Schizophrenia 16 Nov, 2021 Read Time: 6 mins

Überbrückung der Therapietreue zur funktionellen Genesung bei Schizophrenie

Non-adherence to treatment is a key issue in people with schizophrenia and can hold back response, remission and functional recovery goals. In an Otsuka and Lundbeck sponsored Satellite Symposium at the 34th European College of Neuropsychopharmacology Congress in Lisbon, Portugal, Dr Charlotte Emborg Mafi, from Aarhus University Hospital, Denmark; Professor Eric Achtyes, from Michigan State University College of Human Medicine, USA; Dr Daniel Schöttle, from the University Medical Center Hamburg-Eppendorf (UKE), Germany; and Professor Philip Gorwood, from GHU Paris Psychiatry and Neurosciences, France discussed how early intervention and treatment can help aid adherence and lead to functional recovery for people with schizophrenia.

Treatment success for people with schizophrenia can be defined first by response,1 then remission2 and finally by functional recovery.3 Optimizing functioning and health-related quality-of-life are important treatment goals and should be tailored to each patient’s needs and goals.4

Treatment success for people with schizophrenia means not only response, but also functional recovery

 

Myth: How can we improve our practice in the treatment of schizophrenia?

Medication non-adherence, discussed Dr Emborg Mafi, is associated with relapse,5 with consequences in disease progression, worsening relationships and overall functioning.6,7

  • In one study the hazard ratio for first relapse in non-adherent versus adherent patients was 4.89 [95% confidence interval 2.49−9.60].5

Non-adherence can start almost immediately.

  • Another study of 2,588 patients following discharge from first hospitalization found that 54.3% were non-adherent in the first month.8

With this in mind, Dr Emborg Mafi discussed how recovery rates for people with schizophrenia can be significantly enhanced by early psychosis detection and intervention services.9

The use of early psychosis detection and intervention services can significantly enhanced recovery rates for people with schizophrenia

Early use of long-acting injectables (LAIs), compared with oral formulations, may also improve outcomes including:7

  • Relapse rates
  • Hospitalizations
  • Illness-related complications/comorbidities
  • Medical resource use

However, LAIs are not widely used in early schizophrenia, potentially due to:10

  • Overestimation of patient adherence
  • Bias against injections inadequate training
  • Belief that LAIs are not appropriate at this time

 

Fact: What do clinical trials say? “The sooner, the better”

Early use of a long-acting injectable antipsychotic treatment may improve relapse rates, hospitalizations and illness-related complications

Professor Achtyes described how in a 52-week study, use of a LAI (n=269) led to long-term control of positive and negative symptoms and a significantly longer time to impending relapse versus placebo (n=134).11

Another study compared a LAI (n=234) to Clinician’s Choice (CC) (n=235) in patients aged 18−35 years with <5 years antipsychotic use.12

Results included a 44% reduction in incidence rate of first hospitalization with the LAI compared with CC, translating to seven patients needing to receive the LAI to prevent one additional hospitalization, compared with CC.12

In this study, key to patient recruitment success into the LAI arm was prescriber training that included specific education regarding LAIs and discussion of shared decision-making principles.10,12

 

Reality: What do real-world studies say? “It really works”

Dr Schöttle discussed how ‘real world’ studies can be complementary to clinical trials and address knowledge gaps.13

He highlighted his 6-month non-interventional, prospective, multicenter study in Germany following patients who switched from oral treatment to a LAI.14

Overall, this treatment was associated with improved clinical outcomes, including in psychosocial functioning and well-being.14

  • Improvements in psychosocial functioning were more pronounced in younger patients (aged ≤35 years vs >35 years), supporting the use of early intervention as a means of improving outcomes.

Real-world studies confirm the utility of long-acting injectables and show improvements in psychosocial functioning and well-being

Tolerability of the LAI was rated as ‘good’ or ’very good’ by almost all patients and clinicians.14

The results reported are consistent with clinical trials with LAIs, demonstrating that the outcomes can be reproduced in real-world settings with heterogeneous patient populations.14

 

Catch: Is symptom control enough for patients with schizophrenia?

