Long-acting injectable versus oral antipsychotics for the maintenance treatment of schizophrenia: a systematic review and comparative meta-analysis of randomised, cohort, and pre-post studies

Pharmacokinetic characteristics of risperidone ISM for the treatment of schizophrenia

INTRODUCTION

Risperidone-ISM is a novel intramuscular long-acting injectable formulation (LAI) of risperidone approved for the treatment of schizophrenia in adults. Knowledge regarding the pharmacokinetic properties of risperidone-ISM can improve care.

AREAS COVERED

We assessed the pharmacokinetic properties of risperidone-ISM. Most importantly, risperidone-ISM achieves therapeutic blood levels within 12-48 h after the first injection without the need for overlapping oral cotreatment, loading dose, or booster injection. Second, the in-situ microparticle (ISM) technology achieves stable blood levels, allowing currently 1-monthly injections. Third, females and patients with higher body mass index may have lower risperidone-ISM clearance, translating into higher risperidone serum levels. Fourth, there are only minimal risperidone-ISM clearance differences between deltoid and gluteal injections that balance out at steady state. However, aspects including pharmacogenetic and drug-drug interactions involving risperidone-ISM would benefit from further clarification.

EXPERT OPINION

Risperidone-ISM achieves therapeutic blood levels within 12-48 h after a single injection, currently lasting for 1 month, easing the initiation of a LAI risperidone formulation in adults with schizophrenia where LAIs remain underutilized. Prescriptions of LAIs, including risperidone-ISM, are likely to increase with an improved understanding of pharmacokinetic profiles and patient acceptability and outcomes, including in real-world settings informing drug selection.

Real-world outcomes and practice patterns among patients with schizophrenia when switched from oral antipsychotics to long-acting injectable formulations after hospitalization

This study compared rehospitalization and practice patterns among patients with schizophrenia in the United States prescribed oral antipsychotics (OAs), alone or with long-acting injectable antipsychotics (LAIs) at hospital discharge. Data came from a hospital-based payer database from December 2019-June 2021. At discharge, 23,336 (84 %) patients were prescribed OAs and 4293 (16 %) were prescribed LAIs±OAs (first-generation LAIs±OAs, 2990/4293 [70 %]; second-generation LAIs±OAs, 1303/4293 [30 %]). The most prescribed OA and LAI±OA were risperidone (26 %) and haloperidol (37 %), respectively. Significantly greater proportions of patients were rehospitalized within 30, 60, or 90 days after discharge with OAs (11 %, 15 %, and 18 %, respectively) vs LAIs±OAs (8 %, 12 %, and 15 %; numbers needed to treat [NNTs], 37, 35, and 38), and with first-generation (9 %, 13 %, 16 %) vs second-generation (7 %, 10 %, 13 %) LAIs (p < 0.05 for all). Significantly greater proportions prescribed LAIs dosed once every 2 weeks vs monthly were rehospitalized within 60 days (15 % vs 11 %, respectively; NNT 33) and 90 days (18 % vs 14 %; NNT 26) (p < 0.05 for all). Prescriptions were based on clinical characteristics at discharge; those prescribed LAIs±OAs may have had less favorable prognoses. However, these results suggest that prescribing second-generation LAIs±OAs with less frequent dosing at discharge may lower rehospitalization risk for patients with schizophrenia.

Retrospective cohort study of long-acting injectable (LAI) antipsychotic initiation in the inpatient setting: impact of LAI characteristics on transition and continuation of care among patients with schizophrenia in the USA

OBJECTIVES

To investigate long-acting injectable (LAI) antipsychotic prescribing patterns and their associations with transition and continuation of care and healthcare resource utilisation (HCRU) for patients with schizophrenia in the USA.

DESIGN

A retrospective cohort study.

SETTING

Electronic health record data from adults in the USA with schizophrenia were extracted from the NeuroBlu Database V.21R2.

PARTICIPANTS

Adults (aged ≥18 years) with a schizophrenia diagnosis who initiated LAI antipsychotic treatment during psychiatric inpatient admission. The index date was the date of LAI initiation. Patients who had ≥1 primary, secondary or tertiary ICD-9/10 (International Classification of Diseases) diagnosis of schizophrenia at clinical sites that had both inpatient and outpatient facilities were included.

PRIMARY OUTCOME MEASURES

Transition-of-care (eg, risk of rehospitalisation, number of hospital readmissions, number of outpatient visits post discharge), continuation-of-care (eg, first treatment path after discharge, time to index LAI discontinuation and number of patients who restarted LAIs after discontinuation) and HCRU endpoints (eg, length of stay of index hospitalisation and estimated cost for psychiatric outpatient visits pre-index and post-index) were the primary outcome measures.

RESULTS

A total of 1197 patients were included who initiated an LAI in an inpatient setting. Of 339 patients with ≥3 months pre-index and post-index data, median time to rehospitalisation was 135 days. Patients discharged taking an LAI alone had lower frequency of rehospitalisation (incidence rate ratio (IRR)=0.62 (95% CI, 0.46 to 0.84)), lower risk of longer hospital stays (IRR=0.60 (95% CI, 0.43 to 0.84)), lower risk of becoming rehospitalised (HR=0.49 (95% CI, 0.35 to 0.69)) and lower risk of outpatient visits (IRR=0.50 (95% CI, 0.36 to 0.70)) versus patients co-prescribed an oral antipsychotic (LAI+OA). Patients discharged taking an LAI dosed once every 1-2 months or once every 2 weeks had lower frequency of rehospitalisation (IRR=0.85 (95% CI, 0.64 to 1.14)), lower risk of longer hospital stays (IRR=0.90 (95% CI, 0.70 to 1.15)) and lower risk of becoming rehospitalised versus an LAI dosed once every 2 weeks; risk of becoming rehospitalised was no different (HR=1.00 (95% CI, 0.76 to 1.32)) and risk of outpatient visits was greater (IRR=1.25 (95% CI, 0.96 to 1.63)). During hospitalisation, 73.4% of patients were co-prescribed an OA, most frequently risperidone, with their index LAI. From pre-admission to post-discharge, psychiatric clinic costs significantly increased (US$14 231, p<0.01 post-discharge vs pre-admission) among patients co-prescribed an OA. For patients who were prescribed an LAI alone there was minimal change in costs from pre-admission to post-discharge (p=0.068). At 12 months post-index, 75.3% of patients discontinued LAIs, dosed once every 1-2 months versus LAIs, dosed once every 2 weeks (86.5%) and median days to discontinuation was longer (67 (IQR 60-91) vs 32 (IQR 28-49).

CONCLUSIONS

Patients prescribed a combination of LAI and OA at discharge had a higher risk of rehospitalisation compared with those prescribed LAI alone. Additionally, the study findings suggest that patients are more likely to be prescribed oral risperidone, the most frequently used second-generation OA, which may support an easier transition to an LAI of the same molecule.

Budget impact analysis of long-acting injections for the treatment of Schizophrenia in Japan

BACKGROUND

Following policy changes implemented in April 2020 in Japan, long-acting injectable antipsychotics (LAI-As) have been reimbursed as a part of a government initiative for community-oriented mental health care. This study assessed the financial impact of increased LAI-A usage compared to the current LAI-A and oral antipsychotic (OA) usage for the treatment of adult patients with schizophrenia.

METHODS

A budget impact (BI) model was developed to estimate the BI of increased LAI-A usage from the Japanese healthcare payor perspective over five years. The inputs were informed by the most recent available data reflecting the current reimbursement structure and treatment practices. The model considered drug acquisition, administration visit, psychotherapy, and hospitalization costs. Scenario and sensitivity analyses were conducted.

RESULTS

Increasing LAI-A uptake by 10 % from current usage each year resulted in a BI of ¥886,001,060 (0.09 % increase) over five years. Hospitalization and drug acquisition costs constituted 84.1 % and 9.4 % of the total cost, respectively. Variation in the hospitalization inputs for patients on OAs and LAI-As had the greatest impact on the net budget, ranging from being cost saving to resulting in a small positive BI.

CONCLUSION

Increased utilization of LAI-As for schizophrenia treatment in Japan has a minimal BI. Despite the increased drug acquisition and administration visit costs, the decreased hospitalization costs offset the overall impact. Altogether, these findings support the continued reimbursement and usage of LAI-As aligned with the recent policy changes.

Aripiprazole Lauroxil: Development and Evidence-Based Review of a Long-Acting Injectable Atypical Antipsychotic for the Treatment of Schizophrenia

This review article describes why and how aripiprazole was formulated as aripiprazole lauroxil (AL), an extended-release antipsychotic agent that is delivered via a long-acting injectable formulation, and the clinical trials investigating its use. AL was formulated as an inactive prodrug of aripiprazole using LinkeRx® technology to provide a prolonged-release antipsychotic with predictable dissolution over time. The resulting AL pharmacokinetic profile is characterized by a long half-life and little peak-to-trough aripiprazole concentration variability across dosing intervals of every 1 month, every 6 weeks, and every 2 months. The prodrug technology was further refined to develop an AL initiation formulation with a somewhat faster release of aripiprazole, eliminating the need for a 21-day oral aripiprazole supplementation period. With this initiation formulation, AL treatment can be started in 1 day. Key AL characteristics, including pharmacokinetic profile and efficacy, safety, and tolerability data, are presented. In addition to the efficacy and safety established in clinical trials of oral aripiprazole, a placebo-controlled 12-week pivotal study investigated AL 441 mg and 882 mg monthly regimens in patients with acutely exacerbated schizophrenia and provided efficacy and safety information that led to US Food and Drug Administration approval in 2015. Thereafter, studies established the long-term safety profile and durability of the AL treatment effect. The 25-week, active-controlled ALPINE study evaluated the feasibility and effectiveness of AL 1064 mg every 2 months, initiated using the 1-day AL initiation regimen, without further oral supplementation beyond day 1, in patients hospitalized for acutely exacerbated schizophrenia with subsequent transition to outpatient care. In short-term and long-term studies, AL was generally well tolerated at initiation and during acute and maintenance treatment. Pharmacokinetic, efficacy, and safety characteristics support the use of AL across inpatient and outpatient treatment settings.

Clinician differences in attitudes and perceptions on the use of long-acting injectable antipsychotic agents in treating patients with schizophrenia: results from the US DECIDE survey

BACKGROUND

Long-acting injectable antipsychotics (LAIs) reduce relapses in schizophrenia; however, most clinicians reserve LAIs for nonadherence with oral antipsychotics (OAs) or severe disease.

METHODS

US psychiatric clinicians were surveyed regarding their schizophrenia management practices and use of LAIs. Respondents were grouped by LAI use (high [≥ 31% of patients using LAIs], low [≤ 14% using LAIs]; mid not analyzed) and mindset based on their response to "Which of the following best fits the current way you view your use of [LAIs] for your patients with schizophrenia?"

