Empowering clinicians and patients in antipsychotic dose reduction for schizophrenia: the role of online tools

Antipsychotic discontinuation remains a contested topic, with evidence offering both reassurance about side-effects and warnings about relapse.We summarize the components of the debate and conclude that it is important to empower clinicians and patients to make their personal decisions and we direct readers to information centers such as www.illuminatum.com,www.psymatik.organd the APA website.First, the rates of relapse after stopping antipsychotics are high.Antipsychotics reduce relapse rates from 65% to 27% within one year 1,2 .This is one of the largest effects of drugs in medicine 3,4 .The effect is seen not only in chronic patients with multiple prior episodes, but also after a first episode and among those in remission.Even patients who have taken antipsychotics for 3-6 years before stopping medication in randomized trials 2 , and for up to 7 years according to registry studies, face a higher risk of relapse if they discontinue medication compared with those who continue treatment 5 .Second, dose reduction is associated with higher relapse rates.On average, standard doses such as 5 mg/day risperidone equivalent are sufficient 6 .There is considerable interindividual variability, meaning that some patients may do well on lower doses.However, dose-response meta-analyses of fixed doses have shown that the risk of relapse increases disproportionately below 5 mg/day risperidone equivalent.Reviews of dose-reduction studies have likewise found that the lower the dose, the higher the relapse risk 7 .Both older and more recent studies of "intermittent treatment"-stopping medication and restarting it at early signs of relapse-consistently reported relapse rates higher than those observed with continuous treatment 8,9 .Furthermore, national registry studies show that untreated patients have the poorest outcomes 10 .Thus, substantial dose reduction is a risky strategy.Third, antipsychotics have dose-related side effects [11][12][13][14] .However, not all antipsychotics produce the same side effects, and not all patients experience all of them-or consider them equally important.Switching to a different antipsychotic is generally safer than substantial dose reduction and may be tried before a substantial dose reduction 15 .Fourth, the debate about whether antipsychotic drugs cause brain volume loss is important but, in our view, remains unresolved.For example, one research group found that higher doses were associated with greater brain volume loss 16 .Yet, in the same cohort, they also observed that longer durations of relapse were linked to more brain volume loss 17 .This latter finding could suggest that preventing relapses is important.Fifth, the evidence on whether long-term outcomes improve after discontinuing antipsychotics is equivocal.The results of the Dutch HAMLETT study are difficult to interpret: functioning, as