Stopping an antipsychotic

The advice in this topic is intended to support the practical implementation of the antipsychotic recommendations for adults and young people with bipolar disorder or psychotic disorders. For advice on stopping an antipsychotic used for behavioural and psychological symptoms of dementia, see here.

Ideally, stop antipsychotic therapy in collaboration with the patient’s psychiatrist, mental health team or a practitioner experienced in stopping antipsychotics. Most patients value a trial of stopping antipsychotic therapy and may do so without consulting their treatment team. When considering stopping antipsychotic therapy for a psychotic disorder, discuss the significant potential for relapse with the patient; most people who experience a first episode of psychosis experience a relapse after stopping treatment.

Avoid abruptly stopping an antipsychotic because this increases the risk of adverse drug withdrawal effects and rebound psychosis, which is characterised by rapid symptom onset, pronounced positive symptoms, agitation and relative treatment resistance. However, it may be necessary to immediately stop an antipsychotic if a serious adverse effect (eg neuroleptic malignant syndrome) occurs.

Plan antipsychotic discontinuation with the patient and, if the patient consents, their family, carers or significant others. To facilitate stopping an antipsychotic:

treat problem substance use before reducing antipsychotic dose
avoid stopping during a stressful period (eg exams, significant interpersonal stress, changes in employment)
create a management plan that includes descriptions of
- the dosage reduction schedule
- approach to reviewing and monitoring the patient
- role of each member of the treatment team (eg case manager, psychiatrist, general practitioner) and the patient’s family, carers or significant others
- psychosocial interventions; see here for psychoses including schizophrenia or here for bipolar disorder
for an oral antipsychotic, gradually reduce the dose (over at least 3 months for schizophrenia)
for a long-acting injectable antipsychotic, the approach will depend on the antipsychotic pharmacokinetics
monitor for signs and symptoms of relapse during withdrawal and for 12 months after stopping the antipsychotic, and educate the patient and their family, carers or significant others about characteristic early signs and symptoms of relapse—if relapse of a psychotic disorder occurs, see here
advise the patient about problems commonly seen with stopping the relevant antipsychotic and monitor for these problems.

Table 1. Common adverse effects of stopping or reducing the dose of an antipsychotic
[NB1] [NB2] [NB3]
Antipsychotic	Common adverse effects of stopping therapy or reducing the dose
amisulpride	increased risk of unplanned pregnancy due to decrease in blood prolactin concentration
aripiprazole	no specific adverse effects [NB2]
asenapine	no specific adverse effects [NB2]
brexpiprazole	no specific adverse effects [NB2]
cariprazine	no specific adverse effects [NB2]
chlorpromazine	agitation because of decreased sedation [NB4] insomnia [NB4] increased risk of unplanned pregnancy due to decrease in blood prolactin concentration movement disorders cholinergic rebound syndrome
clozapine [NB5]	agitation because of decreased sedation [NB4] insomnia [NB4] cholinergic rebound syndrome
flupentixol	increased risk of unplanned pregnancy due to decrease in blood prolactin concentration
haloperidol	increased risk of unplanned pregnancy due to decrease in blood prolactin concentration movement disorders
lurasidone	no specific adverse effects [NB2]
olanzapine	agitation because of decreased sedation [NB4] insomnia [NB4]
paliperidone	increased risk of unplanned pregnancy due to decrease in blood prolactin concentration
periciazine	agitation because of decreased sedation [NB4] insomnia [NB4] increased risk of unplanned pregnancy due to decrease in blood prolactin concentration cholinergic rebound syndrome
quetiapine	agitation because of decreased sedation [NB4] insomnia [NB4]
risperidone	increased risk of unplanned pregnancy due to decrease in blood prolactin concentration
ziprasidone	no specific adverse effects [NB2]
zuclopenthixol	agitation because of decreased sedation [NB4] insomnia [NB4] increased risk of unplanned pregnancy due to decrease in blood prolactin concentration
Note: NB1:The information in this table is based on a combination of reported adverse effect data and expert opinion; it is intended as a guide only and should be interpreted in the context of the patient (eg concurrent drugs, drug history, physical health, interindividual variation in pharmacokinetics). NB2: For all antipsychotics except clozapine, stopping therapy or reducing the dose can cause movement disorders; this table only includes this as an adverse effect for antipsychotics particularly likely to cause movement disorders. Movement disorders usually settle quickly when dose reduction is slowed. If this is ineffective, seek specialist advice; rarely, these movement disorders become chronic and the antipsychotic may require prolonged dose reduction or, in the case of psychotic disorders, a switch to clozapine. NB3: Rapidly stopping an antipsychotic, particularly clozapine, can cause rebound psychosis, which is characterised by rapid symptom onset, pronounced positive symptoms, agitation and relative treatment resistance. NB4: If this problem is encountered, reduce the rate of dose reduction. NB5: Clozapine must be stopped under psychiatrist supervision.