Consider long-acting injectable antipsychotics more often in early-phase schizophrenia

Preventing relapse and hospitalization in schizophrenia is a major public health challenge. The consequences of relapse can be substantial at all stages of illness. For example, in patients with early-phase schizophrenia, a second episode of psychosis in the same individual responds less well to the same treatment than the first episode. Despite this risk, it has been reported that about 36% of patients admitted for their first hospitalization with schizophrenia stop taking their antipsychotic medication within 30 days of discharge and 54% discontinue their medication within 60 days of discharge. Methods to enhance adherence are needed for patients with early-phase illness.Long-acting injectable antipsychotics (LAIAs) enhance medication adherence in patients with schizophrenia and have the potential to reduce the risk of hospitalization. However, they are rarely used in early-phase schizophrenia treatment. Physicians report that they usually reserve LAIAs for patients who have already had repeated hospitalizations and relapses.A new study in patients with early-phase schizophrenia has examined whether encouraging use of a LAIA (compared with usual care) delays the time to first hospitalization. The Prevention of Relapse in Schizophrenia (PRELAPSE) trial was conducted in 39 mental health centres in 19 US states. Randomization assigned 19 clinics to encourage treatment with long-acting aripiprazole once monthly (prescribed within US Food and Drug Administration–approved guidelines) and 20 to provide treatment with the usual clinician’s choice (possibly including LAIAs). Participants were followed for two years regardless of the treatment received.Participants in the study (age 18–35 years) had a schizophrenia diagnosis confirmed by a structured clinical interview. They also had fewer than five years of lifetime antipsychotic use. The study enrolled 234 patients in the aripiprazole once-monthly group and 255 in the clinician’s choice group. The primary outcome was time to first psychiatric hospitalization.Results showed that of the 489 participants, 225 (46.0%) had one year or less of lifetime antipsychotic use. Fifty-two of the patients (22%) in the aripiprazole once-monthly group and 91 patients (36%) in the clinician’s choice group had at least one hospitalization.The mean survival time until first hospitalization was 613.7 days (95% CI, 582.3–645.1 days) for aripiprazole once-monthly patients and 530.6 days (95% CI, 497.3–563.9 days) for clinician’s choice participants. The hazard ratio for time to first hospitalization was 0.56 (95% CI, 0.34– 0.92; p = 0.02), favouring aripiprazole once-monthly therapy.The number needed to treat to prevent one additional hospitalization with aripiprazole once-monthly was 7.The use of an LAIA (aripiprazole once-monthly) in this population produced a significant (44%) reduction in the incidence rate of first hospitalization compared with the clinician’s choice usual care group. This reduction is particularly notable given that some patients in the usual care group might have received LAIAs, as clinicians in the usual care group could use any therapies of their choice.The investigators conclude that LAIA use in patients with early-phase schizophrenia can significantly delay time to hospitalization, which is a personal and economically important outcome. LAIA treatment should be considered more often for patients with early-phase illness. ReferenceKane JM, Schooler NR, Marcy P, et al. Effect of long-acting injectable antipsychotics vs usual care on time to first hospitalization in early-phase schizophrenia. A randomized clinical trial. JAMA Psychiatry. Published online July 15, 2020. doi:10.1001/jamapsychiatry.2020.2076.

Consider long-acting injectable antipsychotics more often in early-phase schizophrenia

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