Bryce Reynolds, MD

For more information, see the video series at 

https://www.psychiatrictimes.com/case-based-psych-perspectives/treating-schizophrenia-in-the-era-of-covid-19

There are many barriers to the successful treatment of schizophrenia, shared Bryce Reynolds, MD. In addition to patients’ lack of insight about their disease, schizophrenia is associated with cognitive deficits, social isolation, and cultural stigmas. Patients also face lack of motivation, transportation difficulties, and financial issues. These barriers are particularly relevant when addressing treatment adherence, especially with oral medications, and it can be difficult to truly assess adherence to oral medications.“We can’t absolutely guarantee that the person is consistently taking their PO [oral] medication,” stressed Reynolds. In his experience, there are generally 4 underlying reasons when symptoms worsen in a patient who previously achieved effective symptom management. He explained, “One is a decrease in adherence—the others are a medical comorbidity, a substance abuse comorbidity, or a major stressor that may cause an increase in their symptoms, even if they’re on their medication.”

The use of a long-acting injectable antipsychotic (LAI) medication can help overcome the clinical challenges associated with treating schizophrenia, especially adherence. There is an important pharmacokinetic benefit of LAIs, he explained. If a patient on a LAI does not receive an injection on schedule, there is “some additional time where [the LAIs are] still at a therapeutic serum level.” Compared with oral antipsychotic medications, LAI medications offer an extended time to relapse or decompensation. Reynolds emphasized that a longer time to relapse provides patients with benefits such as, “the ability to work and sustain housing and socialization and employment and going to school [for longer periods of time].” Since adherence is a known component for patients who use an LAI, Reynolds noted their contribution to an episode of decompensation is clearer.

Hannah Phillips-Hall, MSN, PMHNP-BC, who joined Reynolds in the discussion, added she is able to identify the possible cause more readily when a patient who is on an LAI decompensates.

Guideline-Recommended Schizophrenia Management with LAIs

Guidelines for the treatment of patients with schizophrenia from the American Psychiatric Association (APA) were updated in 2020 and emphasize a patient-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments. Reynold’s summarized the APA guidelines and recommendations updates for LAI treatment in 3 applications: if it is preferred by the patient; if the patient has a history of poor adherence to oral therapy; and/or the patient’s future adherence to oral medications is questionable or uncertain in the judgment of the provider.

Both Reynolds and Phillips-Hall noted that offering a LAI upfront would be advantageous for several populations in which adherence to oral therapy is uncertain, such as for those with a history of substance use disorder, and those who are homeless or lack transportation to a pharmacy. Reynolds explained, “There is a benefit that the APA has recognized [in] getting them on LAIs, even before you see adherence issues. In fact, in my practice, the first day that I see them is the day that I offer a LAI to them.”

Phillips-Hall added, “Having those [APA] guidelines further validates [the use of LAIs] for the purpose of reimbursement and approval.”

There is an opportunity to implement early treatment with LAIs, which the faculty noted may improve treatment success. For instance, a patient who is diagnosed in their late teens or early 20s may go through 4 cycles of PO medications before they are offered an LAI at age 38. “[In essence], we wait until [their disease] gets really bad before we bring out the tool that perhaps could have kept them from getting bad in the first place,” Reynolds said. Phillips-Hall agreed, noting that offering a LAI upfront is a better way to set up newly diagnosed patients for success versus waiting for them to experience treatment failure with several oral medications.

Patient-Focused Care and Shared Decision Making

Reynolds emphasized the importance of correcting patient misconceptions and empowering them with choices about their treatment using motivational interviewing. Through his own use of this interview technique, Reynolds has identified 4 common patient-reported barriers to LAI treatment selection: 1) feeling that they have no control over the medication schedule, as they would with a pill or tablet; 2) a negative experience with a first-generation oil-based product (eg, knots at site of administration); 3) association of injections with being restrained in the emergency department (ED) during acute episodes of agitation; and 4) fear of injection-associated pain. Understanding these concerns allows clinicians to better address them. Reynolds finds it helpful to “normalize” his patients’ feelings by expressing his understanding of their fears. He then discusses LAIs in the context of the patient’s personal life goals, and points out how their current oral regimen is not helping them achieve their personal goals.

“Some studies show that 60% of people will take LAIs if presented [to them] well. That’s an extremely high number,” Reynolds said. As part of this presentation, the faculty suggested offering a short-term trial of an LAI, as it may help patients feel a greater sense of control over their treatment. “When patients are involved in a collaborative way to make an informed decision, many of them [try the LAI],” Reynolds explained. Since LAIs are available in several administration schedule options, Phillips-Hall noted it empowers the patient to choose how frequently they receive their medicine. Reynolds added that only having to receive medication 4 times a year has been very appealing to some of his patients.

