Joe Avelino, RN, BSN, MHSA, CPHQ, College Medical Center

What I want to do is go around to each of you and let you speak directly to the audience for 30 seconds to a minute and leave them with some pithy thought that you’ve had over the past hour and a half from the past decade or 2. I want to leave time for that before we go. Let’s start with you, Henry.

My closing remarks are as follows: I wish that we, in psychiatry, adopt evidence-based practices for the sake of the patient. We have to stop doing the traditional same old, same old, which is often done in patients with schizophrenia, and start thinking of it as an acute emergency—a brain disorder that needs to be treated just as seriously as a stroke or a heart attack—and the only way to stabilize patients with schizophrenia on an ongoing basis, at least the majority. It’s a heterogeneous disorder, I admit to you. We estimate there are at least 800 types of schizophrenia, genetic and nongenetic. Fortunately, 70% of them respond to dopamine antagonist, which is what the long-acting injectables [LAIs] available are. 

We can manage the patient, keep them well. We need to change the habit of giving them pills when they’re discharged from the hospital only to see them come back again and again, and to think this is the way it is with schizophrenia and accept that disability as a fact of life. This is the worst thing you can do for a patient, to expect negative outcomes. I tell my colleagues in psychiatry, how would you treat your own son or daughter if they develop an acute psychotic episode with schizophrenia? How would you treat them based on the best evidence we know these days? Would you treat them differently from the patients? 

Shouldn’t you treat everybody the same, which is to protect them from the hazards of relapse as early as possible, not dillydally and wait for the patient to have multiple relapses and then use long-acting? By then they are disabled, they’re homeless, they’re incarcerated, they may have committed several suicide attempts, and they’re treatment resistant. All those negative things that can happen, most important the disability. They are written off. They have no life anymore. Wouldn’t you want to treat your son or daughter in a different way from how you’re treating your patient? I would ask them that question, knowing what they know about LAIs.

First of all, great panel. Thank you to the moderator and both of my copanelists. I’ll end with some pithy statement that I started with. This stigma has raised its head throughout my career, and that in many regards is at the foundation of today’s discussion. Stigma very often refers to fear; it’s unrealistic. It’s not based on fact, but it’s perpetuated in an ongoing fashion, and that’s a reasonable consideration for today’s discussion of why it’s so difficult to make the argument, to clinicians, patients, and families, why we should use an empirically based approach and do what’s best for the patient clinically short term and long term.

There’s more. There’s also this idea that, as physicians, there’s stigma within our own profession. This last comment that Henry makes is timely. Much of my career…. You go away and stop all your medications as if the other clinicians and physicians in health care think our medicines don’t matter or that they’re doing something to actually prevent mortality in human beings whose lives are as important to me as they should be to them if that patient has heart disease, diabetes, asthma, cancer, or something that’s a component there as well. It’s likely that other individuals, including other physicians and clinicians, are also sending the same message that one shouldn’t take the medication—you shouldn’t take the injections; you shouldn’t need medication. They’re noncompliant; you don’t really need this. Nothing is wrong with you. We’ve got to make that argument much more effectively.

I’ll end with my comment of my mother. To be a doctor you have a good therapeutic alliance. The bedside manner was always what she talked to me about. I have a daughter who’s a doctor, but I always say the smartest doctor in our family was the one who was a schoolteacher: my mother. It made so much sense. At this time in my career, I’ve appreciated that if patients believe in me in many regards and what I represent, if they trust and believe in the doctor, then they’ll trust and believe in our message. Then they’d arguably be more likely to be compliant. Compliance can also occur with LAIs, and they just happen to be with oral treatment. Today’s discussion was remarkably timely for my patient population and 1 that we all should take to heart. We had a very good session. Thank you for having me.

Joe, this is either very good or very bad. You’ve got the last word. Did they take all the good stuff, or do you have something pithy to say?

