Principles of recovery and relapse prevention in psychoses including schizophrenia

Although most people who have a psychotic episode return to a productive life, this process is complex and multifaceted; antipsychotic therapy is an important component of recovery. Continuous therapy with the antipsychotic the patient best tolerates is also the most effective way to reduce relapse and prevent suicide. See Principles of treating psychoses including schizophrenia for the approach to facilitating recovery, preventing relapse and suicide, and improving quality of life and overall health.

The treatment advice in this topic applies to adults and young people; antipsychotic therapy for recovery and relapse prevention in children follows the same principles but should be guided by a child psychiatrist or an age-appropriate mental health service.

Note: Continue antipsychotic therapy for an adequate duration after a psychotic episode.

Continue antipsychotic therapy (with monitoring for adverse effects) for an adequate duration after a psychotic episode. For duration of antipsychotic therapy after a first episode of psychosis, see here. Longer-term treatment is required if relapse occurs—seek psychiatric advice.

Note: Do not use intermittent antipsychotic therapy (‘drug holidays’).

Do not use intermittent therapy (‘drug holidays’) during treatment, because restarting an antipsychotic early in relapse is not as effective as continuous therapy.

Most patients who recover from a first episode of psychosis experience a relapse. Relapse is usually associated with poor adherence or stopping antipsychotic therapy as part of the treatment plan—see Key questions to assess nonresponse to an antipsychotic for other contributors to relapse.

If a patient is poorly adherent to oral antipsychotic therapy, address this with psychosocial interventions and by monitoring for and addressing adverse effects—see also Adherence to psychotropics. If this is ineffective, switch to a long-acting injectable formulation to improve adherence¹. If the patient does not consent to a long-acting injectable antipsychotic and their poor adherence is associated with worsening symptoms, involuntary community treatment may be necessary².

Advantages and disadvantages of long-acting injectable antipsychotic formulations are detailed in Advantages and disadvantages of long-acting injectable antipsychotic formulations compared to oral antipsychotic formulations. Patients with multiple, severe relapses, comorbid problem substance use or cognitive impairment are most likely to benefit from a long-acting injectable formulation.

Table 1. Advantages and disadvantages of long-acting injectable antipsychotic formulations compared to oral antipsychotic formulations
Advantages	Disadvantages
improved adherence less frequent administration regular contact between the patient and their mental healthcare team; the team will be aware if the patient has not taken their antipsychotic reduced risk of overdose more predictable relationship between dosage and resultant blood concentration (if administered correctly) reduced variability in peak–trough blood concentrations	pain and irritation at injection site less flexible and slower dosage adjustment—depending on pharmacokinetics, take weeks to months to reach steady-state concentration, making treatment response difficult to assess during this time adverse effects can persist for a significant time, even after the antipsychotic has been stopped if given involuntarily, negative relationship with mental health team

If a patient is stabilised on and adherent to an oral antipsychotic, to minimise the risk of adverse effects, slowly reduce to the lowest effective dose; see Approach to reducing antipsychotic dose for a chronic severe psychiatric disorder for approach. Also offer the option of switching to a long-acting injectable formulation, but do not insist upon switching if the patient is tolerating their oral antipsychotic.

Figure 1. Approach to reducing antipsychotic dose for a chronic severe psychiatric disorder

Avoid reducing the antipsychotic dose during a period of stress (eg exams, relationship breakdown, change in employment).
Treat problem substance use before reducing the antipsychotic dose.
Optimise psychosocial interventions.
Create a management plan that describes the:
- target dose and planned frequency of dose reductions
- schedule for review and monitoring, including parameters to be monitored
- role of each member of the treatment team (eg case manager, psychiatrist, general practitioner) and significant others.
Monitor for early warning signs of relapse, and advise the patient and their significant others to be alert for these signs.
Advise the patient about problems commonly seen with reducing the dose of the relevant antipsychotic, and monitor for these adverse effects.

Up to 40% of patients with schizophrenia experience residual symptoms even when clinically stable and adherent with optimal antipsychotic therapy—see Treatment-resistant schizophrenia.

¹ Large population studies in patients with schizophrenia show that long-acting injectable antipsychotics are associated with lower rates of relapse than oral antipsychotics, with the exception of clozapine. Although this benefit was not seen in randomised controlled trials, people who were likely to be nonadherent were excluded from these trials.Return

² If involuntary treatment is required, it must be undertaken in accordance with relevant mental health legislation—see the Royal Australian and New Zealand College of Psychiatrists website.Return