Sesame oil-based first-generation antipsychotic LAIs are associated with more injection site pain, which can be also be addressed. Reynolds and Phillips-Hall indicated that injection-associated pain and discomfort can often be minimized by using second-generation antipsychotic LAIs, or by using an LAI with a small injection volume or decreased administration frequency.

Opportunities to Address Adherence During the COVID-19 Pandemic

As a result of the coronavirus disease (COVID-19) pandemic, patients with schizophrenia have experienced a reduction in their access to care as well as medication access challenges. Therefore, they experienced difficulty maintaining medication adherence. Given reduced office hours in many health care settings, it may be difficult for patients who are decompensating to receive medication adjustments from their provider or pick up their prescription from the pharmacy. For patients on oral medications, Phillips-Hall tries to make sure she prescribes a 90-day supply if their insurance will accommodate such. However, she also noted that the increased availability of, and insurance coverage for, telehealth services as a result of COVID-19 has been a silver lining in patient care.

Although there are additional safety risks associated with in-office visits for administration of LAIs during COVID-19, the faculty noted that routine safety measures can help mitigate the risk of exposure. Improvements in adherence with LAIs may help prevent hospitalizations, which in turn may prevent inadvertent exposure to the COVID-19 virus. “With the COVID risk, you want to limit that risk of hospitalization and going to the ED [due to] the exposure they may have in the ED,” said Reynolds.

Phillips-Hall added that COVID-19 has helped patients and families be more open-minded toward use of LAIs.

Reynolds added, “during the pandemic, LAI administration has been suspended in some areas where it’s identified as an elective procedure. The APA is encouraging hospitals and facilities to continue the use of LAIs for patients at high risk and [to] consider it a necessary procedure.”

When offering advice to community psychiatrists treating patients with schizophrenia, Reynolds said, “All it takes is a little compassion and using the right tools, and I would say LAIs are absolutely one of those right tools.” ❒

Articles

This article provides a summary of key points discussed in a Case-Based Psych Perspectives Series, shared by Bryce Reynolds, MD, and Hannah Phillips-Hall, MSN, PMHNP-BC. 

Case-Based Psych Perspectives: Treating Schizophrenia in the Era of COVID-19 

Bryce Reynolds, MD, and Hannah Phillips-Hall, MSN, PMHNP-BC, share their advice for community psychiatrists treating schizophrenia during the coronavirus pandemic.

I have 1 last question for you, Hannah, before we close. Tell me your advice for community providers treating schizophrenia during COVID-19 [coronavirus disease 2019].

Don’t overly focus on COVID-19. I know that may not sound like good health advice. Obviously, be safe, be wise, wash your hands, wear PPE [personal protective equipment], and all those things. But I have done better in the care I’m providing to my patients by not overly focusing on it. Of course, acknowledging that it exists and normalizing the experience is necessary. But I’m not poking the subject matter if it’s not relevant to our conversation. I want things to seem as normal for my patients as possible. The less disruption, the better. That is my 1 thing with COVID-19. I’m not choosing to view this as my new normal. It is what it is for now, and we’ll deal with it later. Maybe that’s my way of coping.

I agree. It’s just 1 part of my conversation, and a small part in which I talk about safety and what steps they need to do to maintain safety. Otherwise, what we’re talking about is their functioning overall, including their housing, school, and socialization. I focus on the things that really matter to them. For the most part, COVID-19 is not the most major issue in their lives, and I’m not going to focus on it if they’re not focusing on it.

The other is—and this is an offshoot of what you’re saying—consider the tools you have available to keep yourself and the patients safe, and effectively treat them. You can use long-acting injectables to monitor adherence and to decrease that time to relapse, as the studies have already shown.

What I always say to my patients, and what I always think about in terms of what we need to do, is that it’s good to involve 2 things when we’re treating our patients. All it takes is a little compassion and using the right tools. The use of a long-acting injectable is absolutely 1 of those right tools.

Hannah, I appreciate this discussion that you and I have had. I want to say to the audience that both of us hope you have found this information to be valuable to your clinical practice. Thank you for watching this 

® case-based sight perspectives program.

Videos

Advice for Treating Schizophrenia During COVID-19

Bryce Reynolds, MD, and Hannah Phillips-Hall, MSN, PMHNP-BC, discuss the importance of motivating patients with schizophrenia to initiate a long-acting injectable and allowing them to make the final decision.

Getting patients onboard is important. When I say that we have 76% of our patients with schizophrenia on long-acting injectables, people always ask how. All we need is to use some motivational interviewing to make that happen. You counteract the reasons people say, “I don’t want to take an injection.” There are about 4 of those reasons. One of those is control issue. They can’t take the injection out of their body like they can do with a pill.

