Should antipsychotic medications be stopped as early as possible after the first episode?

Professor Merete Nordentoft (Copenhagen University Hospital, Denmark), as proponent for discontinuation, began the session with a focus on the high proportion of patients that can maintain stability without treatment.

In a study of 10-year trajectories in 496 patients with first-episode psychosis, similar proportions of patients on and off antipsychotic medication were in remission at time of follow up. At 1-, 2-, 5-, and 10-years, remission rates were 23%, 26%, 24%, and 30% versus 37% 29%, 29%, and 30% for off and on medication, respectively.¹

Treatment continuation is commonly in the hand of the patient

Professor Nordentoft highlighted the fact that clinicians do not have that much control over treatment discontinuation as it is patients who make the decision to discontinue.

It’s the patients themselves who decide to stop medication, not the clinicians

There is a large group of patients who want to stop medication and we need to know in which patients this can be advised. A naturalistic study in which patients in remission after first-episode psychosis who want to discontinue their medication will be followed monthly on the Scale for Assessment of Positive Symptoms (SAPS) as well as smartphone registration of warning signs is underway.

Treatment discontinuation can have grave consequences

The case against early discontinuation was put forward by Professor Robin Emsley (Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa) who presented five compelling, straightforward reasons against treatment discontinuation:

1. Virtually all patients will relapse. Literature shows the relapse rate after discontinuation after a first psychotic episode in short-term studies is around 80% at 12 months^2-4
2. Potentially grave consequences, including distress to patients and caregivers, derailment of recovery, increased risk of suicide and homicide, and disruption to education and employment⁵
3. Relapses are a critical factor in the emergence of treatment-refractory psychosis⁶
4. No discontinuation strategy has been effective^3,4
5. There are no realistic alternatives to antipsychotic medications

Antipsychotic maintenance treatment should be continued indefinitely, with the lowest effective dose

Further research in this area should be of the highest priority; meanwhile, based on available evidence and experience, for patients who have benefitted from treatment, the advice is to continue antipsychotic maintenance treatment indefinitely, with the lowest effective dose, said Professor Emsley.⁷

Clinicians need to be part of the discontinuation process

Overall, the decision is not clear-cut commented Professor Merete and should be taken on a case-by-case basis, depending on patient risk.

Before we stop treatment, we need to know in which patients we can stop, when to stop, and how to stop said Professor Emsley. As responsible physicians, we should recommend continuation of treatment, but if the patient is set on discontinuing, it is better if the clinicians are part of the discontinuation process.