By: Melissa Yanovitch, MSc, MS

Predictors of relapse in patients with first-episode psychosis following discontinuation of antipsychotic medication
In a study examining the socio-demographic and clinical risk factors associated with risk of relapse after first-episode psychosis (FEP), researchers Di Capite, Upthegrove and Mallikarjum (2016) looked at the relationship between relapse and discontinuation of antipsychotic medication. The focus on medication discontinuation stems from both patient and clinician uncertainty surrounding the optimum duration for treatment with antipsychotics. The authors commented on patient reluctance to continue antipsychotic medication indefinitely, as well as mixed results from research in this area.

In the present study, relapse was defined as a return of symptoms following FEP, “requiring hospitalization, home treatment, or based on clinical team decision.” Participants were patients ages 16-35 in the Birmingham Early Intervention Service (EIS) between 2012 and 2015 with FEP. The research took place over a 12-month period and included 63 participants. All participants had documented discontinuation of antipsychotic medication. Results from the study found the 12-month relapse estimate to be 67%, and the median time to relapse to be 8 months.

Results of the study did not find relapse rate to be related to length of treatment with antipsychotic medication, indicating that longer duration of treatment with antipsychotic medication after FEP does not reduce risk of relapse in the case of discontinuation. The authors discussed how these results point to the need for closer follow-up of patients after discontinuation of antipsychotic medications to help identify relapse earlier. Finally, the study suggests that male patients with NEET (not being in education, employment or training) status and previous psychiatric hospitalizations should be considered as being at higher risk for relapse, and therefore continued treatment with antipsychotic medication may be indicated in these patients.

Reference:
Di Capite, S., Upthegrove, R. & Mallikarjun, P. (2016). The relapse rate and predictors of relapse in patients with first-episode psychosis following discontinuation of antipsychotic medication. Early Intervention in Psychiatry, 9999, 1-7. DOI 10.1111/eip.12385

Caution Needed Around Long-Term Prophylactic Use of Antipsychotics
Murray, Quattrone, Natesan, van Os, Nordentoft, Howes, Di Forti, & Taylor (2016) looked at the research on long-term side effects of prophylactic use of antipsychotics after an acute episode of psychosis. First, the authors focused on potential effects on physical health and brain structures and found that results in these domains were variable depending on whether the medications are first-generation or second-generation antipsychotics. Second, they examined research on the long-term effectiveness of prophylactic antipsychotic medication. Similarly, they found mixed results in this area, but determined that there is little evidence for effectiveness in preventing relapse in patients with schizophrenia after 2 years. Third, they researched supersensitivity to dopamine D2 receptor that may result in decreased effectiveness of antipsychotics as a consequence of long-term use. They found some evidence to support this, but concluded that, at this point in time, results continue to be varied. The authors argue that this is an area for urgent future study using neurochemical imagining. Finally, the authors examined available research and determined that some patients diagnosed with treatment-resistant schizophrenia (TRS) do not show dopamine dysregulation and therefore the author emphasizes that these patients should not be prescribed D2 blockers.

In conclusion, the authors suggest that after treating acute symptoms of psychosis with the minimum effective dose, psychiatrists should reduce the long-term dose to the lowest that is effective at preventing symptoms. Along with treatment with antipsychotic medication, patients should have access to non-pharmacological treatment.

Reference:
Murray, R. M., Quattrone, D., Natesan, S., van Os, Nordentoft, M., Howes, O, Di Forti, M. & Taylor, D. (2016). Should psychiatrists be more cautious about the long-term prophylactic use of antipsychotics? The British Journal of Psychiatry, 209, 361-365. doi: 10.1192/bjp.bp.116.182683