How to Monitor Brexpiprazole Response in Schizophrenia With Hostility or Agitation
How should clinicians monitor functioning, hostility, and agitation when following a patient with schizophrenia treated with brexpiprazole?
When schizophrenia includes hostility or agitation, clinicians need a practical way to track whether treatment is helping beyond psychosis ratings alone. This guide reflects the monitoring framework used in the article's short-term and long-term brexpiprazole analyses, with attention to functioning as well as symptom response.
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Establish baseline functioning with the PSP
Rate functioning with the Personal and Social Performance scale across socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behaviors. The standard PSP total score ranges from 1 to 100, with higher scores indicating better functioning, and the article notes that a change of about 10 points, or one category, has been suggested as potentially clinically meaningful.
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Consider whether hostility and agitation may directly influence PSP scoring
Because the PSP includes a disturbing and aggressive behaviors domain, hostility and agitation can directly affect the total score. In this analysis, the authors addressed that by informally recalculating a modified 3-domain PSP using only socially useful activities, relationships, and self-care, with category midpoints assigned because exact clinician-judgment values could not be derived.
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Reassess at about 6 weeks for early functional change
The short-term trials evaluated outcomes over 6 weeks, providing the key early monitoring interval in this article. Over 6 weeks, brexpiprazole was associated with greater functional improvement than placebo in participants with hostility and in participants with agitation, while participants without agitation showed a nonsignificant difference versus placebo.
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Track hostility response directly with PANSS P7
For patients who met baseline hostility criteria, reassess PANSS P7 and determine whether the score has shifted below 3. In the short-term analysis, hostility response occurred in 72.7% of participants on brexpiprazole versus 61.8% on placebo by Week 6, so this threshold gives a concrete way to judge whether hostility has moved out of the mild-or-worse range used at baseline.
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Track agitation response with percentage change in PANSS-EC
For patients who met baseline agitation criteria, calculate percent change in PANSS-EC from baseline and look for at least 40% improvement. In this study, agitation response numerically favored brexpiprazole at Week 6 but was not statistically significant versus placebo, so clinicians should monitor agitation directly rather than infer improvement solely from overall functioning.
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Reassess longitudinally if treatment continues
In the long-term analysis, participants who continued brexpiprazole showed functional improvement that then stabilized over up to 58 weeks, both with and without baseline hostility or agitation. Hostility response reached 82.6% at Week 32 and 90.6% at Week 58, while agitation response reached 65.1% at Week 32 and 77.5% at Week 58.
Clinical Considerations
- This was a post hoc, exploratory, hypothesis-generating analysis with nominal P values and no adjustment for multiple comparisons.
- The long-term findings were descriptive and based on observed cases among participants who continued brexpiprazole, with 43.4% completing 58 weeks.
- The modified 3-domain PSP was a novel informal approach that used category midpoints, had reduced variability, and requires further validation.
- People with substance use disorders were excluded, which limits generalizability.
Bottom Line
When following brexpiprazole in schizophrenia with hostility or agitation, monitor both functioning and symptom-specific response, using about 6 weeks for early reassessment and continued longitudinal follow-up if treatment is maintained.