Actually, I’m going to begin with LAIs and close with LAIs. This surge of people experiencing psychiatric problems has the potential to impact the health care system for years to come. What I’m talking about is the pandemic has not only interrupted the treatment of people managing mental or substance abuse disorders but has also placed broader segments of the population at risk for developing conditions, such as depression, anxiety, alcohol use disorder, and as Henry alluded to earlier, post-traumatic stress disorder, PTSD. After 25 years in the military, the challenges with PTSD are still forthcoming.

But let me close with this, because we started with LAIs: As our distinguished panelists Rahn and Henry alluded to and you facilitated, Peter, LAI is our hope for the future. We take it for granted, and it’s underutilized. Better education of LAIs for our psychiatric population is certainly a sign of hope.

 I want to thank all of you. This has been a tremendous discussion. Because I’m not a psychiatrist, there was a lot of new information, all of which was hopeful. I didn’t expect it to be. This was great stuff. I want to thank all of you at home, of course, or wherever you’re watching this HCPLive® Peer Exchange broadcast. If you enjoyed the content, we invite you to subscribe for our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox. I’m Dr Peter Salgo. Thank you, and I’ll see you next time.

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A panel of experts in schizophrenic psychiatric care share their thoughts on the practice, patients, and treatment based on their years of experience.  

Schizophrenia: Practice, Patients, and Treatment 

I can hear similar clinicians saying, “You’re going to put somebody on an LAI [long-acting injectable]. Now they get sick with something else, not their schizophrenia. They come in with an MI [myocardial infarction], diabetes out of control, urinary tract infection, and they’re septic. Doesn’t the LAI, which is on board long term, complicate everything? Or do I just treat as if the LAI is not there? Is there something I have to worry about?”

 I can comment because on the hospital acute care side, it’s a med-psych facility. The way we manage these dual diagnoses is to first handle the acute care component. Let’s say a patient has hypertension or diabetes or needs a neurology consult. We consider that as the acute care site admission. Once we stabilize that, we admit them on our behavioral side of the unit, because we have an 84-bed acute care with 137 beds on the behavioral health side and then manage that accordingly. But in this case, what’s interesting is when the patient is admitted in the acute care side; the internist is the primary physician. If it’s primarily behavioral health, the psychiatrist is the admitting and the internist is considered the consultant. 

 The question that’s going to come up—and we have to answer it for the internists, cardiologists, and nephrologists—is, “Can I continue giving the injectable? Do I have to call in the psychiatrist to consult? Will this injectable interfere with a therapy that I want to give for the problem that’s brought the patient to the hospital this time?” These are all legitimate questions. How do you integrate all this into the health care system?

 I don’t think our internists—I can speak to my facility. My internists and my specialists don’t know the LAIs. This is where—

Wait a minute. They would recommend this patient because the “behavior” probably needs a psych consult. I’m not aware of any of my internists or my specialists recommending or initiating orders for LAIs.

What you’re saying is psychiatrists are specialists. You can go ahead and take care of the diabetes and get the psychiatrist on board to help you modulate the LAIs at the same time, work as a team. Now there’s a thought, Henry. You mentioned the team about an hour ago.

Right. It’s the same here. Primary care doctors are not going to write for LAI. I have 2 doing inpatient physicals in my hospital every day and 2 doing outpatient, family medicine doctors. What they should understand is how those medicines work and interact with the medicines they’re using. What they also should do is be sure that the patient is not only medically stable but that we have them on a trajectory toward better overall medical outcomes. I’m regularly still surprised by how often in psychiatry we tolerate patients with high blood pressure, diabetes out of control, and all these things if they have chronic mental illness. Our patients deserve, as we have discussed today, the same level of high-quality medical intervention as they do psychiatric. The team approach is key, but there must be psychiatrists as the team lead.

 What strikes me—I’m an internist and intensivist. It just strikes me that when you set up a silo that says psychiatry and psychiatric illness is different from everything else, you’re setting yourself up for trouble and you’re setting the patient up for trouble. Once you recognize that psychiatric illnesses have a neurological basis, this is a good thing. When we all work together as physicians treating all these things as a team, it strikes me, is the patient going to do better? This makes sense to me. What do you think?

