Do long-acting injectable antipsychotics have a role in early-phase schizophrenia?

The need for early intervention

Management of the first psychotic episode has long-term implications, proposed Tara Niendam (University of California, USA). Duration of untreated psychosis, from first episode to accurate diagnosis, strongly predicts long-term outcome¹. ‘Early’ psychosis (first 5 years after onset of symptoms) is the critical period when treatment has its biggest impact².  Focus on maintaining functioning rather than recovering lost functioning.

Early psychosis is the critical period when treatment has its biggest impact

Reducing the risk of relapse

Potential courses of illness are heterogeneous, and early comprehensive treatment can reduce long-term disability³. Early functioning is the best predictor of later functioning. Give the patient the message that recovery is possible, and focus on the wider treatment goals and roles they wish to pursue, alongside controlling symptoms. Developing a ‘patient relapse prevention plan’ helps them recognize early signs of relapse and respond quickly and appropriately.

Unawareness of illness is an important feature of schizophrenia, said Robin Emsley (Stellenbosch University, Cape Town, South Africa). Insight often remains impaired despite a favorable treatment response⁴, and impacts on ability to be involved in treatment-making decisions.

Stopping medication is the most powerful predictor of relapse

Stopping medication is the most powerful predictor of relapse⁵. Even short periods of antipsychotic discontinuation can lead to relapse and the abrupt return of florid symptoms, often with few early warning signs⁶. Consequences of relapse can be severe, involving psychosocial⁷ and biological effects⁶. The latter include emergent refractoriness⁶, brain volume reduction⁸, and increased mortality⁹.

LAIs can be used to reduce relapse rates

Prof Emsley suggested LAIs should be used to reduce relapse rates. In a meta-analysis, LAIs were associated with a 64% lower risk of rehospitalization than oral medication¹⁰. How the physician presents the option of an LAI can greatly affect the likelihood of acceptance¹¹. Focusing on the treatment benefits for the patient, and not just the modality, is important. Incorporating motivational interviewing allows incorrect treatment beliefs to be challenged.

An LAI, in a clinical trial, significantly delayed the time to first hospitalization in individuals with early-phase schizophrenia, compared to standard care

LAIs are not widely used in the early-phase of schizophrenia, with reasons including overestimation of degree of adherence with oral medication and bias against injections¹². John Kane (Donald and Barbara Zucker School of Medicine, New York, USA) stressed that difficulty in adhering to chronic treatments is a normal human characteristic and should not be stigmatized. Many barriers to the use of LAIs can be overcome with education and training¹². A very recent clinical trial results showed that an LAI significantly delayed the time to first hospitalization in individuals with early-phase schizophrenia, compared to standard care¹³.

Benefits of early-intervention program

Charlotte Emborg Mafi (Aarhus University Hospital, Denmark) discussed the intensive early-intervention program for first episode psychosis introduced in Denmark, with an ‘assertive’ approach to optimizing patient engagement.  Teams have a low staff to patient ratio, allowing home visits and frequent contact. Total direct and indirect medical costs per patient were reduced with this approach, as well as increased adherence to treatment^14,15.

Educational financial support for this Satellite symposium was provided by Lundbeck.