of Life in Schizophrenia. Expert Rev. Pharmacoeconomics Outcomes. Res. 2002; 2: 89–98.CrossRefGoogle Scholar
  20. 20.
    Awad A.G., Antipsychotic Medications in Schizophrenia: How Satisfied are our Patients? In Hellewell J. Editor: Clear Perspectives 1999, 2: 1–6. London, Shire Hall International.Google Scholar
  21. 21.
    Voruganti L.N.P., Heselgrave R.J., Awad A.G., Seeman M., Quality of Life Measurement in Schizophrenia: Reconciling the question for subjectivity with the question of Reliability.Google Scholar
  22. 22.
    Kilian R., Angermeyer M.C., The Effect of Antipsychotic Treatment on Quality of Life of Schizophrenic patients under naturalistic Treatment conditions: An application of random effect regression models and propensity scores in an observational prospective trail. Quality of Life Res 2005; 14: 1275–1289.CrossRefGoogle Scholar
  23. 23.
    Awad A.G., Lapierre Y.D., Augus C., Rylander A., Quality of Life and Response of Negative Symptoms in Schizophrenia to Haloperidol and the Atypical Antipsychotic Remoxipride J. Psychiatry Neurosci. 1997; 22: 244–248.Google Scholar
  24. 24.
    Ritsner M, Kurs R., Gibel A., Hirshchmann S., Shinkarenko E., Ratner Y., Predictors of Quality of Life in Major Psychosis: A Naturalistic Follow up Study. J. Clin Psychiatry 2003; 64: 308–315.PubMedCrossRefGoogle Scholar
  25. 25.
    Ritsner M., Ben-Avi I., Ponizovsky A., Timinsky I Bistrov E., Modai I., Quality of Life and Coping with Schizophrenic Symptoms. Quality Life Res. 2003; 12: 1–9.CrossRefGoogle Scholar
  26. 26.
    Awad A.G., Voruganti L.N.P., Impact of Atypical Antipsychotics on Quality of Life in Patients with Schizophrenia. CNS Drugs 2004; 18: 877–893.PubMedCrossRefGoogle Scholar
  27. 27.
    Corrigan P.W., Reinke R., Landsberger S.A., Charate A., Toombs G.A. The Effect of Atypical Antipsychotic Medications on Psychosocial Outcome Schizophr Res 2003; 63: 91–101.Google Scholar
  28. 28.
    Awad A.G. Voruganti L.N.P., Heselgrave R.J., Measuring Quality of Life in Patients with Schizophrenia. Pharmacoeconomics 1997; 11: 32–47.PubMedGoogle Scholar
  29. 29.
    Jeste D.V., Klausner M, Brecher M., Clyde C., Jone R. Clinical Evaluation of Risperidone in the Treatment of Schizophrenia: A 10 week Open Label Muticentre Trial. Psychopharmacology 1997; 131: 239–247.PubMedCrossRefGoogle Scholar
  30. 30.
    Barcia D., Ayuso J.L, herraiz M.L. Calidad de vida en Pacientes Esquizofrenicos Tratados con Risperidona. An Psiquiatr 1996; 12: 403–412.Google Scholar
  31. 31.
    Voruganti L.N.P., Cortese L., Oyewumi L.K., Cernovsky Z., Zirul S., Awad A.G. Comparative Evaluation of Conventional and New Antipsychotic Drugs with reference to their subjective Tolerability, Side Effect, Profile and Impact on Quality of Life. Schizophr. Res. 2000; 43: 135–145.PubMedCrossRefGoogle Scholar
  32. 32.
    Bobes J., Gutierrez M., Gibert J. et al. Quality of Life in Schizophrenia: Long Term Follow-up in 362 Chronic Spanish Schizophrenic Outpatients undergoing Risperidone Maintenance Treatment. Eur Psychiatry 1998; 13: 158–163.CrossRefPubMedGoogle Scholar
  33. 33.
