Treating Schizophrenia in the Era of COVID-19 - Episode 5
Bryce Reynolds, MD, reviews the highlights of the proposed APA guidelines for the treatment of schizophrenia with long-acting injectables.
Bryce Reynolds, MD: 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.
Hannah Phillips-Hall, MSN, PMHNP-BC: 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?
Bryce Reynolds, MD: 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?
Hannah Phillips-Hall, MSN, PMHNP-BC: 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.
Bryce Reynolds, MD: 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 necessary. 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.
Hannah Phillips-Hall, MSN, PMHNP-BC: 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.
Bryce Reynolds, MD: 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.