Do Not Continue Withholding Antipsychotics
After 2 weeks off antipsychotics, you should restart treatment immediately rather than extending the medication-free period, as the risk of relapse increases substantially with continued discontinuation, and most patients who will respond to a drug-free trial show no benefit within the first few weeks. 1, 2
Critical Relapse Risk Timeline
- Approximately 65% of patients receiving placebo will relapse within 1 year of their acute psychotic phase, compared with only 30% receiving antipsychotics 1
- Over 5 years, approximately 80% of patients experience at least one relapse when off medication 1
- Relapse can occur many months after stopping antipsychotics, occasionally with drastic consequences 2
- Abrupt or prolonged discontinuation is associated with earlier and often more severe illness episodes than gradual discontinuation 3
When Medication-Free Trials Are Appropriate
A medication-free trial may only be considered in newly diagnosed patients who have been completely symptom-free for at least 6 to 12 months 1
However, critical caveats apply:
- Any evidence of disorder recurrence warrants immediate resumption of treatment 1
- This applies only to a small percentage of patients who do not relapse 1
- The patient has already been off medication for 2 weeks, which is sufficient time to assess for early signs of relapse 1
Risks of Extended Discontinuation
Withdrawal syndromes, relapse, and rebound psychosis can occur when antipsychotics are discontinued, especially if stopped abruptly 2
Specific adverse effects of continued withholding include:
- Development of withdrawal dyskinesias, parkinsonian symptoms, dystonias, and potentially neuroleptic malignant syndrome 3
- Greater mood instability and manic relapse in bipolar disorder 3
- More severe psychotic episodes upon relapse 3
Recommended Action
Restart antipsychotic treatment now rather than extending the drug-free period 1
- If restarting is necessary, antipsychotics should be introduced gradually to minimize adverse effects 2, 3
- Close monitoring is essential during the first 4 weeks after restarting 4
- Maintenance treatment should continue for at least 12 months after beginning of remission 1
- For patients stable for several years, any future discontinuation attempts should only be considered in consultation with mental health professionals, with careful attention to relapse risk and patient preferences 1
Common Pitfall to Avoid
Do not assume that because the patient has tolerated 2 weeks off medication without obvious deterioration, it is safe to continue withholding treatment. Relapse often occurs weeks to months after discontinuation, and the longer antipsychotics are withheld, the higher the cumulative relapse risk 1, 2