An Ethics Analysis of Antipsychotic Dose Reduction and Discontinuation: Principles for Supporting Recovery From Psychosis

Objective: To examine the evidence and practice of antipsychotic dose reduction from the lens of biomedical ethics (specifically principlism) to support evidence-based practice and patient choice and self-determination. Methods: An overview of the evidence from randomized controlled trials of antipsychotic dose reduction versus maintenance is presented. This is followed by a theoretical examination of the four key biomedical ethical principles of autonomy, nonmaleficence, beneficence, and justice and how they apply in the case of antipsychotic dose reduction. Results: Existing clinical trial research is dominated by relapse as the primary outcome, with dose reduction associated with a higher risk of relapse than maintenance. Few studies have measured other patient-centered outcomes but have shown preliminary evidence for superior cognitive functioning, lower negative symptoms, and better functioning following dose reduction. Respect for autonomy is a cornerstone of psychiatric rehabilitation, and this includes the right of people to choose to reduce or discontinue antipsychotic medication. Reduced capacity for treatment decision making can be supported. Autonomy and appraisal of nonmaleficence and beneficence associated with dose reduction can be facilitated through shared or supported decision making. Clinicians should continue to strive for justice through the fair allocation of resources to support all people who request antipsychotic dose reduction. Conclusions and Implications for Practice: Clinicians have a responsibility to balance the four core ethical principles to the best of their ability when supporting a person in their recovery journey. Exploring, trialing, and supporting antipsychotic dose reduction may be part of this process if that is the patient's choice. Impact and Implications<br /> Autonomy and justice are upheld when people are supported to reduce or cease antipsychotic medication if that is their choice. Clinicians can balance the principles of nonmaleficence and beneficence (i.e., minimize harm and promote a person's welfare) by staying up-to-date with and sharing the evidence openly with patients, promoting supported or shared decision making, advanced statements, slow hyperbolic tapering, and providing additional monitoring and psychosocial support.