On the first day of the congress, the program included two extremely relevant sessions that addressed the use of long-acting therapies in patients with schizophrenia and the improvement of long-term treatment in patients with treatment-resistant depression.
Check out the main highlights of the first day in detail:
Rewriting the future of patients with schizophrenia with long-acting therapies
During this session, the specialists discussed long-acting injection treatments, their advantages over oral treatments, and shorter-acting injections. The doctors outlined the benefits of long-acting treatments, described the added value of very long-acting treatments, and provided recommendations to optimize treatment efficacy and tolerability.
Dr. David Taylor chaired this session. During his presentation, he noted that although long-acting treatments have been available for more than 40 years, their use varies significantly around the world. While a high proportion of patients in countries like Spain and the UK receive long-acting injections, in other countries, fewer than 10% of people use them.
The most focus on Dr. David lecture was about the challenges of medication adherence in patients with schizophrenia, emphasizing that many do not take their medications as prescribed. A Canadian study revealed that while 97% of patients claimed to be compliant, tablet counts, and electronic monitoring showed that fewer than half were truly adherent. The findings indicated that clinicians often misclassified adherent patients as non-adherent and vice versa. This suggests that non-adherence not only hampers treatment but also leads to inaccurate evaluations by healthcare providers. A study comparing oral and long-acting injectable forms of risperidone was presented. Patients taking oral risperidone had a relapse rate of 50%, while those receiving the long-acting injection had only a 7% relapse rate, demonstrating a significant difference in outcomes.
Dr. David presented promising results from his study titled “Clinical Outcomes with Paliperidone Palmitate 3-Monthly Injection as Monotherapy: Observational 3-Year Follow-Up of Patients with Schizophrenia.” In this observational study of patients with schizophrenia treated with three-monthly paliperidone, results showed that after three years, 60% of patients remained on treatment, with an overall retention rate of 80% for any form of paliperidone injection. Notably, there were no relapses in the last 18 months of the study. The data showed that frequent and correct administration of long-acting injections results in better efficacy and fewer hospital bed days. The proportion of days covered by the injections was a crucial indicator, demonstrating that higher frequency administration is associated with lower relapse rates.
In summary, Dr. David’s lecture highlighted the importance of long-acting injections in the treatment of schizophrenia, emphasizing that they are more effective and better tolerated than oral administration, leading to better clinical outcomes and fewer relapses.
Setting strong foundations: initiation of long-acting therapies early in the disease course
Speaker: María P García-Portilla
During the lecture, Dr. Maria discussed a clinical case of a patient experiencing his second episode of schizophrenia, who initially struggled with adherence to oral paliperidone. He was switched to long-acting injectable paliperidone after his first episode in May 2020, during which he had achieved complete recovery without hospitalizations or suicide attempts.
For his second episode, Carlos received 150 mg of injectable paliperidone, which partially improved his symptoms. To achieve better results, 6 mg of oral risperidone was added, leading to significant improvement. By June, Carlos was symptom-free, active, and engaged in his studies, allowing for a reduction in his medication doses. However, in October, he experienced some negative symptoms like sleepiness and lack of motivation. Dr. María made an adjustment to his treatment by reducing the injectable dose to 100 mg per month and adding 100 mg of venlafaxine. Six months later, Carlos was in full recovery, completed his studies, and planned to start a master’s program. They discussed transitioning to a six-month injection interval, which Carlos preferred.
Dr. María highlighted the benefits of long-acting injections, including consistent bioavailability, reduced relapse risk, fewer adverse events, and more personalized treatment plans. Additionally, she emphasized the importance of preventing new episodes to achieve full remission and functional recovery. Long-acting injections, especially with extended intervals, significantly reduce relapse rates and improve patient outcomes. Despite strong evidence, these injections are underutilized, especially in early-stage treatment when they can be most effective.