RESULTS

Respondents (n = 380) were distributed across LAI use (106 high, 130 low) and mindset (123 early-use, 88 severity-reserved, 113 adherence-reserved, 56 LAI-hesitant) subgroups. Across subgroups, clinicians estimated that OA nonadherence was lower for patients in their practice (21-52%) than for patients nationwide (50-56%). Compared with other subgroups, greater proportions with high LAI use or an early-use mindset were confident in key aspects of LAI treatment like dosing, managing side effects, and access (67-74% high LAI use, 59-70% early-use vs. 11-57% other subgroups; P < .05 each), agreed it was "worth [their] time to resolve issues with the insurance company" (42%, 45% vs. 16-30%; P < .05 each), and were optimistic they would be able to do so (23%, 20% vs. 2-11%; P < .05 each). Clinicians with high LAI use estimated the proportion of patients who initially accept LAIs to be higher (mean, 56%) than clinicians with low LAI use (45%, P < .01); there were no differences among mindsets (49-54%). Clinicians with high LAI use or early-use mindset were more likely to "use any means necessary to ensure that a patient is on an LAI" than clinicians in other subgroups (44% high LAI use, 51% early-use vs. 5-22% other subgroups; P < .01 each) or had used guardianship to assist with treatment (70%, 69% vs. 32-56%; P < .05 each).

CONCLUSIONS

These results indicate that multiple factors (e.g., environmental/demographic factors, access, attitudes, motivation, knowledge/confidence) combine to influence LAI use, and highlight the need to tailor educational materials aimed at improving patient outcomes through increased LAI use.

Comparison of Psychiatric Readmission Rates for Child and Adolescent Patients on Long-Acting Injectable Antipsychotics Versus Oral Antipsychotics: A Mirror Study

Objectives: Current literature shows a benefit in clinical outcomes when long-acting injectable antipsychotics (LAIAs) are utilized in adult patients with psychiatric disorders such as schizophrenia, schizoaffective disorder, and bipolar disorder. Literature regarding LAIA use in pediatric patients is sparse. The objective of this study is to compare the number of acute psychiatric admissions, psychiatric emergency services (PES) visits, and total number of days admitted to an acute psychiatric hospital 1 year prior to and 1-year post-mirror point of index hospitalization and LAIA initiation. Methods: This was a single-site retrospective mirror-image review of patients <18 years of age initiated on an LAIA during an acute psychiatric hospitalization between October 1, 2015, and October 31, 2022. The number of admissions to the acute psychiatric hospital, number of PES visits, and total number of days hospitalized at the acute psychiatric hospital were captured 1-year pre-index hospitalization admission and 1-year post-index hospitalization discharge, with LAIA administration during index hospitalization being the mirror point. Descriptive statistics and a two-tailed paired t-test were utilized to analyze the data. Results: There were 45 unique pediatric patients initiated on an LAIA during the specified timeframe. Across these 45 patients, there were 47 psychiatric admissions 1-year pre-index hospitalization and 38 psychiatric admissions 1-year post-index hospitalization discharge (p = 0.37). Additionally, there were 24 PES visits 1-year pre-index hospitalization admission and 16 PES visits 1-year post-index hospitalization discharge (p = 0.25). Finally, across the 45 patients, there were a total of 1040 days admitted to the acute psychiatric hospital in the 1-year prior to index hospitalization admission compared with 774 days admitted to the acute psychiatric hospital in the 1-year post-index hospitalization discharge (p = 0.48). Conclusions: In this cohort of pediatric patients initiated on an LAIA, there was a positive trend favoring LAIA therapy over oral antipsychotic therapy with LAIA injection as the mirror point; however, there was no statistically significant difference in the number of psychiatric admissions, number of PES visits, or total number of days admitted to an acute psychiatric hospital. Further studies are required to fully understand the impact of LAIA therapy on clinical outcomes for child and adolescent patients with psychiatric disorders.

Clinical, Quality of Life, and Health Care Utilization Outcomes of Switching the Administration Route of Antipsychotic Medications Among People With Schizophrenia Spectrum Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Using long-acting injectable (LAI) antipsychotic medications can improve the outcomes of patients with schizophrenia, such as reducing symptom severity and hospitalization risk. However, the outcomes of switching from oral to LAI antipsychotic medications are unclear.

AIMS

The purpose of this review is to provide a summary of the clinical, quality of life, and health care utilization outcomes of switching from oral to LAI antipsychotics among patients with Schizophrenia Spectrum Disorder.

METHODS

We thoroughly searched the PubMed, Scopus, PsycInfo, and CINAHL databases. To conduct the meta-analysis, we used the Comprehensive Meta-Analysis Program.

RESULTS

Forty-one articles met our inclusion criteria. After switching to LAIs, symptom severity, the number of rehospitalizations, emergency department visits, and overall health care costs were reduced. Also, social functioning significantly improved. However, no differences were observed in the frequency of outpatient visits. Pharmacy costs were increased between pre- and post-LAI initiation.

CONCLUSION

Our findings support evidence that changing the route of administration of antipsychotic medications from oral to long-acting intramuscular injections can improve the clinical, quality of life, and health care utilization outcomes in people with schizophrenia. Health care practitioners might consider encouraging LAI use earlier during treatment for schizophrenia for better clinical outcomes and to reduce health care utilization associated with treatment.

Efficacy, tolerability, and safety of xanomeline-trospium chloride for schizophrenia: A systematic review and meta-analysis

The United States Food and Drug Administration approved xanomeline-trospium combination for schizophrenia on September-26-2024. We conducted a PRISMA 2020-compliant systematic review with random-effects meta-analysis on the efficacy and safety of xanomeline-trospium in randomized controlled trials in patients with schizophrenia (MEDLINE, EMBASE, Cochrane, PsycINFO, October-01-2024). Co-primary outcomes were Positive And Negative Syndrome Scale (PANSS) total score (standardized mean difference=SMD), and all-cause discontinuation (risk ratio=RR). Cochrane's Risk of Bias (RoB) Tool 2 and GRADE were used. Xanomeline-trospium (k = 3, schizophrenia acute exacerbation, RoB=low, baseline N = 690, males=75.5 %, age=44.3 + 11.0, duration=5 weeks) outperformed placebo on PANSS total (SMD=-0.56, 95 % confidence interval/CI=-0.72/-0.40), positive (SMD=-0.59, 95 %CI=-0.75/-0.43), negative (SMD=-0.33, 95 %CI=-0.49/-0.17), and Marder Factor negative symptom score (SMD=-0.36, 95 %CI=-0.60/-0.13), Clinical Global Impression-Severity (SMD=-0.54, 95 %CI=-0.71/-0.37) (GRADE=moderate), and response (≥30 % reduction from baseline: RR=2.13, 95 %CI=1.66-2.75). Risk of ≥7 % weight gain (RR=0.46, 95 %CI=0.25-0.87, NNT=19), low-density lipoprotein-cholesterol and high-density lipoprotein-cholesterol levels were reduced, while risk was increased for vomiting, hypertension, nausea, dry mouth, dyspepsia, constipation (RR=7.60, 95 %CI=1.50-38.57 to RR=2.72, 95 %CI=1.63-4.55), any adverse event (RR=1.33, 95 %CI=1.18-1.51, NNT=6), triglyceride levels and supine heart rate (GRADE=moderate to high). Conversely, the risk was not increased for any other, serious, or severe adverse events or all-cause discontinuation. In post-hoc analyses, xanomeline-trospium outperformed placebo regarding response (≥20 % and ≥30 % threshold) starting at week 2, negative symptoms in patients with prominent negative symptoms, and cognitive symptoms in patients ≥1 standard deviation below the general population norm. Further, pro-/anti-cholinergic side effects were mild-moderate and mostly transient. Xanomeline-trospium is an effective treatment for schizophrenia with a unique tolerability profile, potentially addressing unmet needs.

Impact of long-acting injectable antipsychotics in early psychosis: An umbrella review

OBJECTIVES

There is still no consensus regarding the indications of long-acting injectable antipsychotics (LAIs) in early psychosis (EP). This umbrella review synthesizes findings from systematic reviews and meta-analyses on the risk-benefit balance of LAIs in EP.

METHODS

Eligible systematic reviews and meta-analyses on LAIs in EP were identified by a MEDLINE search from inception until June 2024. Data were synthesized narratively.

RESULTS

Seven systematic reviews and four meta-analyses published from 2007 to 2024 were identified. They included 220 to 14,313 participants recruited in 58 primary unique randomized controlled trials or observational studies. All LAIs were considered in most reviews. Inclusion criteria and diagnoses differed widely across the selected reviews. The reviews and meta-analyses consistently showed a positive impact of LAIs on symptomatic outcome in people with EP, although there was no consensus on whether LAIs outperformed oral anti-psychotics (OAPs). Most reported a greater reduction of treatment discontinuation due to inefficacy or nonadherence with LAIs vs. OAPs, although meta-analyses found no difference between LAIs vs. OAPs regarding all-cause discontinuation. Findings regarding relapse prevention were inconclusive. Similar rates of metabolic adverse drug reaction and potentially lower rates of extrapyramidal symptoms were observed with LAIs vs. OAPs.

CONCLUSION

LAIs should be considered according to users' preferences and could be particularly useful for people with a poor medication adherence risk profile. Further high-quality observational studies in real-life prescribing conditions are needed to support robust recommendations for clinical practice regarding indications of LAIs in EP.

Risperidone In Situ Microparticles: A Review in Schizophrenia

Risperidone in situ microparticles (risperidone ISM®) is a novel long-acting prolonged-release formulation approved in the EU and USA for treating schizophrenia in adults. Once-monthly intramuscular injections of risperidone ISM® provide immediate and sustained therapeutic levels of risperidone, eliminating the need for loading doses or oral supplementation. In the pivotal PRISMA-3 trial in patients with acute schizophrenia exacerbation, risperidone ISM® significantly improved Positive and Negative Syndrome Scale (primary endpoint) and Clinical Global Impression-Severity of Illness (key secondary endpoint) total scores over the 12-week double-blind phase, with improvements observed as early as day 8. Continued treatment sustained efficacy over the 12-month open-label extension phase. Risperidone ISM® also improved social functioning and had a positive impact on health-related quality of life. Patients stable on daily oral risperidone maintained their treatment benefits after switching to monthly risperidone ISM®. Risperidone ISM® was generally well tolerated in clinical trials, with a safety profile consistent with that of oral risperidone. Its fast onset of action, without the need for oral supplementation or loading doses, makes risperidone ISM® a promising long-acting injectable that could enhance treatment adherence.

Do antipsychotic medications work: An exploration using competency to stand trial as the functional outcome

This study explores the effectiveness of antipsychotic medications in restoring competency to stand trial in individuals with severe mental illness, particularly psychotic disorders. While antipsychotic medications are known for reducing symptoms of psychosis, this research focuses on their ability to improve functional outcomes necessary for competency to stand trial (CST). Among over 3,000 patients in California's forensic state hospital system, 86.5% were successfully restored to competency, with 98.8% discharged on antipsychotic medications. Patients on antipsychotic monotherapy demonstrated higher restoration rates compared to those requiring additional mood stabilizers, suggesting that more complex cases demand more intensive treatment. Delusional disorder, traditionally seen as more resistant to treatment, showed a high restoration rate of 93.8% with antipsychotic use.Our findings emphasize the pivotal role of antipsychotics in not only reducing symptoms but also in restoring critical functional abilities for participation in legal proceedings. The functional improvements they enable extend beyond the courtroom. Incorporation of antipsychotic medication as an integral evidence-based mechanism in facilitating community reintegration for individuals with severe mental illness supports the broader goal of transitioning individuals from the legal system back into society, consistent with the ultimate promise of deinstitutionalization.

