Patients with schizophrenia are dependent on treatment with antipsychotic medication for the rest of their lives. However, adherence often leaves much to be desired. Many sufferers suffer from a reduced quality of life due to phases of increased active symptoms. This is usually caused by non-adherence to the medication. Long-acting injectable antipsychotics have the potential to improve treatment adherence and symptom control.
Schizophrenia is a severe mental disorder characterized by positive and negative symptoms, disorganization and cognitive deterioration, affecting self-care and interpersonal relationships [1]. It is one of the top 15 causes of disability worldwide [2]. Treatment and management of the illness requires multimodal management, such as social support, psychological therapies and psychoeducation. However, it is well established that schizophrenia is caused by altered levels of dopamine and glutamate neurotransmitters in the brain and pharmacotherapy, mainly with antipsychotics, remains one of the mainstays in the treatment of schizophrenia to alleviate symptoms, maintain functioning and improve quality of life [3]. The problem: Schizophrenia patients typically suffer from anosognosia, i.e. a lack of insight into the nature of the symptoms and the difficulties associated with the illness [4]. Therefore, effective treatment is often jeopardized by a lack of adherence and compliance.
Phase progression and therapy management
Schizophrenia progresses in phases, which can vary from patient to patient. In the prodomal phase, early symptoms such as concentration disorders, altered perception, sleep and drive disorders and mistrust become apparent. It usually affects young adults whose environment misinterprets the symptoms as normal development during puberty. However, the impairment of performance and the negative social consequences are considerable. During the acute phase, positive symptoms are in the foreground. Due to delusions and hallucinations, those affected are so severely impaired in their perception that hospitalization is often unavoidable. Once the acute phase has subsided, the stabilization or maintenance phase follows. Around a third of those affected become completely symptom-free again and can lead a normal life. Another third are restricted by negative symptoms, which can lead to social withdrawal and reduced resilience in everyday life. In a third of sufferers, this condition is so severe that they are permanently dependent on outside help to cope with everyday life.
The aim in the acute phase is to quickly reduce the very distressing symptoms and prevent self-harm or harm to others. With the help of available medication, this can often be achieved within days to weeks. All guidelines agree that an antipsychotic should be started when psychotic symptoms occur in the context of schizophrenia [6]. For patients with a first episode, the selection of a second-generation antipsychotic is recommended. Subsequently, drug-based relapse prophylaxis should be carried out.
Long-acting preparations for better adherence
It has been shown that long-acting injectable antipsychotics (LAIs) can improve treatment adherence [7]. LAIs are still used rather cautiously in current practice. Paliperidone palmitate is a long-acting antipsychotic that is now available in a 6-month formulation. Clinical studies have shown that 92.5% of treated patients were relapse-free after 12 months [7]. Initial results from a four-year, multicenter, prospective, pragmatic mirror image study support the clinical data: The retention rate after 6 months of treatment was 94%. In addition, it was shown that patient and physician preference for LAIs with longer dosing intervals was the main reason for the introduction/switch to the 6-month formulation, resulting in long treatment duration.
Literature:
- Owen MJ, Sawa A, Mortensen PB: Schizophrenia. Lancet 2016; 388: 86-97.
- GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390: 1211-1259. Erratum in: Lancet 2017; 390: e38.
- Buck SA, Quincy Erickson-Oberg M, Logan RW, et al: Relevance of interactions between dopamine and glutamate neurotransmission in schizophrenia. Mol Psychiatry 2022; 27: 3583-3591.
- Little JD: In schizophrenia, are lack of capacity and lack of insight more usefully understood as anosognosia? Australas Psychiatry 2021; 29: 346-348.
- www.rki.de/DE/Content/Gesundheitsmonitoring/Gesundheitsberichterstattung/GBEDownloadsT/Schizophrenie.pdf?__blob=publicationFile (last accessed on 17.11.2024).
- https://smf.swisshealthweb.ch/de/article/doi/smf.2018.03303 (last accessed on 17.11.2024).
- García-Carmona JA, et al: Preliminary data from a 4-year mirror-image and multicenter study of patients initiating paliperidone palmitate 6-monthly long-acting injectable antipsychotic: the Paliperidone 2 per Year study. Ther Adv Psychopharmacol. 2023 Dec 26;13:20451253231220907.
InFo NEUROLOGY & PSYCHIATRY 2024; 22(6): 26
