Definitions and drivers of relapse in patients with schizophrenia: a systematic literature review

Psychometric evaluation of the illness perception questionnaire for schizophrenia in a Chinese population

BACKGROUND

Illness perceptions have been associated with patients' reactions to health threats and further health outcomes. The Illness Perception Questionnaire for Schizophrenia (IPQS)¹ has been applied in different contexts. However, the validity and reliability of IPQS remain unknown in mainland China.

AIMS AND OBJECTIVES

To test the psychometric properties of the Chinese version of IPQS in mainland China.

DESIGN

A cross-sectional survey.

METHODS

A total of 200 community-dwelling patients with schizophrenia were surveyed in Beijing, China. The validity and reliability of the instrument were tested. As well as demographic data, the IPQS and the Knowledge About Schizophrenia Test (KAST)² were also administered.

RESULTS

Factor analysis was utilised to refine the factor structure of the IPQS. The difference between IPQS and KAST denoted the discriminant validity. The subscale scores among patients of different illness duration, educational attainment, and medication adherence in the past two years were significantly different (P＜0.05), indicating the known-group validity of the IPQS. Except for 'personal control' and 'burdensome effect', other subscales were internally consistent. Most of the subscales proved stable over a four-week period.

CONCLUSION

The Chinese version of IPQS can be used, with some refinements, to assess illness perceptions about schizophrenia for patients in future studies. This will provide empirical evidence for its generalizability and clinical utility and provide deeper insight into Chinese patients' illness perceptions about schizophrenia.

Chronic physical illnesses in patients with schizophrenia spectrum disorders are independently associated with higher rates of psychiatric rehospitalization; a cross-sectional study in Croatia

Background:

Increased physical morbidity in patients with schizophrenia spectrum disorders (SSDs) is well documented. However, much less is known about the association between somatic comorbidities and psychosis treatment outcomes.

Subjects and methods:

This cross-sectional study, nested within the larger frame of a prospective cohort study, was done in 2016 at Psychiatric Hospital Sveti Ivan, Zagreb, Croatia. Data were collected on a consecutive sample of 301 patients diagnosed with schizophrenia spectrum disorders who achieved a stable therapeutic dosage. Key outcome was the number of psychiatric rehospitalizations since diagnosis of the primary psychiatric illness. Predictors were number of physical and psychiatric comorbidities. By robust regression, we controlled different clinical, sociodemographic, and lifestyle confounding factors.

Results:

The number of chronic somatic comorbidities was statistically significantly associated with a larger number of psychiatric rehospitalizations, even after the adjustment for number of psychiatric comorbidities and large number of other clinical, sociodemographic, and lifestyle variables.

Conclusions:

Chronic somatic comorbidities are associated with higher rates of psychiatric rehospitalization independently of psychiatric comorbidities and other clinical, sociodemographic, and lifestyle factors. Therefore, to treat psychosis effectively, it may be necessary to treat chronic somatic comorbidities promptly and adequately. Chronic somatic comorbidities should be considered equally important as the SSD, and should be brought to the forefront of psychiatric treatment and research with the SSD as one entity. The integrative approach should be the imperative in clinical practice.

Defining Treatment Response, Remission, Relapse, and Recovery in First-Episode Psychosis: A Survey among Korean Experts

OBJECTIVE

For the proper treatment of first-episode psychosis, assessment of treatment response, remission, relapse, and recovery is important. Therefore, the present study aimed to develop operational definitions of clinical outcomes in first-episode psychosis.

METHODS

A questionnaire was developed by a panel of experts and underwent three revisions. The final survey was presented to 150 psychiatrists who were members of the Korean Society for Schizophrenia Research. Respondents selected factors that they believed were important to consider while defining treatment response, remission, relapse, and recovery using a 6-point Likert scale. Selected factors that constituted each definition were statistically extracted, and operational definitions were developed.

RESULTS

A total of 91 experts responded to the survey. The extent of reduction in psychopathology, socio-occupational functioning, and duration of each state were the core factors of each definition. Outcomes obtained from discussions and consultations by experts have been summarized and proposed.

CONCLUSION

The criteria developed in this survey tended to be somewhat stricter than those used by other studies. The fundamental reason for this is that this survey focused on first-episode psychosis. A better understanding of each definition in first-episode psychosis is necessary to improve effective treatment outcomes.

Effectiveness of Family Intervention for Preventing Relapse in First-Episode Psychosis Until 24 Months of Follow-up: A Systematic Review With Meta-analysis of Randomized Controlled Trials

BACKGROUND

Relapse risk during the early years of first-episode psychosis (FEP) considerably increases the risk of chronicity. The effectiveness of family intervention for psychosis (FIp) for preventing relapse after FEP remains unknown. We assessed the effectiveness of FIp until 24 months of follow-up for preventing relapse and other relapse-related outcomes in patients following FEP.

METHODS

We searched the Cochrane, PubMed, PsycINFO, and ProQuest databases in June 2018. A systematic review with meta-analysis of randomized controlled trials (RCTs), sensitivity analyses, and publication bias were performed, comparing to treatment as usual (TAU) or TAU plus other psychosocial interventions. Outcomes assessed were relapse rates, duration of hospitalization, psychotic symptoms, and functionality. Risk ratios (RRs) and (standardized) mean differences (SMD; MD) were calculated.

RESULTS

Of the 2109 records retrieved, 14 (11 RCTs) were included. Pooled results showed that FIp was effective for preventing relapse (RR = 0.42; 95% CI = 0.29 to 0.61) compared to TAU and/or other psychosocial interventions. It also proved effective when compared to TAU alone (RR = 0.36) and TAU plus other psychosocial interventions (RR = 0.48). FIp showed benefits in reducing duration of hospitalization (TAU, MD = -3.31; other interventions, MD = -4.57) and psychotic symptoms (TAU, SMD = -0.68), and increased functionality (TAU, SMD = 1.36; other interventions, SMD = 1.41).

CONCLUSIONS

These findings suggest that FIp is effective for reducing relapse rates, duration of hospitalization, and psychotic symptoms, and for increasing functionality in FEP patients up to 24 months. The study's main limitations were the inclusion of published research only; authors were not contacted for missing/additional data; and high heterogeneity regarding relapse definition was observed.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Transitioning from oral risperidone or paliperidone to once-monthly paliperidone palmitate: a real-world analysis among Veterans Health Administration patients with schizophrenia who have had at least one prior hospitalization

Objective: To address gaps in the literature on healthcare resource utilization (HRU) and costs among patients with schizophrenia and prior hospitalization who transition from oral risperidone or paliperidone (oral ris/pali) to once-monthly paliperidone palmitate (PP1M) in a real-world setting by comparing treatment patterns, HRU, and costs 12-months pre- and post-transition to PP1M among Veterans Health Administration (VHA) patients affected by schizophrenia who have had ≥1 hospitalization.Methods: VHA patients with schizophrenia (aged ≥18 years) who initiated oral ris/pali, had ≥1 all-cause inpatient stay, and transitioned to PP1M from January 2015-March 2017 were included from the VHA database. The first transition date to PP1M was identified as the index date. Patients were required to have continuous health plan eligibility for 12 months pre- and post-PP1M. Outcomes were compared using the Wilcoxon signed-rank and McNemar's test, as appropriate.Results: The study included 319 patients (mean [SD] age = 51.6 [4.2] years) during 12 months of baseline and follow-up. During pre-PP1M transition, 7.2% of the patients were adherent (proportion of days covered [PDC] ≥ 80%) to oral ris/pali. Post-PP1M transition, 27.6% of the patients were adherent to PP1M. Comparison of HRU outcomes from the pre- to post-PP1M transition revealed significantly lower all-cause inpatient stays (3.5 vs 1.4, p < .0001) and shorter inpatient length of stay (43.4 vs 18.3 days, p < .0001). Similar trends were seen for mental health and schizophrenia-related HRU. Cost outcome comparison indicated significantly lower all-cause inpatient costs ($64,702 vs $24,147, p < .0001), total medical costs ($87,917 vs $56,947, p < .0001), and total costs ($91,181 vs $69,106, p < .0001). A similar trend was observed for mental health and schizophrenia-related costs.Conclusions: Transitioning from oral ris/pali to PP1M may significantly improve HRU and provide potential cost savings in VHA patients with schizophrenia and ≥1 prior hospitalization.

Detecting relapse in youth with psychotic disorders utilizing patient-generated and patient-contributed digital data from Facebook

Although most patients who experience a first-episode of psychosis achieve remission of positive psychotic symptoms, relapse is common. Existing relapse evaluation strategies are limited by their reliance on direct and timely contact with professionals, and accurate reporting of symptoms. A method by which to objectively identify early relapse warning signs could facilitate swift intervention. We collected 52,815 Facebook posts across 51 participants with recent onset psychosis (mean age = 23.96 years; 70.58% male) and applied anomaly detection to explore linguistic and behavioral changes associated with psychotic relapse. We built a one-class classification model that makes patient-specific personalized predictions on risk to relapse. Significant differences were identified in the words posted to Facebook in the month preceding a relapse hospitalization compared to periods of relative health, including increased usage of words belonging to the swear (p < 0.0001, Wilcoxon signed rank test), anger (p < 0.001), and death (p < 0.0001) categories, decreased usage of words belonging to work (p = 0.00579), friends (p < 0.0001), and health (p < 0.0001) categories, as well as a significantly increased use of first (p < 0.0001) and second-person (p  < 0.001) pronouns. We additionally observed a significant increase in co-tagging (p < 0.001) and friending (p < 0.0001) behaviors in the month before a relapse hospitalization. Our classifier achieved a specificity of 0.71 in predicting relapse. Results indicate that social media activity captures objective linguistic and behavioral markers of psychotic relapse in young individuals with recent onset psychosis. Machine-learning models were capable of making personalized predictions of imminent relapse hospitalizations at the patient-specific level.

