When should you offer a long-acting injectable (LAI) for first-episode patients?

Symptom remission and relapse prevention are top priorities in managing patients with schizophrenia, including those with a first-episode of psychosis. Relapse disrupts eventual recovery to previous function; prevention in young people who are still in school or who just started working is therefore critical. Unfortunately, many first-episode patients relapse after initial symptomatic remission.  The most common reason for relapse is insufficient antipsychotic adherence. Often, patients stop treatment immediately after hospital discharge. Compared to oral antipsychotics, LAIs have been shown to reduce relapse in first-episode patients.

Use of LAIs in first-episode patients requires some special considerations:

• All first-episode patients should be offered a LAI as a good first-line choice since rates of nonadherence are comparable to those with more chronic illness. Moreover, compared to oral antipsychotics, LAIs have been shown to reduce relapse in first-episode patients.
• Those with comorbid substance use, a history of violence or an unstable living situation should be prioritized for LAIs.
• Benefits of LAIs should be discussed with the patient and family, including convenience (not having to remember taking a pill every day) and rationale (i.e., relapse prevention, with prevention of accrued disability over time due to poorly treated psychiatric condition). LAIs avoid uncertainty about adherence and family strife around adherence. In addition, they may improve survival if psychosis results in deaths due to injury or suicide. See this tip on how to talk to patients and their families about starting LAIs.
• Most schizophrenia guidelines recommend metabolically low-risk, second-generation antipsychotics as the initial treatment for first-episode patients.
• Schizophrenia guidelines do not agree on the duration of antipsychotic treatment after remission from a first-episode of psychosis. Most recommend one or two years of treatment.
• While antipsychotic treatment will almost always be initiated with an oral antipsychotic to establish tolerability and dose, a planned shift to a LAI could be discussed at the initiation of treatment. Accordingly, only antipsychotics available as a LAI option should be used if that is the plan.
• First-episode patients generally are very responsive to treatment, and a dose at the lower end of the dosing range should be selected.
• To avoid a gap in treatment or completely falling out of treatment during the transition from in-patient to outpatient care, inpatient units should initiate treatment with a LAI and not defer this discussion to the outpatient team.

Since LAIs assure adherence, the question of true treatment-resistance can be established with more confidence compared to oral treatment. Treatment-resistant patients with first-episode psychosis should be offered clozapine without undue delays.

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