Debate and dilemma on starting and stopping antipsychotics

Starting treatment and considerations about when to stop medication are sometimes a dilemma in the management of patients with schizophrenia. An APA symposium brought together speakers with varying views on antipsychotic drug treatments and their role and use in the management of patients with schizophrenia.

Chairs of the symposium, Dr Michael Flaum of the University of Iowa and Dr Sandra Steingard of the University of Vermont, steered the audience through a range of presentations designed to provoke thought on topics as diverse as what is known about the effects of chronic administration of antipsychotic drugs on brain tissue, through to what is known about the appropriateness and safety of tapering drug treatment in clinical practice settings.

Medication or disease

Dr David Lewis of the Department of Psychiatry and Neuroscience, University of Pittsburgh gave his views on what is known about the effects of long-term antipsychotic treatment on brain volume and structure.  He cautioned that post-mortem evidence of small changes in cortical grey matter volume in patients with schizophrenia  could reflect either (or both) the effects of chronic medication treatment, medication effects or the effects of underlying disease processes. He suggested that the critical question that still needs to be addressed is whether such reductions in brain volume are detrimental.

Start to treat

The notion that ‘psychosis itself may be toxic’ was picked up by Dr Christopher Gordon of Massachusetts General Hospital. He said that failure to treat psychosis early  – whether with medication or by other interventions – has been shown to have detrimental effects for patients, increasing the likelihood of relapse, with worsened outcomes.

In the long term

Psychosis itself may be toxic

Turning away from the importance of starting treatment to the long-term management of schizophrenia, two presenters, Dr Moncrieff of the Critical Psychiatry Network in the UK, and Dr Steingard, each spoke about the potential for long-term side effects with antipsychotic therapies – effects such as weight gain, the metabolic syndrome and tardive dyskinesia.

Presenters and delegates discussed the fact that not all antipsychotic agents have the same side effect profiles.

Dr Steingard said that data on prescription practices from the RAISE-ETP study of treatment of first-episode schizophrenia spectrum disorders suggests that almost 40% of patients might benefit from changes in their prescription, and almost 9% are on higher than recommended doses of antipsychotic therapy. This has prompted some psychiatrists to consider trying to find the minimally effective dose of antipsychotic drug for patients and to some study and exploration of tapering or stopping drug treatment in selected patients.

Dr Moncreiff said she is involved in an ongoing study in the UK (RADAR) which will look at the functional as well as the symptomatic impact of treatment discontinuations. Dr Steingard described her practice experiences of drug tapering. She stressed that patients and their families need to share in informed-decision-making about any proposed changes to a patient’s long-term drug therapy – and that they need to understand the potential risks involved in any modification to regimens used to maintain patients. She added that her experience was that tapering drug doses increased the risk for hospitalization.