Helping people to discontinue antipsychotics: if, when and how

Abstract

The default position in the treatment of psychotic conditions is that lifelong treatment is required after multiple episodes, with some portion of patients able to stop after a single episode. However, there are reasons to question this consensus, including that not everyone who stops antipsychotics relapses, the protective effects of antipsychotics may have been exaggerated due to the possibility that withdrawal itself is associated with adverse effects, including relapse, there is little evidence that antipsychotics target a pathological mechanism and their adverse effects may outweigh their benefits for some users. Recent pragmatic trials that employ a gradual reduction strategy give mixed results. They highlight that relapse is still a potential risk, but there may be gains in terms of social functioning in the long-term. There are no consistent factors that enable identification of people who might be able to discontinue antipsychotics more successfully, suggesting this option should be more widely offered. A gradual, hyperbolic approach to tapering has been proposed to reduce the adverse effects of withdrawal and relapse on stopping—approximated, for example, by reductions of 5-10% of the most recent dose every month. Patients should be supported to make decisions about long-term antipsychotic treatment based on weighing up the pros and cons of antipsychotic effects, in the light of the evidence base and the individual’s priorities. Given that increasing duration of treatment is likely to increase the risk of withdrawal on stopping, long-term antipsychotic treatment should be minimized where possible.