Abstract
Background
There remains controversy regarding the relative risks of maintenance treatment versus discontinuation of antipsychotics following remission in first episode psychosis and reviews of discontinuation strategies have not included real world strategies.
Methods
The study was a systematic review and meta-analysis. Prospective experimental studies including a parallel control group were identified to compare maintenance antipsychotic treatment to total discontinuation or medication discontinuation strategies (graded discontinuation and/or the use of medication for prodromal symptoms (targeted discontinuation)) following remission in FEP. Primary outcome was relapse rate. Secondary outcomes included hospitalization and psychosocial functioning.
Findings
Seven studies were included in the review. Risk of relapse was greater in the discontinuation group compared to the maintenance treatment (pooled risk difference [RD] = 0.26; 95% CIs: 0.18, 0.34). The pooled relapse rate for the discontinuation group was 53% (95% CIs: 39%, 68%), and 19% (95% CIs: 0.05%, 37%) for the maintenance group. RD was lower for hospitalization (RD = 0.12; 95% CIs: 0.05, 0.20). In a subgroup analysis risk of relapse was lower in studies with: a longer follow-up period, a targeted discontinuation strategy (opposed to placebo), a higher relapse threshold, and a larger sample size. In a narrative review there were no differences in functional outcomes between the groups; very few studies included these outcomes.
Interpretation
There is a higher risk of relapse for those who undergo a total or targeted discontinuation strategies compared to a maintenance antipsychotics. However, the effect size is moderate and the risk difference lower in real world practice discontinuation strategies trials. Future studies need to include functional outcomes.
There remains controversy regarding the relative risks of maintenance treatment versus discontinuation of antipsychotics following remission in first episode psychosis and reviews of discontinuation strategies have not included real world strategies.
Methods
The study was a systematic review and meta-analysis. Prospective experimental studies including a parallel control group were identified to compare maintenance antipsychotic treatment to total discontinuation or medication discontinuation strategies (graded discontinuation and/or the use of medication for prodromal symptoms (targeted discontinuation)) following remission in FEP. Primary outcome was relapse rate. Secondary outcomes included hospitalization and psychosocial functioning.
Findings
Seven studies were included in the review. Risk of relapse was greater in the discontinuation group compared to the maintenance treatment (pooled risk difference [RD] = 0.26; 95% CIs: 0.18, 0.34). The pooled relapse rate for the discontinuation group was 53% (95% CIs: 39%, 68%), and 19% (95% CIs: 0.05%, 37%) for the maintenance group. RD was lower for hospitalization (RD = 0.12; 95% CIs: 0.05, 0.20). In a subgroup analysis risk of relapse was lower in studies with: a longer follow-up period, a targeted discontinuation strategy (opposed to placebo), a higher relapse threshold, and a larger sample size. In a narrative review there were no differences in functional outcomes between the groups; very few studies included these outcomes.
Interpretation
There is a higher risk of relapse for those who undergo a total or targeted discontinuation strategies compared to a maintenance antipsychotics. However, the effect size is moderate and the risk difference lower in real world practice discontinuation strategies trials. Future studies need to include functional outcomes.
| Original language | English |
|---|---|
| Pages (from-to) | 215-225 |
| Number of pages | 11 |
| Journal | BJPsych Open |
| Volume | 4 |
| Issue number | 4 |
| Early online date | 29 Jun 2018 |
| DOIs | |
| Publication status | Published - Jul 2018 |
Keywords
- antipsychotic
- discontinuation
- maintenance
- relapse
- first episode psychosis