Antipsychotic dose in maintenance treatment of schizophrenia: A retrospective study

Effect of antipsychotic dose reduction on cognitive function in schizophrenia

Cognitive deficits are predictors of social functioning but remain an unmet therapeutic challenge. While lowering the antipsychotics carries a risk of relapse, it possibly has a beneficial effect on cognitive function. However, this has not been examined in a real-world setting. A prospective naturalistic 6-month follow-up study (n = 71) was conducted with patients between 18 and 45 years in their first five years of illness and the maintenance phase of the treatment. Brief Assessment of Cognition in Schizophrenia (BACS) was administered to assess cognitive functions. Patients were divided into three groups based on the change in dose of antipsychotics. The data were analyzed using linear mixed-effects modeling (LMEM) to examine the group differences. At the end of six months, those with decreased antipsychotic dose had significant improvement in BACS total score, token test, and symbol coding compared to those with no change in the dose of antipsychotic. Reducing the dose of antipsychotics during the maintenance phase was associated with improved cognitive functions without an increased risk of relapse. Antipsychotic dose reduction may be better than discontinuation as the relapse risk is higher with the discontinuation strategy. Clinicians must balance the improvements in cognitive functions and relapse risk.

Reducing long acting antipsychotic injection dosage frequency: A pilot study in a community mental health team

BACKGROUND

Antipsychotic long acting injections (LAI) allow a range of dosage intervals to be administered. Short intervals can be inconvenient for patients and staff. There are few clinical reasons for using them yet this is common practice.

AIMS

This study aimed to examine the feasibility of reducing LAI frequency with service user consent.

METHODS

The study took place in a community mental health team in the north of England. A specialist mental health pharmacist reviewed records of all service users on LAI and drew up an action plan. Each service user then met with the consultant psychiatrist for medication review.

RESULT

Nineteen out of thirty service users on LAI had intervals less than the maximum licensed. The frequency was reduced in eight cases. After 6 months follow-up, there was no deterioration in symptoms. In nine cases, antipsychotic doses were also reduced as a result of the review.

CONCLUSION

Where a service user is prescribed a LAI with a short dosage interval consideration should be given to increase the interval. This can free up service user and staff time. A medication focused review can also lead to other benefits such as dosage reduction.

Cost-effectiveness of 3-month paliperidone therapy for chronic schizophrenia in the Netherlands

BACKGROUND

A new depot formulation of paliperidone has been developed that provides effective treatment for schizophrenia for 3 months (PP3M). It has been tested in phase-3 trials, but no data on its cost-effectiveness have been published.

PURPOSE

To determine the cost-effectiveness of PP3M compared with once-monthly paliperidone (PP1M), haloperidol long-acting therapy (HAL-LAT), risperidone microspheres (RIS-LAT), and oral olanzapine (oral-OLZ) for treating chronic schizophrenia in The Netherlands.

METHODS

A previous 1-year decision tree was adapted, based on local inputs supplemented with data from published literature. The primary analysis used DRG costs in 2016 euros from the insurer perspective, as derived from official lists. A micro-costing analysis was also conducted. For the costing scenario, official list prices were used. Clinical outcomes included relapses (treated as outpatients, requiring hospitalization, total), and quality-adjusted life-years (QALYs). Rates and utility scores were derived from the literature. Economic outcomes were the incremental cost/QALY-gained or relapse-avoided. Model robustness was examined in scenario, 1-way, and probability sensitivity analyses.

RESULTS

The expected cost was lowest with PP3M (8,781€), followed by PP1M (10,325€), HAL-LAT (11,278€), RIS-LAT (11,307€), and oral-OLZ (13,556€). PP3M had the fewest total relapses/patient (0.36, 0.94, 1.39, 1.21, and 1.70, respectively), hospitalizations (0.11, 0.46, 0.40, 0.56, and 0.57, respectively), emergency room visits (0.25, 0.48. 0.99, 0.65, and 1.14, respectively) and the most QALYs (0.847, 0.735, 0.709, 0.719, and 0.656, respectively). In both cost-effectiveness and cost-utility analyses, PP3M dominated all other drugs. Sensitivity analyses confirmed base case findings. In the costing analysis, total costs were, on average, 31.9% higher than DRGs.

CONCLUSIONS

PP3M dominated all commonly used drugs. It is cost-effective for treating chronic schizophrenia in the Netherlands. Results were robust over a wide range of sensitivity analyses. For patients requiring a depot medication, such as those with adherence problems, PP3M appears to be a good alternative anti-psychotic treatment.