Preventing relapse in schizophrenia needs better evidence

Given the considerable contribution of schizophrenia spectrum disorders to the global burden of disease, implementing evidence-based treatments is a global health priority. 1 GBD 2017 Disease and Injury Incidence and Prevalence CollaboratorsGlobal, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392: 1789-1858 Google Scholar , 2 Patel V Saxena S Lund C et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018; 392: 1553-1598 Google Scholar Building on a previous network meta-analysis of randomised trials of antipsychotics for acute symptoms of schizophrenia, 3 Huhn M Nikolakopoulou A Schneider-Thoma J et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet. 2019; 394: 939-951 Google Scholar Johannes Schneider-Thoma and colleagues 4 Schneider-Thoma J Chalkou K Dörries C et al. Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: a systematic review and network meta-analysis. Lancet. 2022; 399: 824-836 Google Scholar assessed 32 oral and long-acting injectable antipsychotics for 14 different efficacy and tolerability outcomes in a systematic review and network meta-analysis published in The Lancet. The primary outcome was the number of participants who relapsed after clinical stabilisation. 4 Schneider-Thoma J Chalkou K Dörries C et al. Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: a systematic review and network meta-analysis. Lancet. 2022; 399: 824-836 Google Scholar The authors found that, for the prevention of relapse, most antipsychotics were superior to placebo, but there were no clinically relevant differences between antipsychotics, as most comparisons included a probability of no difference. Comparing side-effects between antipsychotics generally confirmed findings from trials of acute phase schizophrenia, showing the highest risk of extrapyramidal effects for first-generation antipsychotics, weight gain for second-generation antipsychotics, and hyperprolactinaemia for paliperidone and risperidone. However, for some important side-effects, such as tardive dyskinesia, imprecise results prevented clinical implications from being drawn. Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: a systematic review and network meta-analysisAs we found no clear differences between antipsychotics for relapse prevention, we conclude that the choice of antipsychotic for maintenance treatment should be guided mainly by their tolerability. Full-Text PDF