In recent years, psychiatric care has undergone a shift in the clinical mindset toward medication management for people living with schizophrenia and other chronic mental health conditions. As recognition grows for the breadth and depth of the clinical complexities and psychosocial challenges that patients may face along their diagnostic and treatment journey, there is movement toward ensuring that patients have access to treatment options that integrate their needs and preferences. One notable development is the increasing use of long-acting injectable (LAI) antipsychotics.
Guidelines and research support use of LAIs for appropriate patients
LAIs have historically been used later in a person’s treatment journey or as a “last resort.” However, research supports the value LAIs may provide early in treatment, even as soon as the first episode of psychosis.
The American Psychiatric Association (APA) updated its guidelines for the treatment of patients with schizophrenia in 2019 to recommend LAIs as a first-line treatment for schizophrenia, highlighting their potential to prevent relapse and improve patient outcomes. The goals of the “new evidence-based guidelines,” according to a 2020 APA press release, “are to reduce the mortality, morbidity and significant psychosocial and health consequences of this psychiatric condition.”
Ongoing research supports the role of LAIs in the individual’s treatment journey, as they have been found to support adherence and convenience and reduce hospitalizations. In my experience, I find that patients receiving LAIs have fewer relapses and overall improved functioning compared to those on oral medications, which is meaningful for those living with schizophrenia. By using LAIs, I have observed a delay or even prevention of relapse, which is relevant when treating an illness known to be neuroprogressive.
Benefits of LAIs in treatment protocols
As health care providers for people living with schizophrenia, we know their days are often punctuated by a range of symptoms affecting their thoughts, emotions, and behaviors. These symptoms can impair their ability to function in daily life – impacting work, relationships, and even self-care. In clinical settings, we are tasked with working with our patients to explore treatment options and make treatment recommendations; in doing so, our goals should include symptom management, as well as minimizing psychotic relapse and hospitalization.
Antipsychotics, the standard of care for schizophrenia, are produced in both oral and LAI formulations. While LAIs are recognized by psychiatric experts as viable treatment choices throughout a person’s course of illness, they remain underutilized, especially early in the disease course. In my practice, I have observed several potential considerations related to the choice of an LAI.
One factor for health care providers to weigh, in discussion with patients and caregivers, is the dosing interval of LAIs relative to oral antipsychotics. Specifically, LAIs are injectable formulations of antipsychotic medications administered by a health care provider that can last weeks or months depending on the dosing indication.
For the provider, LAIs can eliminate challenges associated with tracking a patient’s adherence to a medication regimen. While oral antipsychotic medications are generally effective when taken as prescribed, the reality is that we often don’t have direct evidence of medication use. For example, I recently treated a patient living in a supportive apartment complex. We assumed he was taking his medication, as he always endorsed full and consistent medication adherence in our clinical sessions and staff did not appreciate him to be symptomatic. However, during a surprise room search staff discovered he had been hiding pills in a drawer. Any question(s) I may have had about a lack of medication-related side effects was easily answered—no medication means no side effects, but also no disease state management.
Reassurances related to ease and convenience can also extend to patients and caregivers. The indicated duration of LAIs can alleviate struggles with self-care faced by many living with schizophrenia. Taking a pill once or twice a day can be a burden for many patients, requiring them to make the decision up to 60 times each month whether to take their medication. With an LAI, the challenge associated with decision-making and medication management is lessened. In turn, more attention can be devoted to the broader therapeutic needs of these complex chronic illnesses. Additionally, caregivers often find themselves in the unenviable position of “policing” their loved ones’ medication regimen. With LAIs, caregivers may find that their concerns or worries are moderated, allowing them to focus on providing other types of support.
Supporting your patient’s transition to LAIs
Many patients and their caregivers are unaware of LAIs. In my opinion, conversation about the full range of treatment options should happen regularly in a psychiatric clinical practice, and I encourage the clinicians I work with to explore different options with their patients that may optimally address their needs.
Of course, any medication transition requires careful planning and support. It’s essential for providers to tailor a transition strategy to the individual patient. Some patients might be stable on oral medication, while others might require hospitalization before starting an LAI. Patients who are stable on their oral antipsychotics can be assured that they are receiving the same base medication in a form that may be more convenient.
Below are examples of strategies I have found useful in facilitating a smooth transition from oral antipsychotics to LAIs:
1. Present the option in a positive light. Patients might not be interested the first time LAIs are presented. In fact, I don’t expect an affirmative answer the first time I ask the patient whether they want to consider transitioning from their oral antipsychotic.
I make sure the choice to transition to an LAI is presented favorably and in a manner that emphasizes their personal agency. I generally frame it as, “If you could take medicine only once a month or every two months, through a five-minute injection, how would you feel?”
I find that patients are largely amenable when fully informed and when they understand the benefits and risks. Increasingly, there are LAIs available that require even less frequent administration—doses now can be given once monthly, every other month, every three months, or even every six months. Objectively, then, LAIs are less invasive in the patient’s life without compromising clinical objectives and outcomes. Whenever possible, I include patients’ caregivers in these conversations, so everyone involved in a person’s treatment is informed and supportive.
2. Address patients’ questions about transitioning to an LAI. It is essential to address any specific patient questions, especially for those who may lack insight into their illness. Discussing the specifics—such as injection frequency, how and where the injection is administered, and any potential discomfort or side effects—can help alleviate concerns. It is important to offer a balanced perspective so patients and their close caregivers can make comprehensive choices.
Meeting the patient where they are, providing thorough psychoeducation, and involving family members in decision-making can foster a smoother transition. I have found utilizing the shared decision-making technique is key, as patients are more likely to feel empowered in that transitioning isn’t something they are being ordered to do.
The future of LAIs in psychiatric care
Misconceptions about LAIs—for example, that they are hard to administer, they do not work as well, and patients will not want to take them—persist. Yet, with proper training and the right setting of care, administration should not be a barrier. Significantly, insurance companies are on board, recognizing that consistent treatment contributes to reduced health care costs and can help avoid future hospitalization(s). In addition, we are seeing LAIs become more accessible to prescribe in some states, with fewer prior authorization requirements.
As clinicians, educating our patients about appropriate medication options is essential. Alongside reductions in hospitalizations and relapses, our focus should be on patients’ holistic experience of their illness and treatment. Schizophrenia is a complex condition, presenting lifelong challenges. Working together with patients, caregivers, and across the health care team on treatment choice is one pathway to optimal management.
For these reasons, I anticipate that LAIs will increasingly become the standard of care for suitable patients.
Richard W. Miller is a psychiatrist.