Attitudinal Barriers to Prescribing LAI Antipsychotics in the Outpatient Setting: Communicating With Patients, Families, and Caregivers

John M. Kane, MD

Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks; the Department of Psychiatry, Hofstra North Shore-Long Island Jewish School of Medicine, Uniondale; and Behavior Health Services, North Shore-Long Island Jewish Health System, New Hyde Park, New York

Long-acting injectable (LAI) antipsychotics have proven to be efficacious in the treatment of patients with schizophrenia.1,2 However, organizational barriers as well as numerous attitudinal barriers presented by physicians themselves can pose challenges to implementing LAI antipsychotic use in clinical practice. LAI medications can improve adherence rates and reduce the risk of relapse and rehospitalization, thereby warranting a greater use of these agents than is currently observed.3 Examining physicians’ attitudes about LAI antipsychotics may help overcome some of the following attitudinal barriers.

Overestimating Treatment Adherence

Patients with chronic diseases have difficulty taking medication on a regular basis.4 And patients with a psychiatric illness can experience even greater nonadherence than those with other chronic diseases if they have impaired judgment, lack insight into the illness and motivation to treat it, and feel stigmatized.5 However, some physicians may tend to overestimate patients’ adherence and, therefore, oppose switching patients from daily oral to biweekly or monthly LAI antipsychotics.

Accurately determining the extent to which patients are or are not taking the prescribed medication can be difficult. In fact, studies6,7 have shown that, when compared with more reliable methods of counting pills and using electronic monitoring, both patient report and physician assessment grossly underestimated levels of nonadherence. For example, Byerly et al7 found an almost 50% nonadherence rate as determined by MEMS caps and a 0% nonadherence rate according to the Clinician Rating Scale.

AV 1. Ascertaining Adherence to Oral Medication (00:30)

Based on Velligan et al8

When physicians directly ask patients whether they are taking medication as directed, patients may not be aware of the extent to which they are missing medication, they may be embarrassed about missing doses, or they may want to please the doctor, so they may offer the answer they think the doctor wants to hear. Asking patients about their experiences taking medication may be more useful than asking a direct question (AV 1).8

Misinterpreting Literature

Another challenge facing physicians regarding the use of LAI formulations is the confusing and perhaps conflicting results in the literature.5 Mirror-image studies produced overwhelmingly positive efficacy results, while results of naturalistic or cohort studies were mixed, and randomized, controlled trials did not consistently show a difference between LAI and oral medications.

Clinicians need to recognize the subtleties involved with LAI agents in literature. For example, in naturalistic studies, because LAI drugs were probably given to people at higher risk of relapse and rehospitalization and oral medications were probably given to the less severely ill patients, results showing equal efficacy suggest that LAI agents may actually be superior. Additionally, patients in RCTs may have better treatment adherence than those in real-world practice, so comparing oral and LAI antipsychotics in these patients may not result in much difference. Overlooking these subtleties, physicians may only see that the trials did not show a difference between LAI and oral medications and may not be motivated to convince their patients to try the injectable form.

Finding Time and Money

Another attitudinal factor is the increased amount of time that LAI drugs are thought to require. Rather than quickly writing a prescription, physicians may see a burden in having to spend more time and effort discussing the pros and cons of this type of treatment with patients, doing motivational interviewing, and facilitating shared decision making.5 Additionally, physicians may see a time burden in actually administering the injections, which is additional work for which they may perceive no added value.8

AV 2. Factors Contributing to the Underuse of LAI Antipsychotics (00:41)

Based on Iyer et al9

Although the ultimate incentive for physicians is to improve their patients’ outcomes, financial issues of the provider are a factor in the decision-making process. Physicians and their supervisors may balk at the startup costs for supplies and staff training, but long-term costs and patient outcomes can be improved through LAI antipsychotic treatment. A qualitative study9 of psychiatrists’ attitudes toward LAIs revealed, among other factors, a theme of pragmatic barriers including cost, storage, and staffing (AV 2). However, because LAI antipsychotics can help prevent relapse and hospitalization, prescribing an LAI antipsychotic for patients who are good candidates may actually help reduce patient and health care costs. For example, patients who reduce their emergency room or hospital visits can remain in outpatient care, which minimizes overall insurance costs and brings revenue to clinics.

More

Sacrificing Patient Independence

A goal of physicians who treat patients with schizophrenia is to help patients become more independent. Some physicians may believe that they are undermining patients’ ability to develop autonomy if patients can rely on clinician-administered medication rather than having the responsibility to take their own medication every day. Injections could even be perceived as being coercive.9 However, receiving the benefits of medication is an important foundation needed for patients to achieve a more independent life. Patients with schizophrenia typically already have daily challenges in taking care of themselves and participating in work, school, and social life, and medication should not be another daily struggle. If they receive benefit from an LAI antipsychotic, it may actually eliminate some obstacles. In this regard, clinicians are indeed helping patients become more autonomous.

AV 3. Addressing Nonadherence and Family Friction (02:43)

For example, conflict can arise when family members continually ask patients if they are taking their medications as prescribed. Patients may become resentful and may perceive the questioning as an invasion of privacy or feel infantilized. When a daily oral medication is commuted to an LAI antipsychotic, this source of friction within the family can be eliminated (AV 3). Family members who take patients to receive injections will then know that the medication was received. Physicians should appreciate that many stakeholders are involved and understand that medication formulation may be able to help ease some types of conflicts or anxieties.

Adding Injectable Treatment to Oral Medications

Because a patient may already be taking other oral medications, some physicians may think that giving an antipsychotic drug by injection is pointless because the patient will still have to take those oral medications. While this argument is valid, if the patient’s adherence to oral medications is problematic, improving adherence to the antipsychotic is still important. So, even if patients miss doses of other agents, physicians can feel more comfortable knowing that patients with schizophrenia are at least getting their antipsychotic medication. The fact that physicians cannot give every drug by injection does not diminish the potential value of giving the antipsychotic drug by injection.

Conclusion

Several factors influence physicians’ attitudes about using LAI medications, such as overestimating patients’ adherence to oral medications, misinterpreting the literature regarding LAI antipsychotics, perceiving that the added time and cost to administer LAI agents outweighs the benefit of this formulation for patients, and perceiving that administering an LAI medication undermines patients’ autonomy. Much work is needed to get physicians to realize the benefit that LAI drugs could provide to some patients. At the most basic level, using an LAI antipsychotic gives the doctor the knowledge that the patient is actually getting the medicine. In turn, physicians can intervene in an appropriate and timely manner when a patient is experiencing a relapse despite taking medication, which would likely result in a different strategy compared with a patient who is relapsing because of nonadherence. Once physicians better understand and adopt a positive attitude toward LAI drugs, they can hopefully begin using them to optimize treatment for patients who are good candidates for this type of regimen.

Clinical Points

  • Identify your own concerns regarding the use of LAI medications
  • Objectively consider whether your patients with schizophrenia are adherent to an oral agent and whether they would benefit from an LAI antipsychotic
  • Critically evaluate the literature regarding LAI antipsychotic use
  • Weigh the time and costs of using LAI antipsychotics against potential benefits

Abbreviations

LAI = long-acting injectable

MEMS = Medication Event Monitoring System

RCT = randomized controlled trial

References

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