The British Journal of Psychiatry (2009) 195: S20-S28. doi: 10.1192/bjp.195.52.s20
© 2009 The Royal College of Psychiatrists
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REVIEW ARTICLES

First-generation antipsychotic long-acting injections v. oral antipsychotics in schizophrenia: systematic review of randomised controlled trials and observational studies

Peter M. Haddad, MRCPsych, MD

Greater Manchester West Mental Health NHS Foundation Trust, Salford, and University of Manchester

Mark Taylor, BSc(Hons), FRCPsych, FRANZCP

Ballenden House, Edinburgh and University of Glasgow

Omair S. Niaz, MBChB, MRCPsych

Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK

Correspondence: Dr P. M. Haddad, Cromwell House, Cromwell Road, Eccles, Salford M30 0GT, UK. Email: peter.haddad{at}gmw.nhs.uk

Declaration of interest

P.M.H. and M.T. have received fees for lecturing and consultancy from the manufacturers of various antipsychotics, including AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Janssen-Cilag.

Background

Antipsychotic long-acting injections (LAIs) are often used in an attempt to improve medication adherence in people with schizophrenia.

Aims

To compare first-generation antipsychotic long-acting injections (FGA–LAIs) with first- and second-generation oral antipsychotics in terms of clinical outcome.

Method

Systematic literature review.

Results

A meta-analysis of randomised controlled trials (RCTs) showed no difference in relapse or tolerability between oral antipsychotics and FGA–LAIs but global improvement was twice as likely with FGA–LAIs. Four prospective observational studies were identified; two studies reported lower discontinuation rates for FGA–LAIs compared with oral medication and two found that outcome was either no different or better with oral antipsychotics. Mirror-image studies consistently showed reduced in-patient days and admissions following a switch from oral antipsychotics to FGA–LAIs.

Conclusions

The results are variable and inconclusive. Some evidence suggests that FGA–LAIs may improve outcome compared with oral antipsychotics. Methodological issues may partly explain the variable results. Selective recruitment in RCTs and lack of randomisation in observational studies are biases against LAIs, whereas regression to the mean in mirror-image studies favours LAIs. In terms of future research, a long-term pragmatic RCT of an FGA–LAI against an oral antipsychotic, in patients with problematic adherence, would be of value.