One-year symptom trajectories in patients with stable schizophrenia maintained on antipsychotics versus placebo: meta-analysis

Medication non-adherence and associated factors among peoples with schizophrenia: multicenter cross-sectional study in Northwest Ethiopia

BACKGROUND

Schizophrenia is a serious and debilitating psychiatric disorder that is linked to marked social and occupational impairment. Despite the vital relevance of medication, non-adherence with recommended pharmacological treatments has been identified as a worldwide problem and is perhaps the most difficult component of treating schizophrenia. There are limited studies conducted on magnitude and potential factors of medication non-adherence among peoples with schizophrenia in Ethiopia.

OBJECTIVES

This study aimed to assess medication non-adherence and associated factors among peoples with schizophrenia at comprehensive specialized hospitals in Northwest Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 387 peoples with schizophrenia at selected hospitals in the Northwest of Ethiopia from June to August 2022. Study participants were enrolled using systematic random sampling. Medication non-adherence was measured using Medication Adherence Rating Scale (MARS). Data entry and analysis were done using Epi-data version 4.6.0 and SPSS version 24, respectively. A multivariable logistic regression model was fitted to identify factors associated with medication non-adherence. Variables with a p-value of < 0.05 at a 95% confidence interval were considered statistically significant.

RESULTS

The prevalence of medication non-adherence was 51.2% (95% CI: 46.3, 56.3). Duration of treatment for more than ten years (AOR = 3.76, 95% CI: 1.43, 9.89), substance use (AOR = 1.92, 95% CI: 1.17, 3.13), antipsychotic polypharmacy, (AOR = 2.01, 95% CI: 1.11, 3.63) and extra-pyramidal side effect (AOR = 2.48, 95% CI: 1.24, 4.94) were significantly associated with medication non-adherence.

CONCLUSION

In this study, half of the participants were found to be medication non-adherent. Respondents with a longer duration of treatment, substance users, those on antipsychotic polypharmacy, and those who develop extra-pyramidal side effect need prompt screening and critical follow-up to improve medication adherence.

Time-dependent effect of antipsychotic discontinuation and dose reduction on social functioning and subjective quality of life-a multilevel meta-analysis

Background

Meta-analyses indicate superiority of antipsychotic maintenance treatment over discontinuation within up to 24 months after treatment initiation for patients with schizophrenia-spectrum disorders. In terms of functional recovery, long-term trials show improved functioning after discontinuation, suggesting a time-dependent effect of antipsychotic maintenance. However, these trials were not included in previous meta-analyses. We therefore investigated whether the effect of antipsychotic maintenance treatment vs. discontinuation on social functioning and quality of life varies by trial length.

Methods

The study was preregistered with PROSPERO (CRD42021248933). PubMed, PsycINFO, Web of Science, Embase and trial registers were systematically searched on 8th November 2021 and updated on 25th June, 2023 and 10th August, 2023 for studies that compared antipsychotic maintenance to discontinuation and reported data on social functioning or subjective quality of life in patients with schizophrenia-spectrum disorders. Risk of bias was assessed with the RoB 2, the ROBINS-I and the RoB-ME tools. Quality of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Findings

We included k = 35 studies (N = 5924) with follow-ups between one month and 15 years. Overall, maintenance and discontinuation did not differ on social functioning (k = 32; n = 5330; SMD = 0.204; p = 0.65; 95% CI [-0.69, 1.10]) or quality of life (k = 10; n = 943; SMD = -0.004; p = 0.97; 95% CI [-0.22, 0.21]), whilst subgroup analyses of middle- (2-5 years; k = 7; n = 1032; SMD = 0.68; 95% CI [0.06, 1.28]) and long-term follow-ups (>5 years; k = 2; n = 356; SMD = 1.04; 95% CI [0.82, 1.27]) significantly favoured discontinuation. However, the quality of evidence was rated as very low.

