Beyond Clinical Remission in First Episode Psychosis: Thoughts on Antipsychotic Maintenance vs. Guided Discontinuation in the Functional Recovery Era.
Treatment guidelines for first episode psychosis (FEP) recommend at least 1 year of antipsychotic treatment following remission; however, in light of some recent research and the preference of some individuals to discontinue their medication sooner, this recommendation can be questioned. The aim of this article is to appraise the current discontinuation studies given our views on how this field should progress. We conducted a review of randomized controlled trials investigating dose-reduction/medication discontinuation compared with treatment maintenance in clinically remitted FEP patients. Seven trials were identified, and these reported a higher rate of relapse in the dose reduction or discontinuation groups. Relapse rates were higher when a lower threshold for relapse was utilized. However, only three studies specified that concurrent psychosocial interventions were also provided, despite an evidence base for these interventions in reducing symptom severity and relapse. Length of follow-up may also be important, as the study with the longest follow-up (7 years), albeit with some methodological shortcomings, found greater functional recovery in the dose-reduction group and that relapse rates between the two groups (dose-reduction vs. maintenance) were equal after 3 years. Finally, in addition to discontinuation or dose reduction, a diagnosis of schizophrenia, a longer duration of illness, and poor premorbid functioning were associated with a greater risk of relapse. Further trials are needed in this area to establish the long-term risk-benefit ratio of antipsychotic medication in FEP. Meanwhile, young people with FEP who do not fulfil criteria for a diagnosis of a schizophrenia disorder, achieve clinical remission for at least 3 months, attain early functional recovery, and have good social support may be possible candidates for discontinuation of antipsychotic medication bolstered by effective psychosocial interventions provided in the context of a specialized FEP service.
Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, VIC, 3052, Australia. mario.alvarez@orygen.org.au.|Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia. mario.alvarez@orygen.org.au.
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Alvarez-Jimenez
Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, VIC, 3052, Australia. brian.odonoghue@orygen.org.au.|Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia. brian.odonoghue@orygen.org.au.
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O'Donoghue
Division of Mental Health and Wellbeing, University of Warwick, Warwick, UK.
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Thompson
School of Psychology, Australian Catholic University, Melbourne, VIC, Australia.
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Gleeson
Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, VIC, 3052, Australia.|Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia.
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Bendall
Mental Health Centre, University Hospital 'Marques de Valdecilla', Santander, Spain.
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Gonzalez-Blanch
Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, VIC, 3052, Australia.|Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia.
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Killackey
Education and Research, Friesland Mental Health Services, Leeuwarden and University Medical Center Groningen, Sixmastraat 2, 8932 PA, Leeuwarden, The Netherlands.
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Wunderink
Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, VIC, 3052, Australia.|Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia.
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McGorry
D014150:Antipsychotic Agents / Q000008:administration & dosage* / Q000627:therapeutic use*; D006801:Humans; D017410:Practice Guidelines as Topic; D011618:Psychotic Disorders / Q000188:drug therapy*; D012074:Remission Induction; D012559:Schizophrenia / Q000188:drug therapy*; D016896:Treatment Outcome
D014150:Antipsychotic Agents