Objectives. - Antipsychotic medication compliance is low. In the 1980s, studies have shown the value and limitations of alternative methods to continuous standard antipsychotic treatment as intermittent medication or low doses. However, these alternatives were largely abandoned because of their controversial efficacy. Having only one option for maintenance treatment limits treatment choices and constrains therapist's attitude toward maintenance medication at the dosage, which was necessary in the acute phase. This may cause symmetrical relationships with patients, and limits shared decision-making, working alliance and patients empowerment to manage medication. The purpose of this article is to discuss the search for a minimal dosage as a psychiatric and psychotherapeutic intervention to improve insight, treatment adherence and therapeutic alliance and to promote recovery, self-management of health, while reducing side effects and avoiding the negative consequences of relapse. Material and methods. - Development of intervention was based on a literature review focused on shared decision-making, relapse prevention and alternatives to maintenance antipsychotic medication. A clinical vignette illustrates the intervention. Results. - The recovery process needs patient's hope and taking his/her own responsibilities over the management of disease. This is not possible into a compliance paradigm that implies obedience to medical orders. Working alliance, which is one of the best predictors of outcome in psychotherapy, must also become a goal in psychiatric treatment. Moreover, without treatment choices, there is no room for shared decision-making for both patient and therapist. There is thus a need to shift paradigm in order to open choices for antipsychotic treatment beyond continuous maintenance at standard dosage. A new paradigm may be based on several rational arguments. First, a different conception of relapse is necessary. Linear vision of recovery does not match the experience of individuals: knowledge and mastery of disorders often go through the experience of relapse. While relapses may indeed have harmful consequences when they lead the person into a vicious circle of failure, trauma and rejection of treatment, a well-controlled relapse before a full psychotic episode may be an opportunity to know more about the early signs and management of the disorder in a virtuous circle. Second, recommendations of maintenance treatment for several years are based RCTs, which are limited by on short-term follow-up and high rates of discontinuation due to both efficacy and tolerability problems. Third, several studies showed that patients receiving half standard dosage (about 300 mg EQ CPZ) had no more relapse, less side effects, and better social outcomes. Forth, even if maintenance treatment is the best way to prevent relapse for most individuals, the burden of this treatment remains high for individuals. There is therefore a need to detect those who could remain stable with low dosage, very low prophylactic dosage, intermittent treatment or without treatment. A recent meta-analysis shows that relapse is 2.5 times more frequent in the intermittent treatment with respect to continuous treatment. The discontinuous treatment may also cause sensitization and increase the risk of tardive dyskinesia. These observations led in general not to propose alternatives to continuous treatment in clinical recommendations. However, intermittent treatment remains significantly more effective than placebo, with three times fewer relapses at medium-term. The population of people diagnosed as having schizophrenia is heterogeneous and in some studies, 20%40% of patients could benefit from a full stop of medication without relapse. In early psychosis, intermittent treatment can detect 20% of patients who can stop the antipsychotic treatment without relapse. Even for those who relapse, the process could have a long-term positive effect on social functioning. Patient adherence to treatment was also higher during intermittent therapy, and the cumulative dose of antipsychotic lower. At last, neuroscience issues such as aberrant salience and dopamine D(2) receptor occupancy give a biological theoretical background to the search of an optimal dosage of antipsychotics. Finally, the therapeutic relationship should go beyond mere prescription of drug, when some patients and therapists confuse withdrawal of antipsychotic medication with discontinuation of treatment. On the contrary, in view of the search of a minimal dosage, the desire to stop antipsychotic treatment is rather a psychotherapeutic opportunity to develop insight, the ability to identify early signs relapse and to enhance working alliance in a shared decision-making process. Conclusions. - The search for a minimal dosage of antipsychotics in psychosis remains controversial but feasible, scientifically sound and especially recommended for first-episode psychosis. It assumes that the doses needed for prevention of relapse are lower than in the treatment of an acute episode. Process should be considered with caution and at a slow pace, particularly when the desired dosage reaches 300 mg CPZ EQ or leads to a complete interruption of treatment. The counter-indications include non-stabilized symptoms, dangerousness, a history of severe social consequences or a lack of cooperation with the patient and relatives. The potential consequences of relapse must be carefully examined with the person and family. A short delay between the early signs and full psychotic episode is a relative contraindication, especially if previous episodes have significant risks for the person or to others or had serious social consequences. Further studies should determine more precisely who could benefit from such an approach beyond first psychotic episode, in order to offer other choices to individuals than stopping medication against their therapist's advice. (C) 2017 Elsevier Masson SAS. All right reserved.
