Kimberly Garcia, DNP, PMHNP-BC, FNP-BC, GNP-BC, NP-C, CNE, CNEcl, CARN-AP

Maybe we can conclude by talking about advice for clinicians on how they approach this with patients, how they approach this with caregivers, how can we better help our patients understand the disease and understand adherence to therapy—advice to clinicians in general on this whole idea.

My advice to clinicians would be to get to know your patients, their family members, their support system, their living environment. That sounds hypothetical and whatnot, but over time that’s exactly what I’ve been able to do. My medication management appointments are 15 minutes, so I have to use my time wisely. But we have the responsibility to provide our patients with all their options. Let them know what the benefits are—perhaps this could delay the time to relapse. Let them understand what can happen to an individual who has chronic schizophrenia that’s not optimally managed and how that relies on a nice therapeutic relationship with both of us. It’s going to take a village to get the individual back where they’d like to be, to give them the best opportunity. The other thing I would definitely say is—and I really believe this—that if we want to change someone’s life in psychiatry, start a long-acting injectable [LAI] early in the course of illness for a person who’s been diagnosed with schizophrenia.

Yeah, I agree. I’ll just add that I’ve had a fair number of clinicians say to me, “I don’t think my patients will accept this treatment,” or they’re scared of injections, or whatever else it is that we’ve been taught to believe. It’s interesting because we do have literature on this. We clinicians often think patients won’t accept LAIs. If we present it to them in a fair way, highlighting not just the risks but also the benefits, more of them will take LAIs than we think. In addition to what you said, that’s been my advice to clinicians: “I know you don’t think they’ll accept it but why don’t you just give it a try. Ask them, and you may be surprised.” I’ve had a number of them come back who were surprised. They say, “I didn’t think this guy was going to take it, but I asked him and he actually did agree to take it.”

Yes. I’ll have patients or their therapist tell me, “Good luck. This person will never take the injection—never.” The next thing you know, they’re like, “I can’t believe it. It’s already scheduled. They’re coming in tomorrow.” They’re amazed. But it’s all about the presentation. If we present it as an opportunity, not the last resort, not a punishment. I’m cautious with the terminology I use. I’ll make sure to not say things like your shot. I will say your injection. I’m also very cautious with providing them with a realistic picture of what that looks like.

You mentioned earlier that some of the injectables require 2 doses to get those concentrations up a little higher. It’s interesting. If you tell a patient you’re going to get 1 injection every 28 days, and then you’re giving them an appointment for 2 injections in 2 weeks, they look at you like, “Wait a minute, what are you talking about? This isn’t consistent with what we discussed.”That can have a huge impact on therapeutic rapport with our patients, and they’ll lose that confidence in us. I’m very realistic with them, and try to give a very clear picture of what they can expect from my experiences with working with patients.

Just from this last hour, I can tell that you and I could probably talk about this for the next 2 hours and not run out of things to talk about with regard to LAIs and the treatment of our patients. But sadly we’re out of time, so I’m going to have to close. I want to say it’s been a pleasure having this conversation with you.

Thank you. I’ve enjoyed it. Thank you so much for this opportunity.

Absolutely. Thank you all for watching this 

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Sanjai Rao, MD, DFAPA, and Kimberly Garcia, DNP, CRNP provide some advice to clinicians on explaining schizophrenia to patients and caregivers to achieve understanding and therapy adherence.

Advice for Clinicians Treating Schizophrenia

You guys are an LAI [long-acting injectable]–heavy practice, and it sounds as if your state is very forward thinking in the way this stuff gets approached.

[It’s like that] where I work too. In the VA [Veterans Affairs] system, our barriers to getting LAIs are very minimal, and we’re encouraged to have as many people on LAIs as we possibly can. As you’ve looked around not just at your practice but elsewhere, what have you seen as some of the barriers to LAI adoption? And how do you get around those? How do we help people work with that?

