Institution-Focused Management of Schizophrenia - Episode 4

Overcoming Non-Adherence 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, shares advice on overcoming the risk of non-adherence of LAIs for patients with schizophrenia.

Henry Nasrallah, MD: The majority of our patients do not like the idea of getting an injection, to be honest. I expect it when I start talking to them about it, but before I do that, I work with them as their physician/psychiatrist and show them that I care, develop a rapport, and have them trust me. Once a patient trusts their physician and realizes that they care about them, they will listen to whatever they say and follow their advice. That’s why I invest a lot of time and energy to develop this foundation of trust with my patients and then bring up the issue, but even then, sometimes they say, “I don’t like injections.”

I overcome that in several ways. For example, I tell them, “Look, an injection that will relieve you from taking pills, that’s just like a vaccine. You take a vaccine for the flu, and then you don’t have to get sick again. It involves taking an injection, so regard it almost like a vaccine. Many times, we can start with an injection once a month, with no pills needed at all, and we can switch you to every 2 or 3 months after you stabilize. It’ll be very few injections every year.” Another thing I tell my patient is, “You think 1 injection a month is too much for an adult like yourself? Come with me. I’ll take you to the Department of Pediatrics. I will show you young children—ages 6, 7, 8—who are taking 3 injections of insulin a day, so you can take 1 injection a month.” It’s just to give them perspective about it.

I also scare them. I believe in using justifiable, scientific fear to get my patient to accept the long-acting injectable. I show them MRI [magnetic resonance imaging] scans. I say, “Look at what the normal brain looks like. Look at this brain of a patient who had several relapses. Look how shrunk it is. Look how shriveled it is. It looks like early-onset Alzheimer disease. You don’t want your brain to look like this, do you?” That’s part of my education, the fact that every psychotic episode kills hundreds of millions of brain cells. I tell my patients, “You don’t want to lose brain cells, right? It’s almost a guarantee that you’ll become disabled and will not be able to go back to school and socialize with your friends. You will not be able to go back to work.”

This type of education, combined with some fear about the gruesome outcomes of relapses, works for many of my patients. I keep reminding them of something very important, which is that I believe this is the best medication for them because I would use that medication for my own family. If one of my family members developed schizophrenia, that’s exactly what I would use. I want to treat them like a member of my family. When patients hear that, they realize that you really care about them and want to treat them like a family member.

That’s the best treatment you can get, so I do not give up, even though many of them initially resist the injection. I use multiple types of arguments and reasoning in a very empathic, professional, supportive manner to sway them and have them accept it. I tell them, “Try it for a few months, and we can revisit it. If you don’t like it, we can always change, but let’s try it.” Most of my patients stabilize; they really love it and stay with it after a while. The initial hurdle is the resistance, but it can be overcome.

Transcript Edited for Clarity