RESEARCH WEEKLY: Sustaining Long-Term Treatment for People with Schizophrenia
By Elizabeth Sinclair Hancq
(June 22, 2022) Sustaining long-term treatment can be difficult for people with schizophrenia. Side effects of medications, anosognosia, stigma toward mental health treatment and lack of access to treatment due to insurance coverage or costs can all contribute to individuals discontinuing antipsychotic treatment. Antipsychotic treatment interruptions occur at very high rates in individuals with schizophrenia, with research estimates suggesting 34-88% of individuals stop antipsychotic treatment in any three-year period.
Interruptions of antipsychotic treatment can have many negative consequences. These can include higher risk of death by suicide, premature death due to medical comorbidities as well as increased risk of experiencing homelessness, hospitalization, or criminal justice involvement.
New research published in Schizophrenia Bulletin by researchers from Zucker School of Medicine at Hofstra University utilized patient registrar data from a cohort of first-episode psychosis patients in Finland over an 18-year period to determine long-term treatment histories and risk factors for treatment interruption. This included examining treatment discontinuation by type of antipsychotic. They found that although significant treatment interruptions are common in individuals with schizophrenia, long-acting injectable medications significantly reduce this risk and promote the maintenance of long-term treatment.
Study results
The research analysis included 3,343 individuals with first-episode psychosis, including 512 who had schizoaffective disorder. The participants were followed for up to 18 years through a prescription register in Finland.
The authors found that individuals with schizophrenia had an average of six treatment interruptions over an eight-year period. In approximately one-third of patients, this meant that they were not in treatment for a meaningful proportion of their illness course, or less than 80% of the time. Therefore, the results suggest that the pattern of repetitive treatment discontinuation and reintroduction is common in individuals with schizophrenia. “Very possibly many of the individuals with only limited portions of their course of illness covered by antipsychotic treatment, despite residual symptoms, may not perceive that the benefits of long-term antipsychotic treatment outweigh its disadvantages,” the authors wrote.
There are significant risks associated with treatment interruptions and most treatment guidelines recommend against intermittent treatment. Risks include higher chances of tardive dyskinesia, a movement disorder that can be a side effect of medication use, and a lower effectiveness of antipsychotic medications on reintroduction requiring higher dosages.
The frequency of treatment interruptions in individuals with schizophrenia occurred less often later in an individual’s illness course. Whereas in the first year of diagnosis, 30 out of 100 individuals discontinued their antipsychotic medications, only nine out of 100 individuals did in their 10th year after diagnosis. Therefore, the risk for treatment discontinuation decreases over time, perhaps due to the realization of the benefits of antipsychotic medications only after being in treatment for a long enough time.
The data consistently showed that long-acting injectable formularies of antipsychotic medications reduced the risk for treatment interruptions compared to oral antipsychotics. Individuals with schizophrenia were 67% less likely to have a treatment disruption when on a long-acting injectable compared to oral antipsychotic medications. This is consistent with previous research indicating the risk for rehospitalization is lower in individuals on long-acting injectable formularies.
Overall, the results strongly suggest that long-acting injectable medications should be prioritized for individuals with schizophrenia, and especially those at greatest risk for treatment interruptions such as people who are recently diagnosed. Future work should address how best to promote engagement into treatment with long-acting injectable antipsychotic medications, including clinician training and addressing structural and cost barriers to access to this type of medication. The risks of lack of treatment are too great to just accept the fact that treatment interruptions are the norm for individuals with schizophrenia.
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