Can increased focus on patient perspectives improve outcomes in the treatment of schizophrenia?

We should be tailoring treatment to our individual patient’s priorities and goals, encouraged Sofia Brissos, Centro Hospitalar Psiquiátrico de Lisboa, Lisbon, Portugal, instead of the traditional focus of clinicians on targeting relapse prevention and side effect minimization. She started her session at ECNP 2018 in Barcelona by considering the question ‘what are the patient’s priorities?’.

Studies focusing on the treatment priorities of patients with schizophrenia have found that symptom control and functioning treatment goals were rated as more important than reducing possible side effects of medication.¹ Patients gave priority to clear thinking, reduced symptoms and hospitalizations, and participation in social and daily activities.² This may not always be appreciated by healthcare professionals, with one study showing that clinicians significantly undervalued the importance of improved satisfaction, capacity for work, and activities of daily living.³

Patients gave priority to clear thinking, reduced symptoms and hospitalizations, and participation in social and daily activities

There may also be differences between subgroups of patients in their treatment goals said Dr Brissos, describing the recent study that showed 50% of patients with recent onset of schizophrenia emphasized functional goals, while the others emphasized clinical goals.¹ There was a trend for the former to be more likely to be on long-acting injectables (LAIs) (44% versus 26%, p=0.059) and to prefer LAI to oral medication (46% versus 32%, p=0.151).

Professor John Kane, Department of Psychiatry, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA, continued the theme of the importance of individualizing treatment in schizophrenia, by introducing an e-health tool to aid clinical decision-making.⁴ This uses evidence from clinical trials and meta-analyses, to allow a more tailored treatment choice than guidelines alone can provide. Based on the recommendations of an expert panel, the e-health tool makes possible patient-specific management of recent-onset schizophrenia spectrum disorder when maintenance antipsychotic treatment is required. Factors such as adherence, physical comorbidities and social support are taken into account, and Professor Kane discussed a number of case studies which illustrated the benefits of this approach. He also stressed that further evaluation is needed, and that periodic re‑assessments would be required to keep the tool up-to-date.

Improving adherence to long-term treatment

Response and tolerability during the acute phase are likely to impact on longer-term compliance with medication

Professor Jose Manuel Olivares, Department of Psychiatry, University Hospital Area of Vigo, Spain, went on to discuss how the ultimate objectives and outcomes of treatment need to be considered throughout the course of schizophrenia. The patient’s first impression of treatment is very important, and response and tolerability during the acute phase are likely to impact on longer-term compliance with medication.

The largest symptomatic improvement with antipsychotic treatment of an acute episode occurs in the first week of treatment argued Professor Olivares, describing one study showing that approximately 68% of improvement at one year was already achieved by four weeks.⁵ Treatment response over the first two weeks seems to predict continued response, with an early non-response a predictor of final non-response.⁶ He suggested this implies that switching to an alternative antipsychotic should be considered if there is no significant improvement after 2 weeks. Similarly, side effects associated with antipsychotic treatment are often evident early in treatment, and even longer-term side effects can be predicted early.^7-9 Using the knowledge of how antipsychotics differ in their side effect profile, will facilitate a more tailored approach to an individual’s treatment.

Medication adherence is crucial to the success of maintenance treatment

Medication adherence is crucial to the success of maintenance treatment. The aim should be encouraging the ‘upward spiral of adherence’, leading to symptom control and increase in quality of life, versus the ‘downward spiral of non-adherence’¹⁰, with the risk of inadequate symptom control leading to relapse and poor social outcomes. Professor Olivares discussed the role LAIs could play in encouraging adherence, leading to beneficial effects on rehospitalization rates and treatment success.¹¹ He suggested that independent living and reintegration of patients into the community and workplace should be the ultimate goal in schizophrenia treatment.¹²

‘Upward spiral of adherence’ versus ‘downward spiral of non-adherence’

As part of the strategy, he also stressed the importance of effectively treating affective symptoms in early schizophrenia, as depression is one of the most important predictors of poor subjective quality of life.¹³

Perceptions and knowledge both important

Professor Steven Potkin, University of California, USA and Director or Pharmacogenomics and Clinical Neuroscience at long Beach Veterans Administration, USA, also addressed the role of LAIs in improving patient acceptance of maintenance treatment, discussing a recent study that explored the willingness of patients recently diagnosed with schizophrenia to choose a LAI versus an oral medication.¹ Most patients had some willingness to try an injectable treatment, with 53% rating their willingness as 51-100%. The most common reason for preferring an LAI was not needing to remember to take daily medication (51%), while preference for an oral medication was to avoid injections (44%). Importantly, perceptions of LAIs differ significantly between patients who are already on that formulation versus patients on an oral preparation, with the latter more likely to be concerned about loss of control and autonomy.¹⁴ There are also significant differences between clinicians and patients, with mental health professionals rating factors such as loss of autonomy, stigma, and feeling of being controlled, much higher than patients.¹⁴

Clinicians perceive loss of autonomy and control, and stigma, as bigger issues than patients do

Health care professionals’ knowledge, as well as their perceptions, about different antipsychotic formulations is important, and Professor Potkin highlighted research showing that psychiatrists’ greater knowledge about LAIs was positively associated with patients’ favourable attitudes (r=0.39, p<0.001).¹⁵ Communication style also mattered when discussing the option of an LAI with a patient, with uptake more likely if the option is presented in a more positive light with adequate information.¹⁶

Professor Potkin proposed a ‘conversation decision tree’ to aid interactions with patients when initiating treatment, encouraging clinicians to explore a patient’s resistance to a particular medication.¹⁷ Uncovering the severity of resistance and addressing the root issue, is likely to help in overcoming patient objections and encouraging adherence to treatment.

Educational and financial support provided by Otsuka Pharmaceutical Europe Ltd. and H. Lundbeck A/S