Are we getting any better at staying better? The long view on relapse and recovery in first episode nonaffective psychosis and schizophrenia

Relapse in, and recovery from, schizophrenia has been acknowledged since the disease was first described. In this review the authors summarize the long-term (>100 years) data on relapse and recovery in schizophrenia by reviewing the extant older and modern relevant literature. The authors systematically question the utility of pharmacological and nonpharmacological interventions, with an emphasis on first episode nonaffective psychosis. The method used is a narrative review of earlier meta-analytic and systematic reviews. Antipsychotic medication discontinuation studies suggest a role for prophylactic maintenance treatment in the majority of people with schizophrenia, despite recent debate on this subject. The authors conclude that long-term outcomes, including relapse and recovery rates, have improved in the last 100 years, though prospectively identifying those people who do not require long-term antipsychotic treatment has not yet been possible. Data also suggests that interventions and outcomes during the first 5 years of the disease can influence the long-term schizophrenia trajectory.

Relationship between Caregiver Burden and Expressed Emotion in Families of Schizophrenic Patients

BACKGROUND:

Schizophrenia is a clinical syndrome that is variable, but highly disturbing; its psychopathology involves cognition, emotion, perception, and other aspects of behaviour. Schizophrenic patients who are hospitalised, who return to a family environment characterised by high levels of criticism, excessive emotional involvement, or hostility (referred to as high expressed emotion) are more likely to experience the recurrence than schizophrenic patients returning to families characterised by low expressed emotion.

AIM:

We aimed to investigate the level of care load in the families of schizophrenic patients.

METHODS:

This research is an analytic study with a cross-sectional approach. The research site is in the outpatient installation of BLUD Mental Health Hospital of North Sumatra Province using consecutive non-probability sampling. The samples are family members who carry schizophrenic patients go to an outpatient installation at the BLUD Mental Health Hospital of North Sumatra Province that meets the inclusion and exclusion criteria.

RESULTS:

The burden of care for the families of the most schizophrenic patients was mid load as many as 36 people, namely 36%, the light burden of 34 people, 34%, no burden of 18 people, 18%, and the heavy burden of 12 people, 12%. There is a significant relationship between the burden of treatment with expressed emotion, which is 0.004 (p < 0.05).

CONCLUSION:

In this study, we showed a significant relationship between the burden of treatment with expressed emotion (p = 0.004). This study is by the study conducted by Darwin in 2013, and Carra in 2012, which showed that there was a significant relationship between the burden of treatment with expressed emotion in the families of schizophrenic patients. Other studies also show that the burden of care has an impact on emotional, physical health, social life, and financial status as a result of caring for sick people.

Mirror image study (10 years of follow-up and 10 of standard pre-treatment) of psychiatric hospitalizations of patients with severe schizophrenia treated in a community-based, case-managed programme

OBJECTIVES

To determine the psychiatric hospitalizations of patients with severe schizophrenia before (standard treatment in mental health centres) and during treatment in a comprehensive, community-based, case- managed programme, as well as the role played by antipsychotic medication (oral or long-acting injectable).

METHOD

Observational, mirror image study of ten years of follow-up and ten retrospectives ('pre-treatment': standard), of patients with severe schizophrenia in a community-based programme, with pharmacological and psychosocial integrated treatment and intensive case management (n=344). Reasons for discharge from the programme and psychiatric hospital admissions (and whether they were involuntary) were recorded ten years before and during treatment, as well as the antipsychotic medication prescribed.

RESULTS

The retention achieved in the programme was high: after 10 years only 12.2% of the patients were voluntary discharges vs 84.3% on previous standard treatment. The number of patients with hospital admissions, and number of admissions due to relapses decreased drastically after entering the programme (p<0,0001), as well the involuntary admissions (p<0,001). Being on long-acting injectable antipsychotic medication was related with these results (p<0,0001).

CONCLUSIONS

Treatment of patients with severe schizophrenia in a comprehensive, community-based and case-managed programme achieved high retention rates, and was effective in drastically reducing psychiatric hospitalizations compared to the previous standard treatment in mental health units. Undergoing treatment with long-acting injectable antipsychotics was clearly linked to these outcomes.

Human health benefit and burden of the schizophrenia health care pathway in Belgium: paliperidone palmitate long-acting injections

Background

Environmental impact assessments of pharmaceuticals typically consider only a part of the pharmaceutical supply chain, e.g. tablet formulation. While the environmental impact can be expressed in environmental Human Health burden due to resource use and emissions, the Human Health benefit of the pharmaceutical treatment of patients is currently not simultaneously taken into account. The study aims include a cradle-to-grave assessment of all Human Health impacts of the production, administration and disposal of two antipsychotics for the treatment of schizophrenia. This is complemented with the environmental impact of health care providers such as hospitals. The aim is to holistically quantify to what extent the environmental Human Health burden compares to the Human Health benefit associated with the treatment.

Methods

We applied an overall framework which included Life Cycle Assessment to model the environmental Human Health impacts of the pharmaceutical supply chain, administration and disposal of the drug and health care providers. To model the patient benefit, this was complemented with a Markov model with a 1-year time horizon. Three patient groups were modeled: medicine coverage of paliperidone palmitate for either one month (PP1M) or three months (PP3M) at a time, and compared to Treatment Interruption (TI) as a control group. Outcomes were quantified using Years of Life Lost (YLL), Years Lived with Disability (YLD) and Disability-Adjusted Life Years (DALY).

Results

The main environmental impacts were visits to the psychiatrist and psychiatric hospitals. The pharmaceutical supply chain had a limited impact. For 1000 patients for 1 year, PP1M and PP3M respectively avoided 0.38 and 0.49 environmental DALYs compared to TI. PP1M and PP3M further avoided 45.60 and 57.87 YLL and 23.31 and 29.91 YLD compared to TI. The main outcome was the sum of environmental DALYs, YLL and YLD, in which PP1M and PP3M respectively avoided 69.29 and 88.26 DALYs. Alternative analysis of Quality-Adjusted Life Years confirmed the results.

Conclusions

The overall environmental burden was lower for PP1M and PP3M treatment than Treatment Interruption because patients are kept more stable, which reduces the environmental burden due to hospitals. Moreover, the Human Health burden was outweighed by the Human Health benefit.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4247-2) contains supplementary material, which is available to authorized users.

Machine learning for predicting psychotic relapse at 2 years in schizophrenia in the national FACE-SZ cohort

BACKGROUND

Predicting psychotic relapse is one of the major challenges in the daily care of schizophrenia.

OBJECTIVES

To determine the predictors of psychotic relapse and follow-up withdrawal in a non-selected national sample of stabilized community-dwelling SZ subjects with a machine learning approach.

METHODS

Participants were consecutively included in the network of the FondaMental Expert Centers for Schizophrenia and received a thorough clinical and cognitive assessment, including recording of current treatment. Relapse was defined by at least one acute psychotic episode of at least 7 days, reported by the patient, her/his relatives or by the treating psychiatrist, within the 2-year follow-up. A classification and regression tree (CART) was used to construct a predictive decision tree of relapse and follow-up withdrawal.

RESULTS

Overall, 549 patients were evaluated in the expert centers at baseline and 315 (57.4%) (mean age = 32.6 years, 24% female gender) were followed-up at 2 years. On the 315 patients who received a visit at 2 years, 125(39.7%) patients had experienced psychotic relapse at least once within the 2 years of follow-up. High anger (Buss&Perry subscore), high physical aggressiveness (Buss&Perry scale subscore), high lifetime number of hospitalization in psychiatry, low education level, and high positive symptomatology at baseline (PANSS positive subscore) were found to be the best predictors of relapse at 2 years, with a percentage of correct prediction of 63.8%, sensitivity 71.0% and specificity 44.8%. High PANSS excited score, illness duration <2 years, low Buss&Perry hostility score, high CTQ score, low premorbid IQ and low medication adherence (BARS) score were found to be the best predictors of follow-up withdrawal with a percentage of correct prediction of 52.4%, sensitivity 62%, specificity 38.7%.

CONCLUSION

Machine learning can help constructing predictive score. In the present sample, aggressiveness appears to be a good early warning sign of psychotic relapse and follow-up withdrawal and should be systematically assessed in SZ subjects. The other above-mentioned clinical variables may help clinicians to improve the prediction of psychotic relapse at 2 years.

Long-acting atypical antipsychotics in schizophrenia: A systematic review and meta-analyses of effects on functional outcome

OBJECTIVE

Impairment in psychosocial function is common in schizophrenia. Long-acting injectable atypical antipsychotics are thought to enhance psychosocial function by boosting adherence. However, no systematic review has examined the effects of long-acting injectable atypical antipsychotics on psychosocial function in clinical trials.

METHODS

We searched major databases including Medline/PubMed, PsychINFO, EMBASE, CINAHL, Scopus, Web of Science, Cochrane Central Register of Controlled Trials and Clinical Trial Registries for randomised controlled trials that compared long-acting injectable atypical antipsychotics to placebo, oral antipsychotic medications or long-acting injectable atypical antipsychotics for all years till 2018, with no language limits. We performed a systematic review of findings on change in psychosocial function and its predictors in the included reports. Data on change in psychosocial functioning were meta-analysed using a random-effects model.

