Symptom Recurrence Following Intermittent Treatment in First Episode Schizophrenia Successfully Treated for Two Years

Department of Psychiatry, University of Stellenbosch, Cape Town, South Africa.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 04/2012; 73(4):e541-7. DOI: 10.4088/JCP.11m07138
Source: PubMed


An unanswered question in the management of schizophrenia is how long antipsychotic treatment should be continued after a single psychotic episode. In this study, we assessed the rates of symptom recurrence with intermittent treatment in patients with a first episode of DSM-IV-defined schizophrenia or related illness after 2 years of successful continuous treatment. We also investigated antecedents of recurrence, as well as demographic and baseline clinical predictors of early recurrence, and we compared the psychopathology of the recurrence episode with that of the first episode.
Outpatients in an academic psychiatric hospital setting (single site) who had responded well in an open-label study with risperidone long-acting injection were recruited for this intermittent treatment trial, and those who participated had their treatment tapered and discontinued over a period of up to 6 weeks, with follow-up for 3 years or until reemergence of symptoms. Open-label treatment with oral risperidone and risperidone long-acting injection was immediately reinstituted in the event of recurrence of symptoms. The study was conducted between February 2004 and March 2010. The primary outcome measure was symptom recurrence rate at 3 years.
Participants (N = 33) had a mean age ± SD of 28 ± 7.9 years and a mean baseline Positive and Negative Syndrome Scale total score ± SD of 44.8 ± 7.4 at study entry. Symptom recurrence rates were 79% at 12 months, 94% at 24 months, and 97% at 36 months. Onset of recurrence symptoms was fairly abrupt, and symptom severity returned to levels close to those of the first episode. No significant predictors of early recurrence were identified.
Intermittent antipsychotic treatment, even after 2 years of successful treatment, may not be in the best interest of patients who have experienced a single psychotic episode. identifier: NCT00378092.

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    • "In patients who have remitted from a first episode, the mean one-year risk of psychotic symptom recurrence after medication discontinuation is 77% compared to 3% under maintenance treatment [23]. Moreover, after stopping medication, recurrence of psychotic symptoms usually occurs within a short period of time (16 days on average), even in patients with optimal outcome, and does not depend on the time to achieve remission or the length of remission [17] [24] [25]. "
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    ABSTRACT: The use of long-acting injectable antipsychotics (LAIs) in schizophrenia is usually restricted to patients in long-term treatment, who prefer them to oral antipsychotics, and to patients with multiple relapses who have a history of non-adherence. However, preliminary evidence from patients in the early phases of the disease suggest that second generation LAIs may be superior to second generation oral medications with regard to the control of negative symptoms and psychosocial functioning. Moreover, several studies have found that psychiatrists are generally reluctant to prescribe LAI antipsychotics and under-estimate their acceptability by patients. Key elements to take into account when offering a LAI in the early course of schizophrenia should include their potential superiority in allowing early detection of non-adherence and in reducing the number of rehospitalisations and relapses. Copyright © 2014 Elsevier Masson SAS. All rights reserved. Published by Elsevier Masson SAS. All rights reserved.
    European Psychiatry 11/2014; 29S2:1409-1413. DOI:10.1016/S0924-9338(14)70001-X · 3.44 Impact Factor
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    • ") total score (10-point or 20–25% increase) (Boonstra et al., 2011; Emsley et al., 2012; Gaebel et al., 2011), three utilized a minimum threshold score on PANSS or Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham, 1962) total score (Boonstra et al., 2011; Chen et al., 2010; Gitlin et al., 2001), one used clinical evaluation of relapse (McCreadie et al., 1989), and three used additional signs of relapse such as admission to hospital, change in Global Assessment of Functioning scale (GAF) (Endicott et al., 1976) or Clinical Global Impression (CGI) (Guy, 1976) scale (Chen et al., 2010; Gaebel et al., 2011; McCreadie et al., Table 1 Characteristics of the included studies and observed relapse rates. "
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    ABSTRACT: The large majority of individuals with a first episode of schizophrenia will experience a remission of symptoms within their first year of treatment. It is not clear how long treatment with antipsychotic medications should be continued in this situation. The possibility that a percentage of patients may not require ongoing treatment and may be unnecessarily exposed to the long-term risks of antipsychotic medications has led to the development of a number of studies to address this question. We carried out a systematic review to determine the risk of experiencing a recurrence of psychotic symptoms in individuals who have discontinued antipsychotic medications after achieving symptomatic remission from a first episode of non-affective psychosis (FEP). Six studies were identified that met our criteria and these reported a weighted mean one-year recurrence rate of 77% following discontinuation of antipsychotic medication. By two years, the risk of recurrence had increased to over 90%. By comparison, we estimated the one-year recurrence rate for patients who continued antipsychotic medication to be 3%. These findings suggest that in the absence of uncertainty about the diagnosis or concerns about the contribution of medication side effects to problems with health or functioning, a trial off of antipsychotic medications is associated with a very high risk of symptom recurrence and should thus not be recommended.
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