NU675 Unit 2 Antipsychotic Continuation Decision Example

Flattened but Well: A Continuation Decision Paper for a 22-Year-Old Bicycle Mechanic Who Wants to Stop His Antipsychotic Fourteen Months After a First Episode

[Student Name]

Purdue University Global

NU675: PMHNP Diagnosis and Management Across the Lifespan II

Unit 2 Continuation Decision Paper

[Instructor Name]

[Date]

The patient is composite; doses, dates and details are bracketed.

The Patient and His Request

Mr. [B.] is a [22]-year-old bicycle mechanic who had his first episode of psychosis [fourteen] months ago. Over [six] weeks he became convinced that his coworkers were sabotaging bikes to frame him, heard a voice commenting on his work and stopped sleeping. He was admitted for [16] days and treated with aripiprazole, now [15] mg daily. His positive symptoms resolved within [eight] weeks. He returned to work at [four] months and has had no psychotic symptoms for [eleven] months.

He now says the medication makes him feel "flat, like the color's turned down," and that he has gained [6] kg. He wants to stop. He has taken it regularly, confirmed by pharmacy refills, and has used no cannabis since his admission, confirmed by urine screens at two visits. His mother, who lives with him, is worried about relapse.

What Makes His Episode More or Less Serious

Features that raise concern: a hospitalization, a period of [six] weeks of untreated psychosis before admission, and paranoid ideas directed at his workplace, where a relapse would cost him his job. Features that are more reassuring: a rapid and complete response to medication, good premorbid function, no substance use now, stable work and housing, a supportive family, and good insight; he recognizes the voice as part of the illness. He has had no depressive or manic features, and the diagnosis at [six] months was schizophreniform disorder that has not yet met the duration for schizophrenia because he recovered quickly.

What the Evidence Says About Stopping

A systematic review of first-episode psychosis studies found that the risk of symptom recurrence after medication discontinuation was high, with most patients relapsing within a year or two of stopping (Zipursky et al., 2014). A 20-year Finnish nationwide cohort of patients with first-episode schizophrenia found that the risk of treatment failure or relapse after stopping antipsychotics did not decline over the first eight years, and that long-term antipsychotic use was associated with lower mortality (Tiihonen et al., 2018).

Against this, the Dutch trial by Wunderink and colleagues randomized patients in remission from a first episode to guided dose reduction and discontinuation or to maintenance treatment. In the short term, relapse was more common in the reduction group, but at seven years the reduction group had twice the rate of functional recovery, [40.4] percent against [17.6] percent (Wunderink et al., 2013). The authors called for further studies before the finding changes practice.

The evidence says stopping raises the risk of relapse in the next year or two, and one trial suggests a guided reduction may still leave people better off in the long run; both findings apply to him.

Weighing the Options With Him

Three options were discussed with Mr. [B.] and his mother.

1. Continue at [15] mg. Lowest short-term risk of relapse, but his side effects continue, and people who stop on their own, without a plan, often do so abruptly.

2. Stop now. Highest risk of relapse, and abrupt stopping of an antipsychotic can itself cause rebound symptoms.

3. Reduce gradually, with monitoring. A middle path: lower the dose by small steps over several months, watch for early warning signs, and stop only if he remains well, with an agreement to return to the previous dose at the first sign of relapse.

He and his mother chose option three. His reasons: he values his work and does not want a relapse, but he also wants to feel "like myself" and believes the side effects affect his work and relationships. His mother agreed on condition that she can call the clinic if she notices warning signs.

The Plan

1. Reduce aripiprazole from [15] mg to [10] mg for [eight] weeks, then to [5] mg for [eight] weeks, then review whether to stop.

2. Early warning signs, identified with him and his mother from the first episode: sleeping less than [five] hours, feeling that coworkers are talking about him, and withdrawing to his room. Any one of these triggers a call to the clinic within [48] hours and a return to the previous dose.

3. Monthly visits during the reduction, with a brief symptom rating and a check on sleep.

4. Continued abstinence from cannabis, since use would raise his risk sharply.

5. Weight and metabolic check at each dose step.

6. Coordinated specialty care team involvement for family education and supported employment.

His Mother's Concerns

His mother asked two questions. The first was whether the first episode might have been a one-time event caused by stress and lack of sleep. The answer given was that it is possible, since some people have a single episode, but that no test can tell in advance who will stay well, which is why the reduction is gradual and monitored. The second was what she should do if she noticed a warning sign and he disagreed. The plan answers this: she can call the clinic herself, and he agreed in writing that she may do so and that the team may speak with her about his early warning signs, though not about everything he discusses in his visits. She said this made the plan acceptable to her. Including her in this way also reflects the role families play in noticing early relapse, which patients themselves may be the last to recognize.

What the Decision Respects

The decision gives weight to his experience of side effects, which is a legitimate reason to adjust treatment, while keeping the risk of relapse visible and planned for. It avoids the worst outcome, an abrupt unplanned stop, which is what often happens when a patient's wish to stop is refused. It also treats the reduction as an experiment with a clear rule for ending it early, so neither he nor the team has to argue about whether a warning sign counts once it actually appears.

Limitations

The Wunderink trial was a single study in one country; its long-term finding has not been replicated widely, and later trials are under way. The Finnish cohort was observational, so people who stopped may have differed in ways that affected their outcomes. His own course may differ from the averages in either.

References

Tiihonen, J., Tanskanen, A., & Taipale, H. (2018). 20-year nationwide follow-up study on discontinuation of antipsychotic treatment in first-episode schizophrenia. American Journal of Psychiatry, 175(8), 765-773. https://doi.org/10.1176/appi.ajp.2018.17091001

Wunderink, L., Nieboer, R. M., Wiersma, D., Sytema, S., & Nienhuis, F. J. (2013). Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: Long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry, 70(9), 913-920. https://doi.org/10.1001/jamapsychiatry.2013.19

Zipursky, R. B., Menezes, N. M., & Streiner, D. L. (2014). Risk of symptom recurrence with medication discontinuation in first-episode psychosis: A systematic review. Schizophrenia Research, 152(2-3), 408-414. https://doi.org/10.1016/j.schres.2013.08.001