RESULTS

A total of 26 studies were included in systematic review, and 19 studies with 8616 adults, 68.1% males were meta-analysed. Long-acting injectable atypical antipsychotics were superior to placebo (standardised mean difference = 0.39; 95% confidence interval = [0.32, 0.47]; p < 0.001; I² = 0%; 9 studies) and oral antipsychotic medications (standardised mean difference = 0.16; 95% confidence interval = [0.01, 0.31]; p = 0.04; I² = 77%; 10 studies) for improved psychosocial function and superiority was maintained in short- and long trials. Poor psychosocial function was predicted by longer treatment duration, severe symptoms, poor cognition and poor insight. Functioning was assessed by either a single or a combination of measures, but was not the primary outcome in most studies. Other sources of bias include poor blinding and reporting of randomisation.

CONCLUSION

Long-acting injectable atypical antipsychotics are beneficial for recovery of psychosocial function in comparison with placebo, but the magnitude of superiority over oral antipsychotic treatment was small. Severe psychopathology at baseline predicted poor psychosocial function. Future effectiveness trials in which post-randomisation involvement is kept to a minimum, and psychosocial function is included as primary outcome a priori, are needed to capture the real-world impact of long-acting injectable atypical antipsychotics and to address methodological biases.

Feasibility of using a smartphone app to assess early signs, basic symptoms and psychotic symptoms over six months: A preliminary report

BACKGROUND

Psychosis relapses are common, have profound adverse consequences for patients, and are costly to health services. 'Early signs' have been used to predict relapse, in the hope of prevention or mitigation, with moderate sensitivity and specificity. We investigated the feasibility and validity of adding 'basic symptoms' to conventional early signs and monitoring these using a smartphone app.

METHODS

Individuals (n = 18) experiencing a relapse within the past year were asked to use a smartphone app ('ExPRESS') weekly for six months to report early signs, basic symptoms and psychotic symptoms. Above-threshold increases in app-reported psychotic symptoms prompted a telephone interview (PANSS positive items) to assess relapse.

RESULTS

Participants completed 65% app assessments and 58% telephone interviews. App items showed high concurrent validity with researcher-rated psychotic symptoms and basic symptoms over six months. There was excellent agreement between telephone call and face-to-face assessed psychotic symptoms. The primary relapse definition, based on telephone assessment and casenotes, compared well with a casenote-only definition but had better specificity. Mixed-effects models provided preliminary evidence of concurrent and predictive validity: early signs and basic symptoms were associated with most app-assessed psychotic symptom variables the same week and with a number of psychotic symptoms variables three weeks later; adding basic symptoms to early signs improved model fit in most of these cases.

CONCLUSIONS

This is the first study to test a smartphone app for monitoring early signs and basic symptoms as putative relapse predictors. It demonstrates that weekly app-based monitoring is feasible, valid and acceptable over six months.

Association between prior somatic disease and 5-year relapse risk among 11,856 incident patients with schizophrenia

BACKGROUND

Somatic diseases have been associated with an increased risk for subsequent schizophrenia; however, it is unknown whether prior somatic diseases negatively affect early treatment outcomes after a first-time schizophrenia diagnosis.

METHODS

We included all individuals born in Denmark after January 1^st, 1977 and first-time diagnosed with schizophrenia between January 1^st, 1996 and December 31^st, 2015. We identified all life-time somatic hospital contacts and all prescriptions within the year before the first-time schizophrenia diagnosis and followed patients for up to five years regarding risk for schizophrenia (re)-hospitalization (relapse). We performed Cox regression analyses calculating hazard rate ratios (HRR) including 95%-confidence intervals (CI) and adjusted for relevant confounders.

RESULTS

We followed a total of 11,856 patients with a first-time schizophrenia diagnosis (58.7% male, mean age 23.1 (SD = 4.7) years) for 39,033 person-years, whereof 5506 (46.4%) had relapse with schizophrenia re-hospitalization during 5-year of follow-up. Somatic hospital contacts ever before (95.4%; HRR = 1.30; 95%-CI = 1.07-1.59), and specifically during the year before schizophrenia diagnosis (42.5%; HRR = 1.36; 95%-CI = 1.11-1.66) were associated with an increased risk of schizophrenia relapse as were a greater number of prior somatic hospital contacts (p < 0.001). Individuals with up to four different prescriptions for somatic medications showed a trend towards a slightly lower risk of relapse.

CONCLUSION

Somatic diseases and health seeking patterns might have an impact on the course of schizophrenia, where severe somatic comorbidity, specifically during the year before first-time schizophrenia diagnosis, seem to negatively affect early treatment course, whereas previous somatic medication use may indicate a better compliance and help-seeking behavior.

A potential role for adjunctive omega-3 polyunsaturated fatty acids for depression and anxiety symptoms in recent onset psychosis: Results from a 16 week randomized placebo-controlled trial for participants concurrently treated with risperidone

Omega-3 treatment studies for multi-episode schizophrenia or clinical high risk for conversion to psychosis states have had variable, and often negative, results. To examine adjunctive omega-3 treatment for recent onset psychosis, participants aged 15-40 years with recent onset schizophrenia-spectrum (n = 46) or bipolar (n = 4) disorders and current psychotic symptoms were treated for 16 weeks with risperidone and randomly-assigned omega-3 (EPA 740 mg and DHA 400 mg daily) or matching placebo. The primary outcome measure was the Brief Psychiatric Rating Scale (BPRS) total score. Mean lifetime antipsychotic exposure was 18.1 days. Length of time in treatment, risperidone dose and number of omega-3/placebo capsules taken did not differ between conditions. Longitudinal analysis of the total BPRS score revealed a trend level (p = 0.0826) treatment effect favoring omega-3 treatment. Lorazepam was an allowed concomitant medication. Among the subgroup (N = 23) who did not receive lorazepam, the treatment effect on BPRS total scores favoring omega-3 was significant (p = 0.0406) and factor scores analyses revealed a substantial decrease in depression-anxiety with omega-3 but no change with placebo (treatment-by-time interaction, p = 0.0184). Motor side effects did not differ between conditions. Analysis of Systematic Assessment for Treatment Emergent Events assessments revealed fewer adverse events overall with omega-3 compared with placebo with the largest differences between conditions (all favoring omega-3) on confusion, anxiety, depression, irritability, and tiredness/fatigue. These results suggest that omega-3 adjuvant treatment is a potential option for depression and anxiety symptoms of people with recent onset psychosis. Further research is needed to confirm this potential. Clinical trial registration: NCT01786239.

Expressed emotion and socio-demographic and clinical factors in families of Brazilian patients with schizophrenia

BACKGROUND

Families are the main caregivers of people with schizophrenia. Family dynamic and expressed emotion (EE) of relatives are fundamental determinants on the course of schizophrenia.

METHOD

This study analyzed socio-demographic and clinical factors related to EE components. A total of 94 dyads (patients with schizophrenia and their relatives) were recruited from three mental health clinics. A form containing socio-demographic and clinical variables and the Brazilian version of Family Questionnaire were used and the data were analyzed through regression model.

RESULTS

Results showed that factors such as patients' occupation status and patients' age, as well as relatives' gender and the degree of relatedness, were related to emotional overinvolvement and critical comments levels.

CONCLUSION

This is the first study in the Brazilian cultural context that evaluates EE components and related factors on families of patients with schizophrenia. Other studies concerning EE on different cultural contexts and possible interventions must be carried out to help health professionals to improve patient and family care.

Predictors of achieving remission in schizophrenia patients treated with paliperidone palmitate 3-month formulation

PURPOSE

Long-acting injectable (LAI) antipsychotic paliperidone palmitate 3-month formulation (PP3M) is indicated in the United States for the treatment of schizophrenia only after adequate treatment with paliperidone palmitate 1-month formulation (PP1M) for ≥4 months. This analysis aimed to identify patient and disease characteristics during PP1M treatment associated with greater likelihood of achieving remission after transition to PP3M.

METHODS

A post hoc analysis of a randomized, Phase III, double-blind, noninferiority trial of PP3M vs PP1M (ClinicalTrials.gov identifier: NCT01515423) was conducted in adult patients with schizophrenia. Patients achieving clinical stability after 17 weeks of open-label PP1M were randomized to 48 weeks of double-blind treatment with PP3M or PP1M. The primary objective of this exploratory post hoc analysis was to identify demographic and/or clinical variables associated with persistent remission after treatment with PP3M. Multiple logistic regression analysis identified the following significant predictors of remission: Positive and Negative Syndrome Scale (PANSS) Marder negative symptom factor score, Clinical Global Impression-Severity (CGI-S) total score, and Personal and Social Performance (PSP) total score.

RESULTS

At double-blind baseline, a 1-point reduction in Marder negative symptom factor score was associated with a 20% increase in the odds of achieving remission after PP3M treatment; 1-point reduction in CGI-S was associated with a doubling in remission odds; and 7- and 10-point improvements in PSP scores, respectively, were associated with 42% and 65% increases in remission odds.

CONCLUSION

Patients with early clinically meaningful improvements in disease symptoms and severity while establishing stable PP1M dosage are more likely to achieve remission after transition to PP3M.

