Medication adherence in first episode psychosis: the role of pre‐onset subthreshold symptoms

Abstract

JL. Medication adherence in first episode psychosis: the role of pre-onset subthreshold symptomsObjective: The experience of pre-onset subthreshold psychotic symptoms (STPS, signifying a clinical high-risk state) in first episode psychosis (FEP) predicts poorer outcomes during treatment, possibly through differential adherence to medication. We explored whether adherence differs between FEP patients with and without pre-onset STPS. Methods: Antipsychotic medication adherence was compared in 263 STPS+ and 158 STPSÀ subjects in a specialized early intervention program for FEP. Data were gathered from a larger observational study conducted between 2003 and 2016. STPS status, sociodemographic, and baseline clinical variables were tested as predictors of non-adherence using univariate and multivariate logistic regressions. Time to onset of non-adherence was analyzed using Kaplan-Meier curves. The same predictors were tested as predictors of time to onset of non-adherence using Cox regression models. Results: Medication non-adherence was higher in STPS+ participants (78.9% vs. 68.9%). STPS status (OR 1.709), substance use disorder (OR 1.767), and milder positive symptoms (OR 0.972) were significant baseline predictors of non-adherence. Substance use disorder (HR 1.410), milder positive symptoms (HR 0.990), and lack of contact between the clinical team and relatives (HR 1.356) were significant baseline predictors of time to nonadherence. Conclusion: FEP patients who experience pre-onset STPS are more likely to be non-adherent to antipsychotic medication over 2 years of intervention. FEP programs should routinely evaluate pre-onset symptomatology to deliver more personalized treatments, with emphasis on engaging both patients and family members from the beginning of care. Significant outcomes• The experience of pre-onset subthreshold psychotic symptoms (STPS) was associated with higher rates of antipsychotic medication non-adherence over the first 2 years of treatment in a specialized early intervention program for first episode psychosis (FEP).• There was no difference in insight at baseline between FEP patients who had experienced pre-onset STPS and those who had not.• Substance use disorder at baseline, milder positive symptoms at baseline, and lack of contact between the clinical team and relatives at baseline were also associated with non-adherence. Limitations• Some (n = 182) patients provided consent for research but did not complete assessments required for assignment of STPS status and thus could not be included in the analyses. These may represent a subset of patients who are less engaged in services and less adherent to medication.• As with all retrospective instruments, the CORS and TOPE (used to determine STPS status) are potentially susceptible to recall bias.• The PANSS-G12, used to measure insight, may conflate several concepts in a one-dimensional measure.

Improving the Detection of Individuals at Clinical Risk for Psychosis in the Community, Primary and Secondary Care: An Integrated Evidence-Based Approach

“…While there were no clinical or functional differences at baseline (entry to early intervention services) between patients with FEP with and without prior CHR-P states, such differences emerged after 1 year of early intervention services: those with preonset symptoms consistent with a CHR-P state had poorer psychotic symptom outcomes and global functioning (52). Furthermore, there is more frequent nonadherence to antipsychotic medication in the preonset/CHR-P state group (although without corresponding differences in insight) (53). Since this work involved retrospective assessments, it is possible that FEP cases without evidence of a preonset CHR-P phase exhibited a recall bias and that the true prevalence of symptoms consistent with a CHR-P state was substantially higher than measured.…”

Do antidepressants prevent transition to psychosis in individuals at clinical high-risk (CHR-P)? Systematic review and meta-analysis

“…In our opinion, the discrepancy between the fixed-effects and the random-effects model plausibly depends more on the bias in the estimates from smaller component studies introduced by the random-effects model rather than on real heterogeneity across studies. Thus, we think that the protective effect of exposure to ADs at baseline in CHR-P is real and should be considered in light of converging lines of research pointing to the fact that medication exposure is relevant for outcomes (Daneault et al, 2019; Raballo et al, 2020a, 2021a). Several hypotheses can be brought about to explain this effect of ADs.…”

Delay in psychiatric hospitalization from the diagnosis of first-episode schizophrenia and its association with clinical outcomes and direct medical costs: a nationwide, health insurance data-based study

“…A previous study revealed that 45.1% of FEP patients are nonadherent to antipsychotic treatment and more likely to refuse medication at the first offer of treatment [ 30 ]. A recent study reported a 75.4% rate of nonadherence over 2 years of antipsychotic treatment in FEP patients [ 31 ]. Together with the protection and promotion of patients’ rights regarding treatment decisions, it is necessary to improve their treatment compliance after the onset of psychosis, based on evidence supporting the negative impact of the duration of untreated psychosis on prognoses [ 4 ].…”