 I think back to my years when I was working in inpatient and how we would have a patient who was rehospitalized several times and their symptoms very poorly managed. We’d get them established on a long-acting injectable and send them back out to the community only to have their local provider say, “I don’t give long-acting injectables, so I’m going to substitute and put you back on the same oral medication that was not working before.” One of the big frustrating points is inequitable access.

But what’s really interesting is that, especially in my area, some pharmacies have become extremely innovative. They’re willing to send an Uber to get a patient to come in for a long-acting injectable. They’ll go to the house to give the injection, looking at what’s available in the community, as well as what’s available in our own practice. Some of the barriers that I hear from other providers in psychiatry are, “We don’t have a Sharps box. We don’t have anyone comfortable giving the injection. I’m not comfortable even touching the patients.” If it’s an injection that needs to be given in the gluteal muscle, they don’t want to see that element of body. Good education or even a reminder. That’s OK—not every practice would need to accommodate but to be open to other options. Sometimes providers don’t want to prescribe something that they themselves would not administer, and I appreciate that, but I still think it’s a sometimes disservice to the patient.

Yeah. That highlights so many important things, and much of you talked about I categorize as system resistance.

There are inherent points of friction in our system of care that sometimes makes it difficult for patients to continue on LAIs even when they get started. Earlier on, we talked about patient resistance, how we might get around that, and the education we do. The 1 other thing I thought would be useful to highlight is clinician resistance, which you talked about and which I also think of as a by-product of how many of us were originally trained—this idea that LAIs are for the sickest people, and you don’t get there until later. The remnants of that training are still with us in a lot of ways.

Especially in the people who are making the decisions.

They’re all trained at a time when this was the case.

Dr. Sanjai Rao and nurse practitioner Kimberly Garcia explain the barriers patients face in getting treatment with long-acting injectables and how COVID-19 has affected patient care.

Patient Barriers to Long Acting Injectables for Schizophrenia Treatment

You made many key observations. One of the biggest was just because you’re injecting them every 3 months doesn’t mean you have to see them only every 3 months.

In fact, you guys turned it into an opportunity to look at it in a different light. Because we don’t have to spend 5 or 10 minutes working out the mechanics of giving you an injection on these intervening visits, we can use that time to talk about other things.

Talk about other things, exactly. Find out what’s important to them.

Yes. It’s amazing how many of my patients who are on injectables. They’re able to get Social Security benefits, but they’re able to work part time too. It’s beautiful to experience that with them. They realize that it’s going to be very stressful, and for some of them it’s too stressful; they’re not able to do it. But it’s just nice to see our patients in a good spot. We’re able to think about more things than, “Did you take your medicine?”

I imagine, even just from the perspective of the clinic and your staff, that this is much less burdensome. Having to inject somebody one-third as many times as you were before.

 Circling back to your idea of letting us take care of it for you, when we can do this every 6 months then that’s the ultimate let us take care of this for you, right?

Absolutely, yes. Recently I had a patient come in with her mom, and the patient is in her mid-20s. The mother said she has never been well since she had her first psychotic episode. The mother said, “I’m at wit’s end with her. She’s become very paranoid at home. She’s done damage to the property.” The mom and the patient are arguing. We talked about some options, and the mom said, “You know what, we need that 6-month injection.” I’m like, “We’re going to need to take a couple of steps to be able to get there, but let’s have that goal and start working on that now.” So day 1 we’re starting to think about what that’s going to look like and when that can happen. And the patient was invested: “Every 6 months?” It made a big difference.

When I’m talking to people about the monthly, I’ll often say, “Look, if you’re doing well on this, we can extend this to every 3 months.”

It’s a good thing for them to think that this will lead to something better.