Interpretation

Although our findings suggest a time-dependent decrease in the effect of maintenance treatment on social functioning, interpretation of these findings is limited by the serious risk of bias in middle- and long-term trials. Therefore, any conclusions regarding the long-term benefits of antipsychotic treatment or discontinuation for functional recovery are premature and more high-quality trials tailored to comparing state of the art maintenance treatment vs. discontinuation are needed.

Funding

None.

Does short-term antipsychotic discontinuation of up to 3 weeks worsen symptoms in acute schizophrenia? A pooled analysis of placebo washout data

AIM

This study aimed to examine symptom changes during short-term discontinuation of antipsychotics up to 3 weeks including the placebo washout phase in acute schizophrenia.

METHODS

The data from three double-blind, randomized, controlled trials comparing lurasidone versus placebo in patients with acute exacerbation of schizophrenia were analyzed. Symptom severity was assessed using the Positive and Negative Syndrome Scale (PANSS) total and the Clinical Global Impression-Severity scale (CGI-S) scores. The scores before and after the antipsychotic discontinuation phase were compared, and factors associated with score changes were explored.

RESULTS

Among 2154 patients participating in the trials, 600 who received antipsychotic monotherapy and completed the antipsychotic discontinuation phase were included in the analysis. No patients received clozapine. The mean duration of the discontinuation phase was 5.9 ± 2.5 days. The PANSS total and CGI-S scores significantly changed from 94.0 ± 9.5 to 95.4 ± 10.5 (P < 0.001) and from 4.9 ± 0.6 to 4.9 ± 0.7 (P = 0.041), respectively, during this phase; however, the absolute difference was minimal. The score changes were not associated with the type or dose of prior antipsychotics, or the duration or strategy (abrupt vs gradual) of antipsychotic discontinuation.

CONCLUSIONS

Symptoms may not worsen to a clinically meaningful degree after short-term discontinuation of non-clozapine antipsychotics up to 3 weeks in patients with acute exacerbation of schizophrenia, suggesting that antipsychotic efficacy persists at least several days after discontinuation. This finding supports once-daily dosing regimen of antipsychotics and abrupt antipsychotic discontinuation when switching to another antipsychotic.

Placebo versus no treatment for people with schizophrenia

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To compare the effects of placebo versus no treatment in people with schizophrenia.

Predictors of Lack of Relapse After Random Discontinuation of Oral and Long-acting Injectable Antipsychotics in Clinically Stabilized Patients with Schizophrenia: A Re-analysis of Individual Participant Data

OBJECTIVE

To quantify the risk and predictors of relapse among individuals with schizophrenia randomly withdrawn from antipsychotic maintenance treatment.

METHODS

We re-analyzed time-to-event and baseline predictors from placebo arms in five placebo-controlled randomized trials of antipsychotics (n = 688 individuals; 173 stabilized on oral antipsychotic [OAP] and 515 on long-acting injectables [LAI]) for relapse-prevention available in the Yale Open Data Access repository. Using a survival and Cox-proportional hazards regression analyses, we estimated survival rates of "relapse-free" individuals by the end of follow-up (median = 118 days, IQR = 52.0-208.0), the rate of study-confirmed relapse, and adjusted hazard ratios (aHR, 95% confidence intervals [CI]) associated with baseline predictors. We also estimated these parameters for individuals followed for >5 half-lives of the stabilizing antipsychotic, and studied predictors of "rebound psychosis" in OAP-stabilized participants, defined as occurring within 30 days of antipsychotic withdrawal.