    Franz M., Lis S., Pluddemann K., et al. Conventional vs. Atypical Neuroleptic: Subjective Quality of Life in Schizophrenia Patients. Br J Psychiatry 1997; 170: 422–425.PubMedGoogle Scholar
  34. 34.
    Hamilton S.H., Revicki D.A., Edgell E.T., et al. Clinical and Economic Outcomes of Olanzapine compared with Haloperidol for Schizophrenia: Results from a Randomized Clinical Trial. Pharmacoeconomics 1999; 15: 469–480.PubMedCrossRefGoogle Scholar
  35. 35.
    Revicki D.A., Ginduso L.A., Hamilton S.H., et al. Olanzapine vs. Haloperidol in the Treatment of Schizophrenia and Other Psychotic Disorders: Quality of Life and Clinical Outcomes of a Randomized Clinical Trial. Qual Life Res 1999; 8: 417–426.PubMedCrossRefGoogle Scholar
  36. 36.
    Tran P.V., Hamilton S.H., Kunz A.J., et al. Double-Blind Comparison of Olanzapine vs. Risperidone in the Treatment of Schizophrenia and Other Psychotic Disorders. J Clin Psychopharmacology 1997; 17: 407–418.CrossRefGoogle Scholar
  37. 37.
    Ho B.C., Miller D., Nopoulos P., et al. A Comparative Effectiveness Study of Risperidone and Olanzapine in the Treatment of Schizophrenia. J Clin Psychiatry 1999; 60: 658–663.PubMedCrossRefGoogle Scholar
  38. 38.
    Naber D., Moritz S., Lambert M., et al. Improvement of Schizophrenic Patients’ Subjective well-being under Atypical Antipsychotic Drugs. Schizophr Res 2001; 50: 79–88.PubMedCrossRefGoogle Scholar
  39. 39.
    Tempier R., Pawliuk N. Influence of Novel and Conventional Antipsychotic Medication on Subjective Quality of Life. J Psychiatry Neuroscience 2001; 26: 131–136.Google Scholar
  40. 40.
    Strakowksi S., Johnson J., DeBello M., Hamer R., Green A., Tohen M., Lieberman J., Glick I., Patel J., Quality of Life during Treatment with Haloperidol or Olanzapine in the year following a first psychotic Episode. Schizophr Res 2005; 78: 161–169.CrossRefGoogle Scholar
  41. 41.
    Awad A.G. First Episode Psychosis: Olanzapine and Haloperidol provide similar improvement in Quality of Life and Social Functioning; Commentary Evidence-Based Mental Health 2006; 9:47.Google Scholar
  42. 42.
    Meltzer H.Y., Burnett S., Bastani B., et al. Effects of Six months of -Clozapine Treatment on the Quality of Life of Chronic Schizophrenic Patients. Hosp Community Psychiatry 1990; 41: 892–897.PubMedGoogle Scholar
  43. 43.
    Meltzer H.Y., Okayli G., Reduction of Suicidality during Clozapine Treatment of Neuroleptic-resistant Schizophrenia: Impact on Risk Benefit Assessment. Am J Psychiatry 1995; 152: 183–190.PubMedGoogle Scholar
  44. 44.
    Naber D. A self-rating to Measure Subjective Effects of Neuroleptic Drugs, Relationships to Objective Psychopathology, Quality of Life, Compliance and other Clinical Variables. Int Clin Psychopharmacology 1995; 10 Suppl. 3: 133–138.CrossRefGoogle Scholar
  45. 45.
    Rosenheck R., Cramer J., Xu W., et al. A Comparison of Clozapine and Haloperidol in Hospitalized Patients with Refractory Schizophrenia. N Engl J Med 1997; 337: 809–815.PubMedCrossRefGoogle Scholar
  46. 46.
    Bellack A.S., Schooler N.R., Marder S.R., Kane J.M., Brown C.H., Young Y. Do Clozapine and Risperidone Affect Social Competence and Problem Solving? Am J Psychiatry 2004; 16: 364–367.CrossRefGoogle Scholar
  47. 47.
