Small steps for big impact in treatment of schizophrenia

Functional recovery is an important outcome for schizophrenia treatment. Goals should be personalized and optimized to each patient and can include:^1,2

• reducing or eliminating and controlling symptoms
• monitoring for adverse events
• preventing relapse
• maximizing quality of life and adaptive functioning
• enabling and maintaining recovery
• helping patients to achieve their own life goals

Step 1: Identifying psychosis early promotes functional and clinical remission

Functional remission is closely coupled with clinical remission, particularly early in schizophrenia. In a real-world setting analysis of 220 patients who achieved functional remission, there was a significant association with clinical remission (odds ratio [OR] 14.74; p < 0.0001). What’s more, the relationship was strongest in patients with duration of psychosis under 5 years (n = 80; OR 23.73; p < 0.0001).³

Early detection of psychosis leads to higher recovery rates

This underlines the importance of identifying psychosis early, which was investigated in the 10-year follow-up of the Treatment and Intervention in Psychosis Study (TIPS). Significantly higher proportions of patients who had early detection of psychosis had recovered (p = 0.017) or were in full-time work (p = 0.007).⁴

Step 2: Early intervention improves outcomes

Simply identifying psychosis earlier is not enough; it must also be treated earlier. When the duration of untreated psychosis (DUP) was less than 1 year, significantly more patients, in an Italian study, showed a ‘favorable’ clinical course than those with a DUP of more than 1 year (p = 0.049).⁵

Similarly, a 12-month follow-up from the Northwick Park Study of First Episodes showed rates of relapse were halved if the duration of untreated illness (DUI) was less than 44 days, compared with DUI of more than 365 days (p = 0.004).⁶

Early intervention was better than treatment-as-usual in all meta-analyzable outcomes

Early intervention was better than treatment-as-usual in all meta-analyzable outcomes in a meta-analysis of 10 studies totaling 2176 patients. This included global functioning (p = 0.001), general symptom severity (p = 0.001), involvement at school or work (p =0.01), and risk of relapse (p = 0.01).⁷

Step 3: Long-acting injectables reduce hospitalizations

Only half of patients in one study took their medication for at least a month after first hospitalization

Even if the clinician identifies psychosis early and prescribes medications, it counts for nothing if the patient does not take them. In a study of 2588 patients at their first hospitalization in Finland, 54.3% of patients did not collect a prescribed antipsychotic within 30 days of discharge, or used the medication for less than 30 days.⁸

How can clinicians try to improve treatment adherence? One option is to consider a long-acting injectable (LAI) antipsychotic. A cluster randomized study, in the US, tested whether LAIs delayed hospitalization in early-phase schizophrenia compared with clinicians’ choice in a real-world setting.⁹

In a study, long-acting injectable improved adherence and delayed time to hospitalization

The study showed there was a 44% decrease in incidence rate of first hospitalization after treatment with an LAI compared with clinician’s choice.⁹ The number-needed-to-treat with the LAI to prevent one additional hospitalization was 7 patients.⁹

The benefits of LAIs hold across studies. According to a meta-analysis of 42 studies, patients treated with LAIs had a significantly lower hospitalization rate than patients receiving oral antipsychotics (p < 0.001), despite having more severe or chronic illness (p = 0.01). Risk of discontinuation from any cause was also significantly lower with LAIs (p = 0.001).¹⁰

Educational financial support for this Satellite symposium was provided by Otsuka Pharmaceutical Europe Ltd and H. Lundbeck A/S.