PREvent First Episode Relapse (PREFER)

Overview: Before the atypicals were introduced, some of the older antipsychotics were available in oral (pill or capsule) and long-acting (depot) versions. Despite the potential advantages of the depot versions, in those days clinicians in the United States have historically limited the use of long-acting, "depot" antipsychotics to their most treatment-resistant, chronic, patients. Therefore, most clinicians did not routinely consider starting a long-acting antipsychotic early in the course of treatment, such as after the first-episode of schizophrenia.

This whole issue was less relevant after the atypical medications came out, because they were only available in oral versions for long-term treatment. Now that one of the atypical medications (risperidone) is available for use in the United States, the issue of appropriate use of oral vs. long-acting atypical is now very relevant to clinical practice.

For first episode patients, there are been two issues that suggest that the route of medication delivery is an important area to study. First is that almost all first-episode patients will stop their medication too soon. Second, a there now is atypical antipsychotic available in a long-acting preparation (long-acting risperidone, but this option is not often used right away after a first episode, so there is little guidance for clinicians about the effectiveness of long-acting antipsychotics used right away after a first-episode.

Methods: This study compares the effectiveness of the long-acting route of medication to improve adherence and reduce relapse among patients who have been recently diagnosed with schizophrenia or a related psychotic disorder. After patients are stabilized with an atypical antipsychotic and have received patient and family psychoeducation, consenting patients will be randomized to a prospective, random-assignment open-label study comparing any available first-line oral atypical antipsychotic to long-acting risperidone for the maintenance treatment of patients recovering from acute treatment of first-episode schizophrenia.

This study is divided into three study phases. Study Phase I is the acute phase, where consenting patients would be given an acute open-label trial of an oral antipsychotic. Patients who respond within a maximum of 12 weeks to acute therapy will then be invited to participate in Phase II of the study. Patients agreeing to Phase II will then be randomized into staying on their oral antipsychotic medication vs. switching to a long-acting atypical antipsychotic (long-acting risperidone). Patients would be followed for 12 weeks to determine whether or not they accept a recommendation of long-acting antipsychotic or continued oral antipsychotic. Then patients enter into Study Phase III, where they are followed for at the remainder of the year. We want to learn how often patients will accept their doctor's recommendation of a long-acting injection, whether persons taking their antipsychotic medication in long-acting form do better in terms of willingness to stay on their medication, or have better symptom control or fewer side effects, than persons where the doctor recommends the medication in oral (pill) form.

Summary: Patients recently diagnosed as suffering from schizophrenia, e.g. the "first-episode" patient might benefit from an atypical antipsychotic given in a long-acting route of drug- delivery. However, long-acting antipsychotic therapy is not routinely considered in first-episode patients. Studying the acceptance and ultimate effectiveness of a long-acting atypical antipsychotic would be very helpful in understanding how to help patients stay stable and ultimately prevent a revolving door pattern that, if it continues, can be devastating to the recovery process.