Treatment of schizophrenia with an antipsychotic should be initiated early and continued to improve patient outcomes

Continuity of care and treatment is important to prevent adverse patient outcomes in schizophrenia

Continuity of care and treatment after a first psychotic episode are crucial for disease management in people living with schizophrenia as it can help prevent subsequent relapse and rehospitalization.¹ Outpatients who attend one or more follow-up appointments within two months of their hospital discharge are less likely to be rehospitalized than those who fail to attend.¹ One study found that among those who failed to attend an outpatient appointment, rehospitalization was 5.5 times more likely within 90 days, 3 times more likely within 180 days, 2.5 times more likely within 270 days, and 2.3 times more likely within 365 days.¹ Oral antipsychotic (AP) treatment response may also be reduced or delayed after relapse, even when treatment of the first episode of schizophrenia has been effective.⁴

Outpatient AP drug discontinuation rates are high among chronic medication users, and this holds true for schizophrenia patients.⁵ A study showed that 54% of schizophrenia patients did not collect their AP prescription within 30 days of being discharged from hospital, or used their medication for less than 30 days.⁵ Another found that two-thirds of patients fail to attend scheduled or rescheduled initial outpatient mental health appointments after their hospital discharge.² When a patient is discharged from hospital or is no longer part of a controlled clinical trial, they may feel less motivated to adhere to AP therapy, since follow-up and aftercare practices are less rigorous.⁵ 

Patients discharged from psychiatric hospitals are at a greater risk of experiencing adverse outcomes, particularly within the first three months.⁶ Adverse outcomes related to discontinuation of inpatient mental healthcare include:⁶
- Violent criminality (hazard ratio [HR], 10.7)
- Hospitalization due to violence (HR, 10.6)
- Non-fatal self-harm (HR, 94.5)
- All-cause mortality (HR, 23.7)
- Suicide (HR, 137.4)

Several factors affect continual therapy

There are a number of factors that contribute to successful schizophrenia-related outpatient treatment following hospital discharge.^2,7 These include preadmission outpatient mental health visits, absence of a substance use disorder diagnosis, and the use of long-acting injectable (LAI) APs.⁷ Unsuccessful outpatient care is more likely in patients who have not been previously hospitalized, have persistent mental illness, were admitted to hospital involuntarily, or stayed in hospital for 28 days.²

Three clinical interventions may improve continual therapy among outpatients:²
- Good communication regarding discharge plans between inpatient staff and outpatient clinicians
- Initiating the outpatient program before discharge
- Family involvement during the hospital stay

Treating schizophrenia early can improve patient outcomes 

It is also important to identify and treat schizophrenia early to reduce the risk of hospitalization due to relapse and related healthcare costs.⁸ Early treatment intervention can reduce symptom severity, psychiatric hospitalizations, time spent hospitalized, and lower the chance of patients discontinuing treatment.⁹ As well as promoting remission and recovery, early treatment has been shown to improve quality of life and functioning, with patients more frequently involved in school or work activities when treated early.⁹

The relationship between duration of untreated psychosis and patient outcomes has been evaluated across mental health facilities in the US.^8,10 On average, the time between onset of psychotic symptoms and initiation of AP medication is 74 weeks.¹⁰ When psychosis is untreated for longer than 74 weeks, patients have a higher risk of future hospitalization.⁸ Other outcomes linked to longer untreated psychosis include psychotic symptoms at a younger age, increased total symptoms and substance use.¹⁰

Detecting the illness and introducing phase-specific treatment are important aspects of early intervention in psychosis.³ Early detection involves identifying people who are at risk of developing psychosis: people with prodromal symptoms and those who experience psychosis but have not been treated.³ Phase-specific treatments are targeted at patients in the early stages of schizophrenia to prevent disease progression and promote recovery.³

The goals of early intervention include:³
- Identifying and diagnosing patients in the prodromal phase or during early psychosis
- Preventing the progression to psychosis in the prodromal phase
- Promoting recovery in the patient’s first episode of psychosis

LAIs are formulations of AP drugs that were developed to maintain therapeutic drug levels between patient visits and reduce nonadherence rates.¹² In addition to improving medication adherence, they may be beneficial in early treatment initiation and to reduce rates of psychiatric hospitalization, psychotic exacerbation or relapse, and to facilitate clinical decision-making (such as ruling out pseudo resistance and determining correct dosing).^9,12–14

Other early treatment interventions may include cognitive behavioral therapy, APs, psychological support from family and caregivers, supported employment and physical health programs.^3,15