Non-adherence is an important factor in therapeutic failure, which is frequently correlated
with disease progression. This phenomenon is common in most diseases that require
chronic treatment (cardiovascular, metabolic, degenerative, etc.) (Timmerman et al.,
2016). In the case of mental illness and schizophrenia in particular, non-adherence
(total or partial) reaches up to 75% of cases, being rather the rule than the exception
(Kane et al., 2013a; Dobber et al., 2018; Kishimoto et al., 2013a). Medication non-adherence
is associated with poor outcomes, more hospital readmissions, and increased costs
of care in schizophrenia (Winton-Brown et al., 2017; Haddad et al., 2014).
Poor medication adherence is multifactorial, is caused by the lack of insight (the
individual does not want to be treated because he/she does not consider himself/herself
ill), or persistent psychotic symptoms. In contrast, cognitive deficits and causes
related to the evolution of the disease are important factors in the individual's
motivation for taking medication (Lacro et al., 2002).
Strong evidence of the superiority of long-acting injectable antipsychotics (LAIs)
over oral antipsychotics (OA) in relapse prevention and reducing mortality in schizophrenia
is demonstrated in many studies (Taipale et al., 2018). LAIs have been shown to be
more effective in persons under 35 years of age. Avoiding treatment abandon, LAIs
determined more frequently remission and recovery than OA (Kishimoto et al., 2013b;
Kane et al., 2013b). Efficiency has been proven in the prevention of relapses also
in the catatonic forms (Ifteni and Teodorescu, 2017). Experts considered that LAIs
should be introduced as early as possible for better outcome in schizophrenia (Stahl,
2014).
Despite its proven effectiveness and favorable cost-benefit ratio, LAIs are still
underused world-wide due to different reasons including economic (high cost), mistrust,
fear, stigma and outdated concepts (Taylor et al., 2018). On the part of the patients,
the refusal is related in particular to the mode of administration (injection), the
control of the treatment (the feeling that they no longer decide), the administration
protocols (in specialized centers, post injection monitoring in the case of olanzapine
pamoate, etc.) (Yeo et al., 2017).
To all these, new restrictions or limitations of prescription and administration caused
by COVID-19 pandemic are now are added.
In order to limit the possibility of contamination, authorities in many countries,
including Romania, have recommended limitation or restriction of access to hospitals,
which remain strictly intended for emergencies only. General practitioners, but also
psychiatrists, have limited the number of interactions with patients and have started
a difficult process for online consultations. In addition to benefits, issues regarding
ethics, confidentiality, accessibility, etc. are present. Online consultations cannot
capture many aspects of psychiatric pathology and are often impossible in cases with
low income or in rural or isolated areas.
Delayed supply in pharmacies caused by the restriction or cancellation of the export
of medicines or sanitary equipment in the context of a COVID-19 is another barrier.
As a result, a significant number of patients with schizophrenia have been (or will
soon be) undergoing treatment with less expensive, easy-to-obtain, and manageable
oral antipsychotics. In our psychiatric setting (public hospital with 150 beds for
acute patients), the number of LAIs prescriptions decreased dramatically (49% for
risperidone LAI and 90% for olanzapine LAI) from December 2019 to March 2020 (Table
1
).
Table 1
The evolution of LAIs prescription before and after declaration of COVID-19 pandemic.
Table 1
Type of LAIs
Number of prescriptions before WHO declared COVID-19 pandemic
Number of prescriptions after WHO declared COVID-19 pandemic
Reduction of LAIs prescriptions
December 2019
January 2020
February 2020
3 months average
March 2020
aripiprazole
30
33
35
32.66
10
70%
paliperidone
22
27
30
26.33
5
81%
olanzapine
19
21
20
20.00
2
90%
risperidone
35
41
40
38.66
20
49%
The switch from LAIs to OA was requested by patients or caregivers to reduce the number
of trips to pharmacies, medical offices or public mental health centers.
For most forms of intramuscular administration, manufacturers and experts have recommended
that the treatment be done by specialized medical personnel (physicians or nurses)
in centers with experience to avoid any problems. Administration at home is not recommended.
Human natural anxiety related to this unique phenomenon in the last hundred years
is added. Conspiracy theories in media have a major impact on patients with schizophrenia
but not only.
We will probably see in the coming days or weeks many patients in clinical remission
switched from LAI to OA.
Future mirror-image studies will show the consequences of this switch. The effect
size will be directly proportional with duration of the pandemic and the restrictions
imposed. No-one can anticipate the duration of COVID-19 pandemic and this situation
can be prolonged.
What can we do to prevent relapses with its dramatic consequences, especially in patients
who have been undergoing LAIs for years and have not experienced relapses for a long
time, some even considering themselves to be “cured”? What would be the best standard
of care in these situations? Proposed measures such as increasing the dose, delaying
the next injection, or administration by the pharmacists or family members imposed
important risk: stress, pain, too superficial or too profound injection, inadequate
site of injection (deltoid or gluteal), etc.
We must continue to advocate for improved access to long-acting antipsychotics for
the people with previous non-adherence as well as for the young patients at the early
stages of schizophrenia, even in this difficult period.
Role of funding source
None.
Declaration of competing interest
None of the authors have conflicts to report.