Overcoming Barriers With LAIs in Schizophrenia Management

Transcript: Christoph Correl, MD: There are many advantages of long-acting injectables [LAIs] over oral treatments. These advantages in meta-analyses and in database studies are the greatest the more generalized and clinically relevant the samples are. Why are long-acting injectables not prescribed more? When you ask clinicians, “How many patients who see your colleagues do you think will be nonadherent over the next year or so,” they say between 50% and 70%. That is the number that we see in the studies. But still, in the United States, only 10% to 15% of patients get long-acting injectables.

Why is that? There is a disconnect when we see that long-acting injectables reduce the risk of relapse, the risk of hospitalization, and even prolong life. And not just to reduce the suicide-related mortality, but there is a lower risk of mortality that's associated with cardiovascular illness because patients are not as sick, they see their doctors for secondary prevention, they have a healthy lifestyle. Why are clinicians and patients not jumping on this? When you ask clinicians, they say, “My patients are adherent, why would I need to use it?” Their colleagues' patients are not, but our own patients are. We’ve seen in multiple surveys that [clinicians] overestimate adherence in their own patients.

Clinicians often say, “I would like to, but 80% of my patients say no, I don't want an injection.” When studies are done, it seems that 80% of patients have not even been offered an LAI. How can they reject it? It's a complex web. Yes, there are patients who say, “I don't want a needle; I'm needle-phobic, or I don't like the pain.” But if clinicians believe this is one of the best treatments we have and sell it to the patient, do motivational interviewing, share decision-making, and make sure that patients understand, if you want to achieve your goals, then clinicians need to listen to the patient's goals. “If you don't believe me, then maybe talk to Peter, who also didn't want that in the beginning, but now he's a peer counselor because he's doing so well on this treatment.”

There are multiple reasons why clinicians can't or do not want to offer LAIs. One big one in clinical care is time, because patients are seen very quickly. Writing a prescription is very fast. Having to explain why an injection and what's different, what's the advantage, and how is it done, that takes time. Psychoeducation is not a 1-shot deal. You can start it, talk to family members, and then revisit it later down the road.

Clinicians are sometimes afraid that they might undermine the therapeutic alliance. Patients might be adherent now, which is fine. Why would I then say, “You need an LAI, as if it's punitive, or you are lying to me. You're not taking the medication.” I would rather describe that as I take medications, and I don't always take them myself. It’s part of the human condition. “Don't you want to have a safety belt against this illness in order to achieve your goals?”

I think clinicians need to appreciate the data and that patients who are on LAIs like them. Data suggest that clinicians and nurses overestimate the issues that patients might have with LAIs. When you ask patients who are currently on oral treatment, they see fewer problems than clinicians. When you ask patients who have actually tried it, they have even fewer problems.

We did a study, the PRELAPSE study. It was a cluster randomized study to see if an LAI paradigm in first-episode and early phase patients beat in other clinics the oral paradigm. We trained treatment teams, everyone—doctors, nurses, psychologists, and caseworkers. And then we did role-play with them, frequently asked questions, gave them the data, but also the competence and the proficiency, and had the team aligned: “This is the best treatment we have.” It was astounding that in those patients, first-episode and early phase patients within the first 5 years who reached the sites and were offered, “We want you to be part of a study;” cluster randomization means the site is randomized so the patient doesn't have to decide between treatment A and B. They just agree, “Can I be assessed as part of the study?”

Transcript Edited for Clarity

We told them, as part of the study, you will be offered an LAI at one point and 14.4% said, “Leave me alone. I don't want to be convinced because there is a needle involved.” We couldn't talk to them any further to convince them over time. But a lot of the people who said, “OK, let's see how it goes,” 91% received at least 1 injection within 3 months. Subtract those who didn’t receive an LAI, which leaves you with 76%. Three out of 4 patients with early phase schizophrenia within the first 5 years and first episode can be given, and accept and will try, will trust a team, and will try an LAI. That was an eye-opener and a lesson. We need to lower our own objections to the LAI treatment and not say that it's always the patients who have this objection.