In conclusion, Dr. María advocated for setting ambitious treatment goals from the outset and using long-acting injections to prevent relapses, reduce hospitalization, and support patients in achieving full personal autonomy and a better quality of life. The commitment to using evidence-based strategies and not giving up on patients was emphasized as crucial for their recovery and well-being.
Unlocking the potential of long-acting therapies: the added value of longer administration intervals
Speaker: Domenico De Berardis
In this presentation, Dr. Domenico shared a case report of Luca, a 25-year-old man with a complex mental health history, including a strong genetic predisposition to schizophrenia. His mother has schizophrenia, while his brother struggles with substance use disorders. Luca faced bullying in school, which led to increased substance use as a coping mechanism. Luca’s first psychiatric episode involved delusions about poisoned water, resulting in compulsory hospitalization. He exhibited hostility and poor adherence to treatment, primarily with risperidone and valproic acid. Despite these challenges, he showed some improvement over time and expressed a desire for a therapy that would allow him to lead a fulfilling life.
Dr. Domenico said that he introduced long-acting injectable paliperidone, first offering PP1M and later transitioning to PP3M and then PP6M. Luca responded positively to this treatment, experiencing significant improvements in his symptoms and overall functioning. By May 2023, he was stable, socially active, and even pursuing a law degree. He emphasized the benefits of extended dosing intervals, including improved patient autonomy, reduced side effects, and enhanced adherence. Luca reported feeling less burdened by his diagnosis and more empowered in his daily life, highlighting the importance of personalized treatment plans that support recovery and quality of life.
Overall, this case exemplifies the transformative potential of long-acting injectable treatments in psychiatric care, emphasizing the need for shared decision-making and a focus on patient goals.
Improving the long-term care of patients with treatment-resistant depression
The overall goal of this session, chaired by Dr. Mohammad Alsuwaidan, was to describe key factors in planning the long-term treatment of patients with major depressive disorder, particularly those with treatment-resistant depression (TRD). The aim was not just theoretical but practical, providing tools for immediate application with patients. The session began by highlighting the significant burden of depression, emphasizing that patients often spend substantial time on treatment, and the longer the treatment is ineffective, the worse the outcome. About one-third of depression patients become treatment-resistant, and 75% of these do not respond within six months. Many patients do not change their treatment within this period, which is a critical issue that needs addressing.
Achieving remission is crucial, but maintaining it is equally important, as one-third of patients relapse. The STAR*D study, a comprehensive dataset, showed that response and remission rates drop significantly after the first two treatment steps. Recent data from the ESCAPE-TRD study demonstrated better outcomes for patients augmented with quetiapine or intranasal esketamine compared to previous treatments. Side effects were lower in the ESCAPE-TRD study compared to STAR*D. Social and clinical factors contributing to TRD include older age, female gender, lower socioeconomic status, trauma, severe depression, and comorbidities. The WHO consensus article highlighted the limited evidence for many clinical practices, such as extending antidepressant trials, switching antidepressants, and combining antidepressants. However, there is clear evidence for the effectiveness of ketamine and s-ketamine, although long-term data and access remain issues. Combining antidepressants with second-generation antipsychotics is effective but faces stigma challenges. ECT and TMS are effective but also face access and stigma issues.
Expert insights on long-term maintenance therapy in treatment-resistant depression: focus on patient cases
Speaker: Lisa Harding
During her presentation, Dr. Lisa emphasized the importance of planning long-term treatment for patients with major depressive disorder, particularly those with treatment-resistant depression. The primary goal was to equip clinicians with practical tools to improve patient outcomes upon returning to their practice. The speaker highlighted the significant burden of depression, noting that one-third of patients with depression eventually become treatment-resistant. They stressed the necessity of addressing ineffective treatments promptly, as prolonged ineffective treatment worsens patient outcomes.
