Expanding Therapy With Long-Acting Antipsychotic Medication in Patients With Schizophrenia.

Abstract

Long-acting injectable (LAI) antipsychotic medications are significantly underused. In light of their documented efficacy for treatment of psychotic symptoms and robust effect on relapse prevention, their relative lack of use is unfortunate. There are several reasons for this therapeutic neglect, including clinical settings where injections are not part of the usual routine; a belief that LAI medications are reserved for acute intervention or for aggressive or nonadherent patients; and the perception of stigmatization associated with their use. Moreover, randomized clinical trials (RCTs) comparing oral antipsychotic medications with LAI medications have often failed to document the expected advantage of assuring adherence with LAI medications because study participant selection often excludes those who are unable to adhere to the study protocol. Finally, physicians routinely overestimate patients’ adherence to oral medication regimens. In this context, 2 articles 1,2 in JAMA Psychiatry regarding the use of LAI medications may stimulate reconceptualization of this aspect of pharmacotherapy for treating schizophrenia. Subotnik and colleagues 1 describe a 12-month RCT that compared oral risperidone with LAI risperidone in patients with recent-onset schizophrenia. The study was conducted in a clinic with intensive clinical care. Outcomes with LAI risperidone were superior on measures of relapse and symptom control, and the between-group difference was partially, but importantly, related to adherence. The conduct of the study in people who are in the early course of their illness and have not established a pattern of medication adherence helps control for the selection bias observed with multiepisode schizophrenia and may account, in part, for the observed robust difference in efficacy between LAI and oral risperidone. Berwaerts and colleagues 2 used a multiple-stage design in