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Relapse Prevention in First-Episode Schizophrenia—Maintenance vs Intermittent Drug Treatment With Prodrome-Based Early Intervention: Results of a Randomized Controlled Trial Within the German Research Network on Schizophrenia

J Clin Psychiatry 2011;72(2):205-218
10.4088/JCP.09m05459yel

Objective: After acute treatment of the first illness episode in schizophrenia, antipsychotic maintenance treatment is recommended for at least 1 year. Evidence for the optimal subsequent treatment is still scarce. Targeted intermittent treatment was found to be less effective than continuous treatment at preventing relapse in multiple episode patients; however, a post hoc analysis of our own data from a previous study suggested comparable efficacy of the 2 treatment approaches in first-episode patients. The current study was therefore designed to compare prospectively the relapse preventive efficacy of further maintenance treatment and targeted intermittent treatment in patients with ICD-10–diagnosed first-episode schizophrenia.

Method: A randomized controlled trial was conducted within the German Research Network on Schizophrenia. Entry screening took place between November 2000 and May 2004. After 1 year of antipsychotic maintenance treatment, stable first-episode patients were randomly assigned to 12 months of further maintenance treatment or stepwise drug discontinuation and targeted intermittent treatment. In case of prodromal symptoms of an impending relapse, patients in both groups received early drug intervention, guided by a decision algorithm. The primary outcome measure was relapse (increase in the Positive and Negative Syndrome Scale positive score > 10, Clinical Global Impressions-Change score 6, and decrease in Global Assessment of Functioning score > 20 between 2 visits).

Results: Of 96 first-episode patients, only 44 were eligible for the assigned treatment (maintenance treatment, n = 23; intermittent treatment, n = 21). The rates of relapse (19% vs 0%; P = .04) and deterioration (up to 57% vs 4%; P < .001) were significantly higher in the intermittent treatment group than in the maintenance treatment group, but quality-of-life scores were comparable. Intermittent treatment patients received a significantly lower amount of antipsychotics (in haloperidol equivalents; P < .001) and tended to show fewer side effects, particularly extrapyramidal side effects.

Conclusions: Maintenance treatment is more effective than targeted intermittent treatment in preventing relapse, even in stable first-episode patients after 1 year of maintenance treatment, and should be the preferred treatment option. However, about 50% of patients remain stable at a significantly lower drug dose and show fewer side effects, and a substantial proportion refuse maintenance treatment. Alternative long-term treatment strategies, including targeted intermittent treatment, should therefore be provided in individual cases.

Trial Registration: clinicaltrials.gov Identifier: NCT00159120

J Clin Psychiatry

Submitted: June 15, 2009; accepted September 2, 2009.

Online ahead of print: June 29, 2010 (doi:10.4088/JCP.09m05459yel).

Corresponding author: Prof Dr Wolfgang Gaebel, Department of Psychiatry and Psychotherapy, Heinrich-Heine-University, Düsseldorf, Rhineland State Clinics Düsseldorf, Bergische Landstraße 2, D-40629 Düsseldorf, Germany (wolfgang.gaebel@uni-duesseldorf.de).