Long-Term Treatment of Schizophrenia with Depot Medication

There are several problems that occur when schizophrenic patients do not take their antipsychotic medication. According to Stephen Stahl, MD, PhD, adjunct professor in the Department of Psychiatry, University of California, San Diego School of Medicine, and director of Psychopharmacology for the California Dept. of State Hospitals, research shows nonadherence is connected to reduced mental functioning, psychotic hospitalizations, arrests, violence, substance abuse, and perhaps the most troubling of all, reductions in brain grey matter that increase the longer a patient remains untreated. During his presentation on improving long-term outcomes in schizophrenia treatment at the 2013 NEI Psychopharmacology Congress, Stahl said there is also evidence that suggests partial nonadherence of even less than 25% is associated with psychotic relapse.

While there is controversy surrounding whether antipsychotic medications themselves have poor long-term health benefits or may even contribute to medical comorbidities, Stahl told the audience that there is research to support that, “Long-term antipsychotic use is associated with lower mortality compared to no antipsychotic use in patients with schizophrenia.” This is especially true when it comes to the simple fact that individuals who have schizophrenia and do not receive treatment often commit suicide. He also said that continuous maintenance treatment with antipsychotic drugs can result in up to a70% reduction in the risk of relapse.

That being said, what can clinicians do if their patients won’t take their medication regularly? While oral medications may be used more commonly to treat psychiatric patients, clinicians should consider the advantages of long-acting depot antipsychotics, which Stahl said often improve long-term patient adherence compared to oral medication. Stahl further noted that, “Long-term continuation of the treatment often leads to steady improvement in schizophrenia symptoms.”

When it comes to selecting an antipsychotic medication for a patient with schizophrenia, Stahl advised clinicians to consider waiting longer periods of time before switching to another drug because current research suggests that, “Superior efficacy of one antipsychotic over another may require time.” This appears to be especially true in patients who struggle with treatment-resistance. He said clinicians should spend maybe two more weeks with their patient on their current antipsychotic drug before switching medications. He noted that patients who switch medications are more likely to have a higher medication discontinuation rate than patients who do not.

According to Stahl, clinicians need to talk to their patients about which side effects they can tolerate, pick a drug that bests suits their needs, try to wait a longer period before discontinuation of that drug, and see if they can encourage a longer period of treatment by using long-acting depots to ensure patient adherence. He also noted that with some medications, negative side effects may subside after two years of long-term use and that it may take up to a year before differences between drugs in terms of side effects are seen.

However, he advised that clinicians avoid giving patients more than one shot a month. Instead he suggested that clinicians add an oral medication to the depot prescription instead of giving patients multiple shots per month of different drugs if symptoms continue.