Maintenance treatment for patients with a first psychotic episode

To provide an update of recent studies relevant for maintenance treatment with antipsychotic medication after a first psychotic episode (FEP).

Despite controversy derived from a follow-up analysis from an earlier study showing that attempted early discontinuation after remission was associated with improved long-term functioning, most other studies support better long-term outcome with continuous maintenance treatment after the first episode. However, the main question is not whether, but for how long maintenance treatment after FEP should be offered. Consistent evidence shows that withdrawal from antipsychotics increases the risk for a relapse or re-hospitalization. On the other hand, maintenance treatment is associated with the risk to develop burdensome antipsychotic-induced side-effects and one should keep in mind that around 20% of FEP will not have a second episode. In this regard, the decision for maintenance treatment for periods above some months must be the result of a comprehensive risk-benefit evaluation during a shared decision-making process.

There is no replicated evidence that prognosis can be improved by discontinuing antipsychotic medication after a FEP. There is a clear need for additional studies to develop single-subject outcome predictors and to identify long-term efficacy of maintenance treatment beyond relapse (e.g. recovery).