Institutional Best Practices for Treating Schizophrenia - Episode 8
Joe Avelino, RN, BSN, MHSA, CPHQ, reviews the benefits of using long-acting injectables (LAIs) and Henry Nasrallah, MD, reviews his techniques for getting patients to accept LAIs and continue with them.
Peter Salgo, MD: Do you have any data on the benefits of the system of LAIs [long-acting injectables] and decreasing length of stays or institutional stays because LAIs are used as opposed to oral agents? Do we have any hard data on that?
Henry Nasrallah, MD: There’s a lot of data.
Joe Avelino, RN, BSN, MHSA, CPHQ: I will say—but it’s just observation—4 things: 1, I believe that definitely whether or not your patient is taking the medication; 2, patients don’t need to remember to take the medication every day; 3, it reduces the relapse frequency and perhaps even reduces the rehospitalization rates; and last but not least, it allows you to know whether relapse is caused by the lack of response to the medication or because of poor adherence.
Peter Salgo, MD: You guys were talking briefly about patient preference and how that’s become embedded to some degree in the law, or certainly in the way physicians are recommended by protocol to treat these drugs. Yet you’re also telling me that patient preference is flawed because schizophrenics have poor decision-making. Is patient preference ever something you would put in a list of conditions for using LAIs vs oral medications?
Henry Nasrallah, MD: Excuse me, but the answer to your question is obvious. Why are we treating patients with schizophrenia any different from another emergent brain disorder? Do patients with stroke have to decide whether they get interventional removal of their embolus or take tPA [tissue plasminogen activator] injectable or go through rehabilitation for the next 6 months? No, they don’t; they go do it. Why? Because they are able to make a decision, OK? Same thing with cardiology. Patients with heart attacks come to the coronary care unit; they don’t ask permission to give them all the medications to save their life. The cardiologists do it anyway, they don’t wait for the patient to tell them. Many times they are obtundent. Patients are actually unconscious, and they help them. Our patients are not unconscious, but they are not aware of their illness, which is like a different kind of unconscious. We must stop treating patients with schizophrenia like people with a normal, healthy brain who can make a decision. They cannot make the right decision until you treat them. I have treated patients with LAIs for 5, 6 years in a row, and I am amazed by how much their insight and good judgment come back, but it takes at least 2 years of continuous treatment, and their brain actually heals. The inside comes back. But many clinicians don’t see that because either they never start LAIs, or they start it and stop it after a few months because the patient said they don’t want it. That is why they’re missing the opportunity to see the good outcomes with LAIs.
Peter Salgo, MD: If decision-making is really a problem in schizophrenia, what are your techniques to get buy-in from patients to accept the LAIs, then to go on treatment, and to continue going forward on them? You can’t hit them on the head and say, ‘Do it,’ can you?
Henry Nasrallah, MD: I use several techniques, Peter. First, I educate the patient on what the illness is. I scare them. I show them MRI scans. I show them a brain that’s shrunken like a patient with multiple episodes. I have scans showing it’s almost like an early Alzheimer disease, and I say this is a normal brain. You don’t want your brain to look like this, do you? This is what happens if you relapse. Second, I educate them. Why bother taking pills every day? Studies have shown that if you miss 1 day, 1 dose every 4 days, you relapse. These are blood measures that were done, levels of antipsychotics. If you drop 25%, you relapse. That’s how risky it is for patients to be given the responsibility to keep their life well by taking pills when there is injection. That’s another tactic.
Third, I tell them it’s like a vaccine. You want to protect yourself from a viral infection, don’t you? This is protecting you from coming back to the hospital, which you hate to do. You don’t want to get sick and hear voices again and be tortured with paranoia, which you just finished and are emerging from. PTSD [post-traumatic stress disorder], by the way, has been shown to be very high in patients with psychotic episodes. PTSD is due to their life-threatening experience. You don’t want that either. Then I ask them, “Isn’t it nice to just take 1 injection a month and then after 3, 4 months, I can switch you to every 3 months?” There are actually formulations that can be given every 3 months. I say only 4 injections a year, but there’s 1 coming down the pike that is 1 injection every 6 months. One of the companies has submitted to the FDA studies, 1 injection every 6 months, so that will give me even more ammunition to incentivize the patient to forget about the pills, stay well with an injection, and then come and see me every month for psychotherapy support, a vocation rehab, etc.
Peter Salgo, MD: It seems to me that it would be desirable for a patient to say, “Look, I can forget about it.” To use a phrase from late-night television, “Set it, and forget it.” I had my injection, I don’t have to go back for a while.
Henry Nasrallah, MD: LAI for schizophrenia is like the vaccines for the pandemic. Look at how much hope, as Joe said. We are all hopeful because of the vaccine. Same thing. LAIs are like a vaccine for recurrence of schizophrenia at preventing the total disability. But here’s 1 last thought I forgot to mention earlier. Patients with schizophrenia have a very high mortality rate. Death is the worst outcome in medicine. They lose about 25 to 30 years of life. Numerous studies have shown that.
A recent study in Sweden, published in a major journal just last year, looked at all the schizophrenia patients in Sweden—30,000 of them. It followed them for 7 years and kept them on whatever medication they’re taking to see whether there’s a relationship between the medication and mortality. Guess what they reported? The lowest mortality of all the drugs in schizophrenia, the lowest mortality was with the injectable second-generation antipsychotic by about 8-fold lower mortality. That’s another reason why we should use them. We’re saving people’s lives from premature mortality, which is 1 of the major scourges in schizophrenia. That wraps it up in addition to preventing psychosis by preventing early death.
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Transcript Edited for Clarity