On September 1, 2020, the American Psychiatric Association released a new evidence-based “Practice Guideline for the Treatment of Patients with Schizophrenia.”  Their last Schizophrenia Treatment Guideline was quite dated (2004), so this is a welcome publication as psychiatric treatment and treatment philosophies have shifted in the past decade. Specifically, many new LAI formulations have become available, and the benefit of LAIs for relapse-prevention in the treatment of schizophrenia has been shown in clinical trials of second-generation LAIs across a range of clinical situations.
The following guideline statement pertains specifically to the use of long-acting injectable antipsychotics:
“APA suggests that patients receive treatment with a long-acting injectable antipsychotic medication if they prefer such treatment or if they have a history of poor or uncertain adherence.” 
Regarding this statement, we add the following comments:
- Note that a patient can only express a preference if LAIs are offered by the clinician as a good alternative to oral antipsychotics. A major barrier to the use of LAIs is lack of inclusion of this option by clinicians when discussing various antipsychotic therapies.
- While not explicitly noted in the statement, LAIs are a possible choice for any stage of illness, including first-episode psychosis – if patients prefer it.
- LAIs are specifically suggested if non-adherence is a known concern (by history) or a clinical possibility. Consideration of the possibility of non-adherence is important to avoid mistakenly labeling a patient as treatment-resistant. A time-limited LAI trial can resolve this uncertainty around adherence. This is a critical point if clozapine is considered for treatment-resistance.
- The statement does not specifically outline clinical situations where LAI should be strongly considered. Clinical examples may include patients with forensic histories due to untreated psychosis and patients with co-morbidities or symptoms that increase the probability of non-adherence (e.g., active substance use or anosognosia, respectively).
- The APA adds that LAIs (like other pharmacological treatments) “should be implemented in the context of a person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments for schizophrenia.” This deserves emphasis: simply prescribing a LAI does not constitute good psychiatric care.
- The APA Guideline with regards to LAIs is consistent with a recent, extensively revised German Schizophrenia Guideline. The German Guideline emphasizes that LAIs are an evidence-based and effective choice for patients who require antipsychotic maintenance treatment in order to prevent a relapse. The German Guideline adds that choosing a LAI is guided by side effects and injection interval, not efficacy differences. 
 The APA Guideline is available for free here.
 Using the GRADE (Grading of Recommendations Assessment Development and Evaluation) approach, the confidence of the statement is rated as a 2B suggestion (suggestion = balance of benefits and harms less clear compared with a recommendation; B = moderate strength of supporting evidence).
 The German Guideline (in an English version) is available for free here.