Early use of long-acting injectable antipsychotics in bipolar disorder type I: An expert consensus

INTRODUCTION

Long-acting injectable antipsychotics (LAIs) are not routinely offered to patients living with bipolar disorder type I (BP-I), despite widespread evidence that supports their benefits over oral antipsychotics, particularly in early disease.

METHODS

A round-table meeting of psychiatrists convened to discuss barriers and opportunities and provide consensus recommendations around the early use of LAIs for BP-I.

RESULTS

LAIs are rarely prescribed to treat BP-I unless a patient has severe symptoms, sub-optimal adherence to oral antipsychotics, or has experienced multiple relapses. Beyond country-specific accessibility issues (e.g., healthcare infrastructure and availability/approval status), primary barriers to the effective use of LAIs were identified as attitudinal and knowledge/experience-based. Direct discussions between healthcare providers and patients about treatment preferences may not occur due to a preconceived notion that patients prefer oral antipsychotics. Moreover, as LAIs have historically been limited to the treatment of schizophrenia and the most severe cases of BP-I, healthcare providers might be unaware of the benefits LAIs provide in the overall management of BP-I. Improved treatment adherence associated with LAIs compared to oral antipsychotics may support improved outcomes for patients (e.g., reduced relapse and hospitalization). Involvement of all stakeholders (healthcare providers, patients, and their supporters) participating in the patient journey is critical in early and shared decision-making processes. Clinical and database studies could potentially bridge knowledge gaps to facilitate acceptance of LAIs.

CONCLUSION

This review discusses the benefits of LAIs in the management of BP-I and identifies barriers to use, while providing expert consensus recommendations for potential solutions to support informed treatment decision-making.

A review of clinical applications of pharmacokinetic simulations for a 2-month long-acting injectable formulation of aripiprazole

Aripiprazole 2-month ready-to-use (Ari 2MRTU) is a long-acting injectable antipsychotic that was approved for use in Europe in March 2024, for the maintenance treatment of schizophrenia in adult patients stabilized with aripiprazole; it is administered via gluteal intramuscular injection once every two months. This review examines population pharmacokinetic model-based simulations relevant to the use of Ari 2MRTU in Europe, accompanied by expert commentary that contextualizes the simulations and highlights the potential implications of the availability of Ari 2MRTU for patients, caregivers, and clinicians. Various simulations conducted across 8 weeks (representing the first dosing interval), or 32 weeks (representing maintenance dosing) demonstrated an aripiprazole exposure profile for Ari 2MRTU that was similar to aripiprazole once-monthly (AOM), but with an extended dosing interval. In treatment initiation scenarios consistent with the European label, therapeutic levels of aripiprazole (i.e. ≥95 ng/mL) were maintained when transitioning from either AOM or oral aripiprazole, including with a two-injection start regimen with no requirement for 14 days of oral aripiprazole supplementation. Therapeutic levels of aripiprazole were also observed for treatment maintenance scenarios, except when dosing of Ari 2MRTU was delayed by 8 weeks. The availability of Ari 2MRTU extends the range of options for the maintenance treatment of schizophrenia in Europe. Ari 2MRTU may provide adherence benefits due to its extended dosing interval and the option to initiate treatment using a two-injection start regimen, which does not require 14 days of overlapping oral supplementation.

Real-World Effectiveness of Long-Acting Injectable and Oral Antipsychotic Agents in US Medicare Patients with Schizophrenia

INTRODUCTION

Daily oral antipsychotics (OAPs) are the mainstay of schizophrenia treatment; however, long-acting injectable antipsychotics (LAIs) are associated with better treatment adherence and improved outcomes.

METHODS

This study assessed the real-world comparative effectiveness of LAIs and daily OAPs using claims data from a nationally representative sample of fee-for-service Medicare beneficiaries with schizophrenia. Antipsychotic discontinuation, psychiatric hospitalization, and treatment failure were compared relative to different reference groups using within-individual Cox regression models.

RESULTS

The study included 152,835 patients (mean age, 53.5 years; 54.0% male and 61.5% white). LAIs when grouped by dosing intervals were associated with significantly lower risk of antipsychotic discontinuation (hazard ratios [HRs] 0.27-0.69), psychiatric hospitalization (HRs 0.76-0.88), and treatment failure (HRs 0.55-0.74) compared with OAPs. When LAIs of different dosing intervals and OAPs were broken out by type of agent and compared with oral risperidone, second-generation LAIs, specifically LAI paliperidone (every 3 months [Q3M] and monthly [Q1M]), LAI aripiprazole (Q1M), and LAI risperidone (primarily every 2 weeks), had a significantly lower risk of antipsychotic discontinuation (HRs 0.19-0.67), psychiatric hospitalization (HRs 0.76-0.91), and treatment failure (HRs 0.53-0.85). Second-generation LAI paliperidone (Q3M) had the lowest risk for negative outcomes relative to OAPs; this effect was maintained when the reference group was changed to oral risperidone, LAI risperidone, LAI aripiprazole (Q1M), and LAI haloperidol (Q1M) (33-47% lower risk).

CONCLUSION

Efforts are needed to enhance identification of appropriate candidates for LAIs and increase their uptake, especially longer dosing interval LAIs, in the Medicare population.

Trends in Formulary Restrictions for Long-Acting Injectable Antipsychotic Medications Among Medicare Drug Plans, 2019-2023

OBJECTIVE

Long-acting injectable antipsychotics (LAIAPs) enable safe and effective long-term management of chronic psychotic disorders but are underused in clinical practice. The authors examined whether Medicare formulary restrictions (prior authorization [PA] or step therapy) impose barriers to LAIAP uptake.

METHODS

The authors analyzed formulary restrictions and patient cost-sharing for several LAIAPs and estimated the percentage of plans (N=2,494 were available per year) applying formulary restrictions. Analyses were stratified by Medicare Advantage, dual Medicare-Medicaid eligibility plans, and Part D plan group and weighted by the number of enrollees at the per-year, per-plan level.

RESULTS

Application of formulary restrictions for LAIAPs was low (<12% requiring PA [apart from olanzapine] and <4% requiring step therapy) and decreased among nearly all plan types between 2019 and 2023.

CONCLUSIONS

Formulary restrictions do not appear to present a significant barrier to use of LAIAPs for psychiatric patients with Medicare prescription drug coverage. Additional research is needed to further understand factors influencing LAIAP use.

Distribution and correlates of long-acting injectable antipsychotic use among community mental health center patients

Although long-acting injectable antipsychotics (LAIs) are an important pharmaceutical option in the management of schizophrenia and related disorders, little is known about patient characteristics related to LAI use in real-world outpatient settings. We analyzed electronic medical records from 41,401 patients who received psychiatric services from one of 16 regional mental health centers operated by the South Carolina Department of Mental Health in 2022. We compared the use of first- and second-generation LAIs and oral antipsychotics by sociodemographic (age, gender, race/ethnicity, zip code, payment source) and clinical characteristics (psychiatric diagnoses, service use). We used logistic regression models to estimate associations between patient characteristics and the likelihood of using LAIs. In total, 7,029 (17.0 %) patients used LAIs in 2022, including 5,901 with schizophrenia or another psychotic disorder. Compared to White patients, Black (Odds Ratio (OR): 2.19, 95 % Confidence Interval (CI): 1.96 - 2.44) and Asian (OR: 3.39, 95 % CI: 1.54 - 7.43) patients were significantly more likely to use LAIs, controlling for other patient demographic and clinical characteristics. LAI users were also more likely to be male (OR: 1.83, 95 % CI: 1.64, 2.03), to live in suburban areas (OR: 1.25, 95 % CI: 1.10, 1.42), and to use Medicaid (OR: 1.55, 95 % CI: 1.34, 1.79). Similar differences were not found for oral antipsychotics. Results suggest that LAI use differs substantially by patient characteristics independent of psychiatric diagnoses. Identifying and understanding reasons for differences in LAI use is important to promote equitable access to and use of LAIs across racial, geographic, and other sociodemographic groups.

Subconjunctival injection of microcrystalline prodrug of dexamethasone for long-acting anti-inflammation after phacoemulsification surgery

Long-acting injectable formulations of dexamethasone with minimal invasiveness are highly desired to manage chronic ocular inflammatory conditions. Here, we applied microcrystals (MCs) of a hydrophobic acetone-based ketal-linked prodrug of dexamethasone (SKD) to treat postoperative ocular inflammation. We compared the efficacy and safety of SKD MCs through subconjunctival (SC) injection with that of Maxidex (a topical suspension of dexamethasone MCs) through SC injection and eye drops in the phacoemulsification combined with intraocular lens implantation (Phaco-IOL) rabbit model. In Phaco-IOL rabbit eyes, a single SC injection of SKD MCs (0.4 mg dexamethasone equiv.) showed anti-inflammatory effects comparable to Maxidex eye drops and completely alleviated the inflammation within 28 days, while an SC injection of Maxidex at the same dose only provided anti-inflammatory effects for 7 days. The study on the dose-dependent anti-inflammatory effects of SKD MCs showed no significant difference in anti-inflammatory effects for the high dosage (0.8 mg dexamethasone equiv.) and the low dosage (0.4 mg dexamethasone equiv.) in 28 days. Nevertheless, systematic drug distribution of SKD MCs and Maxidex in normal rabbits after SC injection demonstrates that the drug concentration in conjunctiva was higher for the high dosage and that a considerable amount of prodrug and dexamethasone could still be detected in the cornea and iris-ciliary body at least 84 days for SKD MCs at high dosage. Furthermore, no persistent elevated intraocular pressure and abnormality in retinal structure and thickness were observed, confirming the excellent safety of long-acting SKD MCs post-SC injection. Our findings provide valuable insights into using prodrug-based MCs for treating ocular postoperative inflammation, and the detailed drug distribution analysis would promote the clinical translation of these MCs in ocular diseases.

The Underuse of Clozapine and Long-Acting Injectable Antipsychotics

Schizophrenia is among the most devastating and costly human diseases. The public face of the failure to appropriately treat schizophrenia includes approximately 100,000 homeless individuals with schizophrenia and related psychoses and 200,000 incarcerated individuals with similar diagnoses. Clozapine and long-acting injectable antipsychotics are among the most effective treatments, but both are markedly underused. The following organizations should take responsibility for fixing this problem: National Institute of Mental Health, Patient-Centered Outcomes Research Institute, Substance Abuse and Mental Health Services Administration, Centers for Medicare and Medicaid Services, U.S. Food and Drug Administration, American Psychiatric Association, and patient and family advocacy groups.

Preferences for Selecting and Initiating Long-Acting Injectable Antipsychotic Agents for the Treatment of Patients With Schizophrenia: Results From the US DECIDE Survey

Background

Long-acting injectable antipsychotics (LAIs) improve adherence and reduce schizophrenia relapse rates. Data on which LAI attributes drive clinician preference are limited.

Methods

In the DECIDE survey, 380 psychiatric clinicians (psychiatrists, psychiatric nurse practitioners, and physician assistants) were surveyed regarding preferences when selecting and initiating LAIs for patients with schizophrenia. Responses were analyzed by clinician use of LAIs (high [≥ 31% of their patients using LAIs] or low [≤ 14% of their patients using LAIs]) and mindset toward LAI use (early, severity reserved, adherence reserved, and LAI hesitant).