RESULTS

29.9% (95%CI = 23.2-38.5) remained relapse-free by the end of follow-up, 11.1% (95%CI = 5.65-21.9) among those OAP-stabilized, 36.4% (95%CI = 28.4-46.7) among those LAI-stabilized. The study-confirmed relapse rate was 45.2%, 62.4% among those OAP-stabilized and 39.4% among those LAI-stabilized. Predictors of relapse included smoking (aHR = 1.54, 95%CI = 1.19-2.00), female sex (aHR = 1.37, 95%CI = 1.08-1.79), and having been stabilized on OAPs vs LAIs (aHR = 3.56, 95%CI = 2.68-4.72). Greater risk of relapse on OAP persisted even after sufficient time had elapsed to clear antipsychotic plasma level among LAI-stabilized (aHR = 5.0, 95%CI = 3.5-7.1). "Rebound psychosis" did not show predictors.

CONCLUSIONS AND RELEVANCE

Our results corroborate the high relapse risk following antipsychotic withdrawal after symptom stabilization with limited patient-related predictors of safe treatment discontinuation. Stabilization with LAIs reduces the short-/medium-term relapse risk.

Pharmacological treatment algorithms for the acute phase, agitation, and maintenance phase of first-episode schizophrenia: Japanese Society of Clinical Neuropsychopharmacology treatment algorithms

OBJECTIVE

There are only a few treatment algorithms for first-episode schizophrenia. Moreover, all the algorithms apply to acute treatment, but not maintenance treatment. Therefore, we aimed to develop acute and maintenance treatment algorithms for first-episode schizophrenia.

METHODS

The algorithm committee of the Japanese Society of Clinical Neuropsychopharmacology developed pharmacological treatment algorithms for the acute phase, agitation, and maintenance phase of first-episode schizophrenia.

RESULTS

The acute treatment algorithm focuses on drug-naïve patients with first-episode schizophrenia who are not old or very agitated and recommends first-line treatment with aripiprazole, second- or third-line treatment with risperidone/paliperidone or olanzapine, and fourth-line treatment with clozapine. Long-acting injection of the current antipsychotic agent can be used for poor medication adherence or based on patient preference. The agitation treatment algorithm recommends first-line treatment with lorazepam and second- or third-line treatment with quetiapine or levomepromazine and clearly instructs that the medication used for agitation should be reduced and then discontinued after remission of agitation. The maintenance treatment algorithm recommends the gradual reduction of antipsychotics to the minimum effective dose after remission of positive symptoms.

CONCLUSIONS

We hope that our unique algorithms will be used broadly and will contribute to minimizing patients' burden related to antipsychotic treatment.

Risk of withdrawal of consent for treatment with long-acting injectable versus oral antipsychotics: A meta-analysis of randomized controlled trials

BACKGROUND

Despite the clinical importance of antipsychotic long-acting injections (LAIs) in the treatment of schizophrenia, their use may be limited by patients' reluctance to accept the injections. No studies to date have investigated whether patients are more likely to withdraw their consent to treatment with LAIs than to treatment with oral antipsychotics (OAPs). Therefore, we performed a meta-analysis of randomized controlled trials (RCTs) to compare the risk of withdrawal of consent between the 2 routes of administration.

METHODS

PubMed, the Cochrane Library, PsycINFO, and CINAHL were systematically searched. RCTs with open-label or rater-masked design that compared LAIs with OAPs were selected. Data on study discontinuation due to withdrawal of consent and/or loss to follow-up were extracted.

RESULTS

A total of 16 studies (4815 patients) that met the study eligibility criteria were included in the meta-analysis. There was no significant difference between the LAI and OAP groups in the risk of cessation of treatment because of withdrawal of consent. Similarly, there was no significant difference in the risk of study discontinuation because of withdrawal of consent plus loss to follow-up.

CONCLUSIONS

These findings were unexpected and suggest that patients may not be more hesitant to continue LAIs than OAPs after consenting to or receiving treatment. Nevertheless, patients should be provided detailed explanations about the use of LAIs and a support system that encourages them to continue treatment.

