clinical topic updates

Current Thinking on Antipsychotic Medications for Relapse Prevention in Schizophrenia

by Jonathan M. Meyer, MD

Overview

Patients with a first psychotic episode may be misdiagnosed with schizophrenia. Differentiating between schizophrenia and psychosis due to other etiologies (eg, substance use or bipolar disorder) is key in determining whether antipsychotic therapy should continue or whether it could be reduced or discontinued in the absence of any symptoms that are suggestive of schizophrenia.

Expert Commentary

Jonathan M. Meyer, MD

Clinical Professor of Psychiatry
University of California, San Diego
Psychopharmacology Consultant
California Department of State Hospitals
Sacramento, CA

Although the number of patients who are accurately diagnosed with schizophrenia and who can successfully discontinue antipsychotic medication is extremely small, some modestly symptomatic individuals with schizophrenia who are stable may be appropriate candidates for antipsychotic dose reduction to lessen the burdens of treatment.” 

Jonathan M. Meyer, MD

Discontinuation of antipsychotic medication or dose reduction may be considered if a patient with psychosis experiences positive symptom remission, implying minimal or no residual positive symptoms. Discontinuation may be appropriate for those rare individuals whose first psychotic episode was misdiagnosed as schizophrenia (eg, a patient who was initially diagnosed with schizophrenia but may actually have had a psychotic episode related to a condition other than schizophrenia, such as drug-induced psychosis). Suspicion that the diagnosis is not schizophrenia should only be considered in those patients with no positive, negative, or cognitive symptoms. The presence of any of those symptom clusters is a clue that this patient has schizophrenia and that they are likely to relapse without antipsychotic therapy. In addition to the absence of any core schizophrenia symptoms, candidates for medication discontinuation should also have excellent psychosocial support to help detect a relapse of psychotic symptoms. 

Although the number of patients who are accurately diagnosed with schizophrenia and who can successfully discontinue antipsychotic medication is extremely small, some modestly symptomatic individuals with schizophrenia who are stable may be appropriate candidates for antipsychotic dose reduction to lessen the burdens of treatment. This is particularly true for those who report adverse effects, most notably those related to dopamine D2 antagonism. Under such circumstances, it is important to decrease the dose very slowly and in small increments (ie, 5% per month), thus allowing sufficient time to confirm that symptom severity remains at baseline prior to additional dose reductions. 

The need for caution in dose reduction or antipsychotic discontinuation cannot be overstated, as the repercussions of relapse may have long-term life consequences for the patient. In addition to psychiatric hospitalization, patients may lose their current housing situation and other social supports. Moreover, there may also be legal implications (eg, incarceration) if the patient becomes aggressive and/or violent when they relapse. As individuals with psychosis often lose insight into their condition, ensuring that they have appropriate psychosocial support during an attempt at antipsychotic dose reduction will, ideally, contribute to the quick and accurate identification of the emergence of relapse symptoms.

References

Goff DC, Falkai P, Fleischhacker WW, et al. The long-term effects of antipsychotic medication on clinical course in schizophrenia. Am J Psychiatry. 2017;174(9):840-849. doi:10.1176/appi.ajp.2017.16091016

Horowitz MA, Jauhar S, Natesan S, Murray RM, Taylor D. A method for tapering antipsychotic treatment that may minimize the risk of relapse. Schizophr Bull. 2021;47(4):1116-1129. doi:10.1093/schbul/sbab017

Marder SR, Cannon TD. Schizophrenia. N Eng J Med. 2019;381(18):1753-1761. doi:10.1056/NEJMra1808803

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