Optimizing Management of Schizophrenia with LAIs - Episode 20

Schizophrenia Treatment and Outlook

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John M. Kane, MD: Before we conclude, are there any final thoughts?

Erin C. Crown, PA-C: I like that we're emphasizing LAI [long-acting injectable] use early in treatment. I cannot state enough how strongly I support that. But I still get patients coming to me from an inpatient stay, or who have moved here from another community, or who are changing providers, and they may be further along in their schizophrenia journey. While I absolutely agree that we need to use them early, first opportunity that we have, in the state of schizophrenia, I would also say it is never too late.

Henry A. Nasrallah, MD: Yes, the landscape of psychiatry has to change. Many of our colleagues are practicing the same knowledge that they learned in residency. The field is rapidly moving. There are many data that can guide us to deliver better care for our patients. I don't buy this issue of, it's too much hassle. It is not a hassle at all to prescribe injectable antipsychotic [medication]. Think of the patient instead of yourself. We're supposed to do the best thing for our patients. I like to use the metaphor of cardiology. I tell my fellow psychiatrists, please behave like a cardiologist. When a patient comes with the first heart attack to the cardiologist, part of their heart has been destroyed forever. They have an infarction. And every cardiologist realizes that they cannot afford another infarction because then [the patient] will die outright or become so weak they need a heart transplant. So they do everything in their power. They give them multiple medications, change their life, their diet, they change their exercise habit, and they make them stop smoking. They recommend everything possible to avoid that second myocardial infarction.

We should do no less in psychiatry. We're dealing with the first episode of a brain attack. I like to call schizophrenia or psychosis a brain attack. Because part of their brain has been destroyed. And we cannot afford to let them lose more tissue. I wish there were that sense of urgency and empathy. The gratification of doing the best we can for our patients instead of doing the same old same old, giving them pills that they don't take.

Sanjai Rao, MD: We've discussed some topics that make it difficult and troubling to be optimistic. I thought I'd end on a note of optimism here. In reference to what Henry talked about, the landscape of psychiatry changing. A while back, I was doing a talk on long-acting [medications] for a mixed group of people, which included both residents from a good medical school and a number of people who have been out in practice for a while. I asked them the question, “When do you typically see your patient started on a long-acting injectable?” I asked everybody except the residents to answer. The practicing psychiatrists said what you'd expect them to say. They said [the patients] “who have been on 2 or 3 or 4 treatments. And they've had a number of years of illness, and so forth. That's usually when we see it, and that's when we do it.” Then, I went to the residents and said, “OK, what are you guys being taught? When do you initiate?” And every single one of them said, “We are being trained to start LAIs as soon as possible.”

I think that the landscape of psychiatry, at least I'm hopeful, and I'm going to be optimistic about this, that the landscape is changing. But it's changing from under us. And that hopefully what we can do by collaboration like this and by the work that we do day to day, is to nurture that change, and allow it to happen and blossom. For our colleagues who aren't part of that change help them understand where that change is coming from. And that the people they’re training are already part of that change.

Dawn I. Velligan, PhD: I'd like to make sure that as many people as possible know that medication is just the foundation for recovery. And that it takes a lot more for people to get their lives back. But without that foundation, it is not likely to happen.

Henry A. Nasrallah, MD: We need to fight the sense of nihilism. There is a clinical nihilism among many psychiatrists when they believe, “There is nothing we can do, those patients are hopeless. They don't change, no matter what we do, and they keep deteriorating.” We need to completely stop these negative, low expectations that permeate the field. It’s true, these patients are all disabled, and that's because we don't initiate LAIs in the first episode. If we change the paradigm of treatment, that universal disability we see in front of us would change dramatically. That is what I think plagues many of our colleagues, they do not believe that patients with schizophrenia are going to respond, are going to get better, are going to be out of disability. Because the way we practice these days, the general practice of giving pills with multiple relapses, is causing disability everywhere around us.

John M. Kane, MD: Thank you to all of you for sharing your perspectives with us, and I also want to thank our viewing audience. We hope that you found this HCPLive® Peer Exchange discussion to be useful and informative.

Transcript Edited for Clarity