Towards a framework to develop neuroimaging biomarkers of relapse in schizophrenia

Schizophrenia is a chronic disorder that often requires long-term relapse-prevention treatment. This treatment is effective for most individuals, yet approximately 20-30 % of them may still relapse despite confirmed adherence. Alternatively, for about 15 % it may be safe to discontinue medications over the long term, but since there are no means to identify who those individuals will be, the recommendation is that all individuals receive long-term relapse-prevention treatment with antipsychotic maintenance. Thus, the current approach to prevent relapse in schizophrenia may be suboptimal for over one third of individuals, either by being insufficient to protect against relapse, or by unnecessarily exposing them to medication side effects. There is great need to identify biomarkers of relapse in schizophrenia to stratify treatment according to the risk and develop therapeutics targeting its pathophysiology. In order to develop a line of research that meets those needs, it is necessary to create a framework by identifying the challenges to this type of study as well as potential areas for biomarker identification and development. In this manuscript we review the literature to create such a framework.

Mitochondrial function parameters as a tool for tailored drug treatment of an individual with psychosis: a proof of concept study

Pharmacological treatment of mental disorders is currently decided based on "trial and error" strategy. Mitochondrial multifaceted dysfunction is assumed to be a major factor in the pathophysiology and treatment of schizophrenia (SZ) and bipolar disorder (BD). This study aimed to explore the feasibility of using a profile of mitochondrial function parameters as a tool to predict the optimal drug for an individual patient (personalized medicine). Healthy controls (n = 40), SZ (n = 48) and BD (n = 27) patients were recruited. Mental and global state of the subjects, six mitochondrial respiration parameters and 14 mitochondrial function-related proteins were assessed in fresh lymphocytes following in-vitro or in-vivo treatment with five antipsychotic drugs and two mood-stabilizers. In healthy controls, hierarchal clustering shows a drug-specific effect profile on the different mitochondrial parameters following in-vitro exposure. Similar changes were observed in untreated SZ and BD patients with psychosis. Following a month of treatment of the latter patients, only responders showed a significant correlation between drug-induced in-vitro effect (prior to in-vivo treatment) and short-term in-vivo treatment effect for 45% of the parameters. Long- but not short-term psychotropic treatment normalized mitochondria-related parameters in patients with psychosis. Taken together, these data substantiate mitochondria as a target for psychotropic drugs and provide a proof of concept for selective mitochondrial function-related parameters as a predictive tool for an optimized psychotropic treatment in a given patient. This, however, needs to be repeated with an expanded sample size and additional mitochondria related parameters.

The report of the joint WPA/CINP workgroup on the use and usefulness of antipsychotic medication in the treatment of schizophrenia

This is a report of a joint World Psychiatric Association/International College of Neuropsychopharmacology (WPA/CINP) workgroup concerning the risk/benefit ratio of antipsychotics in the treatment of schizophrenia. It utilized a selective but, within topic, comprehensive review of the literature, taking into consideration all the recently discussed arguments on the matter and avoiding taking sides when the results in the literature were equivocal. The workgroup's conclusions suggested that antipsychotics are efficacious both during the acute and the maintenance phase, and that the current data do not support the existence of a supersensitivity rebound psychosis. Long-term treated patients have better overall outcome and lower mortality than those not taking antipsychotics. Longer duration of untreated psychosis and relapses are modestly related to worse outcome. Loss of brain volume is evident already at first episode and concerns loss of neuropil volume rather than cell loss. Progression of volume loss probably happens in a subgroup of patients with worse prognosis. In humans, antipsychotic treatment neither causes nor worsens volume loss, while there are some data in favor for a protective effect. Schizophrenia manifests 2 to 3 times higher mortality vs the general population, and treatment with antipsychotics includes a number of dangers, including tardive dyskinesia and metabolic syndrome; however, antipsychotic treatment is related to lower mortality, including cardiovascular mortality. In conclusion, the literature strongly supports the use of antipsychotics both during the acute and the maintenance phase without suggesting that it is wise to discontinue antipsychotics after a certain period of time. Antipsychotic treatment improves long-term outcomes and lowers overall and specific-cause mortality.

