Mental health professionals’ views and experiences of antipsychotic reduction and discontinuation

Abstract

Background The widely established treatment for psychosis is long-term antipsychotic medication. However, many people stop taking this treatment, and request other options. There are also growing concerns about adverse effects, but currently no professional guidelines to support reducing or stopping these drugs. The views and experiences of individual mental health professionals around reducing and stopping antipsychotics are therefore crucial in treatment decisions. Methods We conducted 7 focus groups with prescribing psychiatrists and other members of community-based statutory mental health services in London. Participants discussed their views about, experiences, and processes of antipsychotic reduction and discontinuation. Data were analysed using thematic analysis. Results Participants acknowledged that antipsychotics can have severe adverse effects. They were generally supportive of trying to reduce these drugs to the lowest effective dose, although stopping antipsychotics was less acceptable. Prior experiences of adverse events after reduction or discontinuation meant that both were approached with caution. Reduction was also reported to be hampered by organisational and knowledge barriers. Lack of resources, pressure to discharge, and poor continuity of care were seen as organisational barriers. Knowledge barriers included inadequate evidence about who might be best suited to reduction, and lack of guidance about how this could be done safely. This meant that reduction was often prompted by patients, and sometimes actively discouraged, and stability with maintenance treatment was often favoured. Conclusions Concerns about risk and other barriers means that clinicians are often reluctant to implement reduction or discontinuation of antipsychotic medication. In order to increase the treatment options available to service users, more research and guidance on how to minimise the risks of antipsychotic reduction and discontinuation is required to enable clinicians to engage more constructively with service users requests, offering people more choice and control in managing their mental health condition.

Barriers to stopping neuroleptic (antipsychotic) treatment in people with schizophrenia, psychosis or bipolar disorder

“…On the other hand, families, carers and clinicians may be reluctant to take the risk of having to endure another relapse, and this makes the process of withdrawal even more difficult, since many people report that they benefit from having support from other people when they try to reduce medication. 46,[53][54][55][56][57] Institutional factors Societal and institutional forces are ranged against any strategy that could increase the risk of a relapse of a severe mental disorder. The shortterm costs of someone having a relapse can be high.…”

“…Yet others do support patients to reduce or stop neuroleptic treatment when they request it, and even encourage patients to consider this option who have not previously done so. 56 Professionals cite the lack of guidance when surveyed about their attitudes towards deprescribing in general, 51 and a desire to identify those patients who are likely to have a good outcome following antipsychotic reduction or discontinuation. 56 Unfortunately, although some individual studies have identified various patient and treatment characteristics that predict subsequent relapse or functional outcome, 42 meta-analyses have failed to confirm any consistent predictors of relapse.…”

“…On the other hand, families, carers and clinicians may be reluctant to take the risk of having to endure another relapse, and this makes the process of withdrawal even more difficult, since many people report that they benefit from having support from other people when they try to reduce medication. 46 , 53 – 57…”

“…Yet others do support patients to reduce or stop neuroleptic treatment when they request it, and even encourage patients to consider this option who have not previously done so. 56 …”

“…Professionals cite the lack of guidance when surveyed about their attitudes towards deprescribing in general, 51 and a desire to identify those patients who are likely to have a good outcome following antipsychotic reduction or discontinuation. 56 Unfortunately, although some individual studies have identified various patient and treatment characteristics that predict subsequent relapse or functional outcome, 42 meta-analyses have failed to confirm any consistent predictors of relapse. 13 , 70 , 71 Few existing guidelines contain any guidance on how to help people stop taking a prescribed medicine.…”