Schizophrenia drugs: a case for tapering.

Schizophrenia drugs: A case for tapering

About 40 years after neuroleptic drugs gained renown for their ability to quell hallucinations and other symptoms of psychosis, psychiatrists face a vexing dilemma in deciding how to use these substances to treat schizophrenia. Prolonged use of neuroleptics, also known as antipsychotic drugs, causes severe movement disorders in a substantial minority of those whose mental condition improves. Yet taking patients off the drugs can trigger the return of schizophrenia in an intensified form.

Either way, physicians may face a lawsuit. And recently, researchers studying how people with schizophrenia react to the withdrawal of neuroleptics drew a federal reprimand after several patients suffered severe relapses and one committed suicide (SN: 3/19/94, p.188).

A new review of all such withdrawal studies concludes that schizophrenia often remains under control after a gradual lowering of the drug dosage to levels much less likely to cause movement disorders, such as the uncontrollable tics and jerks known as tardive dyskinesia. This approach, as opposed to rapid withdrawal, best prevents relapses, the review's authors argue.

"The optimal solution in many cases is to slowly taper neuroleptic therapy, once a patient's condition has become stable, to a substantially lower dose that still controls symptoms of schizophrenia," asserts study director Dilip V. Jeste, a psychiatrist at the University of California, San Diego. "For some patients, it may be possible to stop neuroleptic therapy." In their review of 66 studies conducted between 1958 and 1993, Jeste and his colleagues find that nearly half of all patients diagnosed with schizophrenia remained largely symptomfree for at least 10 months after they stopped taking neuroleptics. A total of 4,365 people with schizophrenia participated in these investigations.

About 53 percent of those taken off neuroleptics had a return or worsening of schizophrenia symptoms within 10 months, compared to 16 percent of those kept on the drugs.

Repeated drug "holidays" lasting several months at a time do not prevent -- and may indeed worsen -- tardive dyskinesia, Jeste and his colleagues contend in the March Archives of General Psychiatry. Moreover, continuous antipsychotic treatment controls schizophrenia much better than intermittent treatment instituted only when psychotic symptoms flare up, they argue. It usually takes a year or more to find the particular type and amount of neuroleptic that best controls a person's schizophrenia. At that point, gradual tapering of the dosage should be tried, Jeste holds. Patients respond best to reduced dosages if they have access to programs that teach social skills, an option that is often unavailable or unaffordable, Jeste notes.

Studies to date have not identified any characteristics of schizophrenia sufferers that mark some as more likely to suffer a relapse following neuroleptic withdrawal, he says.

In comments accompanying the new report, several psychiatrists support frequent neuroleptic tapering. Some note that a new class of medication may replace neuroleptics as a safer alternative in schizophrenia treatment, although the long-term effects of these drugs remain unclear (SN: 6/18/94, p.398). Other clinicians argue that finding the lowest effective neuroleptic dose is often difficult and not worth the risk of a relapse.