I’m glad you mentioned that transition though because it’s important to talk about how you get these things started and the idea that for any of these injections, there’s typically some initiation regimen. For the older ones, it meant you had to oral overlap for a few weeks. For the newer ones, it means you have to give them 2 injections, either in rapid succession or over a few days. But there are a couple—specifically I’m thinking of the monthly subcutaneous risperidone—that don’t require that overlap but also are limited to a max dose of the equivalent of 4 mg. With every agent there’s going to be a little trade-off, but you do have to have this initiation regimen. For the longer-acting formulations, specifically 3 and 6 months, you can’t start with those. You have to start with the monthly and build up a steady state over at least 4 months. Then you have the option to convert them to 3 or 6 months when we have that available.

That’s an important thing to keep in mind. With the long formulations, there’s a process to get there, but it’s a very reasonable process. And getting there involves just being on the monthly for a while.

Yes, and having those goals. I found that the majority of my patients are willing to put in the time and energy to get to that point. When we empower them to become active participants in their care, it’s a game changer because it’s no longer a punishment where the mom is like, “Take your medication.” It doesn’t seem as if it becomes as much of an issue. Patients are willing to come in to get their injections. Sometimes they even look forward to it. We’ll try to incentivize it whenever we can—we’d do a raffle or something for patients who would come in for their appointments, but we haven’t needed to do that. The patients have been internally motivated to comply with the routine and the regimen.

Experts discuss the advantages of using the longest-acting injection formulation to treat schizophrenia, and whether there’s a need to discuss LAIs with patients from onset of illness.

Advantages of Treating Schizophrenia with Long Acting Injectables

It’s a great segue into talking about what’s available to our patients. It’s been gratifying for me because when you and I started doing this, all we had available were a couple of first generations and maybe the earliest of the second generations.

Now we’ve got so many options. We’ve got multiple versions of risperidone. We’ve got the 2-week version and now a monthly subcutaneous version. We’ve got aripiprazole, which you can give every month, every 6 weeks, every 2 months.

Then we’ve got paliperidone, which until recently with monthly and every 3 months, but now it’s every 6 months.

Every 6 months, I know. I have so many patients who were absolutely counting down the days till that happened. That was something we’d been working toward for the right patient, so to see that—when we think about their goals and what they would like to do, it’s interesting. You mentioned going from 1-month to 3-month doses.

I use a great deal of Invega products for my patients with schizophrenia. My patients were on an every-28-day regimen, and I was comfortable with that because I felt that if I was to expand the duration between injections, perhaps they would be lost to follow-up, would feel that they were cured, and would not come back for their next injection. So I was very hesitant. I was not an early adopter of switching patients from the 1-month to the 3-month product. Some of that was because I did not have as much confidence in them as I should have.

Fast-forward to the middle of the pandemic, and I have patients who were coming to the alleyway in the back of the office. We were giving injections in an alley in a dark parking lot. It’s dark out. I’m using my cell phone light to illuminate the arm so I can give the injection. We had people actively with COVID-19 coming to the parking lot to give them their injections. I say to myself, “What am I doing? Why am I doing this when I have a viable option?” It felt like it was inappropriate for me to not at least broach the conversation. I had some patients who said, “No, I’m doing fine on my once a month. I’m not going to switch.” I respect that, absolutely, because they have to have comfort.

That’s the time when I started switching my patients to the every-3-month product. What was so strange about that in its own way was they didn’t stop coming to see me. They’d still be able to see me every month. They were very consistent with their appointment, their symptoms were very well managed, and yet we’re able to use some of that time that we didn’t usually have available because it was very focused on the mechanics of the injection. Now we’re like, “Let’s talk about metabolic screening. Let’s talk about your diet and exercise patterns and look at your cholesterol and all that stuff.”

I definitely realize that those issues were mine, and I believe I held back some of my patients. COVID-19 made that very evident to me. It’s been amazing. I’ll tell you what’s so interesting: patients will come in and out of treatment, especially those on oral products. My patients who are on injectables—and I’m not saying 1 particular type of injectable, I’m talking about across the board—are some of my absolute most consistent patients.