Adherence to Oral Antipsychotics Measured by Electronic Adherence Monitoring in Schizophrenia: A Systematic Review and Meta-analysis

BACKGROUND

Poor adherence to oral antipsychotics is common in patients with schizophrenia; nonetheless, there has been no systematic review or meta-analysis on medication adherence measured by electronic adherence monitoring (EAM), considered by many as the 'gold standard' assessment.

METHODS

We systematically searched MEDLINE and Embase to identify studies investigating adherence to oral antipsychotics using EAM in patients with schizophrenia spectrum disorder. There were no exclusion criteria. We looked at the methodology in each study and defined which type of adherence was used in the study. Data on medication adherence, definition of satisfactory adherence (i.e., the threshold set in terms of the percentage of times medication was taken as prescribed), and factors associated with adherence were extracted for the included studies. Further, data on the rates of medication adherence were quantitatively synthesized.

RESULTS

A total of 19 studies involving 2184 patients were included. EAM-measured medication adherence was classified into three outcome types: taking adherence, regimen adherence, and timing adherence. The meta-analysis yielded oral antipsychotic adherence rates (defined as a continuous variable) of 71.1% for taking adherence [from seven studies, n = 256, 95% confidence interval (CI) 58.0-84.1], 70.0% for regimen adherence (from five studies, n = 174, 95% CI = 63.6-76.4), and 64.9% for timing adherence (from four studies, n = 212, 95% CI 53.2-76.6), respectively. The proportions of patients with oral antipsychotic adherence, when defined as a dichotomous variable, ranged from 50 to 78.3% for the 70% threshold for satisfactory adherence, 29.8-75.7% for the 75% threshold, and 47.8-75.7% for the 80% threshold. Factors associated with poor medication adherence were greater symptom severity, more frequent dosing regimen, poorer insight, and more negative drug attitude.

CONCLUSIONS

Oral antipsychotic adherence rates in schizophrenia, defined as a continuous variable and measured by EAM, were in the range of 70%, lower than the 80% threshold used widely to define satisfactory adherence.

Factors associated with successful antipsychotic dose reduction in schizophrenia: a systematic review of prospective clinical trials and meta-analysis of randomized controlled trials

This systematic review and meta-analysis examined predictors of successful antipsychotic dose reduction in schizophrenia. Prospective clinical trials and randomized controlled trials (RCTs) investigating antipsychotic dose reduction in schizophrenia were selected for systematic review and meta-analysis, respectively. In total, 37 trials were identified. Only 8 studies focused on second-generation antipsychotics (SGAs); no studies investigated long-acting injectable SGAs. Of 24 studies evaluating relapse or symptom changes, 20 (83.3%) met the criteria for successful dose reduction. Factors associated with successful dose reduction were study duration < 1 year, age > 40 years, duration of illness > 10 years, and post-reduction chlorpromazine equivalent (CPZE) dose > 200 mg/day. Clinical deterioration was mostly re-stabilized by increasing the dose to the baseline level (N = 7/8, 87.5%). A meta-analysis of 18 RCTs revealed that relapse rate was significantly higher in the reduction group than the maintenance group (risk ratio [RR] = 1.96; 95% confidence interval [CI], 1.23-3.12), whereas neurocognition was significantly improved (standardized mean difference = 0.69; 95% CI, 0.25-1.12). A subgroup analysis indicated that only a post-reduction CPZE dose ≤ 200 mg/day was associated with an increased risk of relapse (RR = 2.79; 95% CI, 1.29-6.03). Thus, when reducing antipsychotic doses, clinicians should consider the long-term risk of relapse in younger patients with a relatively short illness duration and keep the final doses higher than CPZE 200 mg/day. Further studies, particularly those involving SGAs, are warranted to determine the optimal strategies for successful antipsychotic dose reduction in schizophrenia.

