A recently published study from noted critical psychiatry expert Joanna Moncrieff explored the barriers that prevent clinicians from helping service users in discontinuing or reducing antipsychotics.

The team of London-based researchers investigated mental health professionals’ opinions and experiences regarding the reduction and discontinuation of antipsychotics. While the established treatment for psychosis is antipsychotics, many people either stop taking them on their own or request different treatment. Despite this, and despite concerns about adverse effects of continued consumption of antipsychotics, there are no professional guidelines to reduce or eliminate antipsychotic treatment.

The researchers conducted focus groups with psychiatrists and other members of community mental health services. They discovered a wide range of opinions and experiences regarding antipsychotics. Most professionals mentioned that the drugs can have negative effects, and were supportive of prescribing the lowest effective dose–though eliminating antipsychotics was seen as less acceptable. These opinions were due to organizational and knowledge barriers, as well as the result of prior experience with relapse following antipsychotic discontinuation.

“These systemic barriers are concerning as they may be hindering good practice,” write the authors. “For example, pressure to discharge means that service users may be stabilized quickly through high dose antipsychotics and then discharged to GPs (primary care physicians), who are unlikely to alter this medication. This situation reduces patient choice and may result in the long-term use of potentially unnecessarily high doses.”

The authors cite constraints such as limited time with service users and limited organizational support, as well as limited access to non-medication treatments. These factors force clinicians to rely on medication stabilization alone.

“This may mean that maintenance treatment is favored over reduction for organizational rather than clinical reasons, and that service users may miss out on opportunities to minimize the adverse effects of long-term treatment, or to manage their illness in other ways.”

While antipsychotics are often first-line treatment for psychosis, there are a number of side effects and adverse effects of antipsychotics, especially after long-term use. In addition, a third of patients don’t respond at all to antipsychotics, which causes many to discontinue medication on their own volition. Most research on discontinuation of antipsychotics has investigated sudden rather than gradual discontinuation; one study that compared maintenance treatment to gradual reduction found a short-term risk of relapse in the reduction group, but no long-term difference and higher rates of social recovery. The dearth of research has contributed to the lack of professional guidelines for reducing antipsychotics, necessitating clinicians to make intuitive decisions that are affected by their personal attitudes on antipsychotics.

In the current study, the researchers conducted seven focus groups, each of which contained 3-8 participants: a total of 35 psychiatrists, mental health nurses, social workers and clinical team managers. There were four main areas of emphasis: experiences and views regarding reducing/discontinuing antipsychotics, the process of reduction and discontinuation (such as facilitators and barriers), detection and definition of relapse and support for antipsychotic reduction. Data were analyzed with thematic analysis.

All participants recognized that antipsychotics can have some benefits as well as severe adverse effects, and some noted a perceived overreliance on medication in the industry. Adverse effects discussed included weight gain, diabetes, heart problems, sedation, impaired function, sexual dysfunction and shortened life-span, and concern and empathy were shown for individuals who experienced these adverse effects.

Critique of medication overreliance pointed to a pattern of polypharmacy and sudden dose escalation to stabilize and discharge quickly. A small group of psychiatrists firmly believed that antipsychotic medication, when considered holistically, was absolutely the best course of long-term treatment. These individuals were wary of discontinuation-related relapse.

All psychiatrists noted the importance of reducing antipsychotics in certain instances, with some pointing to a ‘minimally effective dose’ as ideal, aiming to avoid relapse and maximize quality of life. While some nurses and psychiatrists had positive experiences with reducing medication, most pointed to experiences of relapse and other adverse outcomes. These professionals often preferred “maintenance treatment” rather than reducing antipsychotics, accepting over-medication as a risk. As such, discontinuing these drugs was not usually seen as an option. They expressed additional concern that patients might end up on a higher dose of antipsychotics following relapse.

One consulting psychiatrist was quoted as saying, “Unfortunately what we do see in people who against our advice stop their medicines is that they get into a terrible lot of trouble before they get back into the service; you know, they lose their relationships, they lose their jobs, they lose their housing, get involved in drug misuse, criminality.”

Participants identified a number of organizational barriers, such as lack of resources to support the reduction of antipsychotics, including access to and funding for alternative treatment, as well as resource cuts which led to increased pressure to discharge to primary care. This practice leads to over-prescription in order to quickly stabilize individuals. This creates a challenge, as primary care physicians tend not to adjust antipsychotics, lacking the knowledge and clinical support to do so. Thus, people often remain on excessively high doses of antipsychotics for quite some time.

A consulting psychiatrist was quoted as saying, “People get put on high levels of medication often they are put on polypharmacy, and then as soon as they are not acute enough to need the home treatment team they are discharged, often straight back to the GP, so there is never the opportunity for stability and there is never the opportunity for de-escalation, and the GPs very reasonably do not reduce medication because they do not want to particularly when it is antipsychotic polypharmacy.”

Participants further noted the challenge of prescribing or reducing antipsychotics in a system that shuttles people to different services without providing clinical context about medication decision to their new providers, as well as knowledge barriers surrounding clinical guidelines to reduce antipsychotics and who is suitable for antipsychotic reduction.

All focus groups mentioned the importance of communication between clinicians and patients; participants stressed a desire to sustain a good relationship with their patients, and emphasized the importance of respecting and engaging with patients’ requests. Some psychiatrists felt that their professional expertise gave them more authority to make decisions, and as such used a range of strategies to discourage the request to stop taking antipsychotics. All focus groups emphasized the importance of family and caregiver relationships during the reduction process.

There are a host of clinical implications to the information provided from the focus groups, including reduced patient choice as a result of overmedication due to the desire to stabilize and discharge, a prevalent power dynamic leading to reduced patient choice in treatment and a desire for risk aversion in clinicians. Many of these fears may rest in the firm belief in the medical model of psychosis, which suggests that antipsychotics eliminate a chemical imbalance and are thus necessary for recovery. This model may lead clinicians to believe that their patients have diminished decision-making capacity. Given this, involving patients in treatment decisions becomes both more challenging and more vital to eliminate the power disparities between clinician and patient.

“Relapse following reduction or discontinuation is not inevitable, and some service users reasonably wish to reduce their side-effect burden, or consider options other than continuous maintenance treatment,” conclude the authors. “However, when service users stop antipsychotics covertly and abruptly (which may be more likely if support or options to reduce are not offered) their risk of relapse and negative or coercive service experiences may increase.”

The authors hope that future research on gradual antipsychotic discontinuation could inform guidelines to help clinicians engage in discussions of reduction/discontinuation with service users.

“Further support for engaging patients meaningfully and constructively in decision making would be useful, and financial constraints that encourage the prioritization of short-term stability to enable rapid discharge, with long term high-dose antipsychotic prescribing need to be debated.”

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Cooper, R.E., Hanratty, É., Morant, N., & Moncrieff, J. (2019). Mental health professionals’ views and experiences of antipsychotic reduction and discontinuation. PLoS ONE, 14(6): e0218711. https://doi.org/10.1371/journal.pone.0218711 (Link)