 Let me mention something that can address another hidden advantage of the long-acting injectables. Many times, when a patient with schizophrenia gets medically ill, they get hospitalized on an internal medicine floor, they stop all the medications, just like that. Whether they’re taking antipsychotics, antianxiety drugs, or antidepressants, they just stop everything, which I find almost abominable. I never stop my patients admitted to psychiatry receiving epilepsy medication. I don’t stop them, but they do. We keep telling them, “Do not stop these medications. The patient will relapse.” If the patient is taking LAIs, there’s nothing to stop. They can go in and have their surgery, have their internal medicine treatment; nobody can stop anything. They remain well. It protects them through thick and thin, including admissions for other conditions.

I guess you really get questions about this patient having an LAI on board: “If I have to give a vasopressor, is that going to be an issue?” You have to be ready with answers for that.

We can certainly communicate to the colleague who’s asking this question: what are the LAIs, their benefits, and their safety. They’re all approved by the FDA. We have several on the market, and no matter which 1 we use, they all work, and they all are tolerable. Otherwise, the FDA would never have approved them.

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Joe Avelino, RN, BSN, MHSA, CPHQ, and Rahn Bailey, MD, DFAPA, explain protocols a practice can follow when managing a patient with schizophrenia who is frequently hospitalized or has other medical conditions. 

Protocols for Frequently Hospitalized Patients 

 In your experience, Rahn, do you think LAIs [long-acting injectables] are under prescribed? 

 I’d say 4 things. No. 1, we’re having a very good discussion about that. They are under prescribed for a variety of reasons, and we’ve made that point very clear. I think Henry said 10%. I’ve always written in the 15%-to-20% range, but the numbers are definitely much lower than they should be. Second, not only are LAIs under prescribed, but we have data arguing that we should probably use—I think it was only mentioned once today—Clozaril has a greater risk of suicide or psychotic aggression. We often are afraid because the blood draw is an important part of that acculturation to really push the envelope and use best-in-class choice along that line as well. If we begin to appreciate that, the analogy is the same for the use of LAIs first line.

The third thing is this issue of when to use them. Part of the strategy has to be, if we’re going to move toward using them more regularly, arguing against what are the reasonable rationales that many doctors learn early in their career not to use them. That’s this issue that the only way to use them is tertiary, once you fail something else, or you wait to use them once there has been some long history of noncompliance, or what have you. The point was made and we regularly discussed the fact that they’ve been used for a long time much more assertively in Europe than here. We probably should not have so much of a distant approach. This is going to be an area that European psychiatrists get better than us. Reading data from both sides of the pond, so to speak, will also help many of our younger and midcareer doctors.

My final point is that the position regarding long-term outcomes is key. That’s the issue of having high expectations by doctors in our patients and what can occur. I want my patients to have the same 3 things that I have in life: a decent clean place to live, some work or some vocation that I feel respected in, and hopefully a family that loves me. We shouldn’t think that patients have to have a setting where they don’t have that. I know Joe Avelino is in California and can probably teach us better about this, but I haven’t been in a place where the state wants me to discharge persons to homelessness. 

In my entire career—I’ve been doing this in 4 or 5 other states—1 of the goals is to get them stable, and then we work very diligently to get them discharged to a place where they’re likely to be successful: a clean, decent halfway house and they have SSI [Supplemental Security Income], some funding, and theoretically a way to make sure they’re medication compliant. Putting all that together speaks to this overarching issue of why LAIs first line can be best for many more patients.

When I was considering where we were going to go with this discussion, I was considering asking, “What are the demographics among patients that should make you consider an LAI vs an oral agent? But after listening to you folks, I’m not sure there are any demographics that would make you prefer an oral agent over an LAI. Or am I missing something here? Why would you not offer everybody a therapy that prevents recrudescence of this disease? It’s easier to use for the patient, it’s less costly to society, it gets patients out of the hospital and keeps them out. Where’s the downside? What am I missing? Is anybody going to tell me I’m crazy? That’s a strange question to ask a psychiatrist, but go ahead.