Kimberly Garcia, DNP, CRNP, and Sanjai Rao, MD, DFAPA, review the administration frequencies of long acting injectables risperidone, aripiprazole, and paliperidone.

Administration of Available Long Acting Injectables for Schizophrenia

Do you talk to them the first time you see them, the second time you see them? When do you get this going?

Typically, as we’re new into treatment, listening, we’re going over their history. Typically they’ve been in the hospital already by the time they reach me in the outpatient practice. I’ll sometimes ask them, “What are some of your goals? Where would you like to see yourself 5 or 10 years from now?” Then what I’ll typically do is start the conversation and then follow through at subsequent visits. I usually leave a little information.

I will say to them, “One thing you may want to consider, we have a number of injectable products,” and they’ll say, “Injection?” I say, “My gosh, no, it’s not bad at all. It’s very well tolerated. We do many of them here.” I usually will use patient experiences. For some of my patients, they prefer to give me the responsibility of worrying about their medication regimen, so they don’t have to worry about anything. We can take care of having the pharmacy deliver the injection. Patients come in, depending on the product, in 1 to 3 months, now even up to 6 months. We have some patients with that, and it’s exciting if we present this as an opportunity for them.

Where I am in Pennsylvania, the state does not require prior authorizations for long-acting injectables [LAIs]. They want us to use them early and they want us to not experience any barriers to their use. Sometimes we have to educate patients about the reason for that and what that could mean for them and their illness over time. What I find is that, especially if they bring another family member or friend with them or an affiliate, even like a caseworker, for them to hear this information. I don’t push because as soon as we start pushing, there are psychological implications for that. So we just provide them with the information, letting them know that this is an option. We offer this service. If you’d like to take advantage, you could. How interesting it is that often at that next appointment with me, they’ll say, “Could you tell me a little more about that injection? Or “I was looking up information about the injection, and I might be interested in that.”

It’s wonderful. You’re applying a motivational enhancement, motivational interviewing approach where you’re exploring it with them, giving them some options, reinforcing them when they come back with a positive impression of it and want to pursue it more. It’s often enticing them to want to come back and ask for it and increasing their investment in it. I love that. I’ve never heard this approach before, where some patients like us to handle all this stuff for them. If you’d like us to handle all this, we can do that. What a way of portraying the benefit of being on an injection: no, let us take care of it. All you have to do is arrive.

At the end of the day that’s what it’s about. To say to a patient, “Bring me your arm, and that’s the expectation for today’s appointment.” It’s amazing. Injectables were sometimes portrayed in a very negative light, as a treatment of last resort. We’ve flipped that to present this, as I call it, an opportunity. “I have a nice opportunity if you’re interested,” and that’s a lot of the way that I will even talk about it: as an opportunity.

That’s great. I often will try to figure out what part of the LAI experience would be beneficial to them. Are they someone who travels and leaves their meds behind? Someone who wants the freedom not to have to go home and get their med bottle when they need something? Someone who lives with someone and wants some privacy and they doesn’t want a medication bottle lying around? Or are they homeless and keep getting their meds stolen? Whatever their particular experience is, show them that if they were on the monthly injection or a longer duration injection, they wouldn’t have to deal with whatever this problem is that makes it hard to be on oral medications.

Absolutely. I have many patients who are from the Dominican Republic. My patients will oftentimes go for several months at a time back to their country. We know that insurances don’t like to provide a large amount of medication at once, so it’s created a number of barriers for them. Either they’ve had to rely on family members to mail them medications, which is always tricky, or they’ve tried to get equivalent medications or semiequivalent medications in their home country. For them, to get 1 of the longer-acting injectables has been a huge benefit.

Sanjai Rao, MD, DFAPA, starts a conversation on how to discuss long acting injectables with patients and how to best transition from an oral medication.

