The Role of the Extended Health Care Team in Successful LAI Therapy: Education to Overcome Barriers

Christoph U. Correll, MD

Recognition and Prevention Program (RAP), The Zucker Hillside Hospital, Glen Oaks; the Department of Psychiatry and Molecular Medicine, Hofstra-North Shore-Long Island Jewish School of Medicine, Hempstead; and the Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York

Nonadherence is common in patients with schizophrenia and is a major barrier to maximizing the acute and long-term effectiveness of treatments.1 To help prevent relapse and rehospitalization and improve patients’ functioning, clinicians must find appropriate and individualized treatment options to help patients who have problems with nonadherence. One such strategy is the use of LAI antipsychotic medications; instead of taking daily oral medication, patients get injections every 2 to 4 weeks. LAI formulations are underused in practices today, partially due to the lack of knowledge about and experience with them.

Clinicians and ancillary staff, as well as patients and their families, need education about the potential benefits of LAI agents. The first step in this educational process is to acknowledge potential pros and cons of using LAI antipsychotics from the point of view of patients and their families as well as of health care professionals. Following this overview of pros and cons, detailed education about LAI therapy and its most appropriate uses should be tailored to the health care team. Then, these team members can identify patients for whom LAI antipsychotics may improve outcomes and educate those patients and their families about this treatment option.

Pros and Cons for Patients and Families

Clinicians and the extended care team should be able to anticipate and address any issues that patients may have about LAI antipsychotics. Patients may be concerned about having to make more frequent appointments and may be fearful of injection site pain. Patients may worry that the conversion from an oral to an LAI medication might be difficult or that they will be unable to stop the medication when a severe side effect occurs. They may also worry about perceived stigma of LAI antipsychotics and increased medication costs.

When discussing LAI antipsychotics with patients, clinicians need to be able to point out that the benefits can outweigh these concerns. Although for patients to receive the injections they must go to the doctor’s office, these visits provide opportunities for patients to see their treatment team regularly, which helps build the therapeutic alliance and decrease relapse and rehospitalization rates.2 Physicians should describe the process for transitioning to an LAI medication and be sure to stress that injection site pain in general is mild and transient.3 Although injected medication cannot be stopped like an oral agent can, the continuous antipsychotic coverage should be a major benefit rather than a drawback, and most relevant side effects can be managed even in the continued presence of the antipsychotic. Patients may also have fewer side effects than with an oral agent (especially when taken irregularly or stopped and started) because peak-level and withdrawal symptoms should be reduced or eliminated.4 Patients may also feel less stress over the need to remember to take an oral medication regularly. Family members will be relieved of the need to constantly check on patients’ adherence, thus promoting a feeling of more autonomy and diminished conflict and stigma for the patient. Cost questions should be addressed with team members who handle insurance coverage.

AV 1. Educating the Health Care Team Regarding LAI Antipsychotic Treatment and Follow-Up (02:37)

 

Pros and Cons for Health Care Professionals

Members of the health care team may also have reservations about using LAI antipsychotics (AV 1).1 Typically, LAI drugs are used as a last resort for patients who have had multiple hospitalizations.5 This contributes to the stigmatization of LAI antipsychotics as being only for very seriously ill patients who might be given them despite their objection. Also, trials of LAI versus oral antipsychotics have produced mixed outcomes, thus leading some clinicians to doubt the efficacy of LAI formulations, especially if they do not consider the different methodological reasons for some conflicting study results.6 Additionally, many providers lack training and experience with LAI agents, leading some clinicians to worry that switching to an LAI drug may complicate treatment by requiring more time to explain this treatment option to patients, to conduct extra appointments, and to administer the medication. Inflexible dosing concerns as well as organizational barriers, such as lack of health care team buy-in and insufficient financial or staff resources, may also hinder the use of LAI antipsychotics. Additionally, health care providers may lack appreciation of patients’ true nonadherence rates, as measurement methods are unreliable, so they attribute relapses to chronic disease rather than to inconsistent medication adherence.7 (For more on organizational barriers, see “Organizational Barriers to Using Long-Acting Injectables in Practice.”)

LAI antipsychotics do have several benefits. For example, LAIs offer continuous medication delivery, which can help promote adherence, reduce symptoms, and improve functioning.4 Because patients must receive the injection at the provider’s office, practitioners will know if they have missed an appointment and can mobilize the family to help intervene and get patients back into treatment in a timely manner. Moreover, when an LAI agent is stopped, the blood levels do not drop precipitously. This widens the window during which attempts at continuing treatment and preventing relapse can be made. Finally, with LAI formulations, the staff will not be guessing about treatment efficacy. If patients receive the injection and do not experience an adequate improvement, then the medication needs to be changed.

