Treating Schizophrenia in the Era of COVID-19 - Episode 1

New Diagnosis of Schizophrenia Initiated on Long-Acting Injectable

December 2, 2020
Bryce Reynolds, MD

,
Hannah Phillips-Hall, MSN, PMHNP-BC

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.


Bryce Reynolds, MD: Welcome to this Psychiatric Times® 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.

Hannah Phillips-Hall, MSN, PMHNP-BC: Thank you.

Bryce Reynolds, MD: 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?

Hannah Phillips-Hall, MSN, PMHNP-BC: 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.

Bryce Reynolds, MD: 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?

Hannah Phillips-Hall, MSN, PMHNP-BC: 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.

Bryce Reynolds, MD: 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?

Hannah Phillips-Hall, MSN, PMHNP-BC: 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.

Bryce Reynolds, MD: 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.