Treating Schizophrenia in the Era of COVID-19 - Episode 3
Experts in the treatment of schizophrenia discuss the benefits of long-acting injectables, including adherence and lower rate of relapse.
Bryce Reynolds, MD: 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?
Hannah Phillips-Hall, MSN, PMHNP-BC: 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.
Bryce Reynolds, MD: 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.
Hannah Phillips-Hall, MSN, PMHNP-BC: 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.