When and how should medication be withdrawn after a first psychotic episode?
When should antipsychotic medications be discontinued after a first episode, and how should this be done? Are there cases where withdrawal is safer? What risks might it pose to the individual? These are some of the questions often asked by both mental health professionals and people who have experienced a psychotic disorder.
The main benefit of maintaining antipsychotic drug treatment is the prevention of relapse , that is, preventing a second psychotic episode from occurring, since each episode has a major impact on the life of the affected person, with consequences such as:
- Reduced response to treatment.
- Worsening of symptom control in the future.
- Emergence of problems in various life spheres, such as social, family, academic or work life.
- Increased risk of suicide.
Despite this, there are also some drawbacks to continued drug treatment, such as:
- They are not always enough to prevent all relapses.
- They can produce adverse effects, some of which affect a person's functioning.
- They often have a high economic cost.
- They can contribute to the stigma and self-stigma of the person and generate a perception of "non-recovery".
The pharmacological treatment of psychosis
For all these reasons, it is common for people diagnosed with a psychotic disorder such as schizophrenia to discontinue treatment against medical advice, in 80% of cases. On the other hand, it is estimated that 30% of people who have had a first psychotic episode discontinue treatment within the first nine months, and that approximately 10% of people who are in remission after a first episode would not require treatment indefinitely. Despite this, many questions remain about when and how to safely discontinue medication .
Review of published studies
A guide developed by experts to advise professionals on managing antipsychotic treatment after a first psychotic episode was recently published (Asian Network of Early Psychosis Writing Group, 2022). This document reviews various publications and clinical guidelines to assess the outcomes of discontinuing medication . All of them identified a high frequency of short-term relapse, with rates varying between 19% and 82% of cases depending on the study.
In studies with longer follow-up, it was found that only a small number of people were able to sustainably discontinue treatment in the first few years (around 16-20%). Data on subsequent outcomes are conflicting. Some results suggest that people who are able to discontinue treatment maintain better functioning, while, on the other hand, another study detected more cases of negative outcomes when treatment was discontinued , including persistent psychotic symptoms, the need for certain treatments for treatment-resistant symptoms such as clozapine, or risk of suicide. (Wunderink et al., 2013; Hui et al., 2018).
The general recommendation is usually against discontinuing treatment in the short term, due to the high risk of relapse.
It has also been observed that the recurrence of a psychotic episode in the second or third year predicts a negative course for the disorder. This underscores the importance of preventing relapses in the early years to ensure the best possible long-term outcome.
The authors of this guide consider several methodological difficulties in the published studies:
- Most studies include small samples and only follow up in the short term.
- The way in which the treatment is withdrawn can vary greatly, abruptly or gradually, over different periods of time, and the treatments prior to this discontinuation can be diverse.
- People can have different diagnoses
- The definitions of remission and relapse are not always the same.
Despite these difficulties, the general recommendation is usually against discontinuing treatment in the short term due to the high risk of relapse (19-82% in the first year). Studies have been conducted to determine in which cases treatment can be withdrawn more safely, and in which cases the risk of relapse is highest.
What are considered the risk factors for a relapse?
- Not having taken the treatment properly.
- Social difficulties prior to the disorder.
- Longer time to untreated disorder (LTU).
- High emotion expressed by family.
- Substance use.
- Cognitive difficulties.
What are considered protective factors?
- Greater personal resilience.
- Certain personality traits.
- Greater external support.
- Psychological follow-up and psychotherapy.
- Single episode with no subsequent relapses.
- Older age of onset of the disorder.
- Diagnosis different from the schizophrenia spectrum.
Several clinical guidelines, developed by experts, offer recommendations regarding the entire therapeutic process. In clinical guidelines for schizophrenia spectrum disorders, the recommendation after a psychotic episode is to maintain treatment for a minimum of five years. In clinical guidelines for first-episode psychosis, the recommendations are more variable and consider possible withdrawal after one to three years of treatment. In all of these guidelines, recommendations on how to discontinue treatment and what subsequent follow-up should be conducted are limited.
Relapses in psychotic disorders
Recommendations for healthcare professionals
This new guide, which focuses exclusively on the withdrawal of drug treatment after a first psychotic episode , includes the following recommendations for professionals:
- Maintain treatment with antipsychotic drugs for a minimum of one to three years after the first episode (the recommendation is not to withdraw after this time, but not to do so before).
- If the person wishes to discontinue treatment:
- Discuss the risks and benefits with her.
- Address the risk of relapse and the initial signs of decompensation.
- Inform about the risk of long-term effects.
- Prepare her to manage a relapse should it occur.
- Discontinue if there has been a relapse.
- Expect a period of 6-12 months without symptoms and with a recovery of previous functioning.
- Assess whether the person presents factors indicating a good prognosis:
- Diagnosis different from that of schizophrenia spectrum disorders.
- Assess social and occupational functioning.
- Value social support.
- Duration of Untreated Psychosis (DUP).
- Without alterations in cognitive function.
- Without risky behaviors.
- Greater resilience, more favorable personality traits.
After medication withdrawal, it is considered necessary to maintain follow-up for a minimum of two years and implement measures at the psychosocial, occupational and family level.
If it is decided to discontinue treatment , the recommendations on how to do so include:
- Gradually reduce medication over 6-12 months, monitoring for the appearance of symptoms suggestive of relapse.
- Maintain a minimum final dose for 3-6 months.
- Consider changing treatment last with aripiprazole, to minimize the risk of relapse due to receptor sensitization.
After medication withdrawal, follow-up is considered necessary for a minimum of two years. In addition, it is beneficial to implement psychosocial, occupational, and family support measures to promote the individual's stability and well-being.
These recommendations can be very useful when assisting in decision-making to promote stability and quality of life for people who have had a psychotic episode.
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