Antipsychotic discontinuation in schizophrenia: rational or reckless?

Our understanding of schizophrenia has changed dramatically since the introduction of antipsychotic medication in the early 1950s.Multiple avenues of research have established that schizophrenia is highly treatable, relapses are largely preventable, and those affected can lead lives that are happy and satisfying 1,2 .Moncrieff and Horowitz, in their paper, "Helping people to discontinue antipsychotics: if, when and how" challenge the consensus that lifelong treatment of psychotic disorders with antipsychotic medication is required after multiple episodes.It is important to first clarify two aspects of their argument: 1) whether it relates to specifically to individuals with schizophrenia versus any psychotic illness, and 2) whether the argument is about discontinuation of antipsychotic medication versus reduction of dose.It has been common practice for programs specializing in the treatment of first episode psychosis to speak with patients and family members about having a "first episode of psychosis" and to limit discussion of specific diagnoses such as schizophrenia and bipolar disorder.While this approach has its benefits when considerable diagnostic uncertainty exists, it is unhelpful when providing recommendations regarding the risks of discontinuing antipsychotic treatment 3 .Treatment guidelines have rightly focused on the question of antipsychotic discontinuation following a first episode of schizophrenia, for which there is now considerable evidence to support the importance of maintenance treatment 4 .There are certainly other causes of a first episode of psychosis for which a recommendation of long-term treatment may not be appropriate including brief psychotic disorders and substance-induced psychoses.Many first psychotic episodes are due to bipolar disorder.While almost all people with bipolar disorder require maintenance treatment, mood stabilizing medication is often an option and many can be successfully managed without long-term antipsychotic treatment 5 .For the sake of clarity, our critique of the argument put forth by Moncrieff and Horowitz relates to the issue of antipsychotic discontinuation in schizophrenia.We will then address the issue of dose reduction. ANTIPSYCHOTIC DISCONTINUATION IN SCHIZOPHRENIAThe argument against long-term antipsychotic treatment for schizophrenia put forth by Moncrieff and Horowitz is based on the premises outlined below, none of which is supported by the weight of current evidence.We strongly disagree with their conclusions and believe that they will put many people with schizophrenia at needless risk of harm.