In a workshop titled ‘International Update on Acute and Long-term Treatment of Schizophrenia: New Data and New Approaches’, Professor Christoph Correll (The Donald and Barbara Zucker School of Medicine at Hofstra/Nothwell, USA and Charité Universitätsmedizin, Germany), Professor Leslie Citrome (New York Medical College, USA) and Professor Ira Glick (Stanford University of Medicine, USA) discussed research findings and provided practical advice regarding best possible treatment options for patients with schizophrenia in acute phases, in times of agitation and throughout their lifetime.
Treatment management to reduce relapse
In patients with schizophrenia, modifiable risk factors for poor outcomes include longer duration of untreated psychosis.1 This can, according to Professor Correll, be addressed by proper management of first episode patients when response to antipsychotic medication is the greatest.2 Better possible recovery, alongside reductions in relapse, hospitalisation and treatment cessation, is best achieved via early intervention services where medication is combined with psychosocial and therapeutic treatment.3
Early intervention services lead to best rates of recovery and fewer hospitalisations and relapses
Maintenance treatment is key in reducing relapse and Professor Correll suggested continually using motivational interviewing to encourage patients to remain on their medication. He highlighted how once a stable dose of medication is achieved, that best controls symptoms while limiting adverse events (AEs), it should not be lowered as this can increase the risk of relapse4 regardless of how long a person has been receiving medication.5
Maintenance treatment is key
The use of a long-acting injectable antipsychotic (LAI) may aid medication adherence and lower relapse risk6 with parity shown between most of the second-generation antipsychotic LAIs in terms of relapse prevention and treatment discontinuation.7
Of note though, is that AEs associated with some antipsychotics8 can impact functioning, which can decrease quality of life and increase nonadherence.9 This, Professor Correll stressed, means treatments have to be ‘fine-tuned’ to the individual.
Treatments have to be ‘fine-tuned’ to the individual
AEs with antipsychotic medications are, Professor Correll discussed, more predictable than efficacy as they are directly linked to their mechanism of action.10 Metabolic side effects may be of particular concern as in patients with schizophrenia, metabolic syndrome and cardiovascular risk factors are associated with cognitive impairment.11
Treatment of agitation and aggression in schizophrenia
In some patients, schizophrenia symptoms can include periods of agitation12 discussed Professor Citrome. The Best practices in Evaluation and Treatment of Agitation (BETA) project was set up due to a lack of quality guidelines.13 Their consensus statement included a primary goal of calming the patient, which can be initially attempted through nonpharmacological means; discouragement of medication used only as a means of restraint or to induce sleep; and use of intramuscular preparations when there are difficulties administering oral medications.14 A further point was patient participation in medication selection, which, according to Professor Citrome, may forge a better therapeutic alliance.
In patients experiencing agitation, calming is the primary goal
In terms of medications for treatment, Professor Citrome recommended second-generation antipsychotics15 that can also allow for an easier transition to maintenance therapy. He concluded by discussing up and coming inhaled,16 sublingual and nasally administered formulations of SGA.17
Antipsychotic medication for lifetime symptom control
Professor Glick discussed how lifetime treatment of a patient with schizophrenia needs to involve their family, significant other, caretakers and mental healthcare professionals. He discussed three of his studies, all naturalistic, that investigated lifetime antipsychotic adherence, global life outcomes and life satisfaction.
In the first study, in Professor Glick’s clinic, the cohort (n=35) were mostly males (74%; mean age 45.3 years), predominantly without (75%) a comorbid substance use disorder (SUD) and a mean 10.2 years in treatment.18 In the second study, carried out by an independent clinical research organisation at a different centre (n=34), mean age was similar (47.3 years), 61% were male, more participants had a SUD (61%) and there was a mean of 20.6 years in treatment.19 In the third study, of a Veteran’s Administration (VA) hospital cohort (n=20), patients were older (mean 57.0 years), 95% were male and 40% had a SUD.20
Greater adherence leads to higher levels of functioning and life satisfaction
Ratings of adherence and levels of patient- and clinician-rated life satisfaction outcomes and functioning were high in the first study,18 medium in the second19 and lower in the third.20 However, in all of these studies, Professor Glick found that better ratings on these scales were associated with medication adherence.18-20 He noted that the samples were small, the cohorts may not be generalisable and these trials were not randomised or controlled so larger, more formal studies are needed.
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.