The doctor drew attention to the STAR*D study, a comprehensive multi-site naturalistic study, which revealed the declining rates of patient response and remission with each successive treatment step. Comparatively, recent data from the ESCAPE-TRD study showed better outcomes with intranasal esketamine and quetiapine augmentation. Despite the higher dropout rates due to intolerable side effects in the STAR*D study, esketamine demonstrated fewer side effects and better patient retention.
Further, Dr. Lisa shared their professional journey from an ER doctor to a psychiatrist, reflecting on the differences in urgency and treatment expectations between the two fields. They criticized the psychiatric field for its tolerance of prolonged patient suffering due to ineffective treatments. The presentation included a case study of a patient named Luca, who had a long history of major depressive disorder and PTSD, illustrating the challenges and complexities of treating severe depression. The patient underwent various treatments, including antidepressants and augmentation strategies, before achieving remission with esketamine treatment.
Dr. Lisa underscored the need for updated treatment algorithms to incorporate newer, effective treatments like esketamine. They highlighted the importance of holistic health approaches, including yoga, to maintain patient well-being. The session concluded with a call to action for clinicians to rethink current treatment algorithms, focusing on maintaining long-term patient health and addressing the stigma associated with certain psychiatric treatments. The speaker’s experience and insights aimed to inspire immediate application of these strategies in clinical practice to enhance patient outcomes.
Expert insights on long-term maintenance therapy in treatment-resistant depression: focus on patient cases
Speaker: Júlia Vendrell-Serres
Dr. Júlia presentation focused on the topic of treatment-resistant depression (TRD) and the use of esketamine as a potential treatment. The speaker emphasized that approximately 50% of patients do not respond adequately to current treatments, highlighting the need for more effective solutions. A study involving 450 psychiatrists identified poor compliance with treatment, lack of patient collaboration, and antidepressant discontinuation due to adverse effects as significant barriers to achieving full recovery in TRD patients. To address this, she discussed the Treatment Resistant Depression Program established at her center, which serves an area in Barcelona with a population of nearly half a million. The program aims to provide care and promote research in depressive disorders. One of the treatment options offered is esketamine. Dr. Júlia detailed the treatment process, noting that they often increase the dose rapidly if well tolerated, reaching up to 84 milligrams during the second session or week.
During the session the doctor shared a case study of a patient named Lucy, who experienced significant improvement after starting esketamine treatment. Lucy, in her early fifties, had a long history of depression and other medical conditions. After previous treatments failed, she began esketamine therapy and achieved remission within the first month. Dr. Júlia also referenced the REALES study from Italy, which showed that remission and response rates increased significantly after three months of treatment with esketamine. This data suggests that continuing treatment beyond the induction phase can lead to successful outcomes. Another study conducted by the doctor’s group in Barcelona involved 16 patients and indicated that esketamine could be effective even for those who had not responded to other treatments, including electroconvulsive therapy (ECT).
Returning to Lucy’s case, Dr. Júlia explained that her treatment began at 56 milligrams and increased to 84 milligrams by the second session. During the induction phase, she received treatment twice a week, then once a week during the maintenance phase, and eventually every two weeks until tapering off. Lucy’s depressive symptoms showed a dramatic reduction, and she was able to return to work after an extended sick leave.
In conclusion, she highlighted the importance of considering new treatment options like s-Ketamine early in the treatment process for TRD patients, emphasizing rapid dose increases and individualized treatment plans.
Overall, the Improving the long-term care of patients with treatment-resistant depression session provided a comprehensive overview of TRD, emphasizing the need for timely and effective treatment adjustments and the importance of addressing both clinical and stigma-related barriers in managing TRD.
References
1. TAYLOR, D. Rewriting the future of patients with schizophrenia with long-acting therapies. In: 37th ECNP Congress, Milan, Italy.
2. ALSUWAIDAN, M. Improving the long-term care of patients with treatment-resistant depression. In: 37th ECNP Congress, Milan, Italy.
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Highlights 37th ECNP Congress – DAY 1
