Combining nonpharmacological and pharmacological treatment approaches can optimize long-term patient outcomes.¹ Read the article below to learn more about the different treatment options available for patients living with schizophrenia.

Establishing a patient-centric treatment plan is key to continual schizophrenia management

The ultimate goals of schizophrenia treatment include symptom relief, relapse prevention, and improving adaptive function so that the patient can be successfully integrated back into society.¹ When designing a long-term and effective schizophrenia treatment plan, it is important for stakeholders to consider the patient’s views and perspectives and allow them to be part of the decision-making process.² Effective lines of communication should be maintained between the patient and their caregivers, friends, and family.² Support is another key aspect of long-term schizophrenia management to ensure people living with schizophrenia are able to overcome discrimination, maintain their social lives, and avoid isolation.²

The American Psychiatric Association (APA) guidelines provide recommendations to optimize the treatment of patients with schizophrenia

The APA recommends several initial assessments for patients with possible psychotic disorders, such as establishing the reason the individual is being evaluated, their goals and treatment preferences, and an in-depth review of their psychiatric symptoms and trauma history.³ The initial psychiatric evaluation of a patient should include quantitative assessments to determine the severity of their symptoms and any functional impairments that should be the focus of their treatment.³ The APA treatment guidelines recommend that the patient is treated with the appropriate antipsychotic (AP) medication and monitored for efficacy and any possible side effects.³ If a patient’s symptoms improve while on AP medication, it is recommended that they continue with the same treatment.³ The patient should be given a documented and comprehensive treatment plan that includes both nonpharmacological and pharmacological treatment interventions.³

Access the full APA practice guidelines here

Nonpharmacological interventions can support long-term treatment of schizophrenia

Patients that have been diagnosed with schizophrenia rarely return to their baseline level of functioning, but nonpharmacological and pharmacological treatment can help the patient improve their long-term outcomes.¹ Nonpharmacological treatments should be used in addition to, rather than in place of AP medications.¹

The APA recommends or suggests the following nonpharmacological interventions for schizophrenia:³ 

• Speciality care programs for patients experiencing first-episode psychosis
• Cognitive-behavioral therapy
• Psychoeducation
• Supported employment services
• Assertive community treatment based on specified criteria
• Family interventions for patients with ongoing family contact
• Development of self-management skills and enhancement of person-oriented recovery
• Cognitive remediation
• Social skills training for those with a therapeutic goal of enhanced social functioning
• Supportive psychotherapy

Other psychotherapies include meta-cognitive training, narrative therapies, and mindfulness therapy.¹ Patients who have difficulty adhering to their prescribed medication may find psychotherapies such as cognitive-behavioral, personal, and compliance therapy particularly useful as they help to educate the patient on the importance of taking their medication.¹ These nonpharmacological treatments have been shown to lower the chances of rehospitalization and improve social functioning among patients with schizophrenia.¹

The initiation of pharmacological therapy is crucial to treating schizophrenia 

It is difficult to achieve long-term disease management and remission among patients with schizophrenia without the use of effective AP drugs.¹ Early initiation of AP treatment within the first five years after initial psychosis is crucial since this is when most illness-related changes occur in the brain.¹ There are currently several oral and long-acting injectable (LAI) formulations of first generation APs (FGAs) and second-generation APs (SGAs), each with their own side-effect profiles and symptom targets.³ Before AP medication is prescribed, discussions regarding the target symptoms for treatment and the side-effects of the various medication options should occur between the clinician, the patient, and their families.³ Overall, SGAs cause fewer extrapyramidal symptoms than FGAs and are therefore recommended as the first line of treatment for patients with schizophrenia.¹ However, SGAs may also cause metabolic side effects, such as weight gain, hyperlipidemia, and diabetes mellitus, which may subsequently contribute to an increased risk of cardiovascular disease among patients.^1,3

Both oral and LAI formulations of APs offer several benefits for the patient 

Oral and LAI APs have been shown to improve clinical outcomes and reduce the economic burden associated with schizophrenia.⁴ However, numerous reviews have observed different patient outcomes when individuals receive LAIs compared with oral APs, such as a lower risk of hospitalization, relapse, all-cause mortality, and suicide risk.^5,6 LAI APs are administered intramuscularly or subcutaneously and slowly absorbed into systemic circulation, thereby preventing an abrupt decline in therapeutic blood levels.⁷ These drug formulations were developed to address issues of nonadherence to oral AP medication^1,3 and are known to be as effective as their oral counterparts in treating schizophrenia.⁴ Nonadherence is common among schizophrenia patients, and often results in high rates of relapse, rehospitalization, and suicide attempts.⁸ The APA guidelines recommend that LAIs “may also be considered when patients are transitioning between settings (e.g., at inpatient discharge, on release from a correctional facility), when future adherence is uncertain and the risk of reduced adherence may be increased”.³ Some patients may also prefer LAIs due to their convenience.³ Research has found that LAI SGAs are better at preventing relapse than LAI FGAs.⁴ Other studies have assessed the prevalence, adherence, and efficacy of LAIs compared with oral APs.^9,10 In the US, a substantially greater percentage of patients with schizophrenia receive oral SGAs (68.1%) than LAI SGAs (4.6%).⁹ This is despite research demonstrating that patients treated with LAIs are more likely to adhere to their treatment and achieve treatment persistence (no gap in therapy for ≥60 days) than those treated with oral APs.¹⁰

Designing a tailored schizophrenia treatment plan that features both nonpharmacological and pharmacological interventions and considers the patient’s views, lifestyle, social structure, and ability to adhere to their prescribed medication is important to promote long-term disease management and recovery among patients living with schizophrenia.³

References

1. Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: overview and treatment options. Pharmacy and Therapeutics 2014;39:638–45.
2. Swedish Council on Health Technology Assessment. SBU yellow report no. 213, November 2012.
3. American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. 2021. 3rd ed. Available at: https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841. Accessed August 2022. 
4. Stevens GL, Dawson G, Zummo J. Clinical benefits and impact of early use of long-acting injectable antipsychotics for schizophrenia. Early Interv Psychiatry 2016;10:365–77.
5. Kishimoto T, Hagi K, Kurokawa S, Kane JM, Correll CU. 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. Lancet Psychiatry: 2021;8:387–404.
6. Huang CY, Fang SC, Shao YHJ. Comparison of long-acting injectable antipsychotics with oral antipsychotics and suicide and all-cause mortality in patients with newly diagnosed schizophrenia. JAMA Netw Open 2021;4:e218810.
7. Correll CU, Kim E, Sliwa JK, et al. Pharmacokinetic characteristics of long-acting injectable antipsychotics for schizophrenia: an overview. CNS Drugs 2021;35:39–59.
8. Biagi E, Capuzzi E, Colmegna F, et al. Long-acting injectable antipsychotics in schizophrenia: literature review and practical perspective, with a focus on aripiprazole once-monthly. Adv Ther 2017;34:1036–48.
9. Kane JM, Mychaskiw MA, Lim S, et al. Prevalence of oral and long-acting injectable antipsychotic use among patients with schizophrenia in the United States: an analysis of a commercial claims database. Presented at: 34th European College of Neuropsychopharmacology Congress; October 2–5, 2021; Lisbon, Portugal. P.0760.
10. Lee S, Schwartz S. Adherence and persistence to long-acting injectable dopamine receptor blocking agent therapy in the United States: a systematic review and meta-analysis of cohort studies. Psychiatry Res 2021;306:114277.

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