The Earlier, the Better: Long-Acting Injectable Antipsychotics for Managing Schizophrenia

CONFERENCE REPORTER

Medication discontinuation is very common in schizophrenia, leading to relapse, treatment resistance, and poor outcomes.^1-3 Long-acting injectable (LAI) antipsychotics offer a solution to poor adherence, explained Sanjai Rao, MD, at the 2023 Annual Psychiatric Times™ World CME Conference.

“By some estimates, up to half our patients will discontinue medications within the first 6 months of treatment, and perhaps up to 75% will discontinue medications within a year and a half of treatment. When this happens, even if it is after just a single psychotic episode, this can lead to relapse. The more often this happens to your patient, the more often they relapse and the longer it is going to take to get them back to something resembling remission,” said Rao, who is clinical professor of psychiatry and associate residency training director at the University of California, San Diego; site director of residency training at the VA San Diego Healthcare System in San Diego, CA.

LAIs offer several benefits:

1. Clinicians know exactly how much medication the patient is receiving.

2. LAIs ensure stable plasma levels with less peak to trough fluctuation, with equal or increased efficacy, and sometimes fewer side effects than oral counterparts,

3. Missing a dose is not immediately catastrophic for patients, as there is no immediate drop in drug levels.

“The earlier you can intervene and prevent relapse, the more likely you are to have a more favorable outcome,” Rao said.

Furthermore, compared with oral antipsychotics, LAIs reduced the rate of all-cause hospitalizations, reduced the number of all-cause ER visits, and improved treatment adherence, all while having similar overall costs.⁴

Speaking to patients about LAIs is all about reframing, Rao explained. Rather than taking a negative tone (ie, “Since you aren’t taking your pills, you should get the shot.”), it is better to approach with positive communication (“Would it be nicer for you to take your medication once a month instead of every day?”). According to a study of communication patterns concerning LAI antipsychotics, only 9% of psychiatrist communication when presenting LAI antipsychotics to patients focused on positive aspects, and as such only 33% of patients accepted LAI antipsychotic treatment. Once positive communication was used, 96% of patients who initially declined an LAI changed their minds and tried LAI treatment.⁵

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References

1. Lieberman JA, Stroup TS, McEvoy JP, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353(12):1209-1223.

2. Emsley R, Chiliza B, Asmal L, Harvey BH. The nature of relapse in schizophrenia. BMC Psychiatry. 2013;13:50.

3. Lieberman JA, Alvir JM, Koreen A, et al. Psychobiologic correlates of treatment response in schizophrenia. Neuropsychopharmacology. 1996;14(3 Suppl):13S-21S.

4. Lin D, Thompson-Leduc P, Ghelerter I, et al. Real-world evidence of the clinical and economic impact of long-acting injectable versus oral antipsychotics among patients with schizophrenia in the United States: a systematic review and meta-analysis. CNS Drugs. 2021;35(5):469-481.

5. Weiden PJ, Roma RS, Velligan DI, et al. The challenge of offering long-acting antipsychotic therapies: a preliminary discourse analysis of psychiatrist recommendations for injectable therapy to patients with schizophrenia. J Clin Psychiatry. 2015;76(6):684-690.