Another is exactly what you mentioned before. There may be an occasion in which they were given an oil-based substance and 1 of the first-generation agents created knots in their arms or in the gluteal region. That’s uncomfortable, and if we’re using a second-generation medication, we need to normalize their concern and explain that that was their old medication, but that’s not what we’re using now.

It’s the same thing in regard to—I use the term 

. They were held down in the emergency department in an acute agitated state and given an acute injection. They think that’s a long-acting injectable. I have to say to my patients, “If I were held down in an emergency department against my will and given a shot, I can understand not wanting to take an injection. But that’s not what this is.” There are also ways to counteract the pain they feel. There’s no doubt about it. There’s usually pain associated when given the injection, but there are mechanisms and things that can be done to counteract that.

I also point out that we can give the control back to our patients. We talk to them about the emotions that are associated with their delusions. It’s scary and it’s frightening. I normalize that. I would feel the same way too if I felt that I had a delusion that someone wanted to hurt me.

I talk about their goals, which are different from my goals. I don’t talk about an injection by saying it’s going to keep them out of the hospital, because most of my patients don’t believe they’re going back into the hospital. Instead, I talk about their goals, about the fact that whatever treatment they’re getting hasn’t helped them reach the point of getting the housing they want, going to school, going to work, or socializing.

When a patient goes, “I just stick with the pills,” I go, “How does that work for you in terms of—” and then have them fill in the blank. The last strategy is offering them a short-term use of the medication. Give it to them for 1 month. Let them come back after a month. If they’re not feeling better in terms of their anger, frustration, fear, or whatever their symptoms are, and they want to stop the medication, I’ll stop the medication. But I find that when you give that control back to them over their emotions and their goals, whether or not they take the medication, our patients often make a good, informed choice. That’s how we’ve gotten 76% of our patients to agree to a long-acting injectable at this point.

Give them back some control over this situation. It’s hard enough to deal with the stigma, the lack of insight, and everything else that goes along with schizophrenia. Give them back that feeling of control.

What do you see in your practice being helpful?

I have so many things to say about that entire beautiful monologue you just provided. Many wonderful points were brought out. Let me go back to No. 1, giving them back that idea of control. It’s this idea, as you said, of letting them know that this doesn’t have to be their choice forever. They can go back on that decision. They can make a U-turn and go back the other way. It’s not a big deal. I love that. Even though it may be obvious for us, the prescribers, it may not feel obvious to the patient. To hear from their clinician that this is an option that they can have must be very reassuring. You hope to reduce some of that fear and anxiety about what that could look like for them.

As far as reducing the pain when it comes to the injection, it’s really important that we normalize the fear of what pain could look like for them. But on top of that that, just distract them. That’s my fear strategy to use when giving an injection. “What are your plans this weekend?” This is where the open-ended conversations are perfect. Just keep them distracted for that circumstance.

I also know they have done some studies legalizing a topical lidocaine-type ointment to use. I don’t want to use the brand lidocaine, but some type of topical anesthetic will hopefully reduce some of the pain. I know some studies have been published regarding this, and it can help for some of your more sensitive patients.

Yes. In our clinic, we use a refrigerant spray that makes the nerve fibers cold. It disrupts the nerve fibers. Two of 3 of our patients don’t feel the needle going in, by our assessment. Twenty-five percent say there’s a reduction in pain. Ten percent say it’s the same amount of pain, but some of those are standing 10 feet away when they say that to me. One of my patients said, “I know I need this medication.” She actually might, but she said, “I just don’t like the pain associated with that,” and then we did this.

I want to point out something about control. Half the people to whom we offer this way of reducing pain said yes. But half of those have said they no longer need it. I say, “I don’t understand. It reduces the pain.” They say, “Yes, but I can deal with it.” That’s because we’re giving the control back to them. It’s a feeling that now, they make the decision as to whether they’re going to have pain.

As a result, they agree to this. When patients see that they’re doing better—they don’t have to have insight into their illness. But when they are able to be involved in a collaborative way to make an informed decision, as I said, many of them do that. Because of that, I don’t use any forced treatment. I don’t threaten them with hospitalization. I don’t say, “You need to do this.” That doesn’t get me anywhere. Collaborating with them, going over the 4 reasons people don’t take injections, and going over the few steps to motivate them really does make a difference.

Motivating Patients With Schizophrenia to Initiate an LAI

Experts in the treatment of schizophrenia review the different frequencies of long-acting injectable medications and factors that affect the choice of agent.

When you think of classes of long-acting injectables, give me your thoughts about the first vs second generation. Then we’ll talk about the frequency at which we’d give the injection.