 I’ll jump in again. I’ll be brief. I’m a 56-year-old man with high blood pressure for the last 20 years, and I wish there was an LAI that I could take once a month, let alone like a Trinza every 90 days and 1 becoming even longer than that. I often argue to my patients—because I speak about myself quite a bit to patients—it makes the situation pretty real. Although my grandmother at age 95 was on 4 antihypertensives, the reality is that she lived to age 95 and saw her kids graduate from college and her son be a grand physician. Treatments can help. But taking them is what’s key, and she had the ability to take them regularly; otherwise, she probably would have had an MI [myocardial infarction] or a stroke well before she was age 95, maybe when she was in her fifth, or sixth, or seventh decade. The reality for us is that LAI is a remarkable advantage for psychiatrists. It would give patients a chance to be compliant with medicines for a longer period that would let them have a more successful overall life.

Rahn Bailey, MD, DFAPA, explains why long-acting injectables are under prescribed in patients with schizophrenia and why doctors choose not to use them as a first-line treatment.  

Under Prescribing LAIs: Understanding Why 

 Joe, let us transition from patient care protocol upon discharge from the inpatient setting to the outpatient setting. You are managing this every day. How do you manage these protocols, the processes, the best practices to ensure that a patient leaving the inpatient setting continues to get the best standard of care?

There are two scenarios here. No. 1, the use of—for lack of a better word—a home health nurse or community nurse, because some of these patients do not have families. We even have home health that accepts Medi-Cal, and they can be followed up by a home health nurse, so they can adhere to these LAIs [long-acting injectables]. Second, working with the homeless population, working with the shelter, we usually have a liaison or someone who is a worker, and we’d work with them to make sure these homeless patients follow this regimen accordingly. It really is challenging, as Henry and Rahn alluded to, of medication regimen adherence. But those are some of the things we put in place here, making sure that the family members—we talked about this earlier— get involved as part of the plans, not just the patient but their support system as they’re discharged from the facility.

 I come back to the question, Joe. Hard-and-fast protocols. I know doctors have their own order sets, and I know they might like their own order sets. But at the end of the day, if you are letting some patients leave your setting and go to a less controlled outpatient setting, are there hard-and-fast protocols that doctors must adhere to, to be sure their patients get the best care?

 Nothing mandated. Nothing is mandated for psychiatry that I know of. They leave it up the psychiatrist to prescribe what they want, to monitor when they want, to discharge the patient on what they want. The outcomes are very variable. There are physicians who do the right thing and others who do not, but there is no consequence. This is a very loose state of affairs.

 It’s a very important point. It has clinical and forensic implications. I trained in forensic psychiatry, and early in my career, I spent about 6 years not on a board of medical examiners but as a consultant to the board. What I’m ultimately struck by is that it is not when physicians get in trouble with the board. It often started with some difficulty on their job. We are people who often put a lot of our self-esteem, self-identity in our profession, our career, and our job. Too often difficulties occur because a person started doing the wrong thing. Having some degree of oversight is useful or beneficial. That is what algorithms allow because you are following some protocol or some regular set of rules or regulations, so you are online with everybody else. Often these troubles occur when you get off the beaten path—you are off-kilter, and you are not at a practice with a colleague who is going to pull you back and say, “You’re not doing that correctly.” It is to the doctor’s benefit to have some train tracks, to remain in sequence. All too often, when we lose someone, it is because they have gotten too far away from normative practice.

Joe Avelino, RN, BSN, MHSA, CPHQ, describes the patient care protocols upon discharge from the inpatient setting to the outpatient setting to assure that patients will continue their care. 

Joe Avelino, RN, BSN, MHSA, CPHQ, College Medical Center

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