3.1 Rationale for LAI initiation index
There are no initiation guidelines or protocols but only indications and suggestions from experts [13, 14]. Often psychiatrists consider that it is not yet the time, the patient could refuse LAI, the costs can be higher, the supervision must be more careful, thus delaying initiation.
The SLAII Index provided was developed by an experienced schizophrenia research group leading by Petru Ifteni, M.D., PhD, professor of psychiatry at Transilvania University of Brasov, Romania, Faculty of Medicine.
3.3 Theoretical rationale for items
The index items are derived from consideration of important elements involved in the outcome of schizophrenia: age, duration of illness, number of relapses, antipsychotic treatment response, family support and adherence.
I. Age
The patient's age is a key factor in subsequent evolution. Young patients may still have many neurocognitive resources for treatment response, remission and recovery [15]. Thus, for the age between 18 and 25 years we gave 5 points, for the age between 26 and 35 years we gave 3 points, and for those aged between 36 and 45 years, we gave 1 point.
II. Duration of illness
Studies show that neuropathological changes occur in the first years of the disease [16]. Thus, the first 2–5 years can be considered to have major importance for the patient. We rated with 5 points for patients with a disease duration between 2 and 5 years, 3 points for a duration between 6 and 10 years and 1 point for a disease duration over 10 years.
III. Relapses
Relapses and hospitalizations in the early years are a prognostic factor for the unfavorable evolution towards cognitive decline and chronicity [17, 18]. Therefore, experts recommend the early initiation of LAI, after the first relapses caused by non-adherence. We rated with 5 points for at least 3 relapses, 3 points for 2 relapses and 1 point for 1 relapse.
IV. Response to oral antipsychotic
Many young people with schizophrenia respond well to the first trials with antipsychotics, a significant percentage even get remission [19]. Individual responsiveness, the severity of pathology are criteria that influence the choice of antipsychotic and doses. The therapeutic response decreases significantly with the increasing number of relapses [20]. We rated 5 points for complete therapeutic response/remission, 3 points for partial response (residual symptoms at effective doses of oral antipsychotic) and 1 point for lack of response and need for clozapine.
V. Family support
Family support is important as the other elements of therapeutic management [21]. In patients with adherence problems, the lack of family members involved in the therapeutic process is considered a predictor of therapeutic abandonment, even when initiating depot formulas.
The presence of 2 or more family members close to the patient was rated with 5 points, of a single member with 3 points and in situations where the patient is alone only 1 point.
VI. Antipsychotic existing formulation
If the patient received an OAP that also has LAI formulation (aripiprazole, olanzapine, risperidone, and paliperidone) we gave 5 points, if there is only the oral formulation (amisulpride and quetiapine) we gave 3 points and if the patient was on clozapine 1 point.
VII. Treatment adherence
Assessing adherence to treatment is a complex and subjective approach. Many methods have been proposed, none of which are perfect. In general, the patient with schizophrenia can be considered as adherent, partially adherent or non-adherent [22, 23]. In the patient’s file, on admission, it is mentioned if the patient is adherent, partially adherent or non-adherent. The adherence was evaluated using Kemp’s 7-point scale [24]. For the 3 variants listed, we rated 1 point for good adherence, 3 points for partial adherence and 5 points for poor adherence.
3.4. Scoring, interpretation and recommendations
All 7 items of the index have equal importance in the management of the patient with schizophrenia when LAI initiation has taken into account. The final score obtained could range from minimum of 7 points to a maximum of 35 points, placing the patient in one of the following categories:
25–35 points = strong indication for LAI initiation. This score indicates the need for a preventive action. It means that the patient has the premises (age, duration of the disease, support, therapeutic response) and the highest chances of total functional recovery. LAI should be initiated as soon as possible to prevent a new relapse or hospitalization.
15–23 points = moderate indication for LAI initiation. This score indicates the need for a better functionality action. It should be interpreted as a score in which the patient can benefit from LAI for significant improvement in functioning and therefore a better social and professional integration.
07–13 points = low indication for LAI initiation. This score indicates the need for a better autonomy action. It means that long-acting treatment could increase patient’ autonomy especially in the cases of patients with low support, low income or homeless.
The initiation index must be interpreted with few recommendations. In the case of patients with no relapse, there is still the possibility of therapeutic abandonment, so initiation is a preventive measure. In treatment-resistant schizophrenia, we have to decide if it is really a case of resistance or is in fact non-adherence. In the case of false treatment resistance situation, we recommend LAI initiation.
For patients on clozapine for treatment-resistance or for aggressive behavior switching to an LAI is not recommended. In cases of severe adverse events this switch must be done very carefully.