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Niche no more: early use of long-acting injectable antipsychotics in schizophrenia

It is well known that early treatment of schizophrenia leads to better patient outcomes in the long-term, compared with longer durations of untreated illness. How best to manage patients at this early disease stage, and to monitor their treatment outcomes, was the subject of an engaging and interactive session. In this session at ECNP 2018, Dr Charlotte Emborg (Aarhus University Hospital, Denmark), and Dr Iria Grande (Bipolar Disorders Program of the Hospital Clínic at the University of Barcelona), discussed their clinical experiences and decision-making with Congress attendees.

Early engagement with patients and their families to optimize long-term outcomes

Develop a therapeutic alliance and work with patients’ and their families’ goals

Early intervention in schizophrenia ideally entails using treatments that are specifically designed to meet the needs of patients at this early disease stage. Dr Emborg described an integrated care model, with assertive outreach and case management. It focused on developing a therapeutic alliance with patients, and reaching out to them in the community to encourage both their functioning and their attendance at clinic appointments. Engaging with patients has moved from ‘delivering’ psychoeducation on the neurobiology of their disorder, towards hearing from them about the impact of the condition on their identity, and how schizophrenia might have interrupted their life goals. Working at this personal level with patients can enhance their motivation to continue treatment, because they can see that it will help them achieve the things they want for themselves. In addition, Dr Emborg stated that it is extremely important to work with patients’ families at this early stage, to provide the whole system with the support it requires. Such interventions have robust clinical benefits for patients in the long-term. Approaches using specialized early intervention have been shown to produce improvements in both positive and negative symptoms, and in overall patient functioning.

Educate other professionals to identify and signpost patients with early-stage schizophrenia

Ways of detecting and monitoring patients at an early stage

A significant challenge for this treatment approach is how to detect patients at an early disease stage. Although identification in the general population is very difficult, there are some things that could assist patients in accessing the healthcare system. For instance, simple pathways to care could improve detection at an early stage for patients who may well be disorganized because of their disease process, and therefore unable to negotiate complicated care pathways. In addition, physicians can work to educate professionals who may come across individuals in the early stages of schizophrenia (e.g. nurses, police, social workers), to encourage them to direct patients towards appropriate care.

LAIs can address the key issue of non-adherence, and thereby improve patients’ long-term treatment outcomes and functioning

Dr Grande discussed ways of monitoring patient functioning once they are receiving treatment. Many physicians use the Clinical Global Impression (CGI) or the Global Assessment of Functioning (GAF) scales, as these are quick and simple to use. However, they are limited by the fact that they assess both clinical and functional status in one measure, whereas the Functioning Assessment Short Test (FAST) is designed to assess patient function alone.

LAIs are appropriate and acceptable to a large proportion of patients

Early treatment with long-acting injectable antipsychotics

When treating patients at an early stage of schizophrenia, the presenters and many of the participants at this interactive session agreed that long-acting injectable antipsychotics (LAIs) are the most appropriate treatment for a wide range of patients. We are now moving away from older ways of thinking, in which these drugs were reserved for severely unwell patients with a long history of relapses. Instead, both speakers agreed, LAIs can address the key issue of non-adherence, and thereby improve patients’ long-term treatment outcomes and functioning. The use of these drugs in first-episode schizophrenia can also improve patients’ insight, their social and occupational functioning, and produce fewer side-effects than their oral counterparts. In this way, they can contribute to good symptom control, and increased patient quality of life and ability to achieve their life goals.

Patients are encouraged by other patients’ experiences and clear guidance from physicians

Preference for LAIs or oral medications

When surveyed, patients who preferred LAIs said they did so because they did not want to have to remember to take medication each day, that the regimen was easier to follow than oral treatment, and some said they were less worried about relapsing when using an LAI. This is also a common reason why family members and carers of patients are often happier when the patient is taking an LAI. Patients who preferred an oral medication commonly did so because they did not want to have injections. Dr Emborg advised that this reluctance was best addressed in patient groups, by discussions with other patients already receiving LAIs. She also cautioned that a significant barrier to the early use of LAIs lies not in the patient but in the multidisciplinary team. If some of the healthcare professionals working with a patient are ambivalent about the use of LAIs, then the patient will respond to that ambivalence. So, she recommended clear and strong guidance of patients using the therapeutic alliance.

Early intervention in schizophrenia can be achieved and sustained by engaging with the patient and their family

 

In conclusion, early intervention in schizophrenia can be achieved and sustained by engaging with the patient and their family. Moreover, the use of LAIs is appropriate and acceptable to a large proportion of patients, and produces better long-term treatment outcomes.

 

Educational financial support provided by Otsuka Pharmaceutical Development and Commercialization, Inc and H. Lundbeck A/S

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