Treating Schizophrenia in the Era of COVID-19 - Episode 7
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.
Bryce Reynolds, MD: 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 agitation. 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?
Hannah Phillips-Hall, MSN, PMHNP-BC: 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.
Bryce Reynolds, MD: 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.