Beyond clinical remission in first episode psychosis: thoughts on antipsychotic maintenance vs. guided discontinuation in the functional recovery era
Abstract
Treatment guidelines for first episode psychosis (FEP) recommend at least 1 year of antipsychotic treatment following remission; however, in light of some recent research and the preference of some individuals to discontinue their medication sooner, this recommendation can be questioned. The aim of this article is to appraise the current discontinuation studies given our views on how this field should progress. We conducted a review of randomized controlled trials investigating dose-reduction/medication discontinuation compared with treatment maintenance in clinically remitted FEP patients. Seven trials were identified, and these reported a higher rate of relapse in the dose reduction or discontinuation groups. Relapse rates were higher when a lower threshold for relapse was utilized. However, only three studies specified that concurrent psychosocial interventions were also provided, despite an evidence base for these interventions in reducing symptom severity and relapse. Length of follow-up may also be important, as the study with the longest follow-up (7 years), albeit with some methodological shortcomings, found greater functional recovery in the dose-reduction group and that relapse rates between the two groups (dose-reduction vs. maintenance) were equal after 3 years. Finally, in addition to discontinuation or dose reduction, a diagnosis of schizophrenia, a longer duration of illness, and poor premorbid functioning were associated with a greater risk of relapse. Further trials are needed in this area to establish the long-term risk-benefit ratio of antipsychotic medication in FEP. Meanwhile, young people with FEP who do not fulfil criteria for a diagnosis of a schizophrenia disorder, achieve clinical remission for at least 3 months, attain early functional recovery, and have good social support may be possible candidates for discontinuation of antipsychotic medication bolstered by effective psychosocial interventions provided in the context of a specialized FEP service.
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The discontinuation group showed more relapses than the maintenance group in all but 3 studies examined.
“The discontinuation group showed more relapses than the maintenance group83,84 in all but 3 studies examined.57,74,85”
From A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse (2021) · cites this paper as [83]
It is likely that discontinuation studies employing linear dose reductions will be more likely to induce withdrawal reactions (including, potentially, withdrawal psychosis) because reductions in D2 antagonism become increasingly large, causing greater likelihood of dopaminergic rebound.
“It is, therefore, likely that discontinuation studies employing linear dose reductions,74,83,84,86,87 as recommended in some older guidelines,94 will be more likely to induce withdrawal reactions (including, potentially, withdrawal psychosis) because reductions in D2 antagonism become increasingly large, causing greater likelihood of dopaminergic rebound.”
From A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse (2021) · cites this paper as [83]
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- Authors
- Alvarez-Jimenez, M., O’Donoghue, B., Thompson, A., Gleeson, J. F., Bendall, S., Gonzalez-Blanch, C., Killackey, E., Wunderink, L., & McGorry, P. D.
- Affiliations
- University of Warwick (GB)
- Australian Catholic University (AU)
- The University of Melbourne (AU)
- University Medical Center Groningen (NL)
- Venue
- CNS Drugs
- Published
- 2016-04-22
- Volume
- 30
- Issue
- 5
- Pages
- 357-368
- ISSN
- 1172-7047 (ISSN-L)
- 1179-1934
- OpenAlex
- W2336417646
- Cited by
- 80
- References
- 55
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 8 · 2023: 6 · 2022: 7 · 2021: 10 · 2020: 9 · 2019: 10 · 2018: 15 · 2017: 6 · 2016: 2
- FWCI
- 1.57
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- www.springer.com/tdm (tdm)
- Locations
- CNS Drugs (publishedVersion)
- PubMed (publishedVersion)
- Research Bank (Australian Catholic University) (submittedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- Funders
- CR Roper Fellowship
- National Health and Medical Research Council (APP1082934)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Keywords
- first-episode psychosis, antipsychotic discontinuation, antipsychotic dose reduction, antipsychotic maintenance, relapse, clinical remission, functional recovery, psychosocial interventions, schizophrenia, premorbid functioning, disease duration, social support, treatment guidelines
- MeSH terms
- Humans, Psychotic Disorders, Remission Induction, Schizophrenia, Antipsychotic Agents, Treatment Outcome, Practice Guidelines as Topic
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