Optimizing Management of Schizophrenia with LAIs - Episode 19

Schizophrenia Treatment: Overcoming Obstacles

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John M. Kane: Sanjai, in your experience do you think long-acting formulations are underprescribed, and what are some of the barriers?

Sanjai Rao, MD: This is probably the most important question. The answer, based on everything we've talked about, is yes. I’ll summarize the key points that would suggest that. We started off talking about the challenges of oral medication and the high failure rate. The underutilization leads to relapse. Henry has spoken extensively about the irreversible effects of repeated relapses, of untreated psychosis. We know that there is a huge amount of evidence showing improvement in adherence and reduction in relapse with long-acting injections [LAIs]. We know this holds true not just for the classic long-acting patient, who we used to think was the long-acting patient, ones who have relapsed a lot and are very ill. We know that this is true even for people in their first episode and who are early on in their treatment course.

Other countries that are not that different from us treat patients differently. Many European countries use several times the amount of long-acting injections that we are to treat their patients with schizophrenia. For me, the real question would be why wouldn't you use an LAI? Whenever it's possible, and when it's indicated, and your patient can use that as a reasonable choice, why wouldn't you do that? Why wouldn't that be the rule rather than the exception? And for the people who can't tolerate them for some reason, or who don't respond to the particular agents that we have available in an LAI, those are the people who get oral medications, and not the other way around.

John M. Kane, MD: That's an important message. When we’re asked about considering relapse prevention from the outset of the illness, it’s important to share the benefits of long-term treatment. We obviously want to help patients recover from their first episode. We want to help them get back to work, school, living as normal a life in the community as possible. And if we allow them to relapse, they're going to lose the gains that they've worked so hard to achieve. At a young age, it doesn't take that many relapses before we see some of life's opportunity being eroded. It's important that we consider relapse from the very beginning of the illness. That's part of our conversation. It's part of the psychoeducation process that takes place with the patient and with the family. They need to understand the nature of relapse prevention and what we can do to help them avoid the consequences. We've talked about different consequences associated with relapse and rehospitalization. Henry, I know that you discuss this option from the onset of the illness. Do you have any other thoughts that you want to share?

Henry A. Nasrallah, MD: I've written papers about how long-acting injectables and clozapine, 2 extremely useful options for our patients, are the most underutilized in psychiatry. Both of them are vastly underutilized. Only about 10% of patients with schizophrenia in this country are receiving a long-acting [medication], and after many years of relapses, of suffering and disability. About 30% of patients deserve a trial of clozapine, and only 4% to 5% out of this 30% are getting a trial of clozapine. I’m extremely upset that we aren’t doing better for our patients. These are the most vulnerable, young people, in the prime of life, and they lose everything because we're not giving them a trial of something that works. A medication that is likely to work better than what we're doing right now.

So I do everything in my power to treat with an LAI in the first episode. I treat every young person I see as if it's my own son or daughter. It's somebody’s son or daughter, and I have extreme empathy for them. I want to save their life from the ravages of schizophrenia and other degenerative disorders that we can at least halt or stop. I've had incredible success. I've seen young patients go back to school and work even after 2 episodes…. But it takes about 2 to 3 years of a continuous long-acting, second-generation antipsychotic for them to blossom and get back. There is brain regeneration taking place, I suspect, with neurogenesis with neurotrophic factors. We know that happens sometimes with the neuroprotective effects of second-generation [medication].

We must give patients a chance in their first episode to initiate an LAI, which is rarely done. I hope that our viewers watching our program would offer it as an option from the very beginning. But it's not easy. You have to develop rapport with your patient, a sense of trust, therapeutic alliance, educate the patient, and their family