National database study on the use of long-acting antipsychotic injections and hospital readmission proportions in patients with schizophrenia in Japan

AIM

It is important to investigate the current prescription status and clinical outcomes of patients with schizophrenia receiving long-acting antipsychotic injections. We aimed to determine the prescription proportion of long-acting antipsychotic injections and hospital readmission proportions of patients with schizophrenia in Japan.

METHODS

An open dataset was created using data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patient records with the term 'schizophrenia' were included. In Analysis 1, antipsychotic prescription proportions were determined for outpatients who had visited psychiatric facilities between 1 February 2015 and 31 March 2017. In Analysis 2, patients who had been discharged from a psychiatric facility and had received a long-acting antipsychotic injection prescription within 90 days after initial discharge were selected; then, their readmission proportion was examined for 365 days after the initial discharge.

RESULTS

The long-acting antipsychotic injection prescription proportion was 3.5% for outpatients with schizophrenia receiving antipsychotics. The readmission proportion was 41.0% in the entire patient population, 36.2% in patients receiving typical long-acting antipsychotic injections alone, and 23.5% in patients receiving atypical long-acting antipsychotic injections alone.

CONCLUSION

Long-acting antipsychotic injections are not yet widely used in Japan. The readmission proportion was lower in the patients receiving atypical than typical long-acting antipsychotics injections. The results may provide important basic information to develop new future research questions but should be interpreted with caution because generalizability may be limited by the use of aggregated data and the data structure of the database used.

Achieving the Lowest Effective Antipsychotic Dose for Patients with Remitted Psychosis: A Proposed Guided Dose-Reduction Algorithm

Continuing antipsychotic treatment in patients with schizophrenia under clinical remission remains controversial. Even though the mainstream opinion declares an outweighed balance against medication discontinuation, recent reviews and critiques suggest that some patients may remain symptom free and well functioning after stopping antipsychotics, but few predictors can identify who can try medication discontinuation, whilst no guidelines exist for reducing medication to reach the lowest effective dose safely. Analyzing the findings from studies employing different methodologies, adopting evidence from pharmacodynamic research, and observing dose reduction in stable patients, as well as taking inspiration from the metaphor of the Cantor set in natural philosophy, we introduce an alternative solution and propose a guided dose-reduction algorithm that follows a set of clear precautions and instructions. The algorithm recommends only a fraction (no more than 25%) of the dosage to be reduced at a time, with at least a 6-month stabilization period required before reducing another 25% of the dose. Patients are empowered to actively participate in decision making when they are ready for further dose tapering, or should they retreat to a previous dosage if warning signs of a relapse re-emerge. An intermittent or irregular dosing schedule can be used to adapt this algorithm to real-world practice. Our preliminary findings suggest that patients with remitted psychosis can do well along this path. We anticipate that this approach can help optimize the risk-benefit ratio and instill a hope in patients with schizophrenia that they can maintain in stable remission under a lower antipsychotic dose without an increased risk of relapse.

Use of long acting antipsychotics and relationship to newly diagnosed bipolar disorder: a pragmatic longitudinal study based on a Canadian health registry

BACKGROUND

There is limited data from large naturalistic studies to inform prescribing of long-acting injectable medication (LAIs). Guidance is particularly rare in the case of primary mood disorders.

METHODS

This study describes prescribing trends of LAIs in 3879 patients in Quebec, Canada, over a period of 4 years. Health register data from the Quebec provincial health plan were reviewed.

RESULTS

In this specific registry, 32% of patients who received LAIs drugs for schizophrenia had a confirmed diagnosis of bipolar disorder and 17% had a diagnosis of major depressive disorder. Non-schizophrenia syndromes were preferentially prescribed risperidone long-acting antipsychotic, whereas patients with schizophrenia were prescribed an excess of haloperidol decanoate. Patients with non-schizophrenia disorders prescribed long-acting antipsychotics were more frequently treated in primary care compared with patients with schizophrenia.