Results

Overall and across subgroups, side effects were the most important consideration when selecting a particular LAI, with 33% of clinicians ranking this as most important (26%-46% across subgroups). Clinician preference for the molecule was most often ranked least important (47% overall; 39%-59% across subgroups). A significantly higher proportion of clinicians with high vs low LAI use ranked product attributes as the most important consideration (26% vs 13%; P < .01). Across subgroups, multiple injection site options, small/on par needle, and price made at least two-thirds of clinicians somewhat/much more likely to use a particular LAI, and 63%-82% of clinicians reported being somewhat/much more likely to select an LAI dosed once monthly or less often vs 6%-11% being somewhat/much more likely to select an LAI dosed once every 2 weeks.

Conclusions

Overall, results from DECIDE provide insight into the decision-making process of psychiatric clinicians when selecting an LAI and highlight opportunities to help clinicians deliver optimal care for patients with schizophrenia.

Associations between readmission and patient-reported measures in acute psychiatric inpatients: a multicenter prospective longitudinal study

PURPOSE

This study examined whether patient-reported measures (PRMs) addressing quality of life, personal agency, functional impairment, and treatment satisfaction at hospital discharge were associated with future readmission during a 12-month follow-up period. The study also examined whether readmission influenced changes in the same measures.

METHODS

A multicenter prospective cohort study was conducted at 21 psychiatric hospitals in Japan. Participants completed the EuroQol-five-dimensions-five-level (EQ-5D), the Five-item Subjective Personal Agency Scale, and the Sheehan Disability Scale (SDS) at the time of index admission (T1), discharge from index admission (T2), and 6 months (T3) and 12 months (T4) after discharge. Inpatient treatment satisfaction was assessed at T2. Readmission and variables potentially associated with hospitalization and PRMs were evaluated using mixed-effects logistic regression models and mixed models for repeated measures.

RESULTS

A total of 491 participants were followed for 12 months (attrition rate: 19.4%), and 480 were included in the EQ-5D analysis. The most common diagnoses were schizophrenia (59%), depression (14%), and bipolar disorder (13%). No patient-reported measures were significantly associated with readmission over the follow-up period. Interaction of readmission and time did not significantly affect changes in EQ-5D. Readmission did significantly influence SDS score changes between T2 and T3 (B = 1.78, 95% CI = 0.30-3.25, p = 0.018) and between T3 and T4 (B = 1.43, 95% CI = 0.14-2.72, p = 0.029). The same influence of readmission on SDS score changes was not observed in the model which adjusted for all potential covariates.

CONCLUSION

Readmission was potentially associated with changes in self-reported functional impairment. Findings highlight the potential role of intensive post-discharge services in preventing readmission, rather than relying on time-of-discharge PRMs in order to predict readmission risk.

TRIAL REGISTRATION

This study was registered in UMIN Clinical Trials Registry (UMIN000034220).

Dynamics of Clinical Manifestations and Social Functioning in Schizophrenia: A Non-interventional Observational Study of Paliperidone Palmitat Dosage Forms

BACKGROUND

Over the past seven years, the use of long-acting forms of antipsychotic medication has significantly increased in Russia. Specifically, in Moscow, from 2016 to 2021, the proportion of prescribed injectable long-acting antipsychotics had increased more than sevenfold (from 3% to 23%). Studies have shown that the correct selection of target groups for such therapy can reduce the frequency of relapses requiring hospitalization, lower the costs of inpatient care, and shift the focus of therapy from multiple drug administrations to psychosocial work.

AIM

This study was aimed at evaluating changes over time in psychosocial functioning, as well as clinical and psychopathological manifestations, in patients with schizophrenia during early remission and while on therapy with different forms of paliperidone: oral paliperidone (OP), paliperidone palmitate administered once monthly (PP1M), and paliperidone palmitate administered once every three months (PP3M).

METHODS

The observational study included 155 patients: 54 patients who had been treated with another second-generation antipsychotic received OP, 50 patients who had been treated with another antipsychotic received PP1M injections, and 51 patients who had been in remission for four months after treatment with PP1M received PP3M. The duration of the follow-up period was 12 months. Assessment of personal and social functioning was conducted five times: before the start of treatment, and 3, 6, 9, and 12 months later.

RESULTS

Treatment in all groups led to a statistically significant reduction in the severity of positive symptoms (p <0.001). Hallucinations proved more susceptible to therapy (p <0.001), while persistent delusions showed greater treatment resistance. Significantly more patients in the PP1M and PP3M groups had completed the entire program (n=24; 48.0%, and n=30; 58.8%, respectively) compared to the OP group (n=11; 20.4%). The PP3M group demonstrated the highest treatment adherence, with the largest number of patients completing the study, and a similar rate of exacerbations or inadequate efficacy compared to the other groups.

CONCLUSION

Treatment with different forms of paliperidone provides a roughly equal pace reduction in the severity of schizophrenia, including positive and negative symptoms. The PP3M group had better adherence and the highest number of patients who fully completed the study.

Industry effects on evidence: a case study of long-acting injectable antipsychotics

A vigorously debated issue in the psychiatric literature is whether long-acting injectable antipsychotics (LAIs) show clinical benefit over antipsychotics taken orally. In addressing this question, it is critical that systematic reviews incorporate risk of bias assessments of trial data in a robust way and are free of undue industry influence. In this paper, we present a case analysis in which we identify some of the design problems in a recent systematic review on LAIs vs oral formulations. This case illustrates how evidence syntheses that are shaped by commercial interests may undermine patient-centered models of recovery and care. We offer recommendations that address both the bioethical and research design issues that arise in the systematic review process when researchers have financial conflicts of interest.

Long-Acting Injectable Antipsychotics in the Geriatric Population: A longitudinal Study

OBJECTIVE

This study compares demographic, clinical characteristics, and outcomes in older adults on long-acting injectable antipsychotics (LAI-AP) vs. oral antipsychotics (PO-AP).

DESIGN

This observational study with a retrospective cohort utilized the electronic medical record's search engine to review charts of geriatric patients on LAI-AP for a two-year period. A convenience sample on PO-AP formed the comparison group. LAI-AP patients were subcategorized into discontinuation and continuation groups.

SETTING

Conducted at an urban, psychiatric outpatient clinic, using charts from October 2020 to 2022.

PARTICIPANTS

Patients at least 60 years-old with psychotic or mood disorders on antipsychotics for at least 3-months during the study period.

MEASUREMENTS

Demographic and clinical variables, including diagnosis, medication type, side effects, medical comorbidities, neurocognitive status, and secondary medications, were collected for both PO-AP and LAI-AP groups. Outcome variables included missed appointments, psychiatric and medical hospitalizations, and emergency room visits. Correlates of discontinuation of LAI-AP were also assessed.

RESULTS

LAI-AP had a higher proportion than PO-AP of primary psychotic disorders (87.8% vs. 64.3%). During the study, PO-AP had higher rates of missed appointments (median 18% vs. 13% for LAI-AP) and psychiatric admissions (mean 0.019/month vs. 0.006/month for LAI-AP;); Female sex was a risk factor for discontinuation of LAI-AP (86.7% of discontinuation group vs. 55.2% of continuation group).

CONCLUSIONS

The LAI-AP group showed reduced hospitalizations, better treatment engagement, and comparable tolerability to PO-AP. Preliminary data suggests gender may influence LAI-AP discontinuation rates. This study adds to the sparse literature investigating the efficacy and tolerability of LAI-AP in geriatric patients.

Comparing two transitioning strategies to paliperidone palmitate once-every-6-months

BACKGROUND

A double-blind, randomized, active-controlled, parallel-group, noninferiority trial (NCT03345342) demonstrated that paliperidone palmitate once-every-6-months (PP6M) was noninferior to paliperidone palmitate once-every-3-months (PP3M) in preventing relapse in clinically stable adults with schizophrenia. This post hoc analysis assessed efficacy and safety following transition to PP6M from paliperidone once-monthly (PP1M) versus PP3M.

METHODS

Adults with schizophrenia who were clinically stable on moderate/high doses of PP1M or PP3M were randomly assigned 1:2 to dorsogluteal PP3M or PP6M treatment for 12 months. The primary efficacy measure was time to relapse during the 12-month DB phase. Secondary endpoints included change from DB baseline to endpoint in Positive and Negative Syndrome Scale (PANSS) total and subscale scores, Clinical Global Impression-Severity (CGI-S) scale score, and Personal and Social Performance (PSP) scale score. Safety was assessed by treatment-emergent adverse events (TEAEs), vital signs, and clinical laboratory tests.

RESULTS

Of 702 patients in the study, 231 transitioned from PP1M to PP6M and 247 transitioned from PP3M to PP6M. Low relapse rates for PP6M were observed regardless of transition pathway (PP1M/PP6M: 7.8%; PP3M/PP6M: 7.3%). Changes from DB baseline to endpoint in PANSS total, PSP, and CGI-S scores were similar between transition groups. In the DB phase, ≥1 TEAE was observed in 61.0% and 63.2% of patients in the PP1M/PP6M and PP3M/PP6M, groups, respectively.

CONCLUSION

Adults with schizophrenia who transitioned to PP6M from either PP1M or PP3M experienced similarly low relapse rates. Additionally, symptom and functionality scores supported the primary analysis and, along with TEAE incidences, were comparable between transition groups.

Long-term effectiveness of aripiprazole once monthly on functioning and quality of life in schizophrenia: results of year 2 of the ReLiAM study

BACKGROUND

Aripiprazole once-monthly (AOM) has proven effective in the treatment of schizophrenia, although little is known about its impact on global functioning and quality of life beyond 1 year. Here, we investigate the continued impact of AOM on the participants of the ReLiAM study during the second year of follow-up.

METHODS

The participants who were evaluated at ≥ 1 time point during the second year of the ReLiAM study (months 15, 18, 21, and 24; year 1 completers) were assessed via the GAF scale. Secondary outcomes were reported on the SOFAS, CGI-S, and QLS.

RESULTS

109 (86%) completed at least 1 post-12-month visit and 33 (30.3%) patients completed the final assessment at month 24. The improvements observed in the year 1 completers in GAF total score were maintained through to year 2 completers. The improvements in CGI-S and SOFAS that were observed at the end of year 1 were also maintained through the end of the second year. Similar trends of sustained improvement in GAF total score, CGI-S score, and SOFAS were observed in the post-hoc analyses of the year 2 completers. Seventy-four percent (74.3%) of year 1 completers experienced mild treatment-emergent adverse events during the second year, the most frequently reported being weight gain, akathisia, and insomnia. Seventeen percent (17.4%) experienced serious adverse events. Similar findings regarding effectiveness and tolerability were reported in the year 1 completers and in year 2 completers.

CONCLUSIONS

These findings suggest that the favorable effectiveness, including tolerability observed during the first year following AOM initiation, are maintained and may even continue to improve during the second year of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02131415, first posted on May 6, 2014. Overall trial status: Terminated.

Update of the World Health Organization's Mental Health Gap Action Programme Guideline for Psychoses (Including Schizophrenia)

BACKGROUND AND HYPOTHESIS

The World Health Organization's (WHOs) Mental Health Gap Action Programme (mhGAP) aims to improve healthcare for mental, neurological, and substance use disorders in nonspecialized settings, with a focus on low- and middle-income countries (LMICs). mhGAP includes guidelines for the treatment of psychoses (including schizophrenia), which were recently updated in 2023. The complexity of the WHO guideline update process and the updated recommendations on psychoses are presented.

