Antipsychotic drugs: when and how to withdraw them?

Hamlet's augury: how to manage discontinuation of mood stabilizers in bipolar disorder

Research has generated good quality evidence about the treatment and management of bipolar disorder in acute and, to some degree, sub-acute/continuation phases. This has informed various guidelines about the treatment and management of bipolar disorder (BD). However, for the long-term or maintenance phase of illness, most guidelines peter out and, in the absence of sufficiently high-quality research evidence, remain vague. This is particularly evident for the important clinical question of discontinuing mood stabilizing pharmacological agents after a period of remission has been achieved. The aim of this review is to put together current existing evidence about discontinuing mood stabilizers after a period of remission in order to come up with a structured and coherent strategy for managing such discontinuation and to make recommendations for future research. To this end, we reviewed the main relevant treatment guidelines and subsequent evidence following the publication of these guidelines. The current recommended long-term treatment of BD is usually considered within the same principles applicable to any chronic health condition (e.g. hypertension or diabetes) where the focus is on continuing treatment at minimum effective medication dose often life-long, switching to alternative choice of medication due to side-effects and very few, if any, indications for complete cessation. However, in the absence of strong evidence on long-term treatment and the high rate of non-concordance in BD, medication discontinuation is a very important aspect of the treatment that should be given due consideration at every aspect of the treatment.

Addressing non-adherence to antipsychotic medication: a harm-reduction approach

This paper discusses the evidence base for interventions addressing non-adherence to prescribed antipsychotics. A case study approach is used, and the extent to which adherence improvement interventions might be used in collaboration with a specific patient is considered. The principles and application of harm-reduction philosophy in mental health are presented in a planned non-adherence harm-reduction intervention. This intervention aims to acknowledge the patient's ability to choose and learn from experience and to reduce the potential harm of antipsychotic withdrawal. The intervention evaluation method is outlined.

[Iatrogenic psychiatric-like symptoms recognition]

INTRODUCTION

This article proposes a review of atypical multicentre studies for drug-induced movement disorders (and related psychiatric symptoms) and supersensitivity psychosis. A well-conducted antipsychotic treatment consists of regular attempts to reduce the dose by finding the minimal therapeutic dose. To achieve optimal antipsychotic treatment, it is important to distinguish psychiatric symptoms associated with drug-induced movement disorder(s) (DIMD) or supersensitivity psychosis from true relapse.

LITERATURE FINDINGS

Persistent DIMD have been found to be a predictor of supersensitivity psychosis or tardive dyskinesia (DT). DIMD-associated psychiatric symptoms can be classified into three types: directly induced by DIMD; resulting from confounding DIMD with psychiatric symptoms; and supersensitivity symptoms associated with DIMD. Without this distinction, the beneficial effects of antipsychotics are masked by emergent DIMD psychiatric symptoms (as was confounded in the CATIE study).

DISCUSSION

A constant decline in the prevalence of TD (hyperkinetic, involuntary and purposeless movement disorder) has been observed since the introduction of atypical antipsychotics. The neurotoxic effects of classical antipsychotics are well documented and their discontinuation is required. However, the risk of TD still exits with atypical antipsychotics and continued surveillance of emerging cases is very important for clinicians. Moreover, a regular evaluation of DIMD and associated psychiatric symptoms is crucial. It is important to underline the fact that DIMD persists with antipsychotics, with significantly higher total PANSS scores than in patients without DIMD.

CONCLUSION

Supersensitivity psychosis is a drug-induced psychotic relapse (6 weeks following the decrease or withdrawal of an antipsychotic). Discontinuation syndromes can produce psychiatric symptoms (and be confounded with true relapse), but can be improved more quickly after reintroduction of treatment. Interestingly, various data suggest that lower doses of antipsychotics could prevent such symptoms. Anticonvulsants can be efficient adjuvants in the treatment of psychosis. In the United States, many patients received valproate or gabapentin treatment. These adjuvants, by antikindling effect, can facilitate minimal maintenance drug treatment and be efficient for anxiety. Resistant schizophrenia can be related to supersensitivity psychosis; gabapentin and lamotrigine are effective in this case.

A prototype approach toward antipsychotic medication adherence in schizophrenia

Antipsychotic nonadherence in psychotic disorders is a vexing clinical problem. While many risk factors are associated with nonadherence, a risk factor model per se is a poor guide for clinical decisions. We propose a pragmatic clinical prototype approach that incorporates two variables, medication drug attitude and worldview (with regard to mental illness and psychiatric treatment), to create five patient prototypes of adherence: patients with good adherence for the right reasons ("True Believer"), with good adherence for the wrong reasons ("Clinic Trouper"), with reluctant and tenuous adherence ("Reluctant Recruit"), with passive adherence ("The Coffee Guy"), and with unwillingness to take medications ("Constitutional Combatant"). Actual patients can be compared and assigned to one of the prototypes, with the group membership predicting level and character of adherence, and suggesting specific interventions. In this scheme, drug attitude and worldview are key variables for adherence; both can be ascertained during the clinical interview and quantified with rating scales.

Agoraphobia is a disease: a tribute to Sir Martin Roth

The evidence which has accumulated on the course of agoraphobia challenges the DSM view that phobic avoidance is secondary to panic attacks. In particular, a longitudinal study by Wittchen et al. indicates that agoraphobia, as a diagnostic category, is frequently independent of panic disorder and panic attacks, is unlikely to remit spontaneously and entails compromised quality of life. A staging system of agoraphobia is presented. Panic may ensue in the longitudinal development of agoraphobia, as well as of other anxiety disorders, and be conceptualized as a potential outcome in the course of anxiety, phobias and hypochondriasis as more than a specific disease entity. These recent research findings confirm the clinical observations and phenomenological research of Sir Martin Roth (1917-2006) and call for a reassessment of the concept of neurosis.