PsychiatrySpeaks – Surveying current opinion about the care of patients with schizophrenia

PsychiatrySpeaks provides new insights from an international market research survey of 1,650 psychiatrists from eight countries, conducted by Otsuka and Lundbeck in December 2014.

The results of the survey demonstrated that, compared to other key areas in the field of psychiatry, psychiatrists believe that over the past 10 years progress has taken place in the treatment of schizophrenia, although they also believe that much still remains to be done.1

This finding goes hand-in-hand with research on the treatment of schizophrenia presented recently at a number of international congresses (International Conference on early Psychosis Japan 2014, ECNP Amsterdam 2015, APA Toronto 2015, EPA Vienna 2015). Increasingly, psychiatrists are recognising that the treatment of schizophrenia has changed from symptom control and relapse management to enhancing recovery – that is, the ability of the patient to function in the real world.2 Ultimately, it is hoped that prevention of the first psychotic episode and the amelioration of this life-long condition will be possible as scientists and psychiatrists search for markers that will enable those at risk to be identified in childhood.3

However, one major stumbling block to true progress and recovery remains steadfastly in place. The stigma of mental illness – particularly of schizophrenia – remains a barrier to effective treatment even in countries where legislation has been passed outlawing discrimination.4 Many initiatives are in place to help overcome prejudice towards those with mental health problems. For example, a programme of Citizen Psychiatry taking place in Lille, France, has successfully integrated those with mental health problems into the community.5 Interestingly, respondents to the PsychiatrySpeaks survey suggest that there is also prejudice from the wider medical profession towards psychiatry, which suggests that there may be a need for some healers to heal themselves.1

One major change that has come about is not only the recognition that patients’ treatment goals may be different from those of the physician, but that there is a real need to respect the patients’ goals.1 To the physician, one goal is to control symptoms and prevent future relapses, thereby preventing further insults to the brain and avoiding physical deterioration.6,7 A goal that physicians share with patients is the preservation of patient autonomy and the ability to lead a meaningful life.1,7,8 Effective management - diagnosing the condition accurately and early and collaborating with patients to ensure adherence with appropriate therapy - may allow both the physicians’ and patients’ goals to be achieved.9

The recently reported findings from the RAISE (Recovery After an Initial Schizophrenia Episode) study - a US National Institute of Mental Health (NIMH) research project demonstrated that the trajectory and prognosis of schizophrenia can be improved through coordinated and aggressive treatment.10 With early and appropriate intervention, it should be possible to reduce the likelihood of long-term disability in schizophrenia and help patients lead more productive, independent lives. Standard care was compared with the interventional ‘Navigate programme’. This programme consists of 4 components – ensuring patients receive tailored medication designed to their needs; providing resilience training for young people still processing the ideas around their disease and its treatment; supporting employment, education and rehabilitation; and engaging with and supporting families.11

Its 2-year results show that comprehensive intervention can alter the trajectory of this illness. Remarkably, the integrated intervention programme improved outcomes in patients in whom the duration of untreated psychosis was as long as 74 weeks. Beyond this time point, it seemed to be less effective.10 This study raises important points regarding the urgency of effective treatment and adherence to medication.

Current pharmacological treatment options are oral antipsychotic agents or long-acting injectables (LAIs). The preferred treatment option amongst psychiatrists, both for first-episode schizophrenia and following relapse, is oral antipsychotics.1 While randomized, controlled clinical trials suggest that there are no differences in outcomes when antipsychotic drugs are given as oral or LAI formulations12,13 real-life studies suggest otherwise.14,15,16 It has been reported that, compared with oral formulations, LAI formulations are associated with lower rate of relapse and lower hospitalization rates.17

Non-adherence is a major problem in schizophrenia, with most patients at risk of partial- and non-adherence at some time during the course of their illness.18 It has been demonstrated that poor adherence is a common cause of relapse in schizophrenia.19,20 LAIs may increase long-term adherence to treatment and thereby reduce the risk of relapse and improve patient functioning. 21  In addition, attention is increasingly being paid to the benefits of maintenance therapy, even in patients with a good initial response, and LAIs may be beneficial in this context.22

In encouraging better adherence,20,22 LAIs may support the goals of both psychiatrists and patients in preventing disease progression and allowing patients to resume a meaningful life with opportunities for social and family relationships and employment.

