Long-Acting Injectable Antipsychotic May Reduce Costs, Increase Adherence in Schizophrenia

Long-acting injectables should be considered earlier in the treatment of schizophrenia.

Researchers found that adults recently diagnosed with schizophrenia being treated with once-monthly paliperidone palmitate (PP1M), a long-acting injectable antipsychotic, had significantly lower medical costs compared with participants taking oral atypical antipsychotics (OAAs). In particular, recently diagnosed patients being treated with PP1M may have greater medical cost savings compared with recently diagnosed patients being treated with OAAs. These findings were published in BMC Psychiatry.1

Dominic Pilon from Analysis Group, Inc, and colleagues analyzed Medicaid data from 5 states between September 2008 and March 2015 to identify adults with schizophrenia who started treatment on PP1M or OAAs on or after September 2009.

The researchers found that patients initiated on PP1M (n=2053) were younger compared with those receiving OAAs (mean age, 41 vs 44 years), and they had more baseline antipsychotic use (88% vs 62%).

Adherence was similar across the overall cohort, but PP1M in recently diagnosed patients (defined as ages 18-25 years) was associated with better adherence (proportion of days covered ≥80%, 29% vs 21%; P <.001) and with less use of other psychiatric medications compared with OAAs.

The researchers also found that in recently diagnosed patients, lower medical costs associated with PP1M (mean monthly cost difference [MMCD], −$466; P =.028) outweighed the higher pharmacy costs (MMCD, $322; P <.001), which resulted in similar total healthcare costs across the groups (MMCD, −$144; P =.553).

“Overall, findings were similar but there was a trend toward a lower magnitude of medical cost savings (MMCD = $-286; P < 0.001),” the researchers wrote. “Reductions in medical costs were mainly driven by reductions in inpatient days (recently diagnosed RR = 0.85, P = 0.353; overall RR = 0.84, P = 0.004) and in home care visits (recently diagnosed RR = 0.43, P =.008; overall RR = 0.78, P = 0.048).”

Long-acting injectable therapies are not commonly used to treat recently diagnosed patients with schizophrenia, despite research showing that these treatments can be safe and effective in this population.2-5 Reasons for this may include psychiatrists’ concerns over tolerability and patient acceptance, as well as patients’ unawareness of this treatment option.6,7

However, “recently diagnosed patients are important candidates for [long-acting injectables] due to their high risk for non-adherence issues, which may especially affect this population due to poor insight into illness, poor attitudes toward medication, and higher rates of problematic substance use,” the researchers noted. “Indeed, among patients with first-episode psychosis, rates of AP non-adherence may exceed 50%, with approximately 30% of patients discontinuing therapy within 9 months.”

Because of these concerns, long-acting injectables should be considered earlier in the treatment of schizophrenia.8,9 Some clinical guidelines recommend them in early schizophrenia or as first-line treatment in schizophrenia.4,10

Study Limitations

  • The data in this study came from Medicaid patients in 5 states and may not be representative of the entire United States or of non-Medicaid patients.
  • These data span 5 years after approval of PP1M; it will be important to compare these findings as new data become available.
  • These data come from claims and may be subject to billing errors or other inaccuracies or missing information; claims data also do not account for whether medications were taken as prescribed.
  • Patient adherence may have been overestimated because of the design of the study.
  • The definition of recently diagnosed schizophrenia in this study (ages 18-25 years) may lack precision by excluding those with later onset.
  • As with all retrospective administrative claims data, study results may be subject to residual confounding because of unmeasured confounders.

Bruno Emond, Dominic Pilon, Patrick Lefebvre, and Rhiannon Kamstra are employees of Analysis Group, Inc, a consulting company that has received research grants from Janssen Scientific Affairs, LLC, to conduct this study. Erik Muser and Kruti Joshi are employees of Janssen Scientific Affairs, LLC.


1. Pilon D, Muser E, Lefebvre P, Kamstra R, Emond B, Joshi K. Adherence, healthcare resource utilization and Medicaid spending associated with once-monthly paliperidone palmitate versus oral atypical antipsychotic treatment among adults recently diagnosed with schizophrenia [published online June 2, 2017]. BMC Psychiatry. doi: 10.1186/s12888-017-1358-3

2. Medicaid Drug Rebate Program. Centers for Medicare and Medicaid Services. 2016. https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.html.

3. Bossie CA, Fu D-J, Sliwa JK, Alphs L, Ma Y-W. Tolerability of initiation doses of once-monthly paliperidone palmitate in patients with recently diagnosed schizophrenia in an acute treatment trial. Ther Adv Psychopharmacol. 2011;1(4):1111124. doi: 10.1177/2045125311413006

4. Heres S, Lambert M, Vauth R. Treatment of early episode in patients with schizophrenia: the role of long acting antipsychotics. Eur Psychiatry. 2014;29:1409-1413. doi: 10.1016/S0924-9338(14)70001-X

5. Patel MX, Haddad PM, Chaudhry IB, McLoughlin S, Husain N, David AS. Psychiatrists’ use, knowledge and attitudes to first- and second-generation antipsychotic long-acting injections: comparisons over 5 years. J Psychopharmacol. 2010;24(10):1473-1482. doi: 10.1177/0269881109104882

6. Emsley R, Alptekin K, Azorin J-M, Canas F, Dubois V, Gorwood P, et al. Nurses perceptions of medication adherence in schizophrenia: results of the ADHES cross-sectional questionnaire survey. Ther Adv Psychopharmacol. 2015;5(6):339-350. doi: 10.1177/2045125315612013

7. González-Rodríguez A, Catalán R, Penadés R, Garcia-Rizo C, Bioque M, Parellada E, et al. Profile of paliperidone palmitate once-monthly long-acting injectable in the management of schizophrenia: long-term safety, efficacy, and patient acceptability–a review. Patient Prefer Adherence. 2015;9:695-706. doi: 10.2147/PPA.S63948

8. Rauch A-S, Fleischhacker WW. Long-acting injectable formulations of new-generation antipsychotics: a review from a clinical perspective. CNS Drugs. 2013;27(8):637-652. doi: 10.1007/s40263-013-0083-9

9. Emsley R, Chiliza B, Asmal L, Mashile M, Fusar-Poli P. Long-acting injectable antipsychotics in early psychosis: a literature review. Early Interv Psychiatry. 2013;7(3):247-254. doi: 10.1111/eip.12027

10. Llorca PM, Abbar M, Courtet P, Guillaume S, Lancrenon S, Samalin L. Guidelines for the use and management of long-acting injectable antipsychotics in serious mental illness. BMC Psychiatry. 2013;13(1):1. doi: 10.1186/1471-244X-13-340