The decision-making process regarding antipsychotic continuation or discontinuation following remission from first-episode psychosis (FEP) remains complex and underresearched. While discontinuation increases the risk of relapse, concerns over long-term side-effects such as metabolic disturbances and extrapyramidal symptoms also exist. Current guidelines recommend maintaining antipsychotics for 1–5 years, emphasising shared decision-making (SDM) between clinicians and patients.

This study aimed to explore the decision-making process and describe the factors influencing the decision to discontinue or continue antipsychotic treatment following remission from FEP, from the patients’ perspective.

A descriptive qualitative study was conducted with 12 individuals in remission from FEP who received care at early intervention services in Quebec, Canada. Data were collected through online semi-structured interviews and analysed thematically to identify key factors influencing treatment decisions.

The decision-making process was activated by treatment reflection triggers and shaped by various perceptions (of illness, treatment and stigma) and relationships (with friends, family and the clinical team), ultimately leading to decisions to either discontinue, continue (at standard or reduced dose) or remain ambivalent. This dynamic process was guided by participants’ motivators, such as well-being and societal contribution. Most participants felt that discontinuation discussions were not initiated by the clinical team.

The decision-making process is driven by motivators that were found to be linked to the concept of personal recovery. This study highlights the need for proactive, personalised discussions between clinicians and patients. Future research should focus on decision aids tailored to the FEP population to support SDM and improve treatment outcomes.

In patients with remitted psychosis, the dosage of antipsychotics can be lowered without increased risk of relapse. Whether dose tapering can lead to improved cognition is unclear. We compared changes in cognitive performance between patients undergoing dose tapering and those receiving a fixed maintenance dose.

A 2-year prospective trial of patients with stable schizophrenia-related psychotic disorders was conducted: one group received guided dose reduction (GDR) and one group received maintenance treatment. Cognitive function was assessed using the Wechsler Adult Intelligence Scale-Third Edition, Mandarin Chinese version, at baseline, 1, and 2 years. The relations between the ratio of reduced dose and the extent of cognitive improvement were examined by Spearman’s correlation coefficient. We also examined cognitive performance between aripiprazole (ARI) users and non-ARI users.

GDR patients exhibited significantly greater improvements in total intellectual quotient (IQ), particularly working memory, and information and arithmetic subtest scores, with no significant difference in relapse rates between groups. Statistically significant dose–response correlations were found between the degree of dose reduction and improvements in total IQ (n = 72, r = 0.242, p = 0.041), Working Memory Index (n = 72, r = 0.284, p = 0.016), and Arithmetic subtest (n = 72, r = 0.295, p = 0.012). There were no differences in cognitive changes between ARI users and non-users.

Lowering antipsychotic dosage may ameliorate patient performance in several cognitive domains. This finding is worthy of consideration while evaluating the risk-to-benefit ratio of tapering antipsychotics in patients with remitted psychosis.

Antipsychotic (AP) medication in individuals at clinical high risk for psychosis (CHR-P) is not routinely recommended by clinical guidelines but is commonly prescribed. Since little is known about the predictors of AP inception in CHR-P, we analyzed data from two observational cohorts.

To avoid baseline predictors being confounded by previous treatment, participants were selected for analysis from the 764 participants at CHR-P enrolled in NAPLS-2 and the 710 enrolled in NAPLS-3 by excluding those with lifetime histories of AP use. Baseline clinical variables available in both studies were employed as predictors of subsequent AP inception over the next 6 months in univariable and multivariable analyses.

Preliminary analyses indicated no important effects of sample. The final combined population included 79 AP inception participants and 580 participants who did not have AP inception. The AP medications most commonly prescribed were risperidone, aripiprazole, and quetiapine. Univariable analyses identified seven significant predictors of AP inception. The final logistic regression model including these variables was highly significant (χ2 = 36.53, df = 7, p = <0.001). Three variables (current major depression, fewer education years, and current benzodiazepine use) emerged as significant independent predictors of AP inception.

This study is the first to determine baseline characteristics that predict subsequent AP initiation in CHR-P. Some AP use in CHR-P appears to be intended as augmentation of antidepressant treatment for comorbid major depression. Some prescribers may not have detected the attenuated positive symptoms characteristic of CHR-P since their severity did not significantly predict AP inception.

Second-generation antipsychotics (SGAs) are moderately effective treatments for psychotic disorders but are associated with significant weight gain and metabolic complications. These contribute to a nearly 20-year reduction in life expectancy for individuals with enduring psychotic illness. Weight gain can also negatively impact adherence, increase relapse risk, and worsen psychosocial outcomes.

To highlight the mechanisms underlying antipsychotic-induced weight gain (AIWG), examine pharmacological strategies for its prevention and treatment, and argue for the early use of metformin.

This perspective article synthesises current evidence on the pathophysiology of AIWG and evaluates the role of metformin in mitigating these effects.

Weight gain can occur rapidly after initiating antipsychotic treatment, particularly in young people and those prescribed antipsychotics for non-psychotic indications. Presentation and response to interventions vary. Of all pharmacological strategies, metformin has the most robust evidence for both prevention and treatment of AIWG. It is a well-tolerated, low-cost antihyperglycaemic agent with an established safety profile. Metformin should be considered early in the course of antipsychotic treatment for all individuals, regardless of diagnosis, to prevent clinically significant weight gain and reduce long-term health risks. Early intervention may improve adherence, reduce relapse, and enhance overall quality of life.