Discussing Long Acting Injectables for Schizophrenia with Patients

Let’s switch gears a little and talk more about the specific treatment for schizophrenia. I thought we could start by talking about treatment algorithms for patients with schizophrenia. When you’re thinking about a patient with schizophrenia, what algorithm do you follow, or is there 1 to think about? What am I going to treat this patient with, and how is this going to go?

I do have an algorithm. As a provider, it’s interesting to observe the evolution of my algorithm. If this was 15 years ago and we were having this conversation, I’d start with 1 particular antipsychotic. If it’s not effective, then I’d increase the dose until we achieve efficacy or there are tolerability issues. If that’s still not effective in controlling their symptoms, I may add a second agent or think about combining a first- and second-generation antipsychotic.

These days, things have changed for me because I work in an environment that supports the use of long-acting injectables [LAI]. We have a whole nursing department. They administer the majority of those injections. We’ve become known in our community as a facility that offers this as a treatment option. It’s interesting how that gets communicated to other individuals. We’re often approached by patients who are interested in looking at that as a treatment option. The reason that I tend to gravitate more toward injections is, No. 1, the reality is that adherence is going to be a problem. Oftentimes, poor adherence is going to lead to relapse, which is going to lead to hospitalization, incarceration, or other very negative outcomes for the patient.

What I would do now is start them on an oral antipsychotic to begin. I try to identify 1 that has fewer adverse effects than the others. I provide as much education as I can in regard to metabolic syndrome, the need for AIMS [Abnormal Involuntary Movement Scale] testing and tardive [dyskinesia] symptoms, for example. Of course, that also scares patients, but at least allow them the sufficient knowledge to be able to make informed decisions.

However, it’s not long in the treatment trajectory before I start presenting the option to them. If they were interested, they could come into the facility and could receive 1 of the long-acting injectables. We talk about what that process looks like.

Is the potential availability of an LAI 1 of the things you think about when you’re selecting that initial agent for them?

Absolutely. My idea of using injections used to be that they were the last resort. If it was, “If you don’t take your medications, you’re in and out of the hospital,” this is almost going to be punitive for them. “You’re at the point where you’re going to have to have an injectable.” I’ve totally changed my perspective on the use of injectables. I see the value in them. I see the value in improving the patient’s quality of life—and the parents’ quality of life if they’re very involved and they have a child who has schizophrenia. There’s that constant fight between the parents and the young adult child to take their medications. I start them on an oral antipsychotic that would have the potential to be converted into a long-acting injectable. I start that conversation early, not just early in my treatment relationship with the patient but also earlier in the course of illness than I ever thought I would see possible.

So you’re really looking at conversion to LAI, not just because they weren’t doing well on orals, but because you want them on an LAI earlier rather than later as a treatment.

That evolution that you described mirrors the evolution of many of the treatment guidelines that we’ve seen. If you look at the American Psychiatric Association treatment guidelines—the previous set of guidelines, from 10 years ago—they basically said what you said at the beginning. You start oral medications, and you try different oral medications. If the oral medications aren’t working—if the patients are chronically nonadherent, if they have psychosocial or substance abuse problems, or all these other complicating factors—then way down the line you’ll give people a long-acting injectable. Their latest set of guidelines that came out in 2020 says, all those people should still get LAIs, but you can also think about LAIs earlier in the treatment course if the patient prefers to receive an LAI.

I looked at this and said, “This is reasonable.” But I wish they’d gone further in the vein than you’ve gone. It’s not just that an LAI is an “if they prefer it” option. Saying if they prefer it or not really requires more along the lines of what you’re doing, which is actively educating the patient on the potential benefits and risks of an LAI—representing the true benefits of an LAI and then seeing if they prefer it. Not just kind of throwing it out there and saying, “Do you want to do this?” There are real reasons to take an LAI that might offer potential benefits over taking an oral.

Nurse Practitioner Kimberly Garcia and Dr. Sanjai Rao have a discussion on how they treat schizophrenia and highlight the considerations of prescribing long-acting injectables.