Clinical stability, diagnosis and catchment area: the patients of a university-based psychiatric outpatient clinic

ABSTRACT Objective This study aimed to characterize the patients assisted at the general outpatient clinic of the Psychiatry Institute of Universidade Federal do Rio de Janeiro (IPUB-UFRJ) and to assess these patients’ clinical stability. Methods This cross-sectional study collected information using a structured questionnaire filled in by the patient’s physician. The questionnaire, specifically developed for this purpose, included sociodemographic data; the dwelling area; psychiatric diagnosis according to ICD-10; clinical stability assessment by means of five psychiatric instability criteria and the physician’s global clinical impression over the six previous months. Clinical stability was defined as a negative answer to all five pre-defined instability criteria. Results Overall, 1,447 questionnaires were filled in. The sample was composed of 824 (57%) women; with an average age of 49 years; 1,104 (76.3%) patients lived in the city of Rio de Janeiro and 343 (23.7%) lived outside the city; 983 (67.9%) patients had a severe mental disorder (SMD) diagnosis and 946 (65.3%) patients were considered stable. Statistically, the clinical stability by dwelling area did not differ. The most frequent clinical instability criterion was “exacerbation or emergence of acute manifestations of the disease”. Conclusion The major part of the patients displayed a SMD and was considered clinically stable.

Impact of initiating long-acting injectable antipsychotics on hospitalization in patients with bipolar I disorder

Aim: To compare risk of hospitalization in patients with bipolar I disorder (BD-I) initiating long-acting injectable antipsychotics (LAIs). Materials & methods: Using Truven Health Analytics MarketScan® (Medicaid, Commercial and Medicare Supplemental) databases (2012–2016), patients (≥18 years) with BD-I with a LAI (aripiprazole once monthly [AOM 400], fluphenazine-LAI, haloperidol-LAI, risperidone-LAI and paliperidone-4-week-LAI) were identified. Results: The adjusted odds of having hospitalization were significantly higher in haloperidol-LAI (Odds ratio [95% CI]: 1.39 [1.03–1.87] all-cause; p = 0.029; 1.41 [1.03–1.93] psychiatric-specific; p = 0.032) and risperidone-LAI (1.54 [1.12–2.13]; p = 0.009; 1.68 [1.20–2.37]; p = 0.003) users versus AOM 400 users. Risks of hospitalization did not differ comparing fluphenazine-LAI and paliperidone-LAI users with AOM 400 users. Conclusion: AOM 400 may be more beneficial at reducing hospitalization rates in BD-I versus haloperidol-LAI and risperidone-LAI.

Diverse definitions of the early course of schizophrenia-a targeted literature review

Schizophrenia is a debilitating psychiatric disorder and patients experience significant comorbidity, especially cognitive and psychosocial deficits, already at the onset of disease. Previous research suggests that treatment during the earlier stages of disease reduces disease burden, and that a longer time of untreated psychosis has a negative impact on treatment outcomes. A targeted literature review was conducted to gain insight into the definitions currently used to describe patients with a recent diagnosis of schizophrenia in the early course of disease ('early' schizophrenia). A total of 483 relevant English-language publications of clinical guidelines and studies were identified for inclusion after searches of MEDLINE, MEDLINE In-Process, relevant clinical trial databases and Google for records published between January 2005 and October 2015. The extracted data revealed a wide variety of terminology and definitions used to describe patients with 'early' or 'recent-onset' schizophrenia, with no apparent consensus. The most commonly used criteria to define patients with early schizophrenia included experience of their first episode of schizophrenia or disease duration of less than 1, 2 or 5 years. These varied definitions likely result in substantial disparities of patient populations between studies and variable population heterogeneity. Better agreement on the definition of early schizophrenia could aid interpretation and comparison of studies in this patient population and consensus on definitions should allow for better identification and management of schizophrenia patients in the early course of their disease.

Management of depression in patients with schizophrenia spectrum disorders: a critical review of international guidelines

OBJECTIVES

Depression is a frequent but potentially treatable clinical dimension in patients with schizophrenia spectrum disorders (PWS). However, there is a lack of consensual recommendations regarding the optimal strategy to manage depression in PWS. In this study, we aimed to compare the various proposed strategies to define a core set of valid care recommendations for depression management in PWS.

METHODS

After a systematic search of the literature, the methodological quality of 10 international guidelines from four continents was compared using a validated guideline appraisal instrument (AGREE II). Key recommendations for the management of depression in PWS were subsequently reviewed and discussed.

RESULTS

The methodological quality of the guidelines was heterogeneous. Although all guidelines proposed pharmacotherapy, psychosocial interventions were a minor concern. Waiting for antipsychotic effects mostly was recommended during the acute phase of schizophrenia. During the postpsychotic phase of the illness, a switch to a second-generation antipsychotic and/or the adjunction of an antidepressant were the primary recommendations. Cognitive behavioural therapy and other medications were considered with strong variations.

CONCLUSIONS

Further studies are needed to strengthen the level of evidence for antidepressive approaches in PWS. The inclusion of PWS as stakeholders is also considered to be a major issue for future guideline development.

Emoção expressa de familiares e recaídas psiquiátricas de pacientes com diagnóstico de esquizofrenia

RESUMO Objetivo: Avaliar a relação entre recaídas psiquiátricas de pacientes com diagnóstico de esquizofrenia, níveis de emoção expressa de seus familiares e fatores relacionados. Método: Estudo prospectivo, realizado em um serviço ambulatorial de saúde mental e em dois Centros de Atenção Psicossocial, com pacientes e familiares que responderam ao Family Questionnaire − Versão Português do Brasil, um formulário contendo as variáveis sociodemográficas e clínicas e um roteiro estruturado para avaliação de recaídas. Para a análise, utilizou-se do modelo de regressão logística. Resultados: Participaram do estudo 89 díades. Dos pacientes investigados, 31% apresentaram recaídas, e 68% dos familiares, elevada emoção expressa. A relação entre a emoção expressa e as recaídas não foi significativa. A análise de regressão logística mostrou que quanto maior o número de internação nos 2 anos precedentes ao estudo, a chance de o paciente apresentar recaídas no período de 24 meses é de 1,34. Conclusão: A emoção expressa foi insuficiente para predizer recaídas. Assim, as recaídas devem ser compreendidas como um fenômeno multifatorial. Esses resultados fornecem subsídios para intervenções e investigações sobre os múltiplos fatores envolvidos na evolução do paciente com esquizofrenia, acompanhado em serviços de saúde mental de base comunitária.

Comparison of long-acting and oral antipsychotic treatment effects in patients with schizophrenia, comorbid substance abuse, and a history of recent incarceration: An exploratory analysis of the PRIDE study

INTRODUCTION

Comorbid substance abuse is known to blunt response to treatment for underlying psychiatric disorders, but it has not been investigated in schizophrenia when comparing the effects of long-acting injectable antipsychotics with those of oral antipsychotics.

METHODS

This exploratory analysis compared once-monthly paliperidone palmitate (PP1M) with daily oral antipsychotics on time to treatment failure in patients with schizophrenia and a history of incarceration. Subjects were stratified into substance abuse (reported substance or alcohol misuse in the past 30days on the baseline Addiction Severity Index-Lite Version and/or met criteria for a current MINI diagnosis of a substance abuse disorder) and nonabuse cohorts.

RESULTS

In the substance abuse cohort, treatment failure was observed in 56.2% (73/130) and 64.2% (86/134) of subjects in the PP1M and oral antipsychotic groups, respectively. For the nonabuse cohort, treatment failure was observed in 36.5% (35/96) and 53.6% (45/84) of subjects in the PP1M and oral antipsychotic groups, respectively. Median (95% confidence interval [CI]) time to first treatment failure was 291 (179-428) days and 186 (94-296) days in the PP1M and oral antipsychotic groups, respectively. Median (95% CI) time to first treatment failure was >450 and 284 (147 to >450) days in the respective treatment groups.

CONCLUSION

Greater treatment effects were evident with PP1M compared with oral antipsychotics in both cohorts. The observed beneficial effect of PP1M was attenuated in the substance-abuse cohort, further reinforcing both the need for and value of continued research to optimize patient care in these complex patient populations.

Efficacy and safety of aripiprazole lauroxil once-monthly versus aripiprazole once-monthly long-acting injectable formulations in patients with acute symptoms of schizophrenia: an indirect comparison of two double-blind placebo-controlled studies

BACKGROUND

Aripiprazole lauroxil (AL) is a long-acting injectable atypical antipsychotic recently approved for the treatment of schizophrenia.

OBJECTIVE

To indirectly compare the safety and efficacy of AL and aripiprazole once-monthly (AOM).

METHODS

A systematic search was performed to identify randomized, controlled trials of AOM and AL that met criteria for indirect comparison according to Bayesian network meta-analysis. The analysis indirectly compared AL and AOM treatment groups for efficacy by mean change in Positive and Negative Syndrome Scale (PANSS) total score and ≥30% reduction in PANSS total score, as well as tolerability including adverse events, akathisia, and weight gain.

RESULTS

Two studies were selected, resulting in three active-treatment groups: AL 441 mg, AL 882 mg, and AOM 400 mg. All active treatments were efficacious compared with placebo. There were no differences in indirect comparisons of akathisia. All three groups showed some weight gain, but only the AOM 400 mg group was significantly greater than placebo.

CONCLUSIONS

Results of this indirect comparison found that both doses of AL and the single AOM dose were therapeutic and efficacious for the treatment of schizophrenia with a similar safety profile.

Long-term effectiveness of aripiprazole once-monthly for schizophrenia is maintained in the QUALIFY extension study

OBJECTIVE

To evaluate long-term safety and effectiveness of continued treatment with aripiprazole once-monthly 400mg (AOM 400) in patients with schizophrenia.

