DART: A Daily Monitoring Framework for Distinguishing Withdrawal from Relapse During Antipsychotic Tapering

Abstract Background When symptoms re-emerge during antipsychotic dose reduction, standard practice typically interprets this as relapse and responds with dose reinstatement. This assumption is rarely testable: a single-timepoint assessment cannot distinguish genuine relapse from withdrawal—a time-limited response that resolves without intervention—or from unmasking of iatrogenic receptor upregulation, whether as the primary driver or superimposed on underlying illness (dopamine supersensitivity psychosis, DSP). These possibilities require fundamentally different responses, and misidentification carries consequences: dose reinstatement for unmasked supersensitivity treats the immediate presentation while potentially deepening the receptor changes driving it. The frequency of this misclassification is uncertain but may be clinically significant: when Fallon and colleagues (2012) systematically assessed treatment-compliant patients experiencing relapse, 39% met criteria for supersensitivity psychosis. Tapering methodologies and frameworks for identifying discontinuation syndromes exist and have shown promise—but their appropriate use depends on trajectory characterization that current practice cannot provide. A systematic review identified only five antipsychotic discontinuation studies with daily clinical assessment—the frequency necessary to detect short-lasting withdrawal symptoms. No published protocol links observed symptom trajectories to tapering decisions through daily monitoring. Methods From trajectory patterns observed during daily monitoring of occupancy-guided antipsychotic tapering, we derived DART (Daily Adaptive Response Tapering), a decision framework linking tapering progression to observed recovery trajectories. Results Daily monitoring detected withdrawal features invisible to standard assessment intervals: repeated oscillations between apparent recovery (0–1/10) and symptom re-emergence (10/10) extending 53 days, with a tertiary elevation at days 32–39 that resolved without intervention but would register as "relapse" at any single assessment timepoint. Withdrawal dyskinesia covaried temporally with psychotic symptoms, suggesting a common dopaminergic mechanism. Peak severity reached 10/10 during each of eight sequential reductions before amplitude narrowing emerged after months—consistent with receptor normalization timescales but detectable only through sustained daily monitoring. These features informed DART's core elements: confirmation holds, step-size calibration based on prior response, and trajectory-based criteria for distinguishing withdrawal from relapse. Conclusions Daily monitoring revealed withdrawal trajectory complexity that could be misclassified as relapse under standard assessment intervals. DART proposes a transferable, low-resource framework applicable across populations where standard assessment tools are less reliable, including those at elevated risk for supersensitivity. Whether multiphasic withdrawal patterns generalize, and whether DART could improve withdrawal-relapse distinction in practice and research, requires prospective evaluation.