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Abstract
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Joanna Moncrieff and colleagues' Article on the RADAR trial, which compared the effect of slow dose reductions of antipsychotic medication to maintenance treatment in people with schizophrenia, reported that participants in the experimental arm of the trial had an increased risk of severe relapse compared with participants in the maintenance arm. This finding can easily be used as an argument against the practice of tapering antipsychotic medication. After all, who would choose to double their risk for an adverse outcome? When viewing the results through the lens of recovery-oriented mental health care, however, a different perspective emerges. Central to contemporary recovery-oriented mental health care is an emphasis on individual empowerment and the right to choose. Willingness to accept risk is an inherently individual preference and value, thereby allowing evidence-based practice to accommodate a spectrum of diverse decisions. Within this framework, inherent risks are acknowledged and described as a human right, the dignity of risk, whereas the elimination of risk can be seen as dehumanising.
We therefore suggest that the clinical implications of the RADAR trial are to inform people that the only identified consequence of an antipsychotic dose reduction after a 2-year period is an increase of relapse (32 [25%] of 126 participants) compared with maintenance treatment (17 [13%] of 127). It is just as important to inform people that the majority of participants (94 [75%] of 126) did not have a serious relapse. The median dose reduction at 24 months was 33% in the reduction group (compared with zero in the maintenance group) and, at some point during the 2 years, 34 (27%) of 126 participants in the reduction group stopped their medication completely. This trial offers valuable information by suggesting that, although antipsychotic dose reduction elevates the risk of relapse, there appear to be no irreversible consequences from dose reduction, including extended hospitalisations. This absence of notable changes in adverse effects is intriguing. It could stem from the potentially short follow-up period or the possibility that adverse effects are permanent or not strictly dose dependent. Indeed, if metabolic adverse effects prove to be irreversible, this information should be deemed mandatory for clinicians to share with patients when initiating medication.
The qualitative analysis of the RADAR trial shows a diverse spectrum of responses to dose reduction. Whereas some participants experienced a return to a more fulfilling life, others endured negative experiences. These variations in experiences challenge the merits of a narrow focus on nomothetic research. Moreover, the absence of a discernible effect on participants' social functioning might conceal individuals who experienced substantial improvements in functioning following a reduction in adverse effects, juxtaposed with others who encountered difficulties after a severe relapse. Consequently, whether dose reductions failed to enhance social functioning for participants who did not experience a relapse is inconclusive.
Language: en |