    Essock S.M., Hargreaves W.A., Covell N.H. et al. Clozapine’s Effectiveness for Patients in State Hospitals: Results from a Randomized Trial. Psychopharmacology Bull 1996; 32: 683–697.Google Scholar
  48. 48.
    Hellewell J.S. Kalai A.H., Langham S.J. et al. Patient Satisfaction and Acceptability of Long-Term Treatment with Quetiapine. Int J Psychiatry Clin Pract 1999; 3: 105–113.Google Scholar
  49. 49.
    Addington D.E., Jons B., Bloom D. Reduction of Hospital Days in Chronic Schizophrenic Patients treated with Risperidone: A Retrospective Study. Clin Ther 1993; 15: 917–926.PubMedGoogle Scholar
  50. 50.
    Albright P.S., Livingston S., Keegan D.L. Reduction of Health Care Resource Utilization and Cost following the use of Risperidone for patient with Schizophrenia previously treated with Standard Antipsychotic Therapy: A Retrospective Analysis using the Saskatchewan Health Linkage database. Clin Drug Invest 1996; 11: 289–299.Google Scholar
  51. 51.
    Reid W.H., Mason M., Toprac M. Saving in hospital bed days related to treatment with Clozapine. Hosp. Community Psychiatry 1994; 45: 261–263.PubMedGoogle Scholar
  52. 52.
    Dickson R.A. Hospital Days in Clozapine Treated Patients. Can J. Psychiatry 1998; 43: 945–948.PubMedGoogle Scholar
  53. 53.
    Awad A.G., Voruganti L.N.P. Cost-Utility Analysis in Schizophrenia. J. Clin Psychiatry 1999; 60 suppl. 3: 22–26.Google Scholar
  54. 54.
    Voruganti L.N.P., Awad A.G., Oyewumi L.K. Assessing Health Utilities in Schizophrenia: A feasibility Study. Pharmacoeconomics 2000; 17: 273–286.PubMedCrossRefGoogle Scholar
  55. 55.
    Dernovsek M.Z., Prevolnik-Rupel V., Tavcar R. Cost Utility Analysis Research and Practical Applications (Chapter ____).Google Scholar
  56. 56.
    Hargreaves W.A., Shumway M. Pharmacoeconomics of Antipsychotic Drug Therapy. J. Clin Psychiatry 1996; 57: suppl. 9: 66–76.Google Scholar
  57. 57.
    Revicki D. Pharmacoeconomic Studies of Atypical Antipsychotic Drugs for the Treatment of Schizophrenia. Schizophr. Res 1999; 35: 101–109.CrossRefGoogle Scholar
  58. 58.
    Zito J.M. Pharmacoeconomics of the New Antipsychotics for the Treatment of Schizophrenia. Psychiatric Clin. North A.M. 1998; 21: 181–202.CrossRefGoogle Scholar
  59. 59.
    Green M.F., What are the Functional Consequences of Neurocognitive Deficits in Schizophrenia? Am J Psychiatry 1996; 153: 321–330.PubMedGoogle Scholar
  60. 60.
    Keefe R., Poe M., Waker T., Kang J., Harvey P.H. The Schizophrenia Cognition Rating Scale: An interview based Assessment and its Relationship to Cognition, real-work functioning and functional capacity. Am J Psychiatry 2006; 163: 426–432.PubMedCrossRefGoogle Scholar
  61. 61.
    Velligan D.I., Mahurin R.K., Diamond P.L., Hazelton B.C., Eckert S.L., Miller A.L. The Functional Significance of Symptomatology and Cognitive Function in Schizophrenia. Schizophr Res 1997; 25: 21–31.PubMedCrossRefGoogle Scholar
  62. 62.
    Heselgrave R.J., Awad A.G. Voruganti L.N.P., The Influence of Neurocognitive deficits and symptoms on Quality of Life in Schizophrenia. J. Psychiatry Neuroscience 1997; 22: 235–243.Google Scholar
  63. 63.