References

  1. PsychiatrySpeaks Autonomy, choice and schizophrenia: an international survey of psychiatrist opinion. Nov 2015.
  2. Drake RE, Whitley R. Recovery and severe mental illness: description and analysis. Can J Psychiatry. 2014 May;59(5):236-42.
  3. Petruzzelli MG, et al. Markers of neurodevelopmental impairments in early-onset psychosis. Neuropsychiatr Dis Treat. 2015 Jul 20;11:1793-8.
  4. Thornicroft G, et al. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet. 2009 Jan 31;373(9661):408-15.
  5. Daumerie N, Lombart A. Family placement schemes for recovery oriented acute care. http://www.hpft.nhs.uk/_uploads/documents/recovery/family-placement-schemes-for-recovery-oriented-acute-care.pdf 2009 (accessed 27 Nov 2015).
  6. Vita A, et al. Progressive loss of cortical gray matter in schizophrenia: a meta-analysis and meta-regression of longitudinal MRI studies. Transl Psychiatry. 2012 Nov 20;2:e190.
  7. Hasan A, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects. World J Biol Psychiatry. 2013 Feb;14(1):2-44.
  8. Martin et al. Quality of life: As defined by people living with schizophrenia & their families. Schizophrenia Society of Canada, 2009.
  9. Tandon R, et al. Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future. Schizophr Res. 2010 Sep;122(1-3):1-23.
  10. Kane JM, et al. Comprehensive Versus Usual Community Care for First-Episode Psychosis: 2-Year Outcomes From the NIMH RAISE Early Treatment Program. Am J Psychiatry. 2015 Oct.
  11. Mueser KT, et al. The NAVIGATE Program for First-Episode Psychosis: Rationale, Overview, and Description of Psychosocial Components. Psychiatr Serv. 2015 Jul;66(7):680-90
  12. Rosenheck RA, et al. Long-acting risperidone and oral antipsychotics in unstable schizophrenia. N Engl J Med. 2011 Mar 3;364(9):842-51.
  13. Kishimoto T, et al. Long-acting injectable vs oral antipsychotics for relapse prevention in schizophrenia: a meta-analysis of randomized trials. Schizophr Bull. 2014 Jan;40(1):192-213.
  14. Kirson NY, et al. Efficacy and effectiveness of depot versus oral antipsychotics in schizophrenia: synthesizing results across different research designs. J Clin Psychiatry. 2013 Jun;74(6):568-75.
  15. Grimaldi-Bensouda L, et al. Does longacting injectable risperidone make a difference to the real-life treatment of schizophrenia? Results of the Cohort for the General study of Schizophrenia (CGS). Schizophr Res. 2012;134:187–194.
  16. Subotnik KL, et al. Long-Acting Injectable Risperidone for Relapse Prevention and Control of Breakthrough Symptoms After a Recent First Episode of Schizophrenia. A Randomized Clinical Trial. JAMA Psychiatry. 2015 Aug;72(8):822-9.
  17. Kishimoto T et al. Long-acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta-analysis of mirror-image studies. J Clin Psychiatry. 2013 Oct;74(10):957-65.
  18. Cañas F, et al. Improving treatment adherence in your patients with schizophrenia: the STAY initiative. Clin Drug Investig. 2013 Feb;33(2):97-107.
  19. Lindenmayer JP, et al. Medication nonadherence and treatment outcome in patients with schizophrenia or schizoaffective disorder with suboptimal prior response. J Clin Psychiatry. 2009 Jul;70(7):990-6
  20. Emsley R. Non-adherence and its consequences: understanding the nature of relapse. World Psychiatry. 2013 Oct;12(3):234-5.
  21. Tavcar R, et al. Choosing antipsychotic maintenance therapy--a naturalistic study. Pharmacopsychiatry. 2000 Mar;33(2):66-71.
  22. Emsley R, et al. Long-acting injectable antipsychotics in early psychosis: a literature review. Early Interv Psychiatry. 2013 Aug;7(3):247-54.

XX-NOTPR-2015 12-00006186 OPEL/1115/MTN/2100
Date of preparation: December 2015
© 2015 Otsuka Pharmaceutical Europe Ltd. and H. Lundbeck A/S

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