METHODS

Patients who completed the QUALIFY study (NCT01795547) in the AOM 400 arm were eligible for 6 additional once-monthly injections of AOM 400 during an open-label, 24-week extension (NCT01959035). Safety data were collected at each visit. Effectiveness measures included change from baseline in health-related qualify of life and functioning on the Heinrichs-Carpenter Quality of Life scale (QLS) and Clinical Global Impression - Severity (CGI-S) scale.

RESULTS

Of the 88 patients enrolled, 77 (88%) completed the extension study. Most common treatment-emergent adverse events (incidence ≥2%) were weight increased (6/88, 7%), toothache (3/88, 3%) and headache (3/88, 3%). Effectiveness was maintained during the extension study, with small but continued improvements from baseline: the least squares mean (LSM) change (95% CI) from baseline to week 24 was 2.32 (-1.21 to 5.85) for the QLS total score and -0.10 (-0.26 to 0.06) for the CGI-S score. The aggregated LSM change (95% CI) from baseline of the lead-in study to week 24 of the extension study was 11.54 (7.45 to 15.64) for the QLS total score and -0.98 (-1.18 to -0.79) for the CGI-S score.

CONCLUSIONS

AOM 400 was well tolerated in patients continuing AOM treatment during the extension phase of the QUALIFY study. Robust and clinically meaningful improvements in health-related quality of life and functioning were maintained, further supporting the long-term clinical benefits of AOM 400 for the treatment of patients with schizophrenia.

Adherence, persistence, and inpatient utilization among adult schizophrenia patients using once-monthly versus twice-monthly long-acting atypical antipsychotics

AIMS

This study compared healthcare resource utilization (HRU), healthcare costs, adherence, and persistence among adult patients with schizophrenia using once-monthly (OM) vs twice-monthly (TM) atypical long-acting injectable (LAI) antipsychotic (AP) therapy.

MATERIALS AND METHODS

A longitudinal retrospective cohort study was conducted using Medicaid claims data from six states. Patients initiated on aripiprazole or paliperidone palmitate were assigned to the OM cohort; risperidone-treated patients were assigned to the TM cohort. HRU and healthcare costs were assessed during the first 12 months following stabilization on the medication. Adherence was measured using the proportion of days covered (PDC) during the first year of follow-up. Persistence to the index medication was measured during the first 2 years following the index date. Comparison between the cohorts was achieved using multivariable generalized linear models, adjusting for demographic and clinical characteristics.

RESULTS

Patients in the OM LAI cohort had lower inpatient HRU and medical costs when compared with patients in the TM cohort. Higher medical costs in the TM LAI cohort offset the higher pharmacy costs in the OM LAI cohort. Mean PDC during the first 12 months of follow-up was higher in the OM cohort than in the TM cohort (0.56 vs 0.50, p < .01). Median persistence was longer in the OM cohort than in the TM cohort (7.5 months vs 5.5 months), as was the hazard of discontinuing the index medication (hazard ratio = 0.83, p = .01). Kaplan-Meier rates of persistence at 1 year were higher for OM patients than for TM patients (37.6% vs 29.6%, p < .01).

LIMITATIONS

This was a Medicaid sample with few aripiprazole LAI patients (5.4% of OM cohort). Medication use was inferred from pharmacy claims.

CONCLUSIONS

Among Medicaid patients in these six states, OM AP treatment was associated with lower HRU, better adherence and persistence, and similar total costs compared to patients on TM treatment.

Correlates and predictors of antipsychotic drug polypharmacy in real-life settings: Results from a nationwide cohort study

Reasons for using antipsychotic polypharmacy (APP) in routine clinical practice, despite a potentially unfavorable risk-benefit ratio, are poorly understood. This research aimed to determine (1) if severe courses of schizophrenia were associated with APP and (2) if a schizophrenia-related acute event would predict a switch to APP in the short term. Observational prospective data (at baseline and 6months) were drawn from a French nationwide cohort ("Cohorte Générale Schizophrénie"), which included 1859 inpatients and outpatients with schizophrenia. APP was defined as the prescription of ≥2 antipsychotic drugs (there being different active substances). Early-onset schizophrenia, legal guardianship, higher lifetime maximal severity of illness and comorbid antisocial personality were used as proxies for severe courses of schizophrenia. Schizophrenia-related acute events included hospitalization and recent suicide attempts. Logistic regression models were used to determine (1) whether the use of APP at baseline (vs. monotherapy) was associated with a severe course of schizophrenia or not, independent of acute events, and (2) if a switch to APP at 6months (vs. remaining on monotherapy) was associated with acute events, independent of severe courses of schizophrenia. Increased odds of APP use at baseline were independently associated with legal guardianship (OR=1.6; 95%CI=1.3, 2.0) and higher lifetime maximum severity of illness (OR=1.3; 95%CI=1.2, 1.5). A switch to APP at 6months was predicted by a hospitalization occurring since baseline (OR=6.1; 95%CI=3.9, 9.4). In routine clinical practice, APP is more likely prescribed to patients with severe courses of illness, possibly indicating the difficulty to manage these patients.

The association between mental health nursing and hospital admissions for people with serious mental illness: a protocol for a systematic review

BACKGROUND

Relapse in individuals with severe mental illness (SMI) is a frequent occurrence and can add considerably to the burden of disease. As such, relapse prevention is an essential therapeutic outcome for people with SMI. Mental health nurses (MHNs) are well placed to support individuals with SMI and to prevent relapse; notwithstanding, there has been no synthesis of the evidence to date to determine whether MHNs prevent relapse in this population.

METHODS

Electronic databases will be systemically searched for observational studies and clinical trials that report the association between mental health nursing and the hospitalisation of persons living with an SMI. The search will be supplemented by reference checking and a search of the grey literature. The primary outcome of interest will be hospital admission rate. Screening of articles, data extraction and critical appraisal will be undertaken by two reviewers, independently, with a third reviewer consulted should disagreement occur between reviewers. The quality of studies will be assessed using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool and the Cochrane Collaboration risk of bias tool. Depending on the number of studies and level of heterogeneity, the evidence may be synthesised using meta-analysis or narrative synthesis.

DISCUSSION

This review will explore for the first time the clinical potential of mental health nursing in preventing relapse in persons with SMI. The findings of this review will serve to inform future research and education in this area. The evidence may also help inform future policy, including decisions regarding future mental health workforce development and planning.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017058694 .

Real-world data on paliperidone palmitate for the treatment of schizophrenia and other psychotic disorders: a systematic review of randomized and nonrandomized studies

The aim of this study was to perform a systematic review of the effects of 1-month paliperidone palmitate (PP1M) for the treatment of schizophrenia and related psychotic disorders in terms of outcomes reported in real-world evidence studies. A systematic review of real-world randomized and nonrandomized studies with PP1M was performed and is reported according to PRISMA guidelines. Comparative effectiveness data with oral antipsychotics indicate that PP1M has a lower likelihood of relapse-related events, including rehospitalization, and these differences are clinically relevant. A randomized, double-blind study showed that PP1M has no advantage over haloperidol decanoate in the time to treatment failure. Although there was a marked variability across studies, PP1M was not superior to other antipsychotics in terms of study completion rates. Pharmacoeconomic data show that, during a follow-up period of 12 months, the mean total healthcare cost was not significantly different in patients treated with PP1M compared with those receiving oral antipsychotics. The mean maximum prolactin levels were significantly higher with PP1M than with haloperidol decanoate; however, neither drug differs in the frequency of prolactin-related adverse events. Results on prolactin-related adverse events were inconsistent in two randomized comparisons with oral antipsychotics and were not reported in a randomized comparison with aripiprazole. There were no significant differences between haloperidol decanoate and PP1M in the severity of abnormal involuntary movements and parkinsonism, or in the incidence of tardive dyskinesia; however, patients treated with haloperidol decanoate showed greater worsening of akathisia and required treatment for parkinsonism and akathisia significantly more frequently than patients who received PP1M. In conclusion, real-world data that originate from both pragmatic randomized clinical trials and observational studies indicate that PP1M is superior to oral antipsychotics in delaying the time to relapse or treatment failure. Furthermore, the pharmacoeconomic data reviewed for this article suggest that the advantages of PP1M compared with oral antipsychotics are not associated with an increased total cost for healthcare providers.

All-cause hospitalization and associated costs in patients with schizophrenia or bipolar disorder initiating long-acting injectable antipsychotics

OBJECTIVE

To compare all-cause hospitalization and associated costs among patients with schizophrenia or bipolar disorder (BD) treated with long-acting injectable antipsychotics (LAIs).

METHODS

The Truven MarketScan Medicaid claims database was used to identify patients with schizophrenia; MarketScan Medicaid and commercial claims databases were used to identify BD. Adult patients with ≥1 LAI claim from January 1, 2013-June 30, 2014 (ID period) were identified. The first day of LAI initiation was the index date; patients were followed for ≥1 year. Logistic and general linear regression models were used to estimate the risk of hospitalization and associated costs.

