Psych · Psychopharmacology — long-acting injectable antipsychotics
Long-acting injectable antipsychotics
Also known as LAI antipsychotics · Depot antipsychotics · Long-acting injectables · Paliperidone palmitate · Aripiprazole once-monthly · Risperidone microspheres · Olanzapine pamoate
Exam-exhaustive fellowship reference on long-acting injectable antipsychotics — agent map, oral overlap and loading, indications and adherence, real-world evidence (Tiihonen, Kishimoto), PRELAPSE and FEP data, PDSS, missed doses, monitoring, and when LAI does not replace clozapine. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Olanzapine pamoate injection without facility observation — PDSS risk (delirium, sedation, coma)
- Starting an LAI without oral tolerability of the same molecule — multi-week irreversible adverse-effect exposure
- Omitting required oral overlap or loading — early relapse falsely labelled LAI failure
- Using LAI as punishment or sole control tool without a recovery plan and shared decision
- True treatment-resistant schizophrenia on an LAI — do not delay TRRIP-guided clozapine offer
- Missed injection past product re-initiation window — restart correctly; do not invent doses
Meet the patient
A 21-year-old man, eighteen months after his first episode, is on his third admission. Each time the story is identical: well on olanzapine, stops it around week ten, relapses by week sixteen. His mother has started counting tablets. He is not refusing treatment — he is forgetting it, and then avoiding the conversation about forgetting it.[1][5]
The registrar writes "poor insight, non-compliant". The examiner asks the better question: why is this man's treatment plan still built on a daily decision he keeps failing to make?[1][3][6]
References16ShowHide
- [1]Tiihonen J, Haukka J, Taylor M, et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia Am J Psychiatry, 2011.PMID 21362741
- [2]Tiihonen J, Mittendorfer-Rutz E, Majak M, et al. Real-World Effectiveness of Antipsychotic Treatments in a Nationwide Cohort of 29 823 Patients With Schizophrenia JAMA Psychiatry, 2017.PMID 28593216
- [3]Kishimoto T, Hagi K, Kurokawa S, et al. Long-acting injectable versus oral antipsychotics for the maintenance treatment of schizophrenia: a systematic review and comparative meta-analysis of randomised, cohort, and pre-post studies Lancet Psychiatry, 2021.PMID 33862018
- [4]Kishimoto T, Hagi K, Nitta M, et al. Effectiveness of Long-Acting Injectable vs Oral Antipsychotics in Patients With Schizophrenia: A Meta-analysis of Prospective and Retrospective Cohort Studies Schizophr Bull, 2018.PMID 29868849
- [5]Kane JM, Schooler NR, Marcy P, et al. Effect of Long-Acting Injectable Antipsychotics vs Usual Care on Time to First Hospitalization in Early-Phase Schizophrenia: A Randomized Clinical Trial JAMA Psychiatry, 2020.PMID 32667636
- [6]Subotnik KL, Casaus LR, Ventura J, et al. Long-Acting Injectable Risperidone for Relapse Prevention and Control of Breakthrough Symptoms After a Recent First Episode of Schizophrenia. A Randomized Clinical Trial JAMA Psychiatry, 2015.PMID 26107752
- [7]Rosenheck RA, Krystal JH, Lew R, et al. Long-acting risperidone and oral antipsychotics in unstable schizophrenia N Engl J Med, 2011.PMID 21366475
- [8]Berwaerts J, Liu Y, Gopal S, et al. Efficacy and Safety of the 3-Month Formulation of Paliperidone Palmitate vs Placebo for Relapse Prevention of Schizophrenia: A Randomized Clinical Trial JAMA Psychiatry, 2015.PMID 25820612
- [9]Lauriello J, Lambert T, Andersen S, et al. An 8-week, double-blind, randomized, placebo-controlled study of olanzapine long-acting injection in acutely ill patients with schizophrenia J Clin Psychiatry, 2008.PMID 18452346
- [10]Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis Lancet, 2013.PMID 23810019
- [11]Tiihonen J, Lönnqvist J, Wahlbeck K, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study) Lancet, 2009.PMID 19595447
- [12]Howes OD, McCutcheon R, Agid O, et al. Treatment-Resistant Schizophrenia: Treatment Response and Resistance in Psychosis (TRRIP) Working Group Consensus Guidelines on Diagnosis and Terminology Am J Psychiatry, 2017.PMID 27919182
- [13]Kane JM, Robinson DG, Schooler NR, et al. Comprehensive Versus Usual Community Care for First-Episode Psychosis: 2-Year Outcomes From the NIMH RAISE Early Treatment Program Am J Psychiatry, 2016.PMID 26481174
- [14]Bighelli I, Rodolico A, García-Mieres H, et al. Psychosocial and psychological interventions for relapse prevention in schizophrenia: a systematic review and network meta-analysis Lancet Psychiatry, 2021.PMID 34653393
- [15]Correll CU, Galling B, Pawar A, et al. Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression JAMA Psychiatry, 2018.PMID 29800949
- [16]Ostuzzi G, Bertolini F, Tedeschi F, et al. Oral and long-acting antipsychotics for relapse prevention in schizophrenia-spectrum disorders: a network meta-analysis of randomised trials Lancet Psychiatry, 2022.PMID 35524620