Short- or long term focus: Let the debate begin

Professor Peter Haddad, United Kingdom spoke first in support of the motion that the clinician’s management priority should be short-term.  As he suggested, when patients first present they are usually in the throes of psychosis, are experiencing hallucinations and delusions and are likely to be very distressed indeed. Furthermore, if they have been experiencing symptoms for some time, their behaviour is likely to be erratic, aggressive or even violent, making them a risk both to themselves and possibly to others. Thus, the immediate priority is to reduce this risk of harm and to calm and reassure the patient. All too frequently, this demands use of drugs, as psychosocial interventions alone, at this stage, are rarely effective.

Antipsychotic agents effectively manage and relieve psychotic symptoms, their effects usually becoming apparent within the first two weeks from initiation of treatment. Importantly, should the patient fail to respond within this relatively short time period or if adverse effects become apparent, another antipsychotic should be tried until a suitable agent is found. Through the identification of an effective antipsychotic early in the patient’s history, maintenance therapy for long-term management of the patient can be more easily established, thereby preventing relapses and gaining most benefit for the patient.

Should the patient fail to respond within this relatively short time period or if adverse effects become apparent, another antipsychotic should be tried

Adherence is the real focus of the debate

In response, Professor Pierre-Michel Llorca, France, suggested that while long-term success may indeed be gained through selection of an effective antipsychotic early in treatment, in reality, schizophrenia is a chronic condition and long-term use of antipsychotics is plagued by poor adherence. Lack of adherence is driven by many factors not least lack of efficacy and presence of adverse events. Of course, this limits long-term treatment outcomes as the patient will experience less symptomatic and, importantly, functional improvement and a greater likelihood of admission to hospital than if they took their prescribed medication regularly.

Professor Llora argued that antipsychotic selection in the long-term should be based on finding a therapy that will optimize adherence. Sort adherence and clinical and functional improvement will follow.

In effect, as a questioner from the audience suggested, both debaters were making the same argument. Select an effective therapy with few adverse effects and this will not only address the acute stages of the disease but will also facilitate its chronic management.

Select an effective therapy with few adverse effects and this will not only address the acute stages of the disease but will also facilitate its chronic management

Symptom control or improved functioning – what’s your priority?

Arguing that symptom control should be the priority, Professor W. Wolfgang Fleischhacker kicked-off the second debate of the afternoon. He argued that symptom control, particularly early in the psychotic episode, reduces harm (both self-harm and potential harm to others) and helps relieve the distress the patient is experiencing while simultaneously building the patient’s trust and buy-in to their treatment plan.

Choice of medication is based on the needed to effectively control acute clinical symptoms and behavioural symptoms. Previous responses, if any, to antipsychotic therapy also aid medication selection. However, patients need to adhere to therapy as it has been shown that the longer the duration of untreated psychosis, the poorer the long-term outcomes.

Professor Fleischhacker explained that different antipsychotics have different adverse event profiles and the influence these might have on adherence to therapy. Thus, choice of an antipsychotic that suits the patient and that optimizes likely adherence is crucial. Prioritizing acute symptom control could ultimately pave the way for functional improvements long-term.

Personal and social functioning can be improved in the acute setting and relapses prevented in the long-term through the appropriate selection of a suitable atypical antipsychotic agent

No debate – consensus on the importance of adherence

In his response, Dr Ofer Agrid, Canada, acknowledged that quality of life in addition to personal and social functioning can be improved in the acute setting and relapses prevented in the long-term through the appropriate selection of a suitable atypical antipsychotic agent.

Again, the key was ensuring treatment adherence to therapy through the selection of effective agents that permitted a high level of functioning with few side-effects. 

To conclude, this was a session not of debating conflict but of consensual agreement. Effective short-term and long-term management strategies ultimately rely on patient adherence to therapy. And adherence to therapy is driven by patients’ awareness both of effective symptom control in the short-term and improved functioning in the long-term.