The origins and treatment-target-related mechanisms of schizophrenia remain to be fully understood. Pharmacological and non-pharmacological treatments require expansion and improvements to meet peoples’ needs and goals. Nevertheless, antipsychotics are a cornerstone when managing schizophrenia, being essential for reducing symptom severity, preventing relapse, improving long-term functional outcomes, and reducing premature mortality risk.

This narrative review synthesizes key evidence on the efficacy and risks associated with antipsychotic medications. The concept of effect sizes is introduced, allowing to compare antipsychotics across trials with different rating instruments and across different conditions.

The available evidence in schizophrenia and comparison with medications used for medical conditions counters the sometimes-voiced criticism that antipsychotics “do not work.” Instead, for a substantial group of people with schizophrenia, positive psychotic symptoms and global psychopathology improve witha small-medium effect size of about 0.4 versus placebo. These results are comparable to median effect sizes across commonly used medications for somatic disorders. When patients with initial response are continued on antipsychotics, the effect size increases to 0.9 for relapse prevention, translating into a number needed to treat (NNT) of about 3 to prevent one more relapse versus no treatment. This NNT is 10–20 times higher than that for the prevention of poor outcomes in some common medical conditions.

Despite general efficacy and effectiveness of antipsychotics for schizophrenia, further development is needed regarding preventive interventions and medications with mechanisms other than postsynaptic dopamine receptor blockade, with broader efficacy for positive, negative, cognitive, suicidality, and/or reward dysregulation symptomatology, and the identification of illness mechanism/biomarker-targeting treatments to enhance treatment personalization.

Patients in forensic psychiatric care (FPC) are commonly treated with a wide range of psychotropic medications. There is, however, a lack of understanding regarding how pharmacological treatment and psychotropic polypharmacy are used throughout care.

This register-based cohort study included patients admitted to FPC in Sweden between 2009 and 2020. We estimated the prevalence of the use of major psychotropic medication, as well as psychotropic polypharmacy, at admission and discharge. We also examined the change in antipsychotic use after admission.

In total, 1962 patients were included. Antipsychotics were the most used psychotropic medication class, with 86.2% (95%CI: 84.5–87.8) of patients receiving at least one typical or atypical antipsychotic at admission. Changes in the antipsychotic regime were more common at the beginning of FPC, compared to later time points. Within the subgroup of patients discharged during the study period (n = 561), there was a reduction in the use of typical antipsychotics (admission: 34.9%; discharge: 26.6%) and hypnotics and sedatives (admission: 37.4%; discharge: 28.1%). Other major medication classes remained relatively stable. The prevalence of psychiatric polypharmacy at admission was 70.6% (95%CI: 68.5–72.7) and remained similar during care.

Our study documented a high prevalence of antipsychotic use and psychotropic polypharmacy through FPC. Further, a high level of off-label antipsychotic use and antipsychotic polypharmacy was observed. Stronger evidence regarding the effectiveness and safety of these treatment strategies is needed.

Clinical high risk for psychosis (CHR) is often managed with antipsychotic medications, but their effects on neurocognitive performance and clinical outcomes remain insufficiently explored. This study investigates the association between aripiprazole and olanzapine use and cognitive and clinical outcomes in CHR individuals, compared to those receiving no antipsychotic treatment.

A retrospective analysis was conducted on 127 participants from the Shanghai At Risk for Psychosis (SHARP) cohort, categorized into three groups: aripiprazole, olanzapine, and no antipsychotic treatment. Neurocognitive performance was evaluated using the MATRICS Consensus Cognitive Battery (MCCB), while clinical symptoms were assessed through the Structured Interview for Prodromal Syndromes (SIPS) at baseline, 8 weeks, and one year.

The non-medicated group demonstrated greater improvements in cognitive performance, clinical symptoms, and functional outcomes compared to the medicated groups. Among the antipsychotic groups, aripiprazole was associated with better visual learning outcomes than olanzapine. Improvements in neurocognition correlated significantly with clinical symptom relief and overall functional gains at follow-up assessments.

These findings suggest potential associations between antipsychotic use and cognitive outcomes in CHR populations while recognizing that observed differences may reflect baseline illness severity rather than medication effects alone. Aripiprazole may offer specific advantages over olanzapine, underscoring the importance of individualized risk-benefit evaluations in treatment planning. Randomized controlled trials are needed to establish causality.

Patients with psychosis face an elevated risk of cardiovascular mortality and are more likely to disengage from care. While antipsychotics are essential for treatment, they further increase this risk. Despite this, Ghana lacks a national policy for monitoring cardiovascular risk factors in individuals on antipsychotics.

To evaluate disengagement in care and weight changes among newly diagnosed psychotic patients at Accra Psychiatric Hospital, and to inform clinical practice.

A retrospective review of medical records was conducted for patients newly diagnosed with non-affective psychotic disorders between June 2022 and May 2023. Patients were reviewed for 6 months, with assessments at baseline, 3 months and 6 months. Outcomes included antipsychotic prescription patterns, dropout rates, cardiovascular disease monitoring and weight changes. Descriptive statistics, multinomial logistic regression and linear mixed-effects models were used for analysis.

The number of patients disengaged from care within the first month was 53.1%, and within 6 months 75.5%; 62.8% received olanzapine at baseline. Weight gain was exponential, with 40% experiencing clinically significant weight gain at 3 months, increasing to 58% at 6 months. Less than 50% of patients had their blood sugar and lipid profiles checked before starting antipsychotics. Higher baseline weight was associated with increased weight over time (β = 0.96, t = 80, P < 0.001, 95% CI 0.93, 0.98).

High disengagement rates, low cardiovascular disease monitoring and exponential weight gain were observed. Targeted interventions, robust monitoring protocols and further research are needed to improve patient outcomes.