Relapse in schizophrenia contributes to a downward spiral in disease progression. The likelihood of relapse is linked to discontinuation of treatment, which is itself linked to non-adherence. At the ECNP 2021 hybrid meeting, Professor Leslie Citrome of the New York Medical College in Valhalla, NY, USA discussed the role of long-acting therapies in tackling this challenging problem.
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 prevented5
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
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".
There is no reliable way of predicting which patients will relapse4
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.
Non-adherence should be considered as an alternative explanation to lack of efficacy or treatment resistance for treatment failure
"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%12
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 therapy15
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.
ECNP : European College of Neuropsychopharmacology
NY : New York
USA : United States of America
LAT : Long-Acting Therapy
EMEA: Europe Middle East Africa
BE-NOTPR-0119, approval date : 01/2022
