Stopping Antipsychotics after a First Episode of Psychosis

Peter Forster Uncategorized

A recent Spanish study adds to the small literature on the risks of stopping antipsychotic medications following a first episode of psychosis.

In this study, discontinuation of antipsychotics after a full functional recovery from a first episode of psychosis (FEP) appeared to be associated with a very high rate of relapse, compared with those who continued to take antipsychotic medications.

As the researchers of the study note,

“In clinical practice, physicians very often face the dilemma of discontinuing or maintaining antipsychotics in those patients who have fully recovered from their initial episode of psychosis,” they wrote. “In those individuals who are willing to discontinue medication, a planned medication withdrawal strategy with follow-up should be established to prevent unrestrained treatment disengagement. Clinicians should provide accurate information to patients and relatives concerning the risks and benefits of withdrawing medication.”

The data are from an ongoing intervention study for first episode psychosis (FEP) in Spain.

The people in the study had had 18 months of treatment with antipsychotics and had met clinical remission criteria (they had been without symptoms of psychosis) for 12 months and functional recovery criteria (they did not have any impairment in functioning) for six months, and had then been stabilized on the lowest antipsychotic dose that would be effective for three months.

The study was not randomized, the participants got to decide whether or not to continue antipsychotic medication. In this group, 46 people chose to discontinue medication, and 22 stayed on maintenance medication.

In the group that stopped antipsychotics, 31 patients out of 48 had a significant worsening of symptoms that led to a resumption of antipsychotic medications (27 relapses and four cases of deterioration in symptoms).

By contrast, among patients in the maintenance group, only seven patients relapsed over the three-year period.

In addition, in the maintenance group the time to relapse, for those who did relapse, was much longer. The average time to relapse in the maintenance group was 608 days compared with 209 days for those who relapsed in the discontinuation group.

“[T]he rate of symptom recurrence in functionally recovered FEP patients following the self-elected discontinuation of treatment is extremely high,” the researchers state. “Relapsed individuals had a greater severity of symptoms and lower functionality [during the three-year follow-up period] compared with those patients who did not relapse during the follow-up.”

References

Mayoral-van Son J, et al. “Clinical Outcome After Antipsychotic Treatment Discontinuation in Functionally Recovered First-Episode Nonaffective Psychosis Individuals: A 3-Year Naturalistic Follow-Up Study.” J Clin Psychiatry 2015. 10.4088/JCP.14m09540

Bromet EJ, et al.”Diagnostic Shifts during the Decade Following First Admission for Psychosis” American Journal of Psychiatry 168: 1186  November 2011.

Salvatore P, Baldessarini RJ, Tohen M, et al.  “McLean-Harvard International First-Episode Project: Two-Year Stability of ICD-10 Diagnoses in 500 First-Episode Psychotic Disorder Patients.” J Clin Psychiatry 2011;72(2):183–193

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