How is medication compliance optimized for schizophrenia?

Updated: Mar 16, 2018
  • Author: Frances R Frankenburg, MD; Chief Editor: Glen L Xiong, MD  more...
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Noncompliance with or nonadherence to pharmacologic therapy is difficult to estimate but is known to be common, and it is one of the reasons for the use of intramuscular (IM) preparations of antipsychotic medications. A regular routine of IM medication, such as every 2-4 weeks, is preferred by some patients since it obviates the need to take medication every day. As well, it permits easier monitoring of medication adherence by the clinician. In the United States, several drugs have been approved for every 4-6 week dosing (eg, aripiprazole [Abilify Maintena, Aristada], paliperidone [Invega Sustenna]), every 2 month dosing (aripiprazole [Aristada 1064 mg dose]), and every 3 month dosing (eg, paliperidone [Invega Trinza]). IM medication is less widely used in the United States than in Europe.

Whether IM medication is superior to oral medication is not clear.

A large trial that compared long-acting injectable risperidone with the psychiatrist’s choice of oral antipsychotic agent found, somewhat to the surprise of many, that injectable risperidone was not superior to the oral form and was associated with more side effects. [98]

In a meta-analysis of 21 randomized, controlled studies involving more than 5000 patients, the long-acting injectable agents were similar to the oral antipsychotics with regard to relapse prevention. [99] However, in 10 studies using first-generation long-acting injectables, as well as studies published in or before 1991 (8 fluphenazine or long-acting injectable studies), the primary outcome with the long-acting injectable agents was superior to that with oral antipsychotics.

Adherence is usually overestimated by both patient and physician. Nonadherence can be partial or complete, but even partial adherence is associated with relapse. [100] In the past, nonadherence was thought to be due at least in part to the side effects of the conventional antipsychotic agents, such as akathisia. Nevertheless, nonadherence remains a major clinical problem, even with second-generation antipsychotic agents.

Family members of people with schizophrenia, as well as clinicians providing care for them, should encourage them to take their medication, while at the same time respecting their autonomy. This is a difficult balance to achieve.

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