I’ve been a nurse for about a decade and a prescriber for 6 years. My internal framework and what I’ve seen of the utilization of some of the first-generation agents was as a floor nurse. They were used as 1 of the last mechanisms to keep the patient from getting rehospitalized. They were reserved for patients who were there for their third or fourth time in the past 2 months. It felt like a last-ditch effort, and it was not something you felt delighted to give the patient.

I had 1 patient describe to me that the first-generation agent “took away his whimsy.” I loved the verbiage of the word 

, but it always felt a little punitive. This is not to say that 1 class is better than another, but this was my own personal perception due to the era in which I was a floor nurse. We did not have as many easily accessible choices of second-generation agents.

It’s been neat, especially because we know many of our patients are on oral forms of the second-generation medications, rather than first-generation oral medications. It’s an easier transition than into some other, newer long-acting injectables.

I agree with you. I tend to always look at second-generation medications. I do have some patients on first-generation agents, but there are few. When I get a new patient who’s already on a first-generation medication, I try to switch them to a second generation. They’ve added a few different receptor bindings that may or may not—it’s all in theory, of course—have an impact on the client’s overall functioning. But my goal is to reduce the positive symptoms, the negative cognitive impacts, and new deficits that we may see.

I’m also aware that there are a lot of dosing options out there. You can give them every 2 weeks, 4 weeks, 6 weeks, 8 weeks, or 12 weeks. I think about the fact that we’re offering a medication just 4 times a year. That may be much more agreeable to the patient vs having to take a medication 365 days a year. I’ve actually had some patients who have said to me, “I won’t take a monthly injection, but I’ll take 1 that’s every 3 months.” In some cases, I might have to give them monthly for the first few doses, but they’ve agreed to do that. If I can offer somebody something, 6 or 4 times a year, they may partake of that more easily than doing it back in the days when we had to give medications every 2 weeks in some cases.

That’s a great point that you bring up, with posing frequency as the way to determine a treatment modality as well. That’s a great way to give the power back to the patient and allow them to choose the frequency at which they receive their medicine. It’s a great example.

What other factors do you use, in terms of choosing a long-acting injectable?

Prior history of tolerability is used, because we know we always have to do that oral tolerability testing of any agents we’re going to be utilizing. I prefer some of the newer agents because, in the case that my injection nurse is out for the day, I am able to give them a bit more readily because of what they are providing for me in the box. In our little office, I don’t have any filtered needles, which I would technically utilize if I was handed a glass ampule of a Haldol decanoate. For me, it’s also the factor of convenience. What is going to be asked of me as a prescriber, as well as someone who administers these medications? I want it all in 1 package.

I agree with you on that. I want convenience for me. Here I’m recommending an increased prescribing of long-acting injectables, but often we don’t necessarily get an increase in staff availability to give injections.

Spreading them out is the other thing I look for, as well as safety, tolerability, and contraindications. It is client choice. Their history very much comes into play. All those factors come into play, in terms of choosing a long-acting injectable.

At the same time, I want to recognize that there are some barriers in terms of long-acting injectable use in COVID-19 [coronavirus disease 2019] for staff. I’ve heard people say, “Well, I can’t send staff out into the community or have them give that.” One of the ways we’ve been able to counteract that is by saying, “Let’s talk about the safety factors. Let’s talk about PPE [personal protective equipment]. Let’s make sure the patient is not facing the staff directly.” We require our patients to wear a mask when they get an injection. That’s a protection we find to be necessary and important, not only for the patient but also for a staff member.

Absolutely. That would be critical to ensuring that the patients are able to continue to receive their services, as you said. That’s phenomenal to make the staff feel more comfortable in doing so.

Frequency of Long-Acting Injectable Agents for Schizophrenia

Bryce Reynolds, MD, reviews the highlights of the proposed APA guidelines for the treatment of schizophrenia with long-acting injectables.

 One of the things I also find enjoyable is that there are various guidelines that have been coming out. The APA [American Psychological Association] has recently come out with guidelines for the treatment of schizophrenia with the use of long-acting injectables. Let me read a bit about what they say.

They suggest that patients with schizophrenia receive treatment with long-acting injectable antipsychotics for 3 reasons. They state that it’s preferred if the patient has a history poor adherence. But the 1 that’s striking to me is if we think there’s going to be a lack of adherence in the future and if there’s uncertainty as to whether or not they’re going to adhere to it. I find that situation with patients who experience substance abuse issues, homelessness, transportation issues, or difficulty accessing the pharmacy. It could even perhaps be a patient who is a college student and just doesn’t want their college roommates to find out that they’re on medications to treat psychiatric illnesses because of the stigma associated with it. For those patients in which there may be a lack of adherence, or decreased adherence, there’s a benefit that the APA has recognized in getting them on long-acting injectables, even before you see adherence. We don’t have to wait until there’s a lack of adherence before we offer our patients a long-acting injectable.