STUDY DESIGN

The WHO guideline development process is outlined as well as the evidence appraisal and the translation of the evidence into recommendations following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The guideline update process includes a review of the literature, a compilation of systematic reviews, and extracting data related to critical and important outcomes. The updated recommendations and the justifying evidence are discussed.

STUDY RESULTS

The WHO mhGAP guidelines for psychoses are adapted to LMICs, and consist of 13 recommendations in 2023, whereof 5 were updated, and 1 recommendation was newly developed. Background information on how these recommendations were obtained, and significant changes since the previous guideline update in 2015 are provided.

CONCLUSIONS

Unlike other guidelines, the WHO must consider various countries, contextual factors, and the WHO Model Lists of Essential Medicines when developing its guidelines. A transformation of the WHO guideline for psychoses into a living guideline would ensure always up-to-date recommendations and facilitate shared decision-making.

Antipsychotic prescribing practices and their association with rehospitalization in a forensic psychiatric sample

While there is extensive literature examining the effectiveness of antipsychotic prescribing to patients with schizophrenia spectrum or other psychotic disorders in general psychiatric services, there is a dearth of studies examining antipsychotic prescribing practices and their effectiveness in forensic psychiatric services. Forensic psychiatric patients have unique challenges often due to their high-profile offences, public scrutiny, and legal requirements. This longitudinal, retrospective study aimed to examine antipsychotic prescribing and rehospitalization rates in a forensic psychiatric sample, along with relevant socio-demographic, clinical, and forensic characteristics. All patients had a psychotic illness and were prescribed antipsychotic medication. The sample included 153 patients, of which the majority were male (85.6%), Caucasian (71.2%), middle aged (30s to 50s), had schizophrenia or schizoaffective disorder (76.5%), had a substance use disorder (62.1%), and had a most serious index offence against the person (80.4%). Atypical antipsychotics accounted for the majority of antipsychotic prescriptions (75.9%) and the sample had an antipsychotic polypharmacy rate of 39.9%. The sample was divided into four primary antipsychotic formulation types, which were oral (34.0%), injection (39.2%), clozapine (19.0%), and subtherapeutic (7.8%). Regarding rehospitalization, 52.9% of the sample was rehospitalized, with the average number of rehospitalizations being 1.2 (SD = 1.7) and proportion of the follow up period rehospitalized being 16.4% (SD = 27.7%). Patients prescribed clozapine had numerically lower rates of rehospitalization than those prescribed oral and injection formulation types, but it was not statistically significant. With a 19.0% prescription rate, clozapine may be underutilized in this sample. Further research is needed to demonstrate the potential benefits of clozapine regarding rehospitalization in forensic psychiatric patients, as has already been done in general psychiatry. Advancing treatment of the high-profile forensic population can reduce stigma toward people with mental illness and criminal justice involvement.

Introducing S.C.O.P.E.™ (Schizophrenia Clinical Outcome Scenarios and Patient-Provider Engagement), an Interactive Digital Platform to Educate Healthcare Professionals on Schizophrenia Care

Despite evidence of benefits beyond those of oral antipsychotics, long-acting injectable antipsychotics (LAIs) are underused in schizophrenia treatment. Underuse may be partially a result of misconceptions held by some healthcare professionals (HCPs) pertaining to LAIs. A panel of four experts convened between January 2022 and May 2022 to identify these misconceptions, and example cases or scenarios were created to illustrate common clinical situations relevant to these beliefs. Ultimately, an online platform and heuristic tool, Schizophrenia Clinical Outcome Scenarios and Patient-Provider Engagement (S.C.O.P.E.™), was developed to help prescribing clinicians and other HCPs better understand common clinical dilemmas, as well as the place for LAIs in schizophrenia treatment. Three main misconceptions related to the use of LAIs to treat schizophrenia were identified and included "physicians/providers know when patients are nonadherent", "patients do not accept/want LAI treatment", and "LAIs are only appropriate for patients who have demonstrated nonadherence". All misconceptions are refuted by current evidence and were used to develop clinical scenarios with questions to consider when patients present to various sites of care for treatment. These cases are presented on the S.C.O.P.E. educational platform. The platform also includes videos designed to help non-prescribing HCPs and mental health professionals address patient/caregiver concerns and to communicate LAI benefits. In addition, S.C.O.P.E. provides a section with information about each LAI that is currently FDA approved in the United States for the treatment of schizophrenia, to help familiarize HCPs with characteristics of LAIs. S.C.O.P.E. is an educational tool designed for HCPs to help improve their understanding of how to manage common clinical dilemmas in the treatment of people with schizophrenia, to clarify the role of LAIs in medication management, and to increase understanding of the characteristics of available LAIs. S.C.O.P.E. also aims to improve care in schizophrenia by facilitating increased awareness to patients and caregivers.

TV-46000, A Long-Acting Subcutaneous Antipsychotic Agent, Demonstrated Improved Patient-Centered Outcomes in Patients with Schizophrenia

Background

TV46000 is a long-acting subcutaneous antipsychotic (LASCA) formulation of risperidone approved for the treatment of schizophrenia in adults.

Methods

The RISE study (NCT03503318) compared TV-46000 once monthly (q1m) and once every 2 months (q2m) with placebo (1:1:1) in patients with schizophrenia who underwent stabilization on oral risperidone. The SHINE study (NCT03893825) evaluated the long-term safety, tolerability, and effectiveness of TV-46000 in patients who completed RISE without relapse (rollover; placebo rollover randomized [1:1] to q1m or q2m; TV-46000 rollover continued assigned treatment) or who were newly recruited (de novo; randomized [1:1] to q1m or q2m after oral stabilization). Patient-centered outcomes included the Schizophrenia Quality of Life Scale (SQLS), the 5-Level EuroQoL 5-Dimensions Questionnaire (EQ-5D-5L), the Personal and Social Performance Scale (PSP), and the Drug Attitudes Inventory 10-item version (DAI-10).

Results

In RISE, SQLS least-squares mean changes (SE) improved to last assessment (LA) for TV-46000 q1m (-4.15 [1.03]) and q2m (-3.28 [1.06]) but worsened for placebo (1.75 [1.07]; P<0.001 for both). PSP, EQ5D-5L, and DAI-10 showed similar trends. In SHINE, SQLS decreased (improved) at LA for both TV-46000 q1m (-0.43 [0.98]) and q2m (-2.16 [0.98]); reductions were observed in the de novo (q2m only) and placebo rollover (q1m and q2m) cohorts, but not for the TV46000 rollover cohort. Results for PSP, EQ5D-5L, and DAI-10 were consistent with those reported in the RISE study.

Conclusion

Improvements in patient-centered outcomes were observed across cohorts, with the largest improvements observed for patients who began TV-46000 during SHINE (ie, de novo and placebo rollover cohorts), while gains made during RISE were minimally improved or maintained in the TV-46000 rollover cohort, indicating the benefit of uninterrupted TV-46000 treatment. These data support the effectiveness of TV-46000 to improve patient-centered outcomes in patients with schizophrenia.

Relapse Following Electroconvulsive Therapy for Schizophrenia: A Systematic Review and Meta-analysis

BACKGROUND

Evidence regarding schizophrenia relapse following acute electroconvulsive therapy (ECT) is sparse compared with that for depression, and we have no clear consensus on relapse proportions. We aimed to provide longitudinal information on schizophrenia relapse following acute ECT.

STUDY DESIGN

This systematic review and meta-analysis included randomised controlled trials (RCTs) and observational studies on post-acute ECT relapse and rehospitalization for schizophrenia and related disorders. For the primary outcome, we calculated the post-acute ECT pooled relapse estimates at each timepoint (3, 6, 12, and 24 months post-acute ECT) using a random effects model. For subgroup analyses, we investigated post-acute ECT relapse proportions by the type of maintenance therapy.

STUDY RESULTS

Among a total of 6413 records, 29 studies (3876 patients) met our inclusion criteria. The risk of bias was consistently low for all included RCTs (4 studies), although it ranged from low to high for observational studies (25 studies). Pooled estimates of relapse proportions among patients with schizophrenia responding to acute ECT were 24% (95% CI: 15-35), 37% (27-47), 41% (34-49), and 55% (40-69) at 3, 6, 12, and 24 months, respectively. When continuation/maintenance ECT was added to antipsychotics post-acute ECT, the 6-month relapse proportion was 20% (11-32).

CONCLUSION

Relapse occurred mostly within 6 months post-acute ECT for schizophrenia, particularly within the first 3 months. Relapse proportions plateaued after 6 months, although more than half of all patients could be expected to relapse within 2 years. Further high-quality research is needed to optimise post-acute ECT treatment strategies in patients with schizophrenia.

Risperidone ISM®: review and update of its usefulness in all phases of schizophrenia

One of the most important challenges in the management of patients with schizophrenia is to ensure adherence to antipsychotic treatment. The contribution of long-acting injectables (LAI) is undeniable in this matter, but there are still some unmet medical needs not covered by these drugs (e.g. quick onset of action for patients with acute exacerbation of schizophrenia). This article summarises the pharmacokinetics, efficacy and safety of Risperidone ISM (in situ microparticles). The aim of this review is to provide information about the potential uses of this new LAI formulation of risperidone for the treatment of schizophrenia, contextualising and diving into the published evidence. Risperidone ISM shows a rapid release which allows achieving within 12 h risperidone active moiety levels similar to those observed in the steady-state for oral risperidone treatment, achieving a mean average concentration of 38.63 ng/mL. The plasma concentration of active moiety achieved by Risperidone ISM comes with a predictable dopamine D2 receptor occupancy above 65% throughout the 28-day dosing period, which is accepted as a threshold for the efficacy of the antipsychotic treatment. This can be associated with the positive efficacy findings throughout its clinical development. In the short term, it provides an early and progressive reduction of symptoms in adult patients with acute exacerbation of schizophrenia without the need for loading doses or oral risperidone supplementation, which could contribute to reinforcing the therapeutic alliance between the patient and the psychiatrist. In addition, long-term treatment was effective, safe and well tolerated regardless of the initial disease severity or whether patients were previously treated with Risperidone ISM during an acute exacerbation or switched from stable doses of oral risperidone. Improvement and maintenance of personal and social functioning and health-related quality of life were observed in each setting, respectively. All these findings endorse Risperidone ISM as a useful and valuable treatment for the acute and maintenance management of patients with schizophrenia.

Antipsychotic Drugs: A Concise Review of History, Classification, Indications, Mechanism, Efficacy, Side Effects, Dosing, and Clinical Application

The introduction of the first antipsychotic drug, chlorpromazine, was a milestone for psychiatry. The authors review the history, classification, indications, mechanism, efficacy, side effects, dosing, drug initiation, switching, and other practical issues and questions related to antipsychotics. Classifications such as first-generation/typical versus second-generation/atypical antipsychotics are neither valid nor useful; these agents should be described according to the Neuroscience-based Nomenclature (NbN). Antipsychotic drugs are not specific for treating schizophrenia. They reduce psychosis regardless of the underlying diagnosis, and they go beyond nonspecific sedation. All currently available antipsychotic drugs are dopamine blockers or dopamine partial agonists. In schizophrenia, effect sizes for relapse prevention are larger than for acute treatment. A major unresolved problem is the implausible increase in placebo response in antipsychotic drug trials over the decades. Differences in side effects, which can be objectively measured, such as weight gain, are less equivocal than differences in rating-scale-measured (subjective) efficacy. The criteria for choosing among antipsychotics are mainly pragmatic and include factors such as available formulations, metabolism, half-life, efficacy, and side effects in previous illness episodes. Plasma levels help to detect nonadherence, and once-daily dosing at night (which is possible with many antipsychotics) and long-acting injectable formulations are useful when adherence is a problem. Dose-response curves for both acute treatment and relapse prevention follow a hyperbolic pattern, with maximally efficacious average dosages for schizophrenia of around 5 mg/day risperidone equivalents. Computer apps facilitating the choice between drugs are available. Future drug development should include pharmacogenetics and focus on drugs for specific aspects of psychosis.

