Initiating LAI Therapy for the Treatment of Schizophrenia
JUNE 24, 2020
John M. Kane, MD: I take a different approach than asking what factors I consider in choosing a patient for LAIs [long-acting injectables]. I recommend everyone use an LAI. What are the contra-indications? It’s a treatment that’s appropriate for everybody. The first decision that the clinical team has to make is if medication is indicated. Are we confident in the diagnosis? How do we ensure that the patient is going to benefit from the medicine? We should be using a long-acting formulation whenever we can so we are confident the patient will benefit. Sometimes people are confused that it means I’m forcing the patient to take medicine, or I’m taking away the patient’s autonomy. Those arguments don’t make sense because we’re trying to help the patient achieve more autonomy by getting control over his or her illness. We’re not trying to control the patient; we’re trying to control the illness. I’d ask, why not use a long-acting formulation?
If a patient has a contraindication to the drug that I’m using then, yes, that might be an obstacle. There are some people who are frightened by injections. They’re in the minority. In my experience, people who are frightened by an injection after they’ve tried it once they say, “Oh that wasn’t so bad.” My strategy is to get the patient to try it once or twice to see how they feel. There aren’t any strong contraindications for the use of a long-acting formulation. Patients should be receiving it early in the course of the illness. Someone who has just been admitted for their first episode should receive a long-acting formulation when they leave the hospital even if they’ve only had 1 episode. As long as we’ve made a decision that medicine is indicated, then why not give it in a way that the patient is most likely to benefit? It’s ironic because there are many areas in medicine where they don’t have long-acting injectable formulations, and I know many of the clinicians treating patients wish they had long-acting formulations. Many of the patients wish they had long-acting formulations. We’re fortunate we do have them; we should take advantage of them.
We’ve been successful. A lot of it has to do with how you communicate this to the patient, and unfortunately a lot of clinicians are not great at communicating the potential benefits. They may be resistant themselves to the idea or uncomfortable. I’ve heard clinicians say, “I’m afraid I’m going to interfere with the therapeutic alliance if I suggest to my patient that he take a long-acting injection because I’m saying, I don’t trust him to take his medicine.” I don’t think that this interferes with the therapeutic alliance; LAIs can enhance it if we can spend more time talking about the patient’s problems rather than discussing their medicine. When someone is on oral medicine, you end up spending part of each session asking if they missed any of the medicine. That can be avoided if someone is taking a long-acting formulation.
Dawn Velligan, PhD: I talk to people about LAIs the first time they come to me. If they're in a recent episode, or if they’ve been seen in the community for many years, I find that there are people who aren't aware that LAIs are a choice. And why shouldn't they have that choice? I bring them up in the context of recovery roles. Instead of saying I have this injection, which is never going to work, I say, “It doesn't seem like you're doing as well as you'd like to be doing. You want to take better care of your animals? I have a medicine that might help with that. Are you interested in hearing more?” And they always say yes. I let them know, “You only have to take this medicine every month, or every 2 or 3 months. Are you interested in hearing more?” Now they're really interested in hearing more. And then I say, “You would come into the clinic and we would give you an injection.” Some people will say, “No, I don't like shots.” I don't like shots either. I don't know a lot of people who like shots. The issue is the amount of time it takes to get any injection, like a flu shot, the pain compared to the protection that lasts a very long time. The same with schizophrenia.
Consider the pain of a relapse. How much trouble is that going to cause? You have to weigh the pros and cons before you say no. I point out that studies show that on a scale of 0 to 100, the pain of an injection is below 10. “Do you think you could handle that?” Usually, they can. “Maybe you want to give it a try for a few months. Try it for 6 months. See what you think and we can talk about it again.” If they say no, I don't stop there. I bring it up again because I think it's a valuable tool to set the framework for somebody's recovery. If you tie any medication to what the person wants, it's easier for them to be accepting. I haven’t found difficulty trying to get people to accept long-acting injection.
I follow the protocol guidelines that are presented by the APA [American Psychological Association[ or other organizations for initiating long-acting injectables. I find there are some prescribers who use a lot of long-acting [medications] and some who use little. We've done a lot to try to get our prescribers in our organization to use long-acting injections. In the clinics I'm affiliated with, we use a checklist to identify people who aren't doing well. Maybe they've been in the [emergency department], a hospital, or they don't have good control of their symptoms. Or they tell you, “I missed a few doses here and there.” Chances are, they missed more than they remember. Have you tried multiple antipsychotics with them? Are they on more than 1 at once? Any of those things are red flags. It's a simple checklist with 5 questions.
If you answered yes to any of them, offer a long-acting injection. This reminds them of LAI and to make the patient an offer. We found using a checklist does improve or increase the use of long-acting injection. We also have used a patient facing video. It’s a video about decision-making. What's your role in shared decision-making as a patient? You need to tell the doctor certain things. You need to ask questions. And you need to make a choice. How do you make a choice between tablets and long-acting injection? The video discusses the pros and cons. When we show that video, many of the individuals will go in to their provider and ask about using long-acting medication. “Is this a good idea for me? Let's talk about it.” And they start the conversation. If you hit it at both of those angles, you're more likely to be able to increase long-acting injection use.
Transcript Edited for Clarity