CONCLUSION

Data from a large number of patients treated naturalistically in Quebec with long-acting antipsychotics suggests that these compounds, prescribed to treat symptoms of schizophrenia and schizoaffective disorders, were maintained when mood symptoms emerged, even in cases when the diagnosis changed to bipolar disorder. This pragmatic study supports the need to explore this intervention as potential treatment for affective disorders.

Antipsychotic treatment in the maintenance phase of schizophrenia: An updated systematic review of the guidelines and algorithms

BACKGROUND

We updated our previous systematic review regarding clinical guidelines and algorithms on antipsychotic treatment in the maintenance phase of schizophrenia (doi: 10.1016/j.schres.2011.11.021) to incorporate and synthesize more recent findings to guide clinical practice.

METHODS

We conducted a systematic literature search to identify clinical guidelines and algorithms describing antipsychotic treatment in the maintenance phase of schizophrenia using MEDLINE and Embase. We assessed overall quality of the guidelines/algorithms according to the AGREE II instrument and extracted information on treatment recommendations.

RESULTS

We identified 20 guidelines/algorithms from various regions, including 11 updated or newly launched ones after the previous systematic review in 2012. All of the guidelines/algorithms satisfied a certain level of quality. Where mentioned, endorsements were sorted into "recommended", "partially recommended", or "not recommended". As for antipsychotic discontinuation strategy, a majority of guidelines/algorithms that mentioned this strategy did not recommend it for multiple-episode schizophrenia (N = 5/6). On the other hand, the guidelines/algorithms tended to shift from "not recommended" to "partially recommended" both for schizophrenia in general (N = 7/13, N = 7/8 for those published after 2013) and first-episode schizophrenia (N = 10/11, N = 7/7 for those published after 2013) regarding this strategy. All guidelines/algorithms (N = 9/9) converged to discourage antipsychotic intermittent/targeted strategy. Similar to antipsychotic discontinuation strategy, all of the updated or new guidelines/algorithms (N = 6/6) endorsed antipsychotic dose reduction/lower dose strategy.

CONCLUSION

Recent clinical guidelines and algorithms on antipsychotic maintenance treatment in schizophrenia shifted more toward a possibility of antipsychotic discontinuation and dose reduction/lower dose strategies. Nonetheless, clinicians need to contemplate on the risk-benefit balance of these strategies for individual patients.

Symptomatic and functional outcomes after treatment with paliperidone palmitate 3-month formulation for 52 weeks in patients with clinically stable schizophrenia

BACKGROUND

Paliperidone palmitate 3-monthly (PP3M) formulation is a long-acting, injectable antipsychotic treatment approved in many countries worldwide for the maintenance treatment of adult patients with schizophrenia. This single-arm, open-label, phase IIIb study evaluated the efficacy and safety of converting patients with schizophrenia stabilized with paliperidone palmitate 1-month (PP1M) to PP3M in a naturalistic clinical setting.

METHODS

After screening (days -7 to 1), patients were converted from PP1M (50-150 mg eq.) to PP3M (175-525 mg eq.), and entered a 52-week, flexible-dose PP3M treatment period. The primary efficacy endpoint was symptomatic remission (SR) (Andreasen criteria) at last observation carried forward (LOCF) endpoint.

RESULTS

Patients (n = 305) received PP3M, of whom 291 (95.4%) completed the study. Doses of PP3M remained stable during the 12-month treatment period, and changes in dose were uncommon. Overall, 56.8% of patients [95% confidence interval (CI): 51.0, 62.4] achieved SR, and 31.8% achieved both symptomatic and functional remission (Personal and Social Performance scale total score > 70) at LOCF endpoint. Secondary endpoint results were generally consistent with primary endpoint results. There were improvements in Positive and Negative Syndrome Scale total, subscale and Marder factor scores, and also Clinical Global Impression-Severity and -Change scores from baseline to LOCF endpoint. Carer burden was reduced, and the proportion of patients requiring hospitalization for psychiatric reasons decreased from 13.5% in the 12 months prior to baseline to 4.6% during the treatment period. No new safety signals were identified.

