Institution-Focused Management of Schizophrenia - Episode 7

Administration of LAIs in Schizophrenia

March 8, 2021
Henry Nasrallah, MD, University of Cincinnati College of Medicine

University of Cincinnati College of Medicine

Henry Nasrallah, MD: About 10 to 12 percent of patients are taking a long acting injectables. Most of them are getting it very late in the illness, after multiple episodes. So if you want to look at the ideal use of long acting in the very first episode, less than 1 in 10,000 patients gets that. It's extremely rare to see the psychiatric practitioners use long acting injectables very early, which is the ideal time to use them. So what this—this overall use is extremely low anyway, 10 to 12 percent instead of 80 to 90 to 100 percent as I believe, and after multiple episodes, which means they're not going to work as well as using them early. 

They will work, but relapse is still possible after—because of treatment resistance, like I said. If you defer the use of long acting injectables too much, the patient might still relapse. So compared to Europe, for instance, where the use of long acting injectable is 40, 50 percent in some countries, the US is certainly behind. It is vastly underutilized and there are many reasons for that. The most important impediment to using long acting injectables is the attitude of the psychiatrist, they don't want to impose on their patient, they feel like they are being paternalistic, they want the patient to make their own decisions. Which is a noble human decision, yeah, let them exercise their civil liberties. But what they forget is that the patient's frontal lobe, which is where we make decisions, is actually impaired in schizophrenia. They cannot make the right decision. 

They don't know what's good for them. They don't know they're self-destructing, basically, by not taking the pills. So it's really sad that many psychiatrists decide to let the patient manage their own illness. Which works very well in other disorders. If you have diabetes, heart disease, arthritis, of course patients with a normal brain will exercise their wise decision. But not in schizophrenia. So it is—there's also another reason, by the way, why many psychiatrists don't use the long acting injectables very early. Ignorance, scientific ignorance. What I'm referring to here, the damage, the brain damage that occurs with psychosis was not known until 20 years ago. So in the '50s, '60s, '70s, '80s, and '90s, decades, all the psychiatrist trained in those periods had no idea that psychosis is actually neurotoxic and causes brain damage. They didn't know. So they took it at matter of fact. Oh, yeah, patients with schizophrenia relapse, that's too bad, here they come again, in and out. 

They thought it was just another thing schizophrenia patients do. But now that we know, 20 years ago we discovered with research, with follow-up MRI scans after every episode, that the brain is actually shrinking, atrophy. The brain is losing tissue with every episode. That's when we realized that it is a degenerative condition. Psychotic episodes are neurodegenerative, exactly like Alzheimer. Although the type of damage is different. But it's like a stroke, also. Although the type of damage is different. But all of those brain disorders, including psychosis, are neurodegenerative. 

We didn't know that until 20 years ago. So many clinicians are still using their old habits of deferring the use of long acting injectable, not taking psychosis seriously, not really recognizing it as an emergency, which it should be, because of the ignorance and the old training where this was not incorporated in their treatment algorithm. So as you know, even though we discovered it 20 years ago, it takes a long time for a scientific discovery to filter into clinical practice. That's the problem.

Transcript Edited for Clarity