In my practice, the first day I see patients is the day I offer it to them. I want to point something out. One of the things I hear sometimes from folks is, “Well, you’re putting people erroneously on long-acting injectables when they take po [oral] meds.”

My point is that the person always says no the first time. Sometimes they say no even after the second decompensation. But by the third decompensation or so, I can get 60% of patients on long-acting injectables. In fact, some studies do show that 60% of people will take long-acting injectables if presented well. That’s an extremely high number and is approximately 5 to 6 times the national average.

That’s just part of the APA Guidelines. But what are your thoughts about the fact that they mentioned not only people with poor adherence but also those who you predict will not adhere to the medications. Tell me your thoughts on that.

No. 1, I’d love to have a crystal ball to be able to predict the future. But given what we know about the disease state itself and that element of limited insight, especially early in diagnosis—correct me if I’m wrong on this number, but doesn’t the greatest level of decline occur within the first 5 to 7 years of illness? With that idea in mind, and also keeping in mind the limited insight, this is a brand-new thing to accept in the world. You’re setting up some of our newly diagnosed patients for failure by waiting for them to try and fail many times. In Florida, our No. 1 provider of mental health services is the Department of Corrections. It’s a truly heartbreaking thing for you to bear witness to a young person dealing with a felony or some type of illegal issue on their record, secondary to untreated symptomology. Could that have all been prevented with adherence via a long-acting injectable?

You’re absolutely right. We typically find that we need to have that greater assurance that the patient is going to get their medications into themselves. The APA recognizes that. Ask yourself the following questions: When do you know that a patient has stopped their po [oral] medication? I find it’s when they show up in the ED [emergency department] or hospital. But when do I know that they stop their long-acting injectables? I know the day they don’t get their long-acting injectables. Every long-acting injectable has some additional time where it’s still at a therapeutic serum level. As a result, we can intervene during those times. You’re right that early on is when patients have the least amount of insight, and thus, they’re most at risk.

Unfortunately, the data show that a person goes through 4 cycles of po [oral] medications before they’re placed on a long-acting injectable. That’s at age 38, whereas we make the diagnosis in their late teens or early 20s in many of those cases. It’s as if we wait until it gets really bad before we bring out the tool that perhaps could have kept them from getting bad in the first place. That’s the way I look at it.

The APA also recognizes a potentially decreased risk of mortality, hospitalization, treatment discontinuation. In addition, there are potential subjective sense and better symptom control, greater convenience, and reduced conflicts with the family. As I mentioned earlier, you don’t have to have the family member going, “Did you take your medications today?” They even suggest doing what you mentioned earlier, which is moving away from a first-generation antipsychotic because that patient may have had experience with an oil-based substance that created knots in their arms or in their gluteal region. Instead, that discomfort can be minimized with a second-generation antipsychotic. That’s what the APA is recommending overall.

During this pandemic, what advantages have you additionally found when using a long-acting injection? What do you find?

I find reassurance for the family members that their loved one will not end up being rehospitalized. We know that during the pandemic, that results in secondary potential exposure. It’s an unfortunate thing that many of our mental health patients who have schizophrenia end up living homeless, transient lifestyles. We know that during COVID-19 [coronavirus disease 2019], that is the most vulnerable patient or population because of their close living conditions.

It’s 1 way to hopefully reduce risk of illness, not just for the patient but also for their loved ones.

I agree. Unfortunately, during the pandemic, that long-acting injectable administration that has been recognized by the APA gets suspended in some areas where it’s identified as an elective procedure. The APA is encouraging hospitals and facilities to continue the use of long-acting injectables for patients at high risk and consider it a necessary procedure. They actually use the word 

. I have to commend them for doing so. It’s interesting that the APA is doing what you and I recognized many years ago. The use of long-acting injectables can definitely make a difference in terms of how our patients function overall and decrease time to relapse.

Having those guidelines further validated this for the purpose of reimbursement, approval, and extended bed days if that’s necessary. It depends on your setting. It’s nice to have that.

It also takes away from me feeling, when I’m talking with a family member, that this is just my personal decision. Instead, it’s the American Psychiatric Association that looks at it this way.

APA Guidelines for the Treatment of Schizophrenia With LAIs

Bryce Reynolds, MD, and Hannah Phillips-Hall, MSN, PMHNP-BC, discuss the challenges faced when treating patients with schizophrenia and challenges that have presented during the coronavirus pandemic.

