Outpatient Psychiatrists Weigh Relapse Risk Against Patient Wishes When Deprescribing Antipsychotics

Outpatient psychiatrists rarely treat the decision to reduce or stop antipsychotic medication as a simple clinical calculation. According to a new qualitative study published in Community Mental Health Journal, their reasoning is shaped by competing forces: how they conceptualize psychosis and its course, how they weigh relapse risk against side effects and quality of life, and how much they trust the therapeutic relationship they have built with a given patient. The study, led by Guillermo Ruiz-Pérez and colleagues at Brandenburg Medical School, explored how psychiatrists working in outpatient settings in Germany navigate these decisions under conditions of persistent clinical uncertainty.

The research team recruited participants from the register of statutory health insurance physicians in the German states of Berlin and Brandenburg. Between May 31 and September 30, 2023, they contacted 193 outpatient psychiatrists; ten agreed to individual semi-structured interviews lasting between 50 and 90 minutes. A focus group with five additional psychiatrists working in outpatient departments of regional psychiatric hospitals was later convened to complement the interviews and discuss preliminary findings. All interviews and the focus group were conducted online, audio-recorded, and transcribed verbatim. Data collection ran from June 2023 to March 2024.

The researchers analyzed the material using reflexive thematic analysis, a method in which researchers’ own perspectives are treated as integral to knowledge production rather than as biases to be eliminated. Three researchers independently familiarized themselves with the transcripts, coded the data using MAXQDA, and generated initial themes, meeting regularly to discuss interpretations and question assumptions. The analysis was situated within an agential realist framework, meaning that psychiatric categories themselves were understood as taking shape through the interaction of diagnostic classification, treatment practices, and clinicians’ attitudes rather than as pre-existing facts waiting to be discovered. Transcripts were in German and translated into English by bilingual team members, with selected quotes back-translated to check accuracy.

Two interrelated thematic areas emerged from the analysis. The first concerns how psychiatrists conceptualize psychosis and its treatment; the second captures how they experience and manage uncertainty around risk, responsibility, and the conditions under which deprescribing seems feasible. Together, these themes portray deprescribing as a context-dependent and often ambivalent process rather than one governed by fixed criteria.

Within the first theme, several psychiatrists described the long-term consequences they associated with recurrent psychotic episodes, including cognitive decline and persistent social difficulties. These expectations frequently served as part of the clinical rationale for maintaining antipsychotic treatment over time. One psychiatrist stated: “With every psychotic episode, cognitive impairments may become more severe. The negative symptomatology tends to be reinforced. In cases of schizophrenia or schizoaffective disorder, patients often remain in long-term treatment.” Relapse was thus positioned as both a clinically undesirable event requiring renewed intervention and a process potentially associated with cumulative deterioration, making it a central barrier to deprescribing.

Participants often distinguished between transient psychotic episodes and recurrent or chronic conditions, the latter typically associated with a diagnosis of schizophrenia. This distinction directly informed whether they pursued dose reduction or continued treatment. “If someone has a first psychotic episode, we try to reduce within the first six months. But if it turns out to be a Schizophrenia, then we increase the dose again,” one psychiatrist explained. Another stated: “In schizophrenia, you should continue antipsychotics, at least at a low dose. Without medication, the relapse risk quickly approaches 100%.” A diagnosis of schizophrenia was commonly associated with a chronic understanding of the disorder and a reduced likelihood of considering deprescribing, while most psychiatrists described antipsychotics as primarily targeting symptoms rather than underlying causes.

Illness insight emerged as another key factor. Many participants identified the presence of insight as an important condition for medication reduction and linked its absence to higher relapse risk, though the meaning of the term varied: some referred to patients’ ability to recognize early warning signs, while others tied it to accepting the diagnosis and the perceived need for ongoing treatment. Notably, when this view was presented in the focus group, two participants challenged the equation of non-adherence with limited insight, calling it too reductive and arguing that a wish to stop, particularly when driven by side effects, should carry weight in its own right. This internal disagreement illustrates how even core clinical concepts remain contested within the profession itself.

The second theme revealed a deeper layer of ambivalence. Several psychiatrists described a sense of unease when supporting deprescribing, particularly after patients had previously relapsed following dose reduction. “I can’t stop anyone from doing what they want. If they want to reduce or stop, they should. But personally… I feel uneasy. You somehow already expect the outcome,” one psychiatrist said. In the focus group, some participants articulated concerns about being blamed by colleagues, relatives, or the legal system if a patient relapsed after discontinuation. One described continuing to prescribe even while suspecting non-adherence: “Sometimes I think: ‘I don’t know if he’s taking it, but I’ll keep prescribing. Then I’m not responsible if something happens.'” Yet the discussion also qualified these concerns; the participant who raised the fear of blame called continued prescribing to avoid blame “the other extreme” and argued for talking openly about this fear, while others distinguished between personal guilt, which could be eased by sharing decisions, and legal liability, which functioned as a separate source of insecurity.

Trust and the therapeutic alliance emerged as decisive conditions. Psychiatrists described feeling more able to support dose reduction when a stable and reciprocal relationship had been established. “The longer I know the patient and the stronger the basis of trust—meaning not only that I trust them, but that they also trust me—the safer I feel … in the context of reduction or discontinuation,” one participant explained. Conversely, trust appeared fragile and was often assessed indirectly through patients’ behaviour: reluctance to have blood levels checked was read as a potential sign of non-adherence, and a request to switch from a long-acting injectable to oral medication was interpreted by one psychiatrist as “often the beginning of the end.” In some high-risk scenarios, such as after severe psychotic episodes involving aggressive behaviour, deprescribing was not rejected in principle but postponed until a sustained period of stability had been achieved. Even then, participants emphasized that refusing to support a decision did not mean withdrawing care; one described staying in contact and continuing treatment even when patients stopped medication against medical advice, comparing stopping antipsychotics to “riding without reins: it may work, but it feels too unstable and insecure.”

The authors caution that the study reflects the perspectives of a small, self-selected group of psychiatrists in Berlin and Brandenburg, ten of 193 contacted, and that those with a particular interest in or more open stance toward deprescribing may have been more likely to participate. The findings are based on self-reported accounts of practice, which may differ from actual prescribing behaviour, and are not intended to be statistically generalizable. The research team also approached the topic from a position more sceptical toward common long-term antipsychotic treatment practices, which they treated as a starting premise to be reflected on rather than as a conclusion. Even so, the authors note that while they consider antipsychotic deprescribing may be underused in routine care, the evidence on who benefits remains incomplete, and their data do not allow conclusions about its merits. What the study does show is how psychiatrists’ reasoning and the conditions in which they work can make deprescribing more or less thinkable, and how making ambivalence explicit within the therapeutic relationship may support more open and collaborative decision-making between clinicians and the people they treat.

Subject of Research: Outpatient psychiatrists' perspectives on antipsychotic deprescribing

Article Title: Navigating Uncertainty: Outpatient Psychiatrists’ Perspectives on Antipsychotic Deprescribing

Article References: Ruiz-Pérez, G., Ulrich, N., Bettin, J., Lippert, J., Beeker, T., & von Peter, S. (2026). Navigating Uncertainty: Outpatient Psychiatrists’ Perspectives on Antipsychotic Deprescribing. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01745-z

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01745-z

Keywords: antipsychotics, deprescribing, psychosis, schizophrenia, relapse, qualitative research, shared decision-making, outpatient psychiatry, therapeutic alliance, medication tapering, clinical uncertainty, Navigating