Title Page

A Call for a Paradigm Shift in Schizophrenia Treatment: Reassessing Long Term Antipsychotic Use and the Evidence for Psychosocial Interventions

Walter Keim
Støleveien 180
N-4887 Grimstad
Norway

Correspondence: Walter Keim Email: walter.keim@gmail.com

Cognitive Behavioral Therapy (CBT) was significantly superior to treatment as usual (TAU) for the outcome “overall symptoms”, “quality of life” and “functioning” WHO 2023 (mhGAP) guideline

Abstract

Long term antipsychotic treatment shows diminishing benefits, weak evidence for first episode psychosis, and substantial confounding from withdrawal effects. Psychosocial interventions—particularly Cognitive Behavioral Therapy and Open Dialogue—demonstrate superior functional and recovery outcomes. Current evidence supports shifting from lifelong antipsychotic maintenance toward recovery oriented, medication free or reduced medication approaches.

Main Text

International concern is growing regarding the dominance of the biomedical model in mental health care. The United Nations Special Rapporteur on the right to health has argued that global mental health systems rely excessively on psychotropic medication and insufficiently on psychosocial interventions¹. This critique aligns with emerging evidence questioning the long term effectiveness of antipsychotics and highlighting the benefits of psychosocial approaches²,³.

Figure 1: Time-dependent effect of antipsychotic discontinuation

Antipsychotics reduce relapse rates from 65% to 27% within one year⁴. However, this benefit is strongly time dependent, with meta analytic evidence showing substantial decline after two years⁵,⁶. Long term functional outcomes may even favor discontinuation: a four year randomized controlled trial reported better functioning three years after discontinuation compared to maintenance therapy⁷.

No placebo controlled trials include antipsychotic naïve participants, limiting the validity of conclusions about efficacy in first episode psychosis⁹. Systematic reviews highlight that withdrawal effects in placebo groups compromise the interpretability of existing trials¹⁰. Despite this, antipsychotic prescribing remains nearly universal in some countries, with rates exceeding 97% in first episode psychosis¹¹.

Across sixty years of placebo controlled trials, only 9% of patients achieve a “good response” attributable to antipsychotics¹². The majority do not experience clinically meaningful improvement, raising questions about the centrality of antipsychotics in acute care.




Figure 2: Good acute symptom reduction

Systematic reviews find no robust evidence supporting long term antipsychotic therapy¹³. The CATIE trial, involving 1,124 participants, reported a 72% discontinuation rate, underscoring tolerability and effectiveness challenges²⁰. These findings suggest that long term pharmacotherapy may not align with patient experience or long term recovery trajectories.

Psychosocial interventions—including Cognitive Behavioral Therapy, supportive psychotherapy, and Open Dialogue—demonstrate superior outcomes in symptoms, functioning, and quality of life²,see WHO 2023 (mhGAP) guideline3, and Ranjan, R. et al. 2025¹⁴. Long term observational data from Open Dialogue show substantially lower medication use, reduced disability, and fewer readmissions¹⁵.


Figure 3: Open dialogue recovery rates

Despite strong evidence, these interventions remain underutilized due to systemic and cultural barriers¹⁶,¹⁷.

Some authors describe medication free approaches as ideological²¹. However, this framing assumes that antipsychotics are both effective and tolerable long term—conditions not supported by current evidence. A rational, evidence based approach requires reconsidering the default of lifelong medication and expanding access to psychosocial interventions.

The cumulative evidence challenges the assumption that lifelong antipsychotic treatment is necessary or beneficial for most individuals with schizophrenia. Psychosocial interventions demonstrate superior long term outcomes and align with patient preferences¹⁸,¹⁹. A recovery oriented paradigm emphasizing medication free or reduced medication approaches is warranted and consistent with international calls for reform.

References

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  2. Bighelli, I. et al. Cognitive behavioural therapy for schizophrenia: A systematic review and meta-analysis. Psychol. Med. 48, 1–12 (2018).

  3. World Health Organization. mhGAP Intervention Guide, Version 3.0. WHO (2023).

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Data Availability

No new data were generated for this manuscript.

Competing Interests

The author declares no competing interests.

Acknowledgements

None.