Long-acting therapies could reduce schizophrenia relapse

When treating patients with schizophrenia, prevention of relapse is a high priority, as each relapse can lead to irreversible functional decline.¹ Indeed, many clinical guidelines for schizophrenia treatment include it as a key goal.^2-4

For every two patients with schizophrenia continuing treatment, one relapse event is prevented

Within 2 years of stopping medication, 75% of patients with schizophrenia relapse, compared with 25% of those who continue treatment. In other words, for every two patients continuing treatment, one relapse event is prevented.⁵ However, there is no reliable way of predicting which patients will relapse.⁴

There is no reliable way of predicting which patients will relapse

Untangling non-adherence from lack of response

Like many chronic medical conditions, schizophrenia shows high rates of treatment non-adherence, at around 30% to 60%.⁶ As Professor Citrome pointed out, non-adherence tends to be underestimated, and should be considered as an alternative explanation when treatment failure is attributed to lack of efficacy or treatment resistance.

Non-adherence should be considered as an alternative explanation to lack of efficacy or treatment resistance for treatment failure

There are many different risk factors for non-adherence, and it may be helpful to break them down into categories when assessing them in practice:⁷

• Patient-related, such as prior non-adherence and substance abuse
• Treatment-related, such as adverse events and lack of efficacy on the symptoms that matter to the patient
• Environment-related, such as lack of support or practical problems
• Community-related, such as stigma related to the illness or the medication.

If the non-adherence is because a patient will not take a medication, Professor Citrome suggested improving the patient’s perception of treatment through motivational interviewing. However, if the patient cannot take the medication, the clinician should help them to overcome these difficulties.

Long-acting therapies take the guesswork out of adherence

So, preventing relapse is therefore linked to improving treatment adherence. Recent guidance recommends using a long-acting therapy (LAT) antipsychotic if the patient prefers this form of treatment or if they have a history of poor adherence.⁸

Injectable LATs avoid first-pass metabolism and lead to predictable and stable concentrations in plasma.⁹ As well as the clinical advantages, LATs mean the patient does not need to remember to take their medication daily, and therefore avoids the potential loss of efficacy resulting from a missed oral dose.¹⁰ On top of this, many patients prefer LATs.¹¹

Long-acting therapies reduced hospital readmissions by up to 58%

A recent study collected real-world data from over 75000 patients hospitalized with schizophrenia over a 10-year period. Compared with oral medication, LATs reduced hospital readmissions by 29% overall, and up to 58% for patients who were repeatedly hospitalized.¹²

Perception matters

Many of the perceived barriers to uptake of LATs relate to patient attitudes.¹³ However, in a survey of 206 patients receiving LAT antipsychotics, 70% felt more supported due to the regular contact with a clinician.¹⁴

Better information changed the opinion of 96% of patients who initially declined long-acting therapy

Patients vary in their resistance to changes in medication. Communication is important, but a study of 10 community mental health clinics showed positive aspects of LATs were only focused on in 9% of discussions with patients. When more information on the benefits of LATs was given after the visit, 96% of patients who initially declined LATs stated they would be willing to try them.¹⁵

Clinicians can improve conversations with patients by using RULE¹⁶:

• Resist making too many suggestions
• Understand the patient’s motivation
• Listen with a patient-centered, empathic approach
• Empower the patient.

Educational financial support for this Satellite symposium was provided by Janssen Pharmaceutical Companies of Johnson & Johnson in EMEA.