Recommendations on Optimal Treatment for Schizophrenia - Episode 6

Addressing Hesitation in Switching to LAIs in Schizophrenia

October 8, 2019

Peter L. Salgo, MD: Let me paraphrase something you said earlier, because I do want to put a button on this. If we’re talking about relapses, and we’re talking about oral drugs for which you need a longer half-life—the volition—or longer half-life which is administered in a controlled clinical setting, it sounds as if you’re saying to me that the risk of relapse is much lower with injectables. If you can get to the longest-acting injectables, lower still.

John M. Kane, MD: Yes.

Peter L. Salgo, MD: That’s a monosyllabic answer. I love it. It just makes common sense.

John M. Kane, MD: It does, and that’s what’s been so frustrating about the fact that these formulations are used much less frequently than they should be. I’ve been working in this area doing research in the long-term treatment of schizophrenia for really several decades. It’s been frustrating to think that we do have an approach that we believe will be much more effective for many patients, but it’s still not widely used. Why is that?

Peter L. Salgo, MD: Well, that’s a good question, isn’t it? I’m not being facetious.

John M. Kane, MD: Yeah. No, it is.

Peter L. Salgo, MD: It’s a really good question. There were newer antiarrhythmics, so why aren’t they being used? There are better formulations of newer hypoglycemics, and the adoption of these things takes time.

John M. Kane, MD: Yes. I think it’s 1 of the embarrassments of medicine, that it takes more than a decade to implement new findings into clinical practice. In the case of long-acting formulations, it’s been even longer than that. I can give you some sense of what I think the obstacles are. I think we discussed it a little before, in the sense that many clinicians really think their patients are adherent, so they don’t automatically go in this direction. Another factor is that many clinicians will assume that the patient will say no. If I offer you injections, you’re going to say no because why would I want injections? I don’t like needles.

Peter L. Salgo, MD: What jumps out at me from that is diabetes.

John M. Kane, MD: Yes.

Peter L. Salgo, MD: The assumption by clinicians even today is that if they offer injectable insulin, the patient will say, “No, my Great Aunt Matilda had insulin and died.” Whereas in fact, most people say, “Well, yeah, sure, why not?”

John M. Kane, MD: Exactly. In my mind a lot of the problem is the clinician, not the patient, in terms of this communication. I don’t want to just blame clinicians, because in many cases they actually haven’t had adequate training in how to do this. Everyone assumes we’re a doctor, and we went to medical school. That means we can talk to any patient about anything in a very informed and compelling way, but it’s not that simple.

Peter L. Salgo, MD: We can quote Pogo, right? Pogo said, “We have met the enemy, and he is us.”

John M. Kane, MD: Absolutely. Again, I don’t want to demean clinicians, because this is something we haven’t necessarily been trained to do—how to have these conversations. I think there’s a natural impulse to react too quickly if someone reacts negatively. If I say to you, “I think we should use a long-acting formulation,” and you say, “No, I don’t like needles,” really the challenge is what do I say then? Do I give up, which is what many clinicians do, or do I begin to have a dialogue with you over time? I’ve had many patients who initially absolutely refused a long-acting formulation, but over a period of several months we kept talking about it, and eventually they agreed.

Peter L. Salgo, MD: You inure them to the concept.

John M. Kane, MD: Yeah. Eventually they agree. I think it’s a matter of time, patience, and giving patients a chance to express their negative feelings or their negative concerns and reassuring them. How we deliver the message is really important, and I think that’s true in so many areas.

Peter L. Salgo, MD: What is the actual volume of the injectate? How much do you push?

John M. Kane, MD: It varies. It could be 1 cm3, it could be 2 cm3. It varies.

Peter L. Salgo, MD: But you’ve already told me the answer to my next question; it isn’t a lot.

John M. Kane, MD: No, it’s not a lot. Yes, some people have pain when they receive an injection. Interestingly, the studies show that the pain goes down over time, because as you’re more relaxed, the injection is going to hurt less.

Peter L. Salgo, MD: You’re not tensing, so it’s going to hurt less.

John M. Kane, MD: Exactly. Most people who’ve had the experience of receiving these long-acting formulations get to a point where they prefer them. They say, “This really is fine.” We didn’t talk about some other factors involved in taking oral medicine in addition to remembering. But also, sometimes it’s embarrassing. You’re in college. You have a roommate. Your roommate asks you, “Hey, John, what are you taking?” You might not want to say, “I have schizophrenia.” I hope we get to a point someday when that’s fine, when you can just say that, and nobody reacts—there’s no stigma. But right now, for some people it might be a lot easier to have an injection once a month than to take pills every day in front of other people.

Peter L. Salgo, MD: I know what the roommate is thinking, and so do you. “Uh-oh, he’s a schizophrenic, he’s going to go off. I’m in danger. I’m going to write mom. They’re going to move me out of my dorm room.” I know that.

John M. Kane, MD: Yeah, that’s very possible.

Peter L. Salgo, MD: So this is less stigma.

Transcript edited for clarity.