LAI Antipsychotics for Schizophrenia: Early Intervention Strategies to Improve Outcomes

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Dr. Correll: 
Hi, my name is Christoph Correll. I'm Professor of Psychiatry at the Zucker School of Medicine at Hofstra Northwell in New York. Welcome to this program, Overcoming Clinical Barriers to Long-Acting Injectable Antipsychotic, or LAI, Administration.

The problem is that patients with schizophrenia are often nonadherent; 70% or more are, but less than 10% of patients actually are prescribed a long-acting injectable. And the question is why? Now, there are different reasons for nonadherence. They include treatment setting, clinician, illness type, caregiver and social support, patient characteristics, but also particularly treatment type. We know that with a long-acting injectable, you can make nonadherence visible, and patients are staying the course much longer, which can help them achieve their goals.

Why are we not prescribing LAIs as much as needed when we know so many patients are nonadherent? Well, studies suggest that we're actually overestimating the negative attitudes of patients when they are confronted with long-acting injectable treatment options. A study showed that doctors and nurses believe that far more negative beliefs would exist in patients for stigma, feeling of being controlled, that they can't control that medication when it's taken, that they feel less self-dependent or embarrassed. Whereas patients on oral treatment had less of that problem. And people who actually knew what they were talking about, had a long-acting injectable, had the least concern.

Patient refusal is often cited as a primary reason, but clinicians are not even offering the treatment. One study suggested that 75% of prescribers felt they informed the patient but only a third of the patients could confirm that. And let's say that injectable antipsychotics were the preferred formulation for people who were informed and could try it out. Reasons said against long-acting treatments by clinicians are often 86% in one study, ‘Oh, patients are sufficiently adherent to oral treatment.’ But we know that's not true. Patient refusal in 80%. How can people refuse anything that they don't know about? Or that there might be even higher treatment side effects, which is also not true.

With the attitudes that we have, we cannot be convinced or convincing to patients. In a study that looked at communication skills in clinicians that knew that they were audiotaped while offering an LAI suggested that only 9% - 9% of the communication about LAIs was focused on positive aspects of this treatment option, 81% were neutral or negative. And of course, less people are willing to then accept or try this option.

We conducted a study, the PRELAPSE study, that trained the entire treatment team on knowledge about the benefits of LAIs, but also how to offer them with suggested scripts, the role plays, and also went through frequently asked questions. And within the first 3 months of treatment engagement, in first episode in early-phase patients, 91% of patients - 91 accepted admission or administering an LAI, 14% said, ‘Well, I don't want to be in your study because you want to offer me an LAI,’ But 14 and 9 is 25, 75% of patients actually were on an LAI 3 months into treatment.

What are some of the counterarguments that people have in their minds? There might be lots of injection site and reactions. That's actually not true, they're very few. And the pain is also relatively little, especially as people know about the treatment. Side effects are not higher, they're the same or lower than with oral treatments. People can become nonadherent to LAIs. Yes, but much less so than to oral treatment. And also, it's maybe difficult to adjust the dose but we’ll usually stop the LAI after we’ve found the dose. And suggesting an LAI might impede patient autonomy, but actually it gives patients back the autonomy by controlling the illness better and pursuing their goals. And then the final misconception patients might not want this, or it might undermine the treatment alliance. Actually, when informed, patients might prefer the treatment and they can see that doctors and prescribers are caring.

So, despite overwhelming evidence of the benefits of LAIs that are underutilized, reasons are multifactorial, that we need to just be informed and convinced to be convincing and bust some of these misconceptions and the stigma around LAIs to enable patients to make informed decisions about this potentially helpful treatment for them.

Thank you very much.

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