Discussion
psychosocial stressors, psychosis
This is one of the few studies to test guided antipsychotic dose reduction in patients with remitted psychosis (Huhn et al., First, we could successfully manage to keep the relapse rates among patients conducting dose reduction not higher than that of 2 maintenance groups, while the other 4 ongoing dose reduction/discontinuation trials anticipating higher relapse rates as the payoff of medication discontinuation (Begemann et al., Second, a substantial proportion of GDR patients (39.2%) did not conduct successive dose reductions while being eligible for the next dose reduction for a variety of reasons. Since many of our patients had a history of relapse or hospitalization, they were likely to weigh the risk-to-benefit ratio more cautiously. This might be another key to keep the relapse rate of the GDR group not higher than the maintenance group. Respecting patient's autonomy, empowerment of patients and their principal caregivers to participate in shared decision-making could assure if they were ready for the next tapering attempt as to minimize the potential risk of relapse attributable to non-pharmacological factors, such as psychosocial stressors (Horowitz et al., Third, even though the tempo of dose reduction was carried out at such slow pacing, still, 1 out of 4 patients (6 relapses and 7 resuming baseline doses of 51 GDR patients) failed to reduce any antipsychotic dose. The relapse rate is comparable to that of a recent study on a similar yet smaller population (Huhn et al., Fourth, it is encouraging to find that a third of patients could successfully taper antipsychotic doses according to our proposed algorithm to reduce approximately 60% of their baseline doses, suggesting a substantial burden introduced by antipsychotics being lifted. Moreover, patients who could maintain stable under a GDR trial revealed improved clinical severity, personal social performance, and subjective well-being, implying that it is worthwhile to work patiently for desirable outcomes not at the expense of a higher risk of relapse. These patients can still take a comfortable pace in the future, decide if ready to conduct the next dose reduction under supervision, and someday might be able to reach their individual MED, which could be as low as ‘approximate to zero’ [(3/4)Still, there are several limitations to be addressed. First, our irregular dosing schedule might be inconvenient to some patients, and we have not ascertained medication adherence by testing plasma drug concentrations yet. Second, the difference in relapse rates between groups was small while our sample size was not big enough to support sophisticated analyses. Third, we recognized psychosocial stress as an important risk factor and the soundness of a supportive system as an essential protective factor (Bowtell et al., Echoing Leucht's (