Comparative Effectiveness of Antipsychotics in Patients With Schizophrenia Spectrum Disorder

Importance

Antipsychotics are the cornerstone of maintenance treatment in schizophrenia spectrum disorders, but it is unclear which agents should be prioritized by prescribers.

Objective

To investigate the clinical effectiveness of antipsychotics, including recent market entries, in comparison with oral olanzapine in relapse and treatment failure prevention among individuals with schizophrenia spectrum disorder.

Design, Setting, and Participants

This comparative effectiveness research study with a within-individual analysis included data from Swedish health care registers of inpatient and specialized outpatient care, sickness absence, and disability pensions among all individuals aged 16 to 65 years who were diagnosed with schizophrenia spectrum disorder from January 1, 2006, to December 31, 2021, including an incident cohort and a prevalent cohort.

Exposures

Specific antipsychotics.

Main Outcomes and Measures

The risks for psychosis relapse hospitalization and treatment failure (psychiatric hospitalization, death, or change in an antipsychotic medication) were adjusted for the temporal order of treatments, time since cohort entry, and concomitant drugs. Comparisons of all antipsychotics with oral olanzapine, the most commonly used antipsychotic, were investigated.

Results

Among the full cohort of 131 476 individuals, the mean (SD) age of the study cohort was 45.7 (16.2) years (70 054 men [53.3%]). During a median follow-up of 12.0 years [IQR, 5.2-16.0 years], 48.5% of patients (N = 63 730) experienced relapse and 71.1% (N = 93 464) underwent treatment failure at least once. Compared with oral olanzapine, paliperidone 3-month long-acting injectable (LAI) was associated with the lowest adjusted hazard ratio (AHR) in the prevention of relapses (AHR, 0.66; 95% CI, 0.51-0.86), followed by aripiprazole LAI (AHR, 0.77 [95% CI, 0.70-0.84]), olanzapine LAI (AHR, 0.79 [95% CI, 0.73-0.86]), and clozapine (AHR, 0.82 [95% CI, 0.79-0.86]). Quetiapine was associated with the highest risk of relapse (AHR, 1.44 [95% CI, 1.38-1.51]). For prevention of treatment failure, paliperidone 3-month LAI was associated with the lowest AHR (AHR, 0.36 [95% CI, 0.31-0.42]), followed by aripiprazole LAI (AHR, 0.60 [95% CI, 0.57-0.63]), olanzapine LAI (AHR, 0.67 [95% CI, 0.63-0.72]), and paliperidone 1-month LAI (AHR, 0.71 [95% CI, 0.68-0.74]).

Conclusions and Relevance

This comparative effectiveness research study demonstrated large differences in the risk of relapse and treatment failure among specific antipsychotic treatments. The findings contradict the widely held conception that all antipsychotics are equally effective in relapse prevention.

Impact of Demographics and Insurance Coverage on Schizophrenia Treatment and Healthcare Resource Utilization Within an Integrated Healthcare System

Purpose

Little is known about the impact of health disparities on antipsychotic treatment and healthcare resource utilization (HRU) among patients with schizophrenia. The objective of this analysis is to examine treatment patterns and HRU by age, race/ethnicity, and insurance coverage among patients with schizophrenia in an integrated delivery network (IDN).

Patients and Methods

This cross-sectional study used electronic health record data from MedStar Health, an IDN in the Baltimore-Washington, DC, area. Patients were aged ≥18 years and had ≥2 outpatient encounters or ≥1 hospitalization with a diagnosis of schizophrenia between January 1, 2017 and March 31, 2021. Outcomes assessed included oral antipsychotic prescriptions, long-acting injectable antipsychotic (LAI) utilization, hospitalizations, emergency department (ED) visits, and outpatient visits. Analyses compared subgroups based on age, race/ethnicity (non-Hispanic Black, non-Hispanic White, and other), and type of insurance coverage at index (Medicare, Medicaid, and other) during 12 months of follow-up.

Results

A total of 78.1% of patients had ≥1 prescription for an antipsychotic and 69.1% received ≥1 second-generation antipsychotic. Second-generation long-acting injectables (SGA LAI) were utilized by 9.0% of patients, with the elderly and Medicaid beneficiaries having the lowest SGA LAI utilization. Overall, 61.7% of patients had ≥1 hospitalization, 56.4% had ≥1 outpatient visit, and 50.5% had ≥1 ED visit. Hospitalizations and ED visits were most common in those 18 to 24 years of age and in Medicaid beneficiaries, whereas outpatient visits were more common for the elderly and Medicare beneficiaries.

Conclusion

At the population level, the results indicate widespread underprescription/underutilization of antipsychotics that have been shown to improve clinical and economic outcomes in patients with schizophrenia, particularly SGA LAI. Within specific subpopulations, disparities in treatment selection and HRU were observed, suggesting the need for increased attention to at-risk groups to ensure consistent quality of care regardless of age, race/ethnicity, or insurance coverage.

Healthcare utilization and economics evaluation of paliperidone palmitate once-monthly in schizophrenia: a one-year, real-world, and retrospective mirror image study in China

Background

Investigation and analysis of the changes in healthcare resources and burden of schizophrenia in the real world before and after switching from oral antipsychotics (OAPs) to paliperidone palmitate once-monthly (PP1M) could provide evidence to clinicians and patients for choosing treatment modality and data support for health policy optimization.

Methods

The first dosage of PP1M was set as mirror point, and patients with mirror point between January 2020 and June 2022 were recruited in the study. The differences in treatment patterns, healthcare resource utilization, and costs within one year before and after the mirror point were compared.

Results

A total of 72 patients transitioning from OAPs to PP1M (mean age, 35.33 years; 43.06% female) were included in the study. Of the 72 patients, the application of PP1M resulted in a significant reduction in the hospitalization times, emergency room visits, and direct medical costs (P < 0.001), while the pharmacy cost and total cost increased by 222.57% (P < 0.001) and 16.35% (P < 0.001), respectively; PP1M accounted for 88.48% of the pharmacy cost. For patients with ≥1 hospitalization during the OAPs phase (n = 25), the number of hospitalizations, hospitalization days and hospitalization expenses decreased by more than 90% (P < 0.001). Total one-year expenses decreased by 37.67% (P < 0.001), and pharmacy expenses increased by 185.21% (P < 0.001). For patients with no hospitalizations during the OAPs phase (n = 47), emergency and outpatient visits decreased by 70% (P < 0.001) and 30.27% (P < 0.05), respectively, while the total cost increased by 117.56% (P < 0.001), and the pharmacy cost increased by 260.15% (P < 0.001) after initiation of PP1M treatment.

Conclusion

After the transition to PP1M, the number of hospitalizations and outpatient and emergency department visits reduced, and healthcare resources were conserved. Switching to PP1M may be more economically beneficial for patients with prior hospitalizations while on OAP regimens. The high price of PP1M might be an obstacle to its widespread use.

Treatment patterns and hospitalizations following rejection, reversal, or payment of the initial once-monthly paliperidone palmitate long-acting injectable antipsychotic claim among patients with schizophrenia or schizoaffective disorder

BACKGROUND

Once-monthly paliperidone palmitate (PP1M) is a long-acting injectable antipsychotic approved for the treatment of schizophrenia and schizoaffective disorder (SCA) in adults.

OBJECTIVE

To assess treatment patterns and schizophrenia/SCA-related hospitalization following payer rejection, patient reversal, or payment of an initial PP1M claim.

METHODS

This was a retrospective cohort study using the IQVIA Formulary Impact Analyzer database linked to the Medical Claims, Hospital Charge Detail Master, and Experian consumer databases. Patients with schizophrenia/SCA and ≥1 PP1M pharmacy claim from January 1, 2018, to February 28, 2022, were identified and stratified into 3 cohorts based on the transaction status of the initial PP1M claim (index date): rejected (payer not approved), reversed (payer approved, patient abandoned), and paid (payer approved, patient filled). Patient characteristics during the 12 months before the index date, subsequent treatment patterns, and schizophrenia/SCA-related hospitalization for patients with >6 months of follow-up were assessed by cohort.

RESULTS

The rejected, reversed, and paid cohorts included 1,260, 1,046, and 1,686 patients, respectively. Across these cohorts, the mean ages ranged between 39.2 and 44.5 years; more than half were male (50.8%-51.6%) and White (50.6%-58.3%); 19.8%-24.6% of patients had a Quan-Charlson Comorbidity Index score of ≥2. Rates of prior atypical oral and long-acting injectable antipsychotic use ranged between 76.4%-80.3% and 7.8%-12.7%, respectively. Among patients with ≥6 months of follow-up, 52.2% in the rejected and 53.1% in the reversed cohorts had a subsequent paid PP1M claim during the study period; the median (quartile 1-quartile 3) time to the first paid PP1M claim was 22 (5-74) days for rejection and 11 (1-41) days for reversal. In the rejected and reversed cohorts, 10.2% (n = 111) and 9.8% (n = 90) of patients, respectively, did not receive any paid claim for an antipsychotic after the initial PP1M rejection/reversal. The prevalence of schizophrenia/SCA-related hospitalization during follow-up was similar between patients with a paid (7.4%) and rejected PP1M claim (7.0%; P = 0.689) but higher among patients with a reversed claim (10.8%; P = 0.004). After adjusting for confounders, patients in the reversed cohort were 39% more likely to have a schizophrenia/SCA-related hospitalization than those in the paid cohort (odds ratio = 1.39; 95% CI = 1.03-1.87).

CONCLUSIONS

Payer rejection and patient reversal of initial PP1M claims is a form of primary nonadherence and may influence patient trajectory. Data from this study suggest that patient reversal of PP1M may lead to an increased risk of schizophrenia/SCA-related hospitalizations, potentially caused by missed or delayed treatment. Policy initiatives that remove barriers to primary adherence or fulfillment may help improve patients' clinical outcomes.

Antipsychotic use in a large community sample of patients with delusional disorder

BACKGROUND

To examine clinical and sociodemographic differences between patients with delusional disorder; with and without diagnoses of an additional severe mental disorder (SMD) or cognitive impairment.

METHODS

Population-based study including all individuals diagnosed with DD between 2005 and 2021 from a large catchment area in Madrid, Spain. Sociodemographic and clinical characteristics and the antipsychotic prescription patterns of the study population was described. Patients were divided into (i) patients with DD and no additional diagnosis of SMD or cognitive impairment (DD group), (ii) patients with DD and a diagnosis of an additional SMD (DD-SMD group), and (iii) patients with DD and cognitive impairment (DD-CI group).

