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With effective, continuous care, individuals with schizophrenia can experience long periods of wellness, but, unfortunately, many patients end up repeating a cycle of treatment interruptions leading to relapses. In this webcast, Dr John Lauriello and Dr Diana Perkins explore all dimensions of this topic, from the many causes of treatment interruptions to the steps clinicians can take to prevent them. Interviews with actual patients and caregivers are also presented.

Schizophrenia is a chronic disorder that can be effectively controlled but will likely require lifelong treatment. Unfortunately, most patients experience numerous relapses, ongoing symptoms, and impairment, often because of treatment interruptions. Continuous treatment is imperative to prevent relapse and the potentially devastating consequences that can follow a return of psychotic symptoms. Clinicians must better monitor a common cause of relapse, nonadherence, and offer strategies to improve adherence. Strategies can target the patient, the environment, or treatment. One treatment-related strategy is the use of long-acting injectable (LAI) antipsychotics, which have the potential to reduce relapse and rehospitalization for many patients with schizophrenia.

OBJECTIVE To evaluate predictors of treatment discontinuation against medical advice and poor medication adherence among first-episode patients treated with olanzapine, quetiapine, or risperidone. METHOD First-episode patients with schizophrenia, schizophreniform disorder, or schizoaffective disorder (DSM-IV) were randomly assigned to olanzapine (2.5-20 mg/day), quetiapine (100-800 mg/day), or risperidone (0.5-4 mg/day) as part of a 52-week, randomized, double-blind, flexible-dose, multicenter study. Patients were enrolled from 2002 to 2004 at one of 26 sites in the United States and Canada. Survival analysis tested for predictors of treatment discontinuation against medical advice, while mixed models tested for predictors of poor medication adherence. Significant findings from the final models were replicated in sensitivity analyses. RESULTS Of the 400 patients randomly assigned to treatment, 115 patients who discontinued treatment against medical advice and 119 study completers were compared in this analysis. Poor treatment response (p < .001) and low medication adherence (p = .02) were independent predictors of discontinuation against medical advice. Ongoing substance abuse, ongoing depression, and treatment response failure significantly predicted poor medication adherence (p < .01). Higher cognitive performance at baseline and ethnicity (black) were also associated with lower medication adherence (p < .05). An association between poor medication adherence and illness insight at study entry was found at trend level (p = .059). CONCLUSION This study highlights the importance of treatment response in predicting discontinuation against medical advice and poor adherence to medication in first-episode patients. These results also support interventions to improve adherence behavior, particularly by targeting substance use disorders and depressive symptoms. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT00034892 (http://www.clinicaltrials.gov).

Background: Around 50% of patients with schizophrenia do not fully comply with treatment, and noncompliance is linked to relapse, rehospitalization, poor outcome, and high economic costs. The health belief model views noncompliance as a decision made by the patient, arrived at after weighing the perceived risks and benefits of treatment. Data sources: A MEDLINE search for the years 1980-2002 using combinations of the keywords schizophrenia, compliance, adherence, antipsychotics, tolerability, and side effects was used to identify articles investigating the factors influencing compliance in schizophrenia. Results: Many factors influence compliance, including those that affect patients' beliefs about their illness and the benefits of treatment (e.g., insight into illness, belief that medication can ameliorate symptoms), perceived costs of treatment (e.g., medication side effects), and barriers to treatment (e.g., ease of access to treatment, degree of family or social support). Medication side effects that are distressing to patients and linked to noncompliance include extrapyramidal side effects, neuroleptic dysphoria, akathisia, sexual dysfunction, and weight gain. Compliance can be improved by cognitive-behavioral therapies, such as compliance therapy, and other psychosocial interventions associated with improved social functioning and a lower risk of rehospitalization. Treatment adherence may also be improved by use of atypical antipsychotics with few perceived side effects. Conclusion: By considering the factors leading to noncompliance and adopting a comprehensive strategy for improving compliance, encompassing psychosocial intervention and optimum choice of medication, the management of schizophrenia could be greatly improved.

Do you consider long-acting injectable (LAI) antipsychotics when selecting among treatments for schizophrenia? Take part in this CME activity to review the evidence for LAIs vs oral medications and to learn which patients may benefit most from this treatment option. Plus, discover the pharmacokinetic properties of LAIs and barriers to their use.