RESULTS

Adjusted analyses showed that, in the schizophrenia cohort, risks of hospitalization were statistically significantly higher in the haloperidol [OR (95% CI) = 1.51 (1.05-2.16); HR (95% CI) = 1.35 (1.05-1.73)] and risperidone [OR (95% CI) = 1.58 (1.07-2.33); HR (95% CI) = 1.33 (1.01-1.74)] cohorts than in the aripiprazole once monthly extended release (AOM 400) cohort. Similarly, in patients with BD, risks of hospitalization were significantly higher in haloperidol [OR (95% CI) = 1.49 (1.01-2.19); HR (95% CI) = 1.33 (1.03-1.73)] and risperidone [OR (95% CI) = 1.78 (1.19-2.66); HR (95% CI) = 1.33 (1.01-1.75)] than in AOM400. No statistically significant differences in hospitalization costs were observed in either disease group.

CONCLUSIONS

Although the study results may be subject to confounding variables that are not contained in claims databases, such as disease severity, it appears that AOM400 may be more effective than haloperidol and risperidone LAIs among patients with schizophrenia or BD.

The Relationship Between Expressed Emotion and the Probability of Suicide Among Turkish Psychiatric Outpatients: A Descriptive Cross-sectional Survey

The purpose of this study is to examine expressed emotion and the relationship between expressed emotion and suicide probability in psychiatric outpatients (N = 350). Patients who did not receive support from anyone scored higher on the Level of Expressed Emotion (LEE) Scale than those who were supported by family, friends, or their physician provider. Scores by patients, who selected their spouse as a key person, scored higher on the LEE than those who chose one of their children. Spouses on the LEE were often depicted as being more intrusive, reactive, and intolerant when compared with their children. The probability of suicide increased as the LEE scores on expressed emotion increased.

"Impact of drug-reimbursement policies on prescribing: A case-study of a newly marketed long-acting injectable antipsychotic among relapsed schizophrenia patients"

OBJECTIVE

To quantify and explain variation in use of long-acting injectable antipsychotics (LAIs) in the United States, and understand the relationship between patient characteristics, drug reimbursement policies, and LAI prescribing after relapse.

METHODS

A cohort of recently relapsed patients with schizophrenia ages 18 to 64, were identified immediately after discharge from a related inpatient hospitalization, partial hospitalization, or emergency room visit, drawn from 2004 to 2006 Medicaid claims, and followed for 90 days until LAI initiation. Data on state-level Medicaid prior authorization (PA) policies for LAIs were collected. Sequential longitudinal Poisson regression models were developed to understand the relationship between patient and PA policy variables and LAI prescribing, including prior adherence to oral antipsychotics, demographics, clinical variables, and presence of PA policy for LAI.

RESULTS

Among 36 282 patients, 3.1% received risperidone LAI, and 3.8% received a first-generation (FGA) LAI with wide variation across states. Prior adherence ranged from 29% to 89% but was marginally associated with initiation and did not explain variation for LAI prescribing. FGA initiation was associated with geography and race/ethnicity but not PA policy. For risperidone LAI initiation, demographics and clinical factors explained, respectively, 5.0% and 3.0% of the variation; PA policy had a large negative association with initiation (RR = 0.41; 95%CI 0.20-0.87) and explained 8.4% of the variation.

CONCLUSIONS

PA policies may represent a major treatment barrier for risperidone LAI among relapsed patients. Non-adherence plays a little role in predicting which patients receive LAIs. Policy makers and health insurers will need to consider these findings when guiding the use of LAIs. KEY POINTS Among a nationwide cohort of relapsed schizophrenia patients enrolled in US Medicaid, 3.1% received Risperdal Consta, a long-acting injectable antipsychotic (LAI), and 3.8% initiated a first-generation first-generation LAI within 90 days after discharge. During 2004 to 2006, there was marked variation in 90 day post-relapse initiation of Risperdal-Consta-a newly marketed medication during this period-and also marked variation in 90 day post-relapse initiation of any first-generation LAI, which appeared to be associated with race/ethnicity and geography. Prior authorization policies were associated with substantially lower initiation of Risperdal Consta in this cohort of relapsed patients even after accounting for clinical indication (non-adherence), relapse history, demographics, adjunctive medication, and mental health service use.

Once-monthly injection of paliperidone palmitate in patients with recently diagnosed and chronic schizophrenia: a post-hoc comparison of efficacy and safety

BACKGROUND

The use of long-acting injectable antipsychotics in recently diagnosed schizophrenia remains less explored. We evaluated the efficacy and safety of paliperidone palmitate once-monthly (PP1M) treatment in adult patients with recently diagnosed vs. chronic schizophrenia.

RESEARCH DESIGN AND METHODS

These post-hoc analyses included two multicenter studies. Study 1 (NCT01527305) enrolled recently diagnosed (≤5 years) and chronic (>5 years) patients; Study 2 (NCT01051531) enrolled recently diagnosed patients only. Recently diagnosed patients were further sub-grouped into ≤2 years or 2-5 years. The primary efficacy endpoint was the change from baseline in Positive and Negative Syndrome Scale (PANSS) total score.

RESULTS

In Study 1, 41.5% patients had recent diagnosis (≤2 years: 56.8%; 2-5 years: 43.2%); 58.5% had chronic schizophrenia. In Study 2, 52.8% and 47.2% patients were grouped into ≤2 years and 2-5 years, respectively. PANSS total score showed significantly greater improvement in patients with recently diagnosed vs. chronic schizophrenia. Similar results were obtained for PANSS responder rate, improvements in PANSS, and CGI-S scores.

CONCLUSION

PP1M was efficacious in both recently diagnosed and chronic schizophrenia, with the benefits being more pronounced in patients with recently diagnosed schizophrenia. This adds to growing evidence recommending long-acting antipsychotic interventions at early stages of schizophrenia.

Comparison of health-related quality of life among men with different co-existing severe mental disorders in treatment for substance use

BACKGROUND

Patient-perceived health-related quality of life has become an important outcome in health care as an indicator of treatment effectiveness and recovery for patients with substance use disorder. As no study has assessed health-related quality of life among male patients with substance use disorder and co-existing severe mental illness, we compared health-related quality of life among patients with substance use disorder and the following severe mental illness diagnosis in Barcelona, Spain: schizophrenia, bipolar disorder, major depressive disorder, and examined the associations with clinically related variables. Additionally, we compared results for health-related quality of life in patients with substance use disorder and severe mental illness, with Spanish population norms.

METHODS

We assessed 107 substance use disorder male patients using the 36-Item Short Form Health Survey comparing results across three groups with: comorbid schizophrenia (n = 37), comorbid bipolar disorder (n = 34), and comorbid major depressive disorder (n = 36). Multiple analyses of variance were performed to explore health-related quality of life by the type of co-existing SMI and linear regression analyses examined clinical correlates for the 36-Item Short Form Health Survey dimensions for each group.

RESULTS

There were differences in Physical Functioning, Vitality and the Physical Composite Scale among groups. Poorer Physical Functioning was observed for patients with comorbid schizophrenia (80.13±3.27) and major depressive disorder (81.97±3.11) compared with comorbid bipolar disorder patients (94.26±1.93). Patients with substance use disorder and schizophrenia presented lower scores in Vitality (41.6±2.80) than those with co-existing bipolar disorder (55.68±3.66) and major depressive disorder (53.63±2.92). Finally, results in the Physical Composite Scale showed lower scores for patients with comorbid schizophrenia (51.06±1.41) and major depressive disorder (51.99±1.87) than for those with bipolar disorder (60.40±2.17). Moreover, all groups had poorer health-related quality of life, especially Social Functioning, Role-Emotional and Mental Health, compared with population norms. Different clinical variables (e.g. medical disease comorbidity, severity of addiction, psychiatric symptomatology, suicide attempts, drug relapses) were related to different health-related quality of life dimensions depending on the co-existing severe mental illness.

CONCLUSIONS

Among male patients with substance use disorder, co-existing severe mental illness may influence some health-related quality of life dimensions and clinically related variables. Such differences may require tailored therapeutic interventions.

Brexpiprazole in patients with schizophrenia: overview of short- and long-term phase 3 controlled studies

OBJECTIVE

Review efficacy, safety, and tolerability of brexpiprazole in patients with schizophrenia in short- and long-term phase 3 studies.

METHODS

Patients experiencing a current exacerbation of schizophrenia received brexpiprazole in two fixed-dose (2 and 4 mg), 6-week, placebo-controlled studies, one flexible-dose (2-4 mg), 6-week, placebo-control and active reference study, and one fixed-dose (1-4 mg), 52-week, placebo-controlled maintenance study.

RESULTS

The efficacy of brexpiprazole was demonstrated in the two short-term fixed-dose studies with statistically significant improvements from baseline in Positive and Negative Syndrome Scale (PANSS) total score compared with placebo. In the flexible-dose short-term study, treatment with brexpiprazole resulted in numerically greater improvements in PANSS total score than with placebo that approached statistical significance (p=0.056). A meta-analysis of these short-term studies showed a mean change in PANSS total score of -20.1, reflecting a clinically meaningful reduction in symptoms. In the maintenance study, brexpiprazole had a beneficial effect relative to placebo on time to exacerbation of psychotic symptoms/impending relapse (p<0.0001). For all studies, brexpiprazole demonstrated clinically meaningful treatment effects on the Personal and Social Performance scale. Brexpiprazole had a favourable safety profile, with a relatively low prevalence of activating and sedating side effects. Weight gain in the short-term studies was ~1 kg greater than placebo. No safety concerns were observed with brexpiprazole in laboratory values, electrocardiogram, or vital signs.

CONCLUSIONS

Overall, the results indicate brexpiprazole, used either short-term or as part of a long-term maintenance treatment programme, is an efficacious therapy option in adults with schizophrenia and has a favourable safety/tolerability profile.

