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Letter to the Editor

Drs Kane and Correll Reply

John M. Kane, MD,a-c and Christoph U. Correll, MDa-d

Published: June 16, 2020

See letter by Hirakawa and Ishii and article by Kane and Correll

To the Editor: We greatly appreciate the comments on our article1 by Hirakawa and Ishii highlighting the potential role of comorbid depression as a cause for nonadherence in schizophrenia and suggesting the use of second-generation long-acting injectable antipsychotics (LAIs) for patients with schizophrenia and comorbid depression.

Comorbid depression in schizophrenia is an important and frequently undiagnosed condition, associated with increased suicidality2 and impaired quality of life.3 Incidence and prevalence estimates have varied widely for depression comorbid with schizophrenia, ranging from 25%-81% in some reviews.4 This wide range suggests lack of consensus as to the definition of comorbid depression, among other considerations, including a challenging differential diagnosis due to substantial overlap between depressive symptoms and negative symptoms, demoralization, and even subtle akinesia.

Further, the use of rating scales and other measurement-based approaches in routine clinical psychiatry is still limited, and without accurate measurement it is difficult to make reliable diagnostic and treatment decisions. A variety of elements including time constraints and lack of familiarity with and/or training in validated assessment tools probably limit the use of measurement-based approaches in routine clinical care.5 This limitation also applies to measuring nonadherence. In fact, we do not currently have good and scalable measures for identifying nonadherence, if and when it does occur.6

Despite its relevance, clinicians generally tend to spend too little time in discussing and addressing adherence, regardless of the underlying cause. However, we agree with the authors that LAIs can play a major role in facilitating medication adherence and improving outcomes for schizophrenia patients,7 including in the case of a comorbid depression.

We are strong believers in greater utilization of LAIs, and the points emphasized by these authors further strengthen our rationale. If comorbid depression occurs, it should be detected and adequately treated, but that should also encourage clinicians to pursue adherence-enhancing strategies such as LAIs.

aThe Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, New York

bZucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, New York

cThe Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, New York

dCharité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany

Published online: June 16, 2020.

Potential conflicts of interest: See original article [J Clin Psychiatry 2019;80(5):IN18031AH1C] for potential conflicts of interest.

Funding/support: None.

J Clin Psychiatry 2020;81(4):20lr13262a

To cite: Kane JM, Correll CU. Drs Kane and Correll reply. J Clin Psychiatry. 2020;81(4):20lr13262a.

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© Copyright 2020 Physicians Postgraduate Press, Inc.


1.Kane JM, Correll CU. Optimizing treatment choices to improve adherence and outcomes in schizophrenia. J Clin Psychiatry. 2019;80(5):IN18031AH1C. PubMed CrossRef

2.Cassidy RM, Yang F, Kapczinski F, et al. Risk factors for suicidality in patients with schizophrenia: a systematic review, meta-analysis, and meta-regression of 96 studies. Schizophr Bull. 2018;44(4):787-797. PubMed CrossRef

3.Andrianarisoa M, Boyer L, Godin O, et al; FACE-SCZ Group. Childhood trauma, depression and negative symptoms are independently associated with impaired quality of life in schizophrenia: results from the national FACE-SZ cohort. Schizophr Res. 2017;185:173-181. PubMed CrossRef

4.Siris SG. Suicide and schizophrenia. J Psychopharmacol. 2001;15(2):127-135. PubMed CrossRef

5.Correll CU, Kishimoto T, Nielsen J, et al. Quantifying clinical relevance in the treatment of schizophrenia. Clin Ther. 2011;33(12):B16-B39. PubMed CrossRef

6.Kane JM, Kishimoto T, Correll CU. Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies. World Psychiatry. 2013;12(3):216-226. PubMed CrossRef

7.Correll CU, Citrome L, Haddad PM, et al. The use of long-acting injectable antipsychotics in schizophrenia: evaluating the evidence. J Clin Psychiatry. 2016;77(suppl 3):1-24. PubMed CrossRef

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