06 Sep 2010

Whether to discontinue the medications for patients with a good recovery from a single episode of psychosis has been a difficult decision for clinicians due to the lack of solid supporting data. Clinical guidelines recommend maintenance drug treatment for the first year after the onset of illness, but there is no consensus regarding longer periods of maintenance treatment. Many patients resort to covert discontinuation of medication, resulting in relapses (i.e. re-appearance of psychotic symptoms), sometimes with disastrous consequences.

For the first time worldwide, investigators led by a research team of The University of Hong Kong Li Ka Shing Faculty of Medicine provide a key to the question by conducting a definitive double-blind randomised controlled study, showing that maintenance in medication can help reducing the risk of relapses to almost a half. The results are recently published in the “British Medical Journal” (BMJ, 2010;341:c4024).

“The study shows that the risk of relapses is substantial if medication is discontinued even after nearly 2 years of treatment. If patients recovered from first episode of psychosis wish to discontinue medication, they should discuss with their clinicians openly so that they can receive necessary professional support. The discontinuation of medication is best managed with a specialized early psychosis program.” says Professor Eric Chen Yu-hai, Department of Psychiatry, The University of Hong Kong Li Ka Shing Faculty of Medicine, who led the research team.

Professor Chen also emphasizes the importance of the specialized early psychosis care and service for these patients. “Because of the close monitoring during the study, most of the relapses of the participating patients were detected and treated early. Hence, only a small proportion of them needed to be hospitalized.”

Aim of Study:

The study aims to find out scientifically what would happen to remitted early psychosis patients (who are entirely free from psychotic symptoms) if they stop maintenance medication (after an average of 21 months), compared to those who continued to receive medication.

Research Methodology:

178 patients were identified from the Early Assessment Service for Young People with Psychosis service of the Hospital Authority (EASY service) who had recovered from a single episode of psychosis. All the patients had received medication continuously for at least a year and were judged to be free of psychotic symptoms. They were randomised into two groups under double-blind conditions, one group received maintenance medication (quetiapine 400mg), and the other discontinued and received placebo.

During the 12-month study, patients were followed up closely by the research team, and assessed at least once every month to detect whether there had been a recurrence of psychotic symptoms. All patients had hotline access to the research team to report any symptoms and queries. Patients also received close professional monitoring as part of the EASY service.

Research Findings:

The majority of patients (79%) in the discontinuation groups had recurrences of psychotic symptoms. Maintenance medication reduced this risk to 41%. The readmission to hospital rate was much higher in the discontinued medication group, compared with that of the continued medication group (13% vs 4%).

On the other hand, 21% of patients remained relapse-free one year following medication discontinuation. Previous personality, functioning, as well as clinical features, proved to be significant predictors of relapse.

Recommendations:

1. For patients who recovered well from first episode psychosis and their family members:
a. Discuss with clinicians openly about any wish to discontinue medication
b. Take into account the relapse risks found in this study
c. Discontinuation is best managed with specialized early psychosis care, such as the EASY and the Jockey Club Early Psychosis (JCEP) services
d. At the earliest sign of relapse, arrange for early resumption of medication

2. Clinicians should spend time to openly discuss with patients about their wish to discontinue medication and inform them about the relative risks as found in this study. For patients who wish to discontinue medication, they should be supported by specialized early psychosis services.

3. Hospital Authority is advised to provide adequate clinical time and manpower for early intervention so as to support patients in managing relapse and maintenance treatment.

Research team:

The study was carried out by the Psychosis Studies and Intervention (PSI) Unit of the Department of Psychiatry, The University of Hong Kong Li Ka Shing Faculty of Medicine, in collaboration of EASY services of the Hospital Authority based at Castle Peak Hospital, Kowloon Hospital, Kwai Chung Hospital, Queen Mary Hospital and Tai Po Hospital.

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