CONCLUSION

Results from this naturalistic study were similar to those observed in previous randomized clinical trials of PP3M and underline the importance of continuous maintenance treatment in patients with schizophrenia.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

The effect of baseline antipsychotic status on the 12-month outcome in initially stabilized patients with schizophrenia

INTRODUCTION

Recently, the usefulness of antipsychotics has been challenged. The aim of the study was to measure the real-life effect of antipsychotic treatment on remission and recovery rates in already stabilized patients with schizophrenia after 1 year.

MATERIAL AND METHODS

The study included 133 stabilized patients with schizophrenia (77 males and 56 females; aged 33.55 ± 11.22 years). The assessment included testing at baseline and after 1 year with the Positive and Negative Syndrome Scale, Calgary Depression Scale, State-Trait Anxiety Inventory, UKU, Extrapyramidal Symptom Rating Scale, and General Assessment of Functioning.

RESULTS

More patients were on antipsychotics after 1 year (increase by 16.45%). There was an increase in the remission by 75% and in the recovery rate by 66%. It was not possible to predict the outcome on the basis of baseline variables.

DISCUSSION

There is an accumulating beneficial effect of antipsychotic treatment over a 12-month period; early lack of remission is not prognostic of a poor outcome. There might be different neurobiological mechanisms underlying acute and sustained response. Both remission and recovery are difficult to achieve for patients with schizophrenia and characterize only a minority of patients. Only a very small minority of patients (4.5%) that is impossible to identify a priori would do well without off antipsychotics.

Personalizing antipsychotic treatment: evidence and thoughts on individualized tailoring of antipsychotic dosage in the treatment of psychotic disorders

Effectiveness of relapse prevention with antipsychotic drugs has been robustly demonstrated. However, the drawbacks of antipsychotic maintenance treatment have prompted alternative strategies to reduce antipsychotic load. A prominent drawback of antipsychotics is their negative impact on subjective well-being, initiative, and drive related to dopamine D2 blockade. This might compromise functional capacity. First-episode studies from 1980 to 2018, including relevant reviews and meta-analyses, are evaluated, showing a lack of functional outcome data. In addition to relapse rates, which is the primary outcome in the great majority of studies, long-term functional outcome is pivotal, because these two outcome domains may point in opposite directions. The trade-off between relapse rates and functional outcome is discussed by our 2013 dose-reduction study. We conclude that divergent outcomes and various individual risk-profiles preclude the construction of a generic outcome measure. The relationship of relapse and functional outcome is considered, as well as the conceivable role of negative symptoms and some related issues. Future profiling of individual risk/benefit characteristics combined with personal preferences may offer better guidance in antipsychotic pharmacotherapy. More studies are needed to elucidate individual risk profiles, predictive of functional capacity and relapse rates, to draw differential conclusions on long-term risks and benefits of antipsychotics across the spectrum of psychosis.

Do antipsychotic drugs lose their efficacy for relapse prevention over time?

There is a debate about long-term treatment of schizophrenia with antipsychotic drugs, with some experts suggesting that these drugs should be discontinued. In this issue, Takeuchi et al demonstrated by a meta-analysis of 11 trials that antipsychotic drugs maintained their efficacy for relapse prevention for 1 year, whereas patients on placebo kept getting worse. We consider these findings in the light of the current discussion about possible dose-related brain volume loss, supersensitivity psychosis, the high variability of results in long-term follow-up studies and recent approaches to discontinue antipsychotics in patients with a first-episode. The new findings speak in favour of continuing antipsychotics at the same dose, at least in patients whose condition is chronic, but the topic is complex.