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Withdrawing from antipsychotics: an analysis

Withdrawing from antipsychotic medication can take months or even years to complete, as patients need to reduce their doses very gradually, according to analysis by King’s College London and UCL academics.

Picture of a pile of colourful pills

The review, published in Schizophrenia Bulletin in March, is the first ever scientific paper to outline exactly how antipsychotic medication should be reduced in order to minimise both the withdrawal effects as well as the risk of relapse.

Withdrawal symptoms can be severe and may include psychotic symptoms similar to the underlying condition, which can result in patients being advised to remain on the medication indefinitely, even though the new symptoms might have been avoidable with a carefully-managed withdrawal.

Some psychiatrists are reluctant to discuss reducing antipsychotics with their patients. Unfortunately, the consequence is that patients suddenly stop the medication by themselves with the result that they relapse. Much better that psychiatrists become expert in when and how to advise their patients to slowly reduce their antipsychotic.– World expert in schizophrenia, Professor Sir Robin Murray, King’s’ Institute of Psychiatry, Psychology & Neuroscience (IoPPN) and one of the co-authors on the paper

Antipsychotics are one of the fastest growing classes of drugs being prescribed in England, growing from 660,000 people (9.4 million prescriptions) in 2015/2016 to 750,000 people in 2019/2020.

They are often recommended life-long for people diagnosed with schizophrenia or other serious mental illnesses because they are effective at controlling psychotic symptoms in the short term and might reduce the risk of relapse. These drugs are also increasingly prescribed for conditions like insomnia and anxiety ‘off-label’ (without being licensed for these conditions by the UK’s Medicines and Healthcare products Regulatory Agency (MHRA)).

However, some people find the drugs do not help them or that the side effects (which can sometimes contribute to long term health complications) outweigh the benefits, while many people who then stop taking antipsychotics experience withdrawal effects, which can be severe. Some patients say they are helpful in the short-term but harmful in the long-term.

Currently there are no established guidelines on how to stop taking antipsychotics, which is partly why psychiatrists are reluctant to do so. The authors of this proposal reviewed existing evidence into antipsychotic withdrawal, and the mechanisms of the drugs themselves. They describe research, which finds that people with schizophrenia who are slowly taken off their antipsychotics, have twice the chance of functioning well than those who stay on the same dosage, with no worsening in their symptoms.

From my own experience I know how hard it can be to wean off psychiatric medications – so we set out to write guidance on how to withdraw safely from antipsychotics. Stopping medications is an important part of the job of a psychiatrist, yet it has received relatively little attention.– Lead author Dr Mark Horowitz from UCL Psychiatry

These new guidelines on how to reduce antipsychotics align with guidelines the same researchers published recently on how to stop taking antidepressants safely. The principles are similar: doing so cautiously by small amounts, and ensuring patients are stable (with suggested three-to-six month intervals between dose reductions) before making further reductions. Liquid versions of the drug or small dose formulations will be needed to help patients to do this, to avoid having to crush up the tablets themselves.

The reason for stopping drugs gradually is that our brains adapt to long-term use of drugs like antipsychotics (as they do to nicotine, caffeine or opioids). If drugs are stopped too quickly, people can get withdrawal symptoms (which for antipsychotics can include insomnia, tremors and sometimes psychotic symptoms) or can be de-stabilised by the process of coming off.

Antipsychotics are so familiar to prescribers that it is tempting to assume that they are both effective and innocuous. While they are perhaps the most useful treatment for serious mental illness such as schizophrenia, their toxic nature makes them unsuitable for less severe conditions. Antipsychotics induce long-lasting changes to nerve cells in the brain and they need to be withdrawn very slowly (and in a particular way) to allow time for the brain to re-set.– Senior author Professor David Taylor, King’s IoPPN and South London and Maudsley NHS Foundation Trust

Stephen Buckley, Head of Information at Mind said, “Antipsychotic medication can help lots of people who experience psychosis to manage their mental health. Should someone decide to come off their medication then ideally their doctor should be able to support them through the withdrawal process, but we know many clinicians feel they don’t have the guidance or experience to do this with confidence.”

People should be treated as a whole person, so as well as welcoming more research and evidence into how people can withdraw from antipsychotics safely, it’s really important when someone does come off their medication they have some control in their treatment, and are offered trauma informed and culturally relevant treatment options - this could include things like talking or creative therapies, social prescribing, and peer support. – Stephen Buckley, Head of Information at Mind

He added, “Key to this is looking at people’s broader life experiences and making sure people have adequate social support to help them achieve their goals and integrate back into the community, this includes support with loneliness and isolation, finances, unemployment, and housing.”

A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse by

Mark Abie Horowitz, Sameer Jauhar, Sridhar Natesan, Robin M Murray, David Taylor https://doi.org/10.1093/schbul/sbab017 is published in Schizophrenia Bulletin.

Contact

For further information please contact Louise Pratt, Head of Communications, Institute of Psychiatry, Psychology & Neuroscience, King’s College London

Tel: +44 7850 919020
Email: louise.a.pratt@kcl.ac.uk

In this story

Robin Murray

Robin Murray

Professor of Psychiatric Research

David  Taylor

David Taylor

Professor of Psychopharmacology