Barriers to stopping neuroleptic (antipsychotic) treatment inpeople with schizophrenia psychosis or bipolardisorder

摘要

Most guidelines recommend long-term, indefinite neuroleptic (orantipsychotic) treatment for people with schizophrenia, recurrentpsychosis or bipolar disorder, on the basis that these medicationsreduce the chance of relapse. However, neuroleptics have significantadverse effects, including sexual dysfunction, emotional blunting,metabolic disturbance and brain shrinkage, and patients often requestto stop them. Evidence for the benefits of long-term treatment is alsonot as robust as generally thought. Short-term randomised trials showhigher rates of relapse among those whose neuroleptic treatment isdiscontinued compared with those on maintenance treatment, but theyare confounded by adverse effects associated with the withdrawal ofestablished medication. Some longer-term studies show possibleadvantages of medication reduction and discontinuation in terms ofimproved social functioning and recovery. Therefore, there is a goodrationale for supporting patients who wish to stop their medication,especially given the patient choice agenda favoured by The NationalInstitute for Clinical Excellence (NICE). The major barrier tostopping antipsychotics is an understandable fear of relapse amongpatients, their families and clinicians. Institutional structures alsoprioritise short-term stability over possible long-term improvements.The risk of relapse may be mitigated by more gradual reduction ofmedication, but further research is needed on this. Psychosocialsupport for patients during the process of reducing medication mayalso be useful, particularly to enhance coping skills. Guidelines tosummarise evidence on ways to reduce medication would be useful. Manypatients want to try and stop neuroleptic medication for good reasons,and psychiatrists can help to make this a realistic option bysupporting people to do it as safely as possible, with the best chanceof a positive outcome.