RESULTS

Of 1109 patients with a DD diagnosis (62.5 % female), 131 (11.8 %) patients were diagnosed with an additional SMD, and 69 (6.2 %) were diagnosed with cognitive impairment. DD-SMD patients were on average 10 years younger and had longer time between first mental healthcare contact and DD disorder than DD patients. DD-CI patients were on average 10 years older and had a higher proportion of females. Paliperidone (21.9 %) and aripiprazole (20.6 %) were the modal antipsychotic drugs chosen overall. DD-SMD patients were more likely to receive paliperidone and to be prescribed long-acting injectable medication; DD-CI were more likely to receive risperidone or quetiapine; and DD patients were more likely to receive olanzapine.

CONCLUSIONS

Sociodemographic and clinical characteristics and choice of antipsychotic drug and delivery method for individuals with DD vary based on its comorbidity.

Patient-derived induced pluripotent stem cells: Tools to advance the understanding and drug discovery in Major Depressive Disorder

Major Depressive Disorder (MDD) is a pleomorphic disease with substantial patterns of symptoms and severity with mensurable deficits in several associated domains. The broad spectrum of phenotypes observed in patients diagnosed with depressive disorders is the reflection of a very complex disease where clusters of biological and external factors (e.g., response/processing of life events, intrapsychic factors) converge and mediate pathogenesis, clinical presentation/phenotypes and trajectory. Patient-derived induced pluripotent stem cells (iPSCs) enable their differentiation into specialised cell types in the central nervous system to explore the pathophysiological substrates of MDD. These models may complement animal models to advance drug discovery and identify therapeutic approaches, such as cell therapy, drug repurposing, and elucidation of drug metabolism, toxicity, and mechanisms of action at the molecular/cellular level, to pave the way for precision psychiatry. Despite the remarkable scientific and clinical progress made over the last few decades, the disease is still poorly understood, the incidence and prevalence continue to increase, and more research is needed to meet clinical demands. This review aims to summarise and provide a critical overview of the research conducted thus far using patient-derived iPSCs for the modelling of psychiatric disorders, with a particular emphasis on MDD.

A Long-Term Safety and Tolerability Study of TV-46000 for Subcutaneous Use in Patients with Schizophrenia: A Phase 3, Randomized, Double-Blinded Clinical Trial

BACKGROUND

TV-46000 is a long-acting subcutaneous antipsychotic (LASCA) formulation of risperidone that is approved by the United States Food and Drug Administration for the treatment of schizophrenia in adults. In the phase 3, randomized, double-blind RIsperidone Subcutaneous Extended-release (RISE) study, TV-46000 once monthly (q1m) and once every 2 months (q2m) significantly prolonged time to impending relapse compared with placebo [5.0-fold (q1m) and 2.7-fold (q2m)]. This phase 3, randomized, double-blind Safety in Humans of TV-46000 subcutaneous INjection Evaluation (SHINE) study was designed to evaluate the long-term safety, tolerability, and exposure of TV-46000 in schizophrenia.

METHODS

Patients who completed RISE without relapse (rollover) or who were newly recruited (de novo) were eligible for the SHINE study. Patients were initially stabilized on oral risperidone for 12 weeks (completed in RISE for rollover, or in SHINE for de novo). Patients in the de novo cohort and patients who received placebo in RISE were randomized 1:1 in SHINE to receive TV-46000 q1m or q2m for up to 56 weeks. Primary endpoint for SHINE was frequency of reported adverse events (AEs); event rates [ER; events per 100 patient-years (PYs)] were calculated for each AE by patients upon general questioning.

RESULTS

Overall, 336 patients were randomized in SHINE [TV-46000 q1m, n = 174; TV-46000 q2m, n = 162; of these, de novo, n = 109 and rollover, n = 227 (n = 172 patients were treated and n = 55 received placebo)]. A total of 334 patients were evaluated for safety [q1m, n = 172 (PY = 97.8); q2m, n = 162 (PY = 104.5)]. Proportions of patients (ER) with ≥ 1 AE and ≥ 1 treatment-related AE were 37% (180.0) and 21% (84.9) for TV-46000 q1m and 46% (157.9) and 20% (70.8) for TV-46000 q2m, respectively. Frequent treatment-related AEs [≥ 3% of patients in either group; proportion of patients (ER)] were injection site pain [q1m, 5% (24.5); q2m, 4% (22.0)] and injection site nodule [q1m, 2% (9.2); q2m, 6% (12.4)]. The proportions of patients with serious AEs was 5% for TV-46000 q1m and 7% for TV-46000 q2m; serious AEs reported for ≥ 2 patients overall were worsening schizophrenia [q1m, n = 1 (< 1%; ER, 1.02); q2m, n = 2 (1%; ER, 1.91)] and hyperglycemia [q1m, n = 1 (< 1%; ER, 1.02); q2m, n = 1 (< 1%; ER, 0.96)]. Of three reported deaths, none were related to treatment. Overall, eight patients discontinued treatment because of AEs. Similar or somewhat lower rates of AEs were reported for patients who rolled over from TV-46000 treatment compared with those who had no prior TV-46000 treatment (de novo and placebo rollover). Most AEs related to injection site reactions were mild; no patient had a severe reaction.

CONCLUSION

Results from this long-term safety study add to the favorable safety profiles of TV-46000 q1m and q2m, consistent with other formulations of risperidone and previous studies with TV-46000.

REGISTRATION

ClinicalTrials.gov, NCT03893825; 27 March 2019.

Electroconvulsive therapy in a tertiary Australian mental health facility between 2009 and 2020

BACKGROUND

Despite electroconvulsive therapy being one of the most effective treatments in psychiatry, few studies report trends in the provision of electroconvulsive therapy over time. This study aims to investigate the use of electroconvulsive therapy between 2009 and 2020 in an Australian public tertiary mental health facility, and to describe the electroconvulsive therapy patient population and change in courses of treatment.

METHODS

Routinely collected data for 677 patients who received 1669 electroconvulsive therapy courses of treatment at an Australian public tertiary mental health facility between 2009 and 2020 were examined.

RESULTS

The provision of acute electroconvulsive therapy was stable across the study period; however, the number of maintenance electroconvulsive therapy courses commenced declined over the study. Schizophrenia was the most common indication for index treatment (37.4%). The majority of patients (85.7%) received acute electroconvulsive therapy only. Voluntary provision of electroconvulsive therapy declined over the study period, reducing from 44.9% in 2009 to 16.3% in 2020.

CONCLUSION

Over the study period, there was a significant reduction in the number of maintenance electroconvulsive therapy courses commenced, and a large increase in involuntary treatment. The provision of electroconvulsive therapy was more likely to occur in males with a diagnosis of schizophrenia. Further studies are needed to generate a greater understanding of the factors influencing the provision of electroconvulsive therapy within differing geographical, social and healthcare landscapes.

An overview of the currently available and emerging long-acting formulations of risperidone for schizophrenia and bipolar disorder

INTRODUCTION

Long-acting injectable (LAI) antipsychotic medications can help improve treatment adherence in patients with schizophrenia and bipolar disorder. Despite this, they are underutilized. In 2003, intramuscular risperidone became the first available LAI atypical antipsychotic medication, and since then, a number of competing long-acting risperidone formulations have been brought to market, with additional options under active development. These include intramuscular, subcutaneous, long-acting oral, and implantable formulations.

AREAS COVERED

This review summarizes currently available and emerging long-acting risperidone formulations, including efficacy and safety data, and practical considerations aimed to help prescribers distinguish one formulation from another.

EXPERT OPINION

There is an expanding number of currently available LAI antipsychotic medications giving patients and providers an opportunity to personalize and individualize care. Rates of adherence to treatment in patients with schizophrenia and bipolar disorder are low, and individualizing care can help improve this. The risperidone LAI treatment landscape includes five options approved by the U.S. Food and Drug Administration, with others under clinical development. These options differ in regard to mode of administration, approved indications, available dose strengths, injection intervals, needle size, injection volume, storage, and other variables. Prescribers should be familiar with these differing options to help patients find the best fit for their individual needs.

Psychiatry and Family Medicine Residents' Likelihood of Prescribing HIV Pre-exposure Prophylaxis to Patients With Mental Illness and HIV Vulnerability

BACKGROUND

People living with mental illness (PLMI) experience disproportionately high incidence of and vulnerability to HIV. Pre-exposure prophylaxis (PrEP) is an effective and safe HIV prevention method, but data regarding prescription to PLMI are lacking. Psychiatrists may serve as important points of access for PrEP prescription for PLMI.

METHODS

We conducted a vignette-based study of residents in psychiatry and family medicine (FM) to assess likelihood of prescribing PrEP and assumptions about the fictional patient. Participants were randomized to one of five vignettes in which the patients' psychiatric diagnosis was varied (schizophrenia on long-acting injectable or oral antipsychotic, bipolar disorder, major depression) or a control vignette without a psychiatric diagnosis.

RESULTS

A total of 439 residents participated. We found that high percentages of psychiatry (96.8%) and FM (97.4%) residents were aware of PrEP. High percentages of psychiatry (92.0%-98.1%) and FM (80.8%-100%) residents reported that PrEP was indicated for all patient conditions. Family medicine residents were more likely to prescribe PrEP to all experimental conditions than psychiatry residents. There was no difference in likelihood of prescribing to the control condition without a psychiatric diagnosis. The belief that PrEP prescription was out of scope of practice was greater among psychiatry residents.

CONCLUSIONS

A majority of psychiatry residents responded that PrEP was indicated for an array of patients with psychiatric diagnoses. However, psychiatry residents were broadly less likely to prescribe PrEP to patients with these diagnoses. The high percentage of psychiatry residents who reported that PrEP was indicated for all patients suggests that additional training is needed to facilitate PrEP prescription by psychiatrists.

Treatment adherence in forensic patients with schizophrenia spectrum disorders discharged on long-acting injectable antipsychotics: a comparative 3-year mirror-image study

In this retrospective 3-year mirror-image study, 81 patients with schizophrenia spectrum disorders (SSD) were categorized according to whether they were prescribed long-acting injectable antipsychotics (LAI) or not upon discharge from the inpatient forensic psychiatric unit. Antipsychotic adherence, which was staged based on the 'proportion of days covered' method, as well as other clinical outcomes was compared between pre- and post-index mirror periods. In both Oral-only (n = 46) and Oral + LAI (n = 35) groups, the number of hospitalizations, convictions and months spent in the hospital were significantly lower in the post-index period than the pre-index period. Differences in these three variables between pre- and post-index periods were NS between the two groups. A mixed effect ordinal logistic regression model with random intercept showed that the odds ratio of obtaining a higher treatment adherence score in the post-index period was more pronounced in the Oral + LAI group than in the Oral-only group, considering adherence at baseline and the length of stay during the index hospitalization as potential confounders. Discharge with LAIs in a forensic psychiatric cohort of SSD was associated with a greater mid- to long-term improvement in antipsychotic medication adherence compared to discharge with oral-only antipsychotics.

Three-Year Outcomes of 6-Month Paliperidone Palmitate in Adults With Schizophrenia: An Open-Label Extension Study of a Randomized Clinical Trial

Importance

Long-acting injectable (LAI) antipsychotics have the potential to improve adherence and symptom control in patients with schizophrenia, promoting long-term recovery. Paliperidone palmitate (PP) once every 6 months is the first and currently only LAI antipsychotic with an extended dosing interval of 6 months.

