Institutional Best Practices for Treating Schizophrenia - Episode 6

Introducing Long-Acting Injectables (LAIs) in Schizophrenia

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Henry Nasrallah, MD, recalls the history behind long-acting injectables in patients with schizophrenia.

Peter Salgo, MD: I know that we just put our toe in the water about long acting injectables [LAIs]. Henry, you talked about it. What are the American Psychological Association guidelines regarding the use of LAIs for the treatment of schizophrenia? Is there a guideline here? 

Henry Nasrallah, MD: One of the worst things that happened to LAIs, which are an incredibly useful tool for treating patients' long term, is that they got the reputation of being a last resort. This started in the 1970s, when the old first-generation drugs, Prolixin and later Haldol, the only 2 available long-acting medications in the first generation, which I never use anymore because they are bad for your brain it turned out. Clinicians never really adopted them for a variety of reasons. Some of them were totally irrational reasons like, “I don’t want to impose on my patient. Let the patient make their own decision,” when the greatest problem with schizophrenia is that their frontal lobe cannot make the right decision. It’s a neurological deficit, and they also have anosognosia, they are not even aware they are sick. The psychiatrists were so liberal, they said let the patient make their own decision.

The other reason that they were so passive in managing and not using long-acting very early and aggressively, is ignorance. As I told you earlier, we did not know until the year 2000, just 20 years ago, that the brain in schizophrenia, during psychotic episodes, undergoes massive loss of brain tissue. We did not know that in the ’70s, ’80s, and ’90s. It only became known from research 20 years ago. They did not take it seriously. Another psychotic episode, the patient comes back to the hospital, they say, “That’s what patients with schizophrenia are supposed to do.” Completely oblivious to the fact that they must and should prevent the psychotic relapse in every patient. LAIs were shown in numerous studies to be better than oral medications, published as far back as in the mid-’70s, and nobody read them, nobody seems to care. That is the problem.

Peter Salgo, MD: Now, we have National Council for Behavioral Health guidelines recommending the use of LAIs. What do those recommendations look like at this point in 2021?

Rahn Bailey, MD, DFAPA: There are several, I have them right here. First, patients who may be at high risk, medication noncompliance, I think the point that Henry just made. But the reality is, we should have for a long time considered that these should be first-line treatments, and not only secondary or tertiary care treatments. The reality is they work as well in the first line, and you are less likely to relapse in the first place if you use them up front. But they are also very helpful for transitions of care. It gives a reason for another person to be involved—your case manager, your team, the family support that we discussed earlier. That entire construct works more effectively for that individual.

This idea that it is a burden of medication taking, you have to remember it, you cannot lose it. I always make the comment to my families and patients—myself, my wife, we all make this tongue-in-cheek joke that we have never finished a 14-day course of antibiotics for anything from an infection or whatever the case may be. Why do we think that psychiatric patients remembering would be different? If you do not finish the course of antibiotics for 14 days, who’s likely going to finish the course when we are taking medicine for at least 6 months, sometimes for a year to 2 years to try to prevent relapse? We always have appreciated the need to find different strategies to put patients on a better course toward long-term progress and success. I think the LAIs certainly do so, and the guidelines indicate that.

It also can be personal choice. I think the point that we just made is also true. If we do not really talk about it and discuss it with some degree of positivity, the patient is unlikely to view, subconsciously or the like, from us that it’s a good thing. We have a lot to say and a role to play in increasing the likelihood the patient will accept LAIs as a treatment choice.

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Transcript Edited for Clarity