Educational Foci

Following the overview of pros and cons, more in-depth education of the health care team can begin. The first educational focus is the efficacy of LAI drugs and the fact that randomized controlled trials might not reflect patient and treatment realities in real-world settings. The other focus is the underuse of LAI medications, examining data on the attitudes of prescribers and patients in relation to their respective knowledge about and experience with LAI treatments. This education should challenge the paradigm of reserving LAI antipsychotics only for patients with an already established track record of frequent relapses. Then, LAI agents can be used more in the early phases of the illness to change the treatment strategy from an intervention to more of a prevention model, taking place at critical periods in the patients’ lives when they are at risk of losing the most of their social, educational, vocational, and psychological capital.

Effectiveness data for LAI antipsychotics. For patients with schizophrenia, meta analyses have shown that depot medications reduced relapse rates (P = .03)8 and decreased hospitalization rates (P < .001)9 more than oral antipsychotics. In one of those meta analyses,9 23 of 25 studies showed that the LAI treatment period was significantly superior than the oral treatment period, even though different outcomes measures were used. Additionally, naturalistic studies4 have also indicated that, even among patients with first-episode psychosis, depot antipsychotics were superior to their oral equivalents in terms of increased duration of taking the medication, reduced relapse rates, and less hospitalization. Education of mental health professionals should emphasize the extent and deleterious effect of treatment nonadherence and the effectiveness of LAI antipsychotics, so that these agents can have a place in the care of more patients with schizophrenia than currently receive them. (For more information on attitudinal barriers, see “Attitudinal Barriers to Prescribing LAIs in the Outpatient Setting: Communicating With Patients, Families, and Caregivers.”)

Underutilization: attitudes, knowledge, and experience. Compared with those receiving only oral medication, those prescribed LAIs have had more psychiatric hospitalizations and arrests and have greater psychopathology (especially disorganized thinking and psychotic symptoms).10 Therefore, patients who have high levels of insight or are in the early phase of illness and who might actually understand the need for LAI treatment and benefit from it the most are approached the least.11

More

Patients are usually only offered LAI antipsychotics at a crisis point. For example, a multisite, observational, 3-year study12 found that only 12.4% of patients who were not taking oral therapies as prescribed were switched to an LAI antipsychotic. Further, a survey5 indicated that more than 90% of psychiatrists never or rarely recommend switching to a depot antipsychotic after a first episode and only 50% recommend switching after multiple relapses. The most common reasons psychiatrists have cited that at least sometimes influence their not prescribing LAI atypical antipsychotics included sufficient adherence to oral medications, patient refusal, medication cost, and inappropriateness in first-episode schizophrenia.13

AV 2. Psychiatrists’ Attitudes Regarding Long-Acting Injectable Antipsychotics (00:41)

Data from Patel et al15

Education about LAI drugs makes a difference in clinicians’ attitudes about them. A study14 of psychiatrists’ attitudes about maintenance antipsychotics showed that those who had more knowledge about LAI antipsychotics had better appraisals and were more likely to prescribe them. In a similar follow-up study,15 94% of the psychiatrists felt that LAI antipsychotics are just as efficacious as oral agents; 36% felt that depot medications are stigmatizing, and 52% believed that LAI antipsychotics are less acceptable to patients than oral formulations (AV 2).15 These results have much to do with how LAI drugs are presented to patients. For example, psychiatrists have cited patient refusal as a primary reason for not prescribing LAI antipsychotics.13 However, a survey5 indicated that 75% of psychiatrists felt that they had informed the patients about all formulations of antipsychotics, while 67% of patients stated that they did not receive information about depot antipsychotics from their psychiatrist.5 These results demonstrate the need for education to avoid miscommunication and better explain LAI agents to patients.

Once patients try an LAI medication, many like them. In a survey16 of patients with at least 3 months of LAI antipsychotic experience, results showed that they actually preferred that formulation. Further, 70% of patients said they felt better supported in their illness because of regular contact with the health care provider who administered the injections.16 If clinicians offer LAI antipsychotics to more patients, they may find that more patients than expected will accept this treatment and will even come to prefer that formulation.17

Conclusion

LAI antipsychotics are a valuable treatment option for patients with schizophrenia. In order for patients to benefit from them, more education about the benefits and risks of LAI agents is needed for clinicians, treatment teams, patients, and their families. Misconceptions and attitudinal barriers should be addressed so that patients who may benefit from LAI treatment can be identified. Education should also address the prevalence of nonadherence and the real-world effectiveness data on LAI drugs. Using LAI formulations at an earlier phase of illness may actually provide the opportunity to intervene during a period when nonadherence is common and relapses take away more of patients’ still-available psychosocial functioning.

Clinical Points

  • Be aware that data from studies can be confusing regarding LAI antipsychotic efficacy
  • Acknowledge that nonadherence is a major barrier in patients with schizophrenia and that LAI agents have been proven to be beneficial in promoting adherence in generalizable treatment settings
  • Consider an LAI antipsychotic at an earlier phase of illness than when the patient has relapsed multiple times, using it in a preventive fashion
  • Educate all members of the treatment team about LAI antipsychotics so that they can help educate patients and their families and improve treatment

Abbreviation

LAI = long-acting injectable

References

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