Canadian Guidelines for the Pharmacological Treatment of Schizophrenia Spectrum and Other Psychotic Disorders in Children and Youth

OBJECTIVE

Schizophrenia spectrum and other psychotic disorders often have their onset in adolescence. The sequelae of these illnesses can negatively alter the trajectory of emotional, cognitive, and social development in children and youth if left untreated. Early and appropriate interventions can improve outcomes. This article aims to identify best practices in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders.

METHODS

A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders in children and youth (under age 18 years). Recommendations were drawn from the National Institute for Health and Care Excellence guidelines on psychosis and schizophrenia in children and youth (2013 and 2015 updates). Current guidelines were adopted using the ADAPTE process, which includes consensus ratings by a panel of experts.

RESULTS

Recommendations identified covered a range of issues in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders. Further work in this area is warranted as we continue to further understand their presentation in the developing brain.

CONCLUSIONS

Canadian guidelines for the pharmacotherapy management of children and youth with schizophrenia spectrum disorders are essential to assist clinicians in treating this vulnerable population. Ongoing work in this area is recommended.

Effect of continued cannabis use on medication adherence in the first two years following onset of psychosis

Uncertainty exists whether the use of non-prescription psychoactive substances following onset of a first episode of psychosis (FEP), in particular cannabis use, affects medication adherence. Data from FEP patients (N=233) obtained through prospective assessments measured medication adherence and pattern of cannabis and other substance use in the first two years following onset of psychosis. Multiple logistic regression analyses were employed to compare the different substance use groups with regard to risk of medication non-adherence, while controlling for confounders. The proportion of non-adherent patients was higher in those who continued using high-potency forms of cannabis (skunk-like) following the onset (83%) when compared to never regular users (51%), corresponding to an Odds Ratio (OR) of 5.26[95% Confidence Interval (CI) 1.91-15.68]. No significant increases in risk were present in those who used cannabis more sporadically or used milder forms of cannabis (hash-like). Other substances did not make an independent contribution in this model, including cigarette use ([OR 0.88, 95% CI 0.41-1.89]), alcohol use ([OR 0.66, 95% CI 0.27-1.64]) or regular use of other illicit drugs ([OR 1.03, 95% CI 0.34-3.15]) following the onset. These results suggest that continued use of high-potency cannabis following the onset of psychosis may adversely affect medication adherence.

The Cost of Relapse in Schizophrenia

INTRODUCTION

Schizophrenia is a chronic and debilitating mental illness characterised by periods of relapse that require resource intensive management. Quantifying the cost of relapse is central to the evaluation of the cost effectiveness of treating schizophrenia.

OBJECTIVES

We aimed to undertake a comprehensive search of the available literature on the cost of relapse.

METHODS

We performed a search on multiple databases (MEDLINE, Embase, PsycINFO and Health Management Information Consortium) for any study reporting a cost of relapse or data from which such a cost could be calculated. Costs are reported in 2015 international dollars.

RESULTS

We found 16 studies reporting costs associated with relapse over a defined period of time and identified a cost associated with hospitalisation for relapse in 43 studies. Eight clinical decision analyses also provided cost estimates. Studies from the US report excess costs of relapse of $6033-$32,753 (2015 Purchasing Power Parity dollars [PPP$]) over periods of 12-15 months. European studies report excess costs of $8665-$18,676 (2015 PPP$) over periods of 6-12 months. Estimates of the cost of hospitalisation for relapse are more diverse, and associated with marked differences in typical length of stay across jurisdictions.

CONCLUSIONS

Wide ranges in the estimated cost of relapse may reflect differences in sample section and relapse definition as well as practice styles and differences in resource costs. Selection of the most appropriate cost estimate should be guided by the definition of relapse and the analysis setting.

Real-world adherence and economic outcomes associated with paliperidone palmitate versus oral atypical antipsychotics in schizophrenia patients with substance-related disorders using Medicaid benefits

AIM

Compare medication utilization, costs and healthcare resource use in schizophrenia patients with substance-related disorders initiated on once-monthly paliperidone palmitate (PP1M) or an oral atypical antipsychotic (OAA).

MATERIALS & METHODS

Data from six Medicaid states (07/2009-03/2015) were used to compare outcomes between PP1M and OAA patients.

RESULTS

PP1M patients had higher 12-month antipsychotic adherence and persistence than OAA patients. PP1M patients had lower medical (mean monthly cost difference [MMCD] = US$-191, p = 0.020), higher pharmacy (MMCD = US$250, p < 0.001) and similar total costs (MMCD = US$59, p = 0.517) during the overall follow-up. PP1M patients had lower rates of outpatient visits and inpatient days but higher rates of mental health-related utilization.

CONCLUSION

PP1M was associated with higher antipsychotic adherence and persistence, and similar total costs versus OAA.

Poor medication adherence and risk of relapse associated with continued cannabis use in patients with first-episode psychosis: a prospective analysis

BACKGROUND

Cannabis use following the onset of first-episode psychosis has been linked to both increased risk of relapse and non-adherence with antipsychotic medication. Whether poor outcome associated with cannabis use is mediated through an adverse effect of cannabis on medication adherence is unclear.

METHODS

In a prospective analysis of data acquired from four different adult inpatient and outpatient units of the South London and Maudsley Mental Health National Health Service Foundation Trust in London, UK, 245 patients were followed up for 2 years from the onset of first-episode psychosis. Cannabis use after onset of psychosis was assessed by self-reports in face-to-face follow-up interviews. Relapse data were collected from clinical notes using the WHO Life Chart Schedule. This measure was also used to assess medication adherence on the basis of both face-to-face interviews and clinical notes. Patients were included if they had a diagnosis of first-episode non-organic or affective psychosis according to ICD-10 criteria, and were aged between 18 and 65 years when referred to local psychiatric services. We used structural equation modelling analysis to estimate whether medication adherence partly mediated the effects of continued cannabis use on risk of relapse. The primary outcome variable was relapse, defined as admission to a psychiatric inpatient unit after exacerbation of symptoms within 2 years of first presentation to psychiatric services. Information on cannabis use over the first 2 years after onset of psychosis was investigated as a predictor variable for relapse. Medication adherence was assessed as a mediator variable on the basis of clinical records and self-report data. Study researchers (TS, NP, EK, and EF) rated the adherence.

FINDINGS

397 patients who presented with their first episode of psychosis between April 12, 2002, and July 26, 2013 had a follow-up assessment until September, 2015. Of the 397 patients approached for followed up, 133 refused to take part in this study and 19 could not be included because of missing data. 91 (37%) of 245 patients with first-episode psychosis had a relapse over the 2 years of follow-up. Continued cannabis use predicted poor outcome, including risk of relapse, number of relapses, length of relapse, and care intensity at follow-up. In controlled structural equation modelling analyses, medication adherence partly mediated the effect of continued cannabis use on outcome, including risk of relapse (proportion mediated=26%, βindirect effects=0·08, 95% CI 0·004 to 0·16), number of relapses (36%, βindirect effects=0·07, 0·003 to 0·14), time until relapse (28%, βindirect effects=-0·26, -0·53 to 0·001) and care intensity (20%, βindirect effects=0·06, 0·004 to 0·11) but not length of relapse (6%, βindirect effects=0·03, -0·03 to 0·09). The adjusted models explained moderate amounts of variance for outcomes defined as risk of relapse (R2=0·25), number of relapses (R2=0·21), length of relapse (R2=0·07), time until relapse (R2=0·08), and care intensity index (R2=0·15).

INTERPRETATION

Between 20% and 36% of the adverse effects of continued cannabis use on outcome in psychosis might be mediated through the effects of cannabis use on medication adherence. Interventions directed at medication adherence could partly help mitigate the harm from cannabis use in psychosis.

FUNDING

This study is funded by the National Institute of Health Research (NIHR) Clinician Scientist award.

Low dietary intake of n-3 fatty acids, niacin, folate, and vitamin C in Korean patients with schizophrenia and the development of dietary guidelines for schizophrenia

Inappropriate dietary intake and poor nutritional status are reported to be associated with metabolic syndrome and psychopathology in patients with schizophrenia. We hypothesized that inappropriate dietary habits and insufficient dietary intake of specific nutrients are associated with schizophrenia. To test the hypothesis, we assessed the dietary habits and nutritional intake of patients with schizophrenia and then developed suitable dietary guidelines. In total, 140 subjects (73 controls and 67 patients with schizophrenia from community mental health centers) were included, and dietary intakes were analyzed using a semi-quantitative food frequency questionnaire. As a result, the proportion of overweight or obese patients was significantly higher in schizophrenia subjects (64.2%) compared with control subjects (39.7%) (P=.004). The male schizophrenia patients had significantly lower dietary intakes of protein, polyunsaturated fatty acids (PUFAs), vitamin K, niacin, folate, and vitamin C than the male control subjects. In all multiple logistic regression models, subjects with the "low" dietary intake of protein, n-3 PUFAs, niacin, folate, and vitamin C had a significantly higher odds ratios for schizophrenia compared with those with the "high" dietary intake category of each nutrient. Therefore, maintenance of a healthy body weight and sufficient dietary intake of protein, PUFAs, niacin, folate, and vitamin C are recommended for Korean patients with schizophrenia.

