Rethinking the role of long-acting atypical antipsychotics in the community setting

Abstract

Schizophrenia is a relapsing and evolving condition, which requires treatment continuity. Increasing evidence shows that antipsychotic discontinuation is associated with relapse in most patients, and that early interventions have a positive impact on long-term outcomes. Poor adherence to antipsychotics is a major factor in the treatment of schizophrenia and a relevant risk factor for relapse. Considerable effort has been made toward improving adherence, including the development of long-acting injectable (LAI) antipsychotics. LAIs have traditionally been reserved for patients with repeated nonadherence; currently, several misconceptions prevent their more widespread use. The recent introduction of LAI formulations of atypical antipsychotics and the encouraging results in terms of the reduction in relapse rates and avoidance of hospitalization warrant a reassessment of the role of LAIs in the management of schizophrenia. This paper presents the position of a panel of nine Italian schizophrenia experts on the use of novel LAI medications, with a focus on community-based services, the prevailing setting of schizophrenia treatment in Italy. The need to change the attitude toward LAIs--no longer a treatment of last resort, but a component of multimodal strategies leading patients to remission and rehabilitation--is emphasized. The paper also presents recommendations for LAI atypical antipsychotic use in the community setting.

The Use of Continuous Treatment Versus Placebo or Intermittent Treatment Strategies in Stabilized Patients with Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with First- and Second-Generation Antipsychotics

“…On the other hand, evidence is growing that early interventions have a positive impact on long-term outcomes, including a lower relapse/hospitalization risk and a higher probability of sustained remission [195]. Thus, taken together, evidence suggests that treatment discontinuation is associated with reduced patient benefit and, under most circumstances, should not be recommended.…”

The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal

“…Thus, adherence is a key factor for treatment continuity and, at the same time, uninterrupted treatment administration appears to favour good adherence [Altamura et al 2012].…”

“…A radical change in attitude among clinicians and patients is required to reconsider LAI APs from a new perspective: no longer medications of last resort, but rather a potential first step to ensure treatment continuity and maximize clinical remission [Altamura et al 2012]. Achieving and maintaining clinical remission is important [Andreasen et al 2005], since patients in remission show significantly better social functioning and quality of life [Brissos et al 2011].…”

“…In fact, several authors propose that LAI APs should not be restricted to patients with adherence problems, but instead should be more widely prescribed [Altamura et al 2012], and systematically offered to all patients through shared decision-making ].…”

Therapeutic continuity in the treatment of psychiatric disorders

“…Il decorso della patologia schizofrenica è legato alla natura tendenzialmente progressiva della malattia, anche se viene fortemente condizionato da variabili psicologiche e sociali, che fanno del soggetto schizofrenico un paziente con tratti di specificità e unicità (20). Studi di neuroimaging hanno ripetutamente documentato, in soggetti schizofrenici, l'alterato funzionamento di aree strategiche, quali la corteccia prefrontale, l'ippocampo, le strutture limbiche e i gangli basali, oltre a dilatazione ventricolare e perdita di sostanza grigia corticale (21).…”