Discontinuing Antipsychotic Therapy

Abstract

Antipsychotics, both the long established typical drugs and the recently introduced atypical drugs clozapine and risperidone, are highly effective in acute and maintenance treatment of schizophrenia. However, typical antipsychotics are associated with tardive dyskinesia after long term use, and many other clinical situations arise for which discontinuation of therapy may be appropriate. For patients who have recovered from a first episode of psychosis, it is recommended that antipsychotics are continued for 1 to 2 years before withdrawal is considered. Patients who have experienced recurrent psychotic episodes need long term maintenance treatment and there is no simple guide as to when discontinuation might be attempted. The risk of potentially dangerous psychotic relapse is high in most circumstances. Long term prognosis may also be worsened by the occurrence of repeated psychotic relapses. Additionally, there can be withdrawal reactions, which are mostly attributable to cholinergic rebound. The problems of discontinuation are minimised by very gradual dosage reduction and, occasionally, the temporary addition of anticholinergic medications. A key principle for maintenance treatment is the use of the lowest effective dose of antipsychotic, established by trial and error. If discontinuation of typical antipsychotic medication is essential, an option is to switch to risperidone or clozapine. Because of the problems associated with both continuation and withdrawal of antipsychotics, the decision to discontinue should be made with the informed consent of the patient and their carers.