Behavioral sensitization to methamphetamine induces specific interneuronal mRNA pathology across the prelimbic and orbitofrontal cortices

Schizophrenia is associated with significant pathophysiological changes to interneurons within the prefrontal cortex (PFC), with mRNA and protein changes associated with the GABA network localized to specific interneuron subtypes. Methamphetamine is a commonly abused psychostimulant that can induce chronic psychosis and symptoms that are similar to schizophrenia, suggesting that chronic METH induced psychosis may be associated with similar brain pathology to schizophrenia in the PFC. The aim of this study, therefore, was to examine mRNA expression of interneuron markers across two regions of the PFC (prelimbic (PRL) and orbitofrontal cortices (OFC)) following METH sensitization, an animal model of METH psychosis. We also studied the association between GABA mRNA expression and interneuronal mRNA expression to identify whether particular changes to the GABA network could be localized to a specific inhibitory cellular phenotype. METH sensitization increased the transcriptional expression of calbindin, calretinin, somatostatin, cholecyctokinin and vasoactive intestinal peptide in the PRL while parvalbumin, calbindin, cholectokinin and vasoactive intestinal peptide were upregulated in the OFC. Based on our previous findings, we also found significant correlations between GAD₆₇, GAT₁ and parvalbumin while GAD₆₇, GAD₆₅ and GAT₁ were positively correlated with cholecystokinin in the PRL of METH sensitized rats. Within the OFC, the expression of GABA_Aα1 was positively correlated with somatostatin while GABA_Aα5 was negatively associated with somatostatin and calbindin. These findings suggest that METH sensitization differentially changes the expression of mRNAs encoding for multiple peptides and calcium binding proteins across the PRL and the OFC. Furthermore, these findings support that changes to the GABA network may also occur within specific cell types. These results, therefore, provide the first evidence that METH sensitization mediates differential interneuronal pathology across the PRL and OFC and such changes could have profound consequences on behavior and cognitive output.

Brief cognitive-behavioural therapy for patients in the community with schizophrenia: randomised controlled trial in Beijing, China

BackgroundBrief cognitive-behavioural therapy (CBT) is an emerging treatment for schizophrenia in community settings; however, further trials are needed, especially in non-Western countries.AimsTo test the effects of brief CBT for Chinese patients with schizophrenia in the community (trial registration: ChiCTR-TRC-13003709).MethodA total of 220 patients with schizophrenia from four districts of Beijing were randomly assigned to either brief CBT plus treatment as usual (TAU) or TAU alone. Patients were assessed at baseline, post-treatment and at 6- and 12-month follow-ups by raters masked to group allocation.ResultsAt the post-treatment assessment and the 12-month follow-up, patients who received brief CBT showed greater improvement in overall symptoms, general psychopathology, insight and social functioning. In total, 37.3% of those in the brief CBT plus TAU group experienced a clinically significant response, compared with only 19.1% of those in the TAU alone group (P = 0.003).ConclusionsBrief CBT has a positive effect on Chinese patients with schizophrenia in the community.

Predictive Validity of the Brazilian Portuguese Version of the Family Questionnaire for Relapse in Patients With Schizophrenia

Background and Purpose: The Family Questionnaire-Brazilian Portuguese Version (FQ-BPV) has been preliminarily validated in the Brazilian population. This study assessed the predictive validity of the FQ-BPV for relapse in patients with schizophrenia. Methods: Ninety-four dyads (patients with schizophrenia and their relatives) were recruited from three mental health clinics. Expressed emotion was assessed using the FQ-BPV. Presence of relapse was assessed at 6-, 9-, 12-, and 18-month follow-ups and analyzed through logistic regressions. Results: The critical comments (CC) domain of the FQ-BPV was statistically significant at 18 months. However, the model was not sufficiently robust to classify individuals correctly into relapse or no relapse categories. Conclusion: The FQ-BPV did not predict relapse well and we cannot recommend it for that purpose in Brazil without further studies.

Treatment patterns in Medicaid patients with schizophrenia initiated on a first- or second-generation long-acting injectable versus oral antipsychotic

BACKGROUND

Poor antipsychotic (AP) adherence is a key issue in patients with schizophrenia. First-generation antipsychotic (FGA) and second-generation antipsychotic (SGA) long-acting injectable therapies (LAI) may improve adherence compared to oral antipsychotics (OAP). The objective of the study was to compare treatment adherence and persistence in Medicaid patients with schizophrenia initiated on first-generation long-acting injectable therapies (FGA-LAI) or second-generation long-acting injectable therapies (SGA-LAI) versus OAP.

METHODS

Adults with schizophrenia initiated on FGA-LAI, SGA-LAI, or OAP on or after January 2010 were identified using a six-state Medicaid database (January 2009-March 2015). Outcomes were assessed during the 12 months following treatment initiation. Index medication adherence was assessed using the proportion of days covered ≥80%, while persistence was assessed as no gap of ≥30, ≥60, or ≥90 days between days of supply. Outcomes were compared between FGA/SGA-LAI and OAP cohorts using chi-squared tests and adjusted odds ratios (OR).

RESULTS

During follow-up, AP polypharmacy was more common in FGA-LAI patients (N=1,089; 36%; P=0.029) and less common in SGA-LAI patients (N=2,209; 27%; P<0.001) versus OAP patients (N=20,478; 33%). After adjustment, SGA-LAI patients had 24% higher odds of adherence at 12 months (OR: 1.24; P<0.001), in contrast to FGA-LAI patients who had 48% lower odds of adherence (OR: 0.52; P<0.001) relative to OAP patients. SGA-LAI patients were more likely to be persistent (no gap ≥60 days) at 12 months than OAP patients (37% vs 30%; P<0.001), but not FGA-LAI patients (31% vs 30%; P=0.776). In comparison to OAP patients, SGA-LAI patients had 46% higher adjusted odds of persistence (no gap ≥60 days; OR: 1.46; P<0.001), while FGA-LAI patients were not significantly different (OR: 0.95; P=0.501).

CONCLUSION

Medicaid patients initiated on SGA-LAI demonstrated better treatment adherence and persistence compared to OAP patients, while those initiated on FGA-LAI did not show significant improvement in adherence or persistence and had more AP polypharmacy relative to OAP patients. These findings suggest the potential value of SGA-LAI in the treatment of schizophrenia.

Productivity and deadweight losses due to relapses of schizophrenia in Japan

BACKGROUND

No study has examined the financial impact of relapses on schizophrenia from the perspective of Japanese society. This study aimed to estimate the societal costs in Japan caused by the relapses of schizophrenia.

METHODS

The societal costs in Japan in 2013 due to relapses of schizophrenia were estimated by summing the productivity loss and deadweight loss caused by schizophrenia relapses in 2013. Deterministic sensitivity analysis was conducted for deadweight loss rate, relapse rate, and patient income.

RESULTS

Japan incurred JPY 55,039 million societal costs because of relapses in 2013. This consists of JPY 3,990 million for productivity loss and JPY 51,049 million for deadweight loss. Rate of deadweight loss is the most significant cost driver in the sensitivity analysis.

CONCLUSION

Relapses of schizophrenia could generate huge amount of societal costs by reducing labor productivity and economic efficiency. To curb these costs, relapse prevention is desired in treating schizophrenia.

Healthcare resource utilization of second-generation long-acting injectable antipsychotics in schizophrenia: risperidone versus paliperidone palmitate

OBJECTIVE

This retrospective longitudinal cohort study aimed to compare treatment patterns, healthcare resource utilization (HRU), and costs in patients with schizophrenia treated with second-generation antipsychotic long-acting injectables (SGA-LAIs): biweekly risperidone LAI versus once-monthly paliperidone palmitate.

METHODS

Patients who initiated risperidone LAI or paliperidone palmitate between 1 July 2007 and 31 December 2012 (index date) were identified from the Truven MarketScan Commercial, Medicare Supplemental, and Medicaid Multi-State insurance databases. Outcomes were assessed 12 months after the index date. Propensity score matching (1:1) based on patients' demographics and comorbidities was conducted. Outcome differences between the two cohorts were evaluated using t-tests for continuous variables, chi-square tests for categorical variables, and Wilcoxon rank-sum tests for count and cost variables. Regression models estimated the difference in medication use and adherence, likelihood of HRU, number of HRU events, and healthcare costs when comparing risperidone LAI versus paliperidone palmitate, while further adjusting for patient characteristics and pre-index HRU.

RESULTS

Patient characteristics were well balanced between the two cohorts (n = 499 each). Significantly lower discontinuation rates (36.5% vs. 53.3%; p < 0.001) and longer days of LAI coverage (233.6 vs. 131.7 days; p < 0.001) were observed in the paliperidone palmitate cohort versus the risperidone LAI cohort, respectively. Patients treated with paliperidone palmitate were 12.5 (95% confidence interval [CI]: 9.0-17.8) and 11.7 (95% CI: 8.0-17.4) times more likely to be adherent based on medication possession ratio and proportion of days covered, respectively (p < 0.001). Patients treated with paliperidone palmitate had reduced likelihood of hospitalization (adjusted odds ratio [95% CI]: 0.72 [0.55-0.95]), fewer emergency department (ED) visits (adjusted incidence rate ratio [aIRR]: 0.67 [0.61-0.73]) and reduced length of inpatient stay (aIRR: 0.86 [0.82-0.90]), which resulted in lower monthly inpatient hospitalization costs (-$77.58; p = 0.038) and ED visits (-$9.77; p = 0.021) relative to risperidone LAI.

LIMITATIONS

Pharmacy costs were derived from health plan payment in the claims data and do not account for any discounts or rebates. This may have overestimated the branded drug costs in this analysis.

CONCLUSIONS

These findings highlight the value of once-monthly paliperidone palmitate in the treatment of patients with schizophrenia.