Let’s move away from the cases that we’re talking about. Let’s look at some of the challenges and unmet needs in dealing with patients who have schizophrenia. You know some of the challenges that we’ve already mentioned. There’s the stigma associated with it. There are also cognitive deficits, decrease in insight, decrease in motivation, and social isolation. We also have support systems that may not always see this as a positive thing because of their lack of understanding about it or cultural beliefs, access to services and medications, the office-based visits, transportation difficulties, and financial issues. But 1 of the main issues I constantly see is being able to monitor adherence with a po [oral] medication. We can’t absolutely guarantee that the person is consistently taking their medication. Have you found similar things in your practice? What are your thoughts about treating people with schizophrenia, in terms of the challenges you find?

I want to piggyback off this idea of difficulty in truly assessing oral adherence. You’re right. We know if they pick up the medication from the pharmacy. However, they can be going home and using it as fish food or plant fertilizer. We don’t actually know what is happening to those oral medications. A roommate could steal them. Any number of things can occur. That’s a very difficult element in and of itself.

Also, if we do have that family member there, then unfortunately, we’re placing a bit of—I don’t like to use the terms 

 because they love the person they’re caring for. But we can destroy that early relationship dynamic by asking the family member to be their makeshift nurse and trying to monitor if their son, daughter, or even spouse takes the medications. It’s a very difficult thing to incorporate into a relationship.

Yes. On the other hand, my patients sometimes find it difficult to hear from their parents every single day: “Have you taken your medication? Have you taken your medication?” It makes them feel as if they’re not treated like an adult. This is 1 way you can avoid being asked that question. You can explain to the family that you have a consistent amount of medication. It’s a good point on that 1.

How about the challenges with oral medications during COVID-19 [coronavirus disease 2019]? Do you find differences with that, as opposed to pre-COVID?

I’ve been trying to respond to that with my patients who are on oral medications by making sure I’m able to prescribe a 90-day supply if their insurance will accommodate it. However, the concern is if the patient isn’t doing well and is potentially decompensating. Our office hours have been dramatically reduced. The overall question is access to care to receive medication adjustments, not to mention being able to go to the pharmacy to pick up their prescription, etc.

I’m aware of the adherence issues with po [oral] medications at any time, and COVID-19 certainly has not made it any better. It may have made it worse. But 25% of patients discontinue their medications 7 to 10 days after hospitalization; 35% in 6 weeks; 50% in 6 months. A study that looked at the CATIE study, which examined people 18 months after they started their medications, found that 74% of them were not taking their medications. At that point, 3 of 4 people are not taking their po [oral] medication.

During COVID-19, it’s even harder because they have difficulty accessing the medications. It’s difficult to monitor that. We’re a service. I work on an ACT [assertive community treatment] team, so I’m in the communities. But because of COVID-19, I’m no longer able to go into their homes. I have to see them outside. Monitoring their po [oral] medications, even with pillboxes or bubble packs, is difficult to do when you’re outside their homes. They’re not necessarily wanting to bring medication from inside their home outside. Those things happen.

I also want to point something out about relapse data. One of the studies compared po [oral] medications with injections. On injections, the time to relapse was almost doubled. The time to get into a hospital, go to jail, or decompensate was almost double. What does that give the patient? Is it the ability to work, sustain housing and socialization, and work or go to school? It helps us as providers and it helps our teams be able to work more closely with a patient on maintaining those things. They want to function, but that may be difficult because of their overall illness.

With the COVID-19 risk, you also want to limit that risk of hospitalization and going to the ED [emergency department]. I think about the exposure that they may have in the ED. The cost is so significant. EDs in hospitals have limited resources these days. There are a lot of other patients who require medical care there. If we can keep someone from relapsing back to the hospital, that’s really helpful.

One of the ways we can help monitor the injection part of it and the benefits the patient has is using telehealth. We can certainly utilize that as a means to monitor progress. But typically, telehealth doesn’t tell whether the person is adequately or consistently taking their po [oral] medication. Do you do telehealth in your practice?

I didn’t until COVID-19 forced me into this modern age, and I’m loving it. I love that insurance companies are reimbursing for telehealth, which they previously weren’t. That is 1 of the silver linings of COVID-19 that I’m grateful for. I look forward to being able to continue to render telemed services in the future with my patients.

That sounds really good. I’m curious as to how your prescribing has changed in the past 6 months during COVID-19.

You and I had an opportunity to talk a bit before, and I’m going to echo your feeling. My practice of the prescribing hasn’t changed much because, even pre–COVID-19, I was still gung ho on the utilization of long-acting injectables. With COVID-19, it has maybe facilitated a more expedited yes from patients or families. But the only change is the reception or the response to it, especially when we take into consideration how our patients with schizophrenia can decompensate because of increases in stress. That is what COVID-19 is at its core. It is an increase in overall stress societally. I can imagine how that could possibly exacerbate patients’ psychotic symptoms.

