Optimizing Management of Schizophrenia with LAIs - Episode 18

Patient-Physician Collaboration and Schizophrenia Outcomes

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John M. Kane, MD: Erin, how would you go about communicating the benefits of an LAI [long-acting injectable] formulation to your patients?

Erin C. Crown, PA-C: I start the conversation at the first opportunity we have. That may be different related to our treatment settings. Sanjai is an inpatient psychiatrist, and he needs to consider when that conversation needs to happen related to the patient's acuity of illness, their ability to comprehend the conversation, and what are their concerns. In the outpatient setting where I am, there can be more flexibility. But I do it at my earliest opportunity. If I have a patient coming to me with schizophrenia and it's the first time I've met with them, it's on the table from the first time we meet. I don't take a “no” then as a “no” forever. I will continue to offer and educate and share the benefits of these treatments.

I rarely get a decline when I'm offering it. That is in part because we work hard here to build relationships with our patients, getting to know what matters to them. There are so many benefits to long-acting injectables that if we know our patient and what their concerns are, we can offer it to them in a way that's going to resonate with them. Some people will say, “I don't want another pill added.” We talk to them about eliminating a pill and in some cases multiple pills, if they're on something that's being dosed 2 or 3 times a day. We can talk to them about eliminating oral medications by substituting it with the long-acting injectable. It's more convenient. They can live their life without living it around their next dose of medication. This is great across the lifespan, and is particularly wonderful for the young population, who may want to be active, social, and engaged, going to school or going to work.

We want them to do those things, as long as they're able to do it from a cognitive and social perspective. We can share with them that they can be confident that their medication wasn't missed. With Penn State University here, I see a number of college students. These folks are living in roommate situations. A long-acting injectable can be offered as a discrete option for that population. They won't have a roommate rummaging through their medicine cabinet, finding out what medications they're on and going to “Dr Google,” then thinking that their roommate is crazy and damaging those relationships. Even for an older population, folks in a group home setting….

John M. Kane, MD: Those are very important points. One of the things you mentioned, that it’s a question of persistence. If someone declines to try a long-acting formulation, you don’t give up at that particular moment, you’re going to discuss it again at a subsequent occasion. We’ve heard from some clinicians that they’re afraid if they offer a long-acting formulations to their patient, that is somehow going to interfere with the therapeutic alliance. That the clinician is saying to the patient, “I don't trust you to take your medicine, so I'm going to give you injections.” And I think that's a very unfortunate way of viewing it because if anything, this should facilitate the therapeutic alliance. You don't have to spend so much time in each visit asking the patient whether he or she took their medicine. There are real advantages in terms of the therapeutic alliance from my perspective.

Erin C. Crown, PA-C: Sometimes I wonder who is more afraid of the change, the patient or the provider? If it is the patient, then be careful with your language. Don’t use the word “change.” And if you happen to know that they had some bad experiences in childhood, going to the doctor worried about whether they were going to get a shot, be a little more sterile and clinical, and use the term “injection.” It's fine to be sterile and clinical in that situation.

Sanjai Rao, MD: Erin, I like to say, “The medication that you're on right now is actually available in a monthly version. You wouldn't have to take it every day, you could just take it once a month. Is that something that would be interesting to you?”

It’s really just normalizing it and letting them know that it's not a change. It's still the same thing, just a better delivery system.

Erin C. Crown, PA-C: I've heard it done by other providers with younger people who tend to be much more open to technological advances. Because they've grown up in this era of seeing people go from flip phones to smart phones, and box TVs to flat screens and smart TVs, and so forth. I've even heard it presented as a more technologically advanced option for someone who they felt that that would resonate for. That’s reasonable in the young population. I feel like it's about relationship at the end of the day. Know your patient, build the relationship and speak to them. These are not cookie-cutter people. They are individuals with independent lives. Let's help them maintain independence for as long as we can.

Transcript Edited for Clarity