How to Consider an LAI at Discharge for Bipolar I
How should clinicians use this study to decide whether to consider a long-acting injectable antipsychotic at discharge for a hospitalized patient with bipolar I disorder?
Patients with bipolar I disorder are at high risk for early relapse and rehospitalization after discharge, especially when adherence to oral treatment is unreliable. This study addresses the postdischarge window in which LAIs, particularly second-generation formulations, were associated with fewer BD-I-related readmissions than oral antipsychotics.
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Identify patients in the high-risk postdischarge window
Apply this guide to adults hospitalized with a primary or admitting diagnosis of bipolar I disorder who are approaching discharge. The study focused on rehospitalization outcomes within 30, 60, and 90 days after the index hospitalization, with the clearest benefit concentrated in the early postdischarge period.
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Review whether oral adherence is a likely barrier
Use the study to frame LAIs as a consideration when adherence to oral antipsychotics is a concern. The article emphasizes nonadherence to oral treatment as a major barrier in long-term bipolar I management and notes that LAIs may be particularly relevant for patients with poor adherence, severe symptoms, or multiple relapses.
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Discuss the expected magnitude of rehospitalization benefit
Explain that LAIs were associated with lower BD-I-related rehospitalization than oral antipsychotics at 30 days (3.9% vs 5.0%; HR 0.784) and 60 days (5.9% vs 7.2%; HR 0.818), while the 90-day difference did not reach statistical significance in the overall LAI group. Frame the absolute benefit as modest: the article reports an absolute risk reduction of 1.1% at 30 days for all LAIs, corresponding to an approximate number needed to treat of 91.
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Favor second-generation LAIs when an LAI is being considered
If an LAI is being considered, use the study's strongest signal to prioritize second-generation LAIs. In the subgroup analysis, second-generation LAIs were associated with lower BD-I-related rehospitalization at 30 days (3.6% vs 5.4%; HR 0.653), 60 days (5.2% vs 7.5%; HR 0.692), and 90 days (6.8% vs 9.1%; HR 0.742) compared with oral antipsychotics.
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Set expectations about what LAIs may and may not change
Use LAIs primarily as a strategy to reduce short-term readmission risk rather than to shorten a later admission. The study found that average length of stay during rehospitalization was statistically similar between LAI, second-generation LAI, and oral antipsychotic groups.
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Build the LAI into discharge and follow-up planning
Incorporate the LAI decision into discharge planning rather than treating it as a standalone prescribing choice. The article's clinical implication is that integrating LAIs into discharge and follow-up planning may support adherence and reduce short-term readmissions in appropriate patients.
Clinical Considerations
- This was an observational retrospective database study, so the findings show association rather than proof that LAIs caused lower rehospitalization.
- The overall LAI benefit for BD-I-related rehospitalization was statistically significant at 30 and 60 days but not at 90 days.
- Absolute risk reductions were modest, although the study notes they may still matter in high-risk patients.
- The LAI group was defined by receiving an LAI during hospitalization, whereas the oral antipsychotic group was defined by treatment at discharge, which may have introduced exposure misclassification.
Bottom Line
For hospitalized adults with bipolar I disorder, consider an LAI at discharge when early relapse or oral nonadherence is a concern, with the strongest evidence in this study favoring second-generation LAIs for reducing short-term BD-I-related rehospitalization.