Especially if they’re not taking their po [oral] meds consistently. Thus, there is a need to have long-acting injectables onboard, and there are potential benefits of doing that.

Challenges and Unmet Needs When Treating Schizophrenia 

Experts in the treatment of schizophrenia discuss the benefits of long-acting injectables, including adherence and lower rate of relapse.

The team that I work with supports the idea of long-acting injectables, but we’ve also seen, as I mentioned earlier, the limitations we have in monitoring adherence during the time of COVID-19 [coronavirus disease 2019].

I subscribe to a 30/60/90 rule. The national average of people taking long-acting injectables hasn’t changed much in the past 30 years. It’s still about 10% to 12% of patients with schizophrenia who are on long-acting injectables. I would love to see 30% of patients on an injectable in a community mental health center or private practice, 60% of ACT [assertive community treatment] team patients, and 90% of those on an inpatient unit.

I did a chart review 3 days ago to determine the number of people who we have on my team on long-acting injectables. We have 76% of our patients on long-acting injectables. We have no forced medications in North Carolina. Thank you on that. We have no forced meds in North Carolina and no forced treatment that we use. We use motivational interviewing to get them onboard. It sounds like, from what you just said, your prescribing habits haven’t changed a lot because you use a lot of long-acting injectables. Would you agree with that?

Absolutely. Long-acting injectables make my job easier. I have that element of known adherence in my patient. I am then able to perhaps skirt past those first 5 to 7 minutes of doing a tango about full adherence vs partial adherence. There is that factor of known adherence. If there is possibly a decompensation, it can help me to identify where it comes from. Is this because of stress? Is this because of a worsening of disease state? Is this because of drugs? It helps to tease out what’s going on if the patient does, in fact, decompensate.

Hannah, I like the way you think on that. To me, when someone is doing well and then all of a sudden not doing well, with schizophrenia, there are usually only about 4 reasons for that. One is a decrease in adherence, or an elimination of their taking of a medication. You can monitor that with a long-acting injectable. The others are medical comorbidity, a substance abuse comorbidity, or a major stressor that may cause an increase in their symptoms, even if they’re on their medication. But you’re right. That absolutely takes it out of the equation. I don’t have to spend my time with them saying, “Are you taking your medication?” and doing that little dance to determine whether they’re taking their medication. It really does make my job easier.

I also find that when my patients are doing better, as a whole, I can talk to them about fun things. I can discuss getting them back to work, going to school, or their housing. I can say, “What’s it like to move to your new place?” That is a lot more enjoyable. It is a bit more work up front, but the decompensation or relapse is almost half of what it was. It results in my patients doing better. My conversations in the long run are more enjoyable. That’s what I’ve found, and it sounds like you do the same.

Your description of all the work up front and benefit in the back is perfect. It’s a joy to get to work with the humans and choose to know them for who they are vs their symptom.

The Benefits of Long-Acting Injectables for Schizophrenia

Bryce Reynolds, MD, reviews how long-acting injectable medications for schizophrenia could enhance outcomes in a patient who has been unsuccessful on oral therapy for many years.

Let me go over another scenario. This is No. 2, in which we have a patient who’s recently been switched to a long-acting injectable from a po [oral] medication. This is not a newly diagnosed patient but a 37-year-old woman. She was diagnosed with schizophrenia 10 years ago, and she’s on oral therapy, but she’s been on and off the oral therapy in that time. She forgets to take her medications but has been resistant to a long-acting injectable in the past. Give me some ideas as to what you would do with this patient in regard to a long-acting injectable, Hannah.

 It’s important to identify what you said, which is that she’s been ill for about a decade, correct?

This is a patient who may have had some prior negative experience in the past. Maybe she’s been hospitalized and potentially received an emergency treatment order [ETO]. Maybe her association with the long-acting injectable therapy is with that ETO. That’s where it’s our job to be proactive and dispel some of those misconceptions for the patient.

Additionally, given that time period, we cannot just say 1 class of long-acting injectables is better than another. We have a multitude of treatment options available because all our patients are unique. But perhaps she had a negative experience with 1 of the sesame oil–based products that may have resulted in some pain. Perhaps it had been offered to her only within the framework of someone saying, “You’re not on your oral meds.” People can take that as a failure. They may feel, “I failed. I’m not good. Therefore, I’m now on this shot.” They view it in that framework, rather than seeing the empowering aspect of a long-acting injectable therapy.

