Patients With Schizophrenia Switched Early to LAIs Show Markedly Better Long-Term Outcomes

Patients with schizophrenia who switch from oral antipsychotics to long-acting injectables (LAIs) within the first three years of treatment can reduce their risk of symptom relapse, future rehospitalizations, and mortality. Patients who had been taking oral medications for three years or more prior to switching showed no significant improvements outside of improved medication adherence, according to a study published in the Journal of Clinical Psychiatry. 

“[I]ncreasing evidence suggests that during the early stages of schizophrenia, a critical time when the disease is most treatable, patients may experience more beneficial effects of LAI treatment,” wrote Su-Chen Fang, Ph.D., of Mackay Medical College in New Taipei City, Taiwan, and colleagues. “These real-world data demonstrated that LAIs in the early stage of treatment of hospitalized patients increased disease control and had long-term benefits.”

Fang and colleagues used Taiwan’s national health insurance database to compile data on over 19,000 people aged 16 to 65 who had a schizophrenia diagnosis, were taking oral antipsychotics, and were hospitalized for acute psychosis between 2002 and 2005. They identified 678 patients who were having a psychotic episode and were switched from oral medication to an LAI during hospitalization; they continued to receive the LAI after discharge.

Of these patients, 312 were switched to an LAI within three years of their first oral antipsychotic prescription (early stage), while 366 were switched following three or more years of oral medication use (late stage). All patients were followed up from their date of hospitalization until the end of the study period (December 31, 2015) or death, whichever came first.

As expected, Fang and colleagues found that all patients who switched to LAIs following hospitalization had better medication adherence, as determined by prescription refill data. In addition, those who switched during the early stage of schizophrenia had a 37% reduced risk of psychiatric rehospitalization, a 42% reduced risk of a psychiatric-related emergency room visit, and a 51% reduced risk of mortality compared with patients who stayed on oral medications. For patients who were switched during the late stage of illness, the risk of mortality of emergency room visits did not decrease, and in fact they showed a slightly increased risk of psychiatric rehospitalization compared with patients who stayed on oral medications.

“Patients in the later stages of schizophrenia, especially those who require hospitalization, may represent a group of patients whose condition is unstable,” Fang and colleagues wrote. “This may partly explain the lack of LAI-mediated protective effects in patients who adopted LAIs in the late stage.”

To read more on this topic, see the Psychiatric News story “Real-World Data Show Patients With Schizophrenia Adhere Better to Clozapine and LAIs.”

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Wide Racial and Geographic Disparities Found in Clozapine and LAI Prescriptions

Regional and racial variations in the prescribing of psychotropic medications to patients with schizophrenia may underlie some of the health inequities associated with these disorders, reports a study in Psychiatric Services in Advance.

“The most dramatic interstate differences were in prescription of clozapine and LAIs [long-acting injectable antipsychotics], which have distinctive roles in medication management,” wrote Natalie Bareis, L.M.S.W., Ph.D., of Columbia University and colleagues. “[C]lozapine has efficacy in managing treatment-resistant schizophrenia and reducing suicidal behaviors and has low rates of prescription by clinicians, and LAI medications address nonadherence, but they require clinician administration and pose risks for coercion.”

Specifically, non-Hispanic Blacks and people of other race-ethnic groups were more likely than non-Hispanic Whites to fill prescriptions for LAIs, whereas non-Hispanic Whites were more likely than all other groups to fill prescriptions for clozapine.

Bareis and colleagues used the national Medicaid Analytic eXtract databases to compile data on adults aged 18 to 64 who had been diagnosed with schizophrenia or schizoaffective disorder in 2011 and filled at least one 15-day prescription for an oral antipsychotic, antidepressant, benzodiazepine, or mood stabilizer or one prescription for an injectable LAI in 2012. Their sample included 357,914 adults from 47 states plus the District of Columbia (Hawaii, Idaho, and Maine had missing data and were not included).

The analysis showed wide ranges in psychotropic prescriptions across states. For example, the percentage of patients receiving LAIs ranged from 4% in Colorado to 22% in Rhode Island, while the percentage of patients receiving clozapine ranged from 1% in Nevada to 11% in South Dakota. Prescriptions for other psychotropics also varied geographically.

There were also significant variations at the patient level:

• Non-Hispanic Blacks were 39% more likely to be given an LAI compared with non-Hispanic Whites and 60% less likely to be given clozapine.
• Hispanics were 26% more likely to be given an LAI compared with non-Hispanic Whites and 37% less likely to be given clozapine.
• Native Hawaiians/Pacific Islanders were 26% more likely to be given an LAI compared with non-Hispanic Whites and 20% less likely to be given clozapine.
• Asians had similar rates of LAI prescriptions as non-Hispanic Whites, but 17% less likely to be given clozapine.
• Non-Hispanic Whites were more likely to receive prescriptions for non-antipsychotic medications than all other ethnic groups.

“Psychiatric training that is culturally sensitive and seeks to minimize disparities by race or ethnicity and that requires competency in the prescription of clozapine and LAI antipsychotic medications may reduce variation,” Bareis and colleagues wrote. “A better understanding of the causes of wide variation in LAI and clozapine prescriptions is needed to improve access to these important treatment options.”

To read more on this topic, see the Psychiatric News article, “More Minority Patients May Be Able to Safely Use Clozapine.”

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LAIs May Lower Rehospitalization Risk in Older Patients With Schizophrenia

Older people with schizophrenia who are treated with long-acting injectable antipsychotics (LAIs) are less likely to be rehospitalized than their peers who are treated with oral antipsychotics, suggests a study in the American Journal of Geriatric Psychiatry.

Ching-Hua Lin, M.D., Ph.D., of the Kaohsiung Municipal Kai-Syuan Psychiatric Hospital in Taiwan and colleagues followed 1,168 patients aged 60 years or older who were discharged from the public psychiatric hospital between 2006 and 2017. The patients had either schizophrenia or schizoaffective disorder, 151 were discharged on LAIs, and 1,017 were discharged on oral antipsychotics. The researchers reviewed rehospitalizations that occurred within a year of discharge for both groups of patients, including those who had exhibited significant psychotic symptoms, dangerous or violent behavior, or a decline in functioning.

Eighty-one patients (53.6%) in the LAIs group and 672 (66.1%) in the oral antipsychotics group were rehospitalized within one year of discharge. Patients in the LAIs group had a significantly longer time to rehospitalization, a median of 257 days compared with a median of 115 days for those in the oral antipsychotics group. When reviewing the patients’ records, the researchers found that shorter hospitalizations and fewer hospitalizations prior to the study were also associated with a longer time between discharge and rehospitalization.

Lin and colleagues noted several limitations to their study, notably that the follow-up was only one year, and longer follow-up may reveal other differences between the two groups. Additionally, all patients were discharged from a single facility in Taiwan, so results may not be generalizable to other facilities and countries.

“In the future, further studies focusing on factors associated with risk of rehospitalization and effective interventions to prevent rehospitalization should be explored,” they wrote.

For related news, see the Psychiatric Services article “Comparison of Injectable and Oral Antipsychotics in Relapse Rates in a Pragmatic 30-Month Schizophrenia Relapse Prevention Study.”

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