Experiences of reduction and discontinuation of antipsychotics: a qualitative investigation within the RADAR trial

Nicola Morant; Maria Long; Sandra Jayacodi; Ruth Cooper; Johura Akther-Robertson; Jacki Stansfeld; Mark Horowitz; Stefan Priebe; Joanna Moncrieff

doi:10.1016/j.eclinm.2023.102135

Experiences of reduction and discontinuation of antipsychotics: a qualitative investigation within the RADAR trial

EClinicalMedicine. 2023 Sep 28:64:102135. doi: 10.1016/j.eclinm.2023.102135. eCollection 2023 Oct.

Authors

Nicola Morant¹, Maria Long^{1

2

3}, Sandra Jayacodi⁴, Ruth Cooper^{5

6

7}, Johura Akther-Robertson³, Jacki Stansfeld³, Mark Horowitz^{1

3}, Stefan Priebe⁵, Joanna Moncrieff¹

Affiliations

¹ Division of Psychiatry, University College London, London, UK.
² Health Services Research & Management, City University, London, UK.
³ Research & Development Department, North East London NHS Foundation Trust, London, UK.
⁴ Service User and Independent Peer Researcher, UK.
⁵ Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK.
⁶ East London NHS Foundation Trust, Newham Centre for Mental Health, London, UK.
⁷ NIHR Mental Health Policy Research Unit, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Abstract

Background: Antipsychotics are a core treatment for psychosis, but the evidence for gradual dose reductions guided by clinicians is under-developed. The RADAR randomised controlled trial (RCT) compared antipsychotic reduction and possible discontinuation with maintenance treatment for people with recurrent psychotic disorders. The current study explored participants' experiences of antipsychotic reduction or discontinuation within this trial.

Methods: This qualitative study was embedded within the RADAR RCT (April 2017-March 2022) that recruited 253 participants from specialist community mental health services in 19 public healthcare localities in England. Participants were adults with recurrent non affective psychosis who were taking antipsychotic medication. Semi-structured interviews, lasting 30-90 min, were conducted after the trial final 24-month follow-up with 26 people who reduced and/or discontinued antipsychotics within the trial, sampled purposively for diversity in sociodemographic characteristics, trial variables, and pre-trial medication and clinical factors. Data were analysed using thematic analysis and findings are reported qualitatively.

Findings: Most participants reported reduced adverse effects of antipsychotics with dose reductions, primarily in mental clouding, emotional blunting and sedation, and some positive impacts on social functioning and sense of self. Over half experienced deteriorations in mental health, including psychotic symptoms and intolerable levels of emotional intensity. Nine had a psychotic relapse. The trial context in which medication reduction was explicitly part of clinical care provided various learning opportunities. Some participants were highly engaged with reduction processes, and despite difficulties including relapses, developed novel perspectives on medication, dose optimisation, and how to manage their mental health. Others were more ambivalent about reduction or experienced less overall impact.

Interpretation: Experiences of antipsychotic reductions over two years were dynamic and diverse, shaped by variations in dose reduction profiles, reduction effects, personal motivation and engagement levels, and relationships with prescribers. There are relapse risks and challenges, but some people experience medication reduction done with clinical guidance as empowering. Clinicians can use findings to inform and work flexibly with service users to establish optimal antipsychotic doses.

Funding: National Institute for Health Research.

Keywords: Antipsychotics; Experiences; Medication optimisation; Mental health; Psychosis; Qualitative.