I agree with you on that. This illness precludes people from taking po [oral] medication. When you have decreased insight, cognition, and motivation, it’s inherent in the illness. We as treatment providers need to provide tools to counteract these very symptoms that the illness causes. Those include cognitive difficulties, motivation, and that lack of insight. That’s where long-acting injectable comes into play.

Again, this is another situation in which we’re talking about starting a person on a long-acting injectable during COVID-19 [coronavirus disease 2019]. You bring up a point that her past experience may come into play. But in any case, she’s not fully adherent with po [oral] medications. This is 1 way to ensure that she’s getting a consistent amount of medication into her system.

Transitioning to Long-Acting Injectables in Schizophrenia

Bryce Reynolds, MD, and Hannah Phillips-Hall, MSN, PMHNP-BC, share their thoughts on the case of a 20-year-old man with newly diagnosed schizophrenia being initiated on a long-acting injectable.

® case-based psych perspectives program titled “Treating Schizophrenia in our Current Environment.”

I am Dr Bryce Reynolds, a psychiatrist working for Carolina Outreach in Durham, North Carolina. Our discussion today is going to focus on challenges in treating schizophrenia during COVID-19.

Joining me in the discussion is Hannah Phillips-Hall, psychiatric nurse practitioner at Big Bear Behavioral Health in Maitland, Florida. Welcome, Hannah.

Let’s begin and review a couple of case scenarios.

Scenario No. 1 involves a client who has a new diagnosis of schizophrenia with a long-acting injectable [LAI] prescribed.

It involves a 20-year-old man who is otherwise healthy. He is brought to the ED [emergency department] by roommates for paranoid ideation with auditory hallucinations. Symptoms have been present for almost a year. The patient was diagnosed with schizophrenia and prescribed an LAI.

My initial impression when I think about this patient is that I have to commend the providers for starting a long-acting injectable instead of the usual po [oral] medication. The majority of newly diagnosed patients with schizophrenia—at least 60% of them—do not have insight into their illness. Expecting them to take PO medications consistently is difficult, especially with stigma, denial, and concerns that others may find out. Hannah, what are your thoughts about this case?

I agree with that exact sentiment you just described, especially given that it was his roommates who brought him into the emergency department. Clearly this is a young man who is living independently and cohabitating with peers, so he may not want them to find out what he’s being treated for. That’s a phenomenal observation.

Thanks. One of the things that is important, especially with someone who’s newly diagnosed, is try to involve the family. As long as we have the patient’s permission, it would be helpful to involve them. They can provide support and understanding and reduce stigma. It’s also important to explain to the family that this is not a punitive measure. Sometimes, I hear from a family member, “You must think my son or daughter is really bad or sick to use a long-acting injectable.”

My response is, “No. I’m using the long-acting injectable to keep your daughter or son from getting really sick or doing badly.” How about your perspective on that?

That stance from parents also speaks to the concept of denial. They’re in denial as well. It’s a very difficult thing to accept that your child now has a chronic, lifelong condition that they’re going to have to address.

There is denial. I have a little joke: Denial ain’t just a river in Egypt. Thank you for politely laughing. We unfortunately see that, not just with patients themselves because of that lack of insight you described but also with family members.

It’s interesting how sometimes, a child is a reflection of the parent themselves. When there’s that parental ego, to acknowledge an illness in a child is viewed as a shortcoming in themselves. It’s a true multimodal moment for the family to come together.

That’s a really good point. On top of that, I know there are difficulties in starting this patient on a long-acting injectable during COVID-19 [coronavirus disease 2019]. I’d like to hear your thoughts, in terms of what difficulties you have in that process. Would you start this patient on a long-acting injectable during the time of COVID-19?

That would be the ideal time to start this type of patient on an injectable. No. 1, it’s a good selling point to the patient and the family members when they’re considering an injection. I say, “Look, this might reduce the risk ofrehospitalization for your son or daughter. Wouldn’t it be nice to stay out of this type of environment in the midst of a pandemic?”

It also depends on what state you’re in. In Florida, we recently passed legislation to allow pharmacists to administer injections. That has been a fantastic response to some of those disparities and gaps in care, secondary to COVID-19.

Even if it were not the most convenient to do the injection wherever this young man is being treated, there are other environments and locations where that might be provided to him.

You bring up a really good point about pharmacists doing injections. Sometimes, with COVID-19 occurring, office-based practices have decreased. Sometimes, to limit that patient’s exposure to an office-based practice, it makes sense to go somewhere else to get the injection if that’s possible.

I’m also concerned about natural supports not always being there because of social isolation. Overall, access to outpatient services is somewhat more limited during COVID-19. The more that we can make sure the patient is getting a consistent amount of medication into them by using injections, the better. I agree with you on that one.