Medication Discontinuation Difficult in First-Episode Schizophrenia

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Key Takeaways

A 2-year prospective randomized controlled design enrolled 131 DSM-IV first-episode schizophrenia-spectrum patients aged 18–45 years who had maintained remission for 6 months.
Symptom-guided tapering/discontinuation produced higher relapse than maintenance low-dose atypicals (43% vs 21%; P=.001).
Sustained antipsychotic cessation was uncommon, with 20% discontinuing successfully and 30% restarting treatment after symptom recurrence.
Mean discontinuation duration reached 4.6 months with tapering versus 0.8 months with maintenance, arguing against universal discontinuation and for identifying predictive clinical markers.

Medication adherence is a particular challenge for patients with first-episode schizophrenia. In addition to physician and patient concerns about adverse effects of antipsychotics, many patients at this stage are particularly resistant to continuing medications over the long term.

Medication adherence is a particular challenge for patients with first-episode schizophrenia. In addition to physician and patient concerns about adverse effects of antipsychotics, many patients at this stage are particularly resistant to continuing medications over the long term. With these issues in mind, researchers from the University Medical Center Groningen in the Netherlands sought to compare the effectiveness of a guided discontinuation strategy versus maintenance treatment for patients who were in remission from first-episode psychosis. The results of the study were published in the May issue of the Journal of Clinical Psychiatry.

The prospective, 2-year, randomized, controlled trial included 131 patients aged 18 to 45 years who were in remission from their first episode of schizophrenia or a related psychotic disorder, as diagnosed by DSM-IV. Patients who were in remission for 6 months were randomly assigned to a discontinuation strategy, which was carried out with gradual symptom-guided tapering of atypical dosage and discontinuation if feasible, or a maintenance treatment, which included the use of low-dose atypicals. There were no significant differences between patients in the 2 strategy groups.

In the discontinuation group, twice as many patients relapsed (43% vs 21%; P = .001) and only 20% were successfully discontinued from treatment. Another 30% restarted antipsychotic treatment when symptoms recurred; discontinuation was not feasible for the remaining patients. The mean duration of discontinuation was 4.6 months in the discontinuation group and 0.8 months in the maintenance group.

The researchers concluded that only a limited number of patients with first-episode schizophrenia can successfully discontinue treatment, and the high relapse rates indicated that using a discontinuation strategy should not be universal practice. They emphasized the need for further research in establishing the predictors of successful discontinuation and in determining which patients might benefit from medication discontinuation.