Changing vistas of psychosis and antipsychotic drug dosing toward personalized management of antipsychotics in clinical practice.

Abstract

Objective: To discuss current evidence on tapering antipsychotic drugs in view of changing vistas of psychosis, suggesting a provisional framework for safely tapering antipsychotic drugs to an optimal low dose, in collaboration with patients and their relatives, to promote functional recovery while preventing relapse. Methods: Paradigm shifts during recent years regarding the nature of psychotic disorders and the role of the dopamine system are discussed, including the positive effects of dopamine blockade in acute psychosis and the limitations and drawbacks of dopamine blockade regarding negative and cognitive symptoms after remission of positive symptoms. Recent advances in tapering strategies and upcoming ways to solve the dilemma between the need to prevent relapses with antipsychotics on the one hand and the need to minimize side effects by tapering these drugs on the other are presented. Results: Modern tapering strategies appear to reduce relapse risk to acceptable levels and offer a feasible personalized option to find the least effective dose to treat and prevent positive symptoms without redundant side effects and functional incapacity. These findings need replication, and several trials that might provide more certainty are on their way. Conclusions and Implications for Practice: Preliminary evidence and clinical experience indicate that personalized dose reduction of antipsychotics is feasible and safe if carried out in close collaboration with patients and their relatives, according to a provisionally suggested framework presented here. These preliminary directions still must be confirmed, revised, and adjusted according to upcoming trial results. Impact and ImplicationsMany patients with psychosis want to discontinue their antipsychotic drugs due to serious side effects hampering their daily functioning in the long term. The main drawback of discontinuation is relapse. Modern tapering strategies seem to reduce relapse risk to an acceptable level. Based on available evidence and clinical experience, provisional guidelines for personalized, safe, and sound tapering of antipsychotics to an optimal low dose are presented.