    Moritz s., Ferahli S., Naber D. Memory and Attention Performance in Psychiatric patients: Lack of correspondence between Clinician-rated and patient-rated functioning with neuropsychological test results. J. Int Neuropsychol Soc. 2004; 10: 623–633.PubMedCrossRefGoogle Scholar
  64. 64.
    Bowie C., Reichenberg A., Patterson T., Heaton R., Harvey P. Determinants of Real-World Functional Performance in Schizophrenia Subjects: Correlations with Cognition, Functional Capacity and Symptoms. Am J Psychiatry 2006; 163: 418–425.PubMedCrossRefGoogle Scholar
  65. 65.
    Hooker C., Park S. Emotion processing and its relationship to Social Functioning in Schizophrenic Patients. Psychiatry Res 2002; 112: 41–50.PubMedCrossRefGoogle Scholar
  66. 66.
    Wise R.A. Addictive Drugs and Brain Stimulation Reward. Ann Rev Neurosci. 1996; 19: 319–340.PubMedCrossRefGoogle Scholar
  67. 67.
    Fibiger H.C. Neurobiology of Depression – focus on Dopamine. Adv Biochem Psychopharmacology 1995; 49: 1–7.CrossRefGoogle Scholar
  68. 68.
    Voruganti L.N.P., Slomka P., Zabel P., Costa G., So A., Mattar A., Awad A.G. Subjective Effects of AMPT induced Dopamine Depletion in Schizophrenia. The Correlation between D2 binding ration and Dysphoric Responses. Neuropsychopharmacology 2001; 25: 642–650.PubMedCrossRefGoogle Scholar
  69. 69.
    de Hann L, Lavalaye J., Linszen D., Dingemans P.M.A.J., Booij J. Subjective Experiences and Striatal Dopamine D2 Receptor Occupancy in Patients with Schizophrenia stabilized by Olanzapine or Risperidol. Am J Psychiatry 2000; 157: 1019–1020.CrossRefGoogle Scholar
  70. 70.
    Voruganti L.N.P., Awad A.G. Subjective and Behavioural Consequences of Striatal Dopamine Depletion in Schizophrenia-findings from an in VIVO SPECTS study. Schiz Res (in press)Google Scholar
  71. 71.
    Voruganti L.N.P., Awad A.G. Role of Dopamine in Pleasure, Reward and Subjective responses as Important aspects of Quality of Life.Google Scholar
  72. 72.
    Gill T.M., Feinstein A.R. A Critical Appraisal of the Quality of Quality of Life Measurements. JAMA 1994; 272: 619–626.PubMedCrossRefGoogle Scholar
  73. 73.
    Awad A.G. Voruganti L.N.P. Intervention Research in Psychosis: Issues related to the Assessment of Quality of Life. Schizophr Bull 2000; 26: 557–564.PubMedGoogle Scholar
  74. 74.
    Awad A.G., Voruganti L.N.P. The Subjective/objective dichotomy in Schizophrenia: Relevance to nosology, research and management. In: Gaebel W., editor. Zukunftsperspktiven in Psychiatries Und Psychotherapie. Darmstadt: Steinkopff Verlag, 2002: 21–27.Google Scholar
  75. 75.
    Skantze K., Malm U., Dencker S.J., May P.R.A., Corrigan P. Comparison of Quality of life with standard of living in Schizophrenic Out-patients. Br J. Psychiatry 1992; 161: 797–801.PubMedCrossRefGoogle Scholar
  76. 76.
    Skantze K. Subjective Quality of Life and Standard of living: A 10-year Follow up of Out-patients with Schizophrenia. Acta Psychiatr Scand. 1998; 98: 390–399.PubMedGoogle Scholar

Copyright information

© springer 2007

Authors and Affiliations

  • A. George Awad
    • 1
  • Lakshmi N.P. Voruganti
    • 2
  1. 1.Department of Psychiatry and the Institute of Medical ScienceUniversity of Toronto, Chief of Psychiatry, Humber River Regional HospitalCanada
  2. 2.McMaster UniversityHamiltonCanada

Personalised recommendations