Better treatment adherence can contribute to functional recovery

Schizophrenia, discussed Professor Gorwood, is associated with wide-ranging functional disability in social functioning; vocational outcomes; independent living; and physical fitness.15 Factors contributary to achieving functional recovery include:16

  • Fewer negative symptoms and briefer psychotic episodes
  • Higher cognitive performance and no comorbid substance abuse
  • Better treatment adherence and family support
  • More comprehensive treatment and a good therapeutic relationship

Professor Gorwood highlighted how that for functional recovery, clinical recovery and remission should be achieved. For instance, in a 12-month prospective observational study he led that included early-to-mid stage patients with schizophrenia treated with an LAI, of those achieving functional remission (n=226), 72% also achieved clinical remission and only 14.9% did not.21

Assessment tools can be used to help measure and track functional remission17−20

 

Educational financial support for this webinar was provided by Otsuka Pharmaceuticals Europe Limited and H. Lundbeck A/S.

 

 

References

1.       Correll CU, et al. Quantifying Clinical Relevance in the Treatment of Schizophrenia.  Clin Ther 2011; 33: B16−39.

2.       Lambert M, et al.  Remission in schizophrenia: Validity, frequency, predictors, and patients' perspective 5 years later. Dialogues Clin Neurosci 2010; 12: 393−407.

3.       Harvey PD, Bellack AS. Toward a terminology for functional recovery in schizophrenia: is functional remission a viable concept? Schizophr Bull 2009; 35: 300−306.

4.       Hasan A, et al. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 2: Update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects. World J Biol Psychiatry 2013; 14: 2−44.

5.       Robinson D, et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 1999; 56: 241−247.

6.       Emsley R, et al. The evidence for illness progression after relapse in schizophrenia. Schizophr Res 2013; 148: 117−121.

7.       Stevens, et al. Clinical benefits and impact of early use of long-acting injectable antipsychotics for schizophrenia. Early Interv Psychiatry 2016; 10: 365−377.

8.       Tiihonen J, et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry 2011; 168: 603−609.

9.       Correll CU, et al. Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Psychiatry 2018; 75: 555−565.

10.   Kane JM, et al. Patients With Early-Phase Schizophrenia Will Accept Treatment With Sustained-Release Medication (Long-Acting Injectable Antipsychotics): Results From the Recruitment Phase of the PRELAPSE Trial. J Clin Psychiatry 2019; 80: 18m12546

11.   Kane JM, et al. Aripiprazole intramuscular depot as maintenance treatment in patients with schizophrenia: a 52-week, multicenter, randomized, double-blind, placebo-controlled study. J Clin Psychiatry 2012; 73: 617−624.

12.   Kane JM, et al. Effect of Long-Acting Injectable Antipsychotics vs Usual Care on Time to First Hospitalization in Early-Phase Schizophrenia: A Randomized Clinical Trial. JAMA Psychiatry 2020; 77: 1217−1224.

13.   Sherman RE, et al. Real-World Evidence - What Is It and What Can It Tell Us?.  N Engl J Med 2016; 375: 2293−2297.

14.   Schöttle D, et al. The use of long-acting Aripiprazole in a multi-center, prospective, uncontrolled, open-label, cohort study in Germany: a report on global assessment of functioning and the WHO wellbeing index.  BMC Psychiatry 2020; 20: 77.

15.   Harvey PD, et al. Prediction of disability in schizophrenia: Symptoms, cognition, and self-assessment. J Exp Psychopathol 2019; 10: 2043808719865693.

16.   Silva MA, Restrepo D.  Functional Recovery in Schizophrenia. Rev Colomb Psiquiatr (Engl Ed) 2019; 48: 252−260.

17.   Llorca PM, et al. The "Functional Remission of General Schizophrenia" (FROGS) scale: development and validation of a new questionnaire. Schizophr Res 2009; 113: 218−225.

18.   Amri I, et al. Minimum Clinically Important Difference in the Global Assessment Functioning in Patients with Schizophrenia. Value Health 2014; 17: A765−766.

19.   Morosini PL, et al. Development, reliability and acceptability of a new version of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS) to assess routine social functioning. Acta Psychiatr Scand 2000; 101: 323−329.

20.   Barak Y, et al.Psychosocial remission in schizophrenia: developing a clinician-rated scale. Compr Psychiatry 2010; 51: 94−98.

21.   Gorwood P, et al. Predictive factors of functional remission in patients with early to mid-stage schizophrenia treated by long acting antipsychotics and the specific role of clinical remission. Psychiatry Res 2019; 281: 112560.