Objective

To assess long-term outcomes of PP received once every 6 months in adults with schizophrenia.

Design, Setting, and Participants

In a 2-year open-label extension (OLE) study of a 1-year randomized clinical trial (RCT), eligible adults with schizophrenia could choose to continue PP every 6 months if they had not experienced relapse after receiving PP once every 3 or 6 months in the 1-year, international, multicenter, double-blind, randomized noninferiority trial. The present analysis focused on patients receiving PP every 6 months in the double-blind trial through the OLE study (November 20, 2017, to May 3, 2022).

Intervention

Patients received a dorsogluteal injection of PP on day 1 and once every 6 months up to month 30.

Main Outcomes and Measures

End points included assessment of relapse and change from the double-blind trial baseline to the OLE end point in Positive and Negative Syndrome Scale (PANSS) total and subscale, Clinical Global Impression-Severity (CGI-S) Scale, and Personal Social Performance (PSP) Scale scores. Treatment-emergent adverse events (TEAEs), injection site evaluations, and laboratory tests were also assessed.

Results

Among 121 patients (83 [68.6%] male), mean (SD) age at baseline was 38.6 (11.24) years and mean (SD) duration of illness was 11.0 (9.45) years. At screening of the double-blind study, 101 patients (83.5%) were taking an oral antipsychotic and 20 (16.5%) were taking an LAI antipsychotic. Altogether, 5 of 121 patients (4.1%) experienced relapse during the 3-year follow-up; reasons for relapse were psychiatric hospitalization (2 [1.7%]), suicidal or homicidal ideation (2 [1.7%]), and deliberate self-injury (1 [0.8%]). Patients treated with PP every 6 months were clinically and functionally stable, and outcomes were well maintained, evidenced by stable scores on the PANSS (mean [SD] change, -2.6 [9.96] points), CGI-S (mean [SD] change, -0.2 [0.57] points), and PSP (mean [SD] change, 3.1 [9.14] points) scales over the 3-year period. In total, 101 patients (83.5%) completed the 2-year OLE. At least 1 TEAE was reported in 97 of 121 patients (80.2%) overall; no new safety or tolerability concerns were identified.

Conclusions and Relevance

In a 2-year OLE study of a 1-year RCT, results supported favorable long-term outcomes of PP once every 6 months for up to 3 years in adults with schizophrenia.

Finding the Right Setting for the Right Treatment During the Acute Treatment of Individuals with Schizophrenia: A Narrative Review and Clinical Practice Guideline

Background

Schizophrenia is most times a chronic and often debilitating illness associated with poor mental health outcomes. Early and effective treatment of schizophrenia in the most appropriate setting can make a significant difference in the long-term recovery. The aim of this narrative review was to provide suggestions and recommendations for effectively managing patients with schizophrenia during acute exacerbations and to enhance awareness and skills related to personalized medicine.

Methods

A panel of academics and clinicians with experience in the field of psychosis met virtually on July 13th 2023 to narratively review and discuss the research evidence and their clinical experience about the most appropriate acute treatments for patients with schizophrenia. This manuscript represents a synthesis of the panel analysis and discussion.

Results

First contact is very important for service users, as is finding the most adequate treatment setting. If patients present to the emergency department, which may be a traumatic setting for service users, a dedicated environment with adequate space and specialized mental health support, including personnel trained in de-escalation techniques, is recommended. A well-connected continuum of care is strongly recommended, possibly with seamless links between inpatient units, day hospital services, outpatient facilities and rehabilitation services. Ideally, this should be structured as part of a coordinated step-down service line. Treatment challenges include suboptimal response, side effects, and nonadherence, which is reduced by the use of long-acting injectable antipsychotics.

Conclusion

Individual circumstances, including age, gender, and presence of hostility/aggression or self-harm, cognitive impairment and negative symptoms, comorbidities (depression, substance use disorders) or associated symptoms (anxiety, insomnia), should be considered when selecting the most appropriate treatment for the acute phase of schizophrenia. Efficacy and feasibility, as well as acceptability and tolerability of treatments, require joint consideration from the early stages of schizophrenia, thereby enhancing the possibility of improved short- and long-term outcomes.

Health economics study of paliperidone palmitate in the treatment of schizophrenia: a 12-month cohort study

BACKGROUND

To analyze the economic benefits of paliperidone palmitate in the treatment of schizophrenia.

METHODS

We collected 546 patients who met the diagnostic criteria for schizophrenia according to the 《International Statistical Classification of Diseases and Related Health Problems,10th》(ICD-10). We gathered general population data such as gender, age, marital status, and education level, then initiated treatment with paliperidone palmitate. Then Follow-up evaluations were conducted at 1, 3, 6, 9, and 12 months after the start of treatment to assess clinical efficacy, adverse reactions, and injection doses. We also collected information on the economic burden before and after 12 months of treatment, as well as the number of outpatient visits and hospitalizations in the past year to analyze economic benefits.

RESULTS

The baseline patients totaled 546, with 239 still receiving treatment with paliperidone palmitate 12 months later. After 12 months of treatment, the number of outpatient visits per year increased compared to before (4 (2,10) vs. 12 (4,12), Z=-5.949, P < 0.001), while the number of hospitalizations decreased (1 (1,3) vs. 1 (1,2), Z = 5.625, P < 0.001). The inpatient costs in the direct medical expenses of patients after 12 months of treatment decreased compared to before (5000(2000,12000) vs. 3000 (1000,8050), P < 0.05), while there was no significant change in outpatient expenses and direct non-medical expenses (transportation, accommodation, meal, and family accompanying expenses, etc.) (P > 0.05); the indirect costs of patients after 12 months of treatment (lost productivity costs for patients and families, economic costs due to destructive behavior, costs of seeking non-medical assistance) decreased compared to before (300(150,600) vs. 150(100,200), P < 0.05).

CONCLUSION

Palmatine palmitate reduces the number of hospitalizations for patients, as well as their direct and indirect economic burdens, and has good economic benefits.

In-Hospital Use of Long-Acting Injectable Antipsychotics and Readmission Risk in Patients With First-Admission Schizophrenia in Taiwan

Importance

Long-acting injectable antipsychotics (LAIs) can help decrease the rate of nonadherence to medications in patients with schizophrenia, but these drugs are underutilized in clinical practice, especially in Asian countries. One strategy for the early prescription of LAIs is to administer the drugs during patients' first admission, when they have more time to absorb medication-related knowledge.

Objective

To estimate the prevalence of and risk factors for in-hospital use of LAIs among first-admission patients with schizophrenia in Taiwan and to examine the association of early discontinuation with readmission risk among patients receiving LAIs.

Design, Setting, and Participants

This cohort study included data from a claims database for patients with a first admission for schizophrenia at psychiatric wards in Taiwan from 2004 to 2017. Eligible patients were diagnosed with schizophrenia or schizoaffective disorder at discharge and aged between 15 and 64 years. Data analysis was performed from April to September 2022.

Exposure

In-hospital use of LAIs with or without early discontinuation.

Main Outcome and Measures

Readmission for any psychotic disorder following discharge from first admission, with risk estimated via multivariable survival regression analysis, including the Cox proportional hazards (CPH) model and accelerated failure time (AFT) model.

Results

Of the 56 211 patients with a first admission for schizophrenia (mean [SD] age, 38.1 [12.1] years; 29 387 men [52.3%]), 46 875 (83.4%) did not receive any LAIs during admission, 5665 (10.1%) received LAIs with early discontinuation, and 3671 (6.5%) received LAIs without early discontinuation. The prevalence of receiving LAIs increased by 4%, from 15.3% (3863 of 25 251 patients) to 19.3% (3013 of 15 608 patients) between 2004-2008 and 2013-2017. After controlling for sex, year, prior antipsychotic use, age at first admission, and length of stay, the CPH regression analysis revealed that the readmission risk increased among patients receiving LAIs with early discontinuation (adjusted hazard ratio [aHR], 1.25; 95% CI, 1.21-1.30) but decreased among patients receiving LAIs without early discontinuation (aHR, 0.88; 95% CI, 0.84-0.92) compared with patients not receiving LAIs. Results remained similar for the AFT model.

Conclusions and Relevance

The incidence of in-hospital use of LAIs among patients with a first admission for schizophrenia has remained low. In this study, early discontinuation of LAIs was associated with readmission risk-specifically, early discontinuation with a higher risk while the lack of early discontinuation with a lower risk compared with treatment with oral antipsychotics alone-which suggests our results have implications for improving the efficacy of LAI administration among patients with a first admission for schizophrenia.

Efficacy and safety of long-acting injectable versus oral antipsychotics in the treatment of patients with early-phase schizophrenia-spectrum disorders: a systematic review and meta-analysis

Background

Long-acting injectable antipsychotics (LAIs) have advantages over oral antipsychotics (OAPs) in preventing relapse and hospitalization in chronically ill patients with schizophrenia-spectrum disorders (SSDs), but evidence in patients with first-episode/recent-onset, that is, early-phase-SSDs is less clear.

Objectives

To assess the relative medium- and long-term efficacy and safety of LAIs versus OAPs in the maintenance treatment of patients with early-phase SSDs.

Method

We searched major electronic databases for head-to-head randomized controlled trials (RCTs) comparing LAIs and OAPs for the maintenance treatment of patients with early-phase-SSDs.

Design

Pairwise, random-effects meta-analysis. Relapse/hospitalization and acceptability (all-cause discontinuation) measured at study-endpoint were co-primary outcomes, calculating risk ratios (RRs) with their 95% confidence intervals (CIs). Subgroup analyses sought to identify factors moderating differences in efficacy or acceptability between LAIs and OAPs.

Results

Across 11 head-to-head RCTs (n = 2374, median age = 25.2 years, males = 68.4%, median illness duration = 45.8 weeks) lasting 13-104 (median = 78) weeks, no significant differences emerged between LAIs and OAPs for relapse/hospitalization prevention (RR = 0.79, 95%CI = 0.58-1.06, p = 0.13) and acceptability (RR = 0.92, 95%CI = 0.80-1.05, p = 0.20). The included trials were highly heterogeneous regarding methodology and patient populations. LAIs outperformed OAPs in preventing relapse/hospitalization in studies with stable patients (RR = 0.65, 95%CI = 0.45-0.92), pragmatic design (RR = 0.67, 95%CI = 0.54-0.82), and strict intent-to-treat approach (RR = 0.64, 95%CI = 0.52-0.80). Furthermore, LAIs were associated with better acceptability in studies with schizophrenia patients only (RR = 0.87, 95%CI = 0.79-0.95), longer illness duration (RR = 0.88, 95%CI = 0.80-0.97), unstable patients (RR = 0.89, 95%CI = 0.81-0.99) and allowed OAP supplementation of LAIs (RR = 0.90, 95%CI = 0.81-0.99).

Conclusion

LAIs and OAPs did not differ significantly regarding relapse prevention/hospitalization and acceptability. However, in nine subgroup analyses, LAIs were superior to OAPs in patients with EP-SSDs with indicators of higher quality and/or pragmatic design regarding relapse/hospitalization prevention (four subgroup analyses) and/or reduced all-cause discontinuation (five subgroup analyses), without any instance of OAP superiority versus LAIs. More high-quality pragmatic trials comparing LAIs with OAPs in EP-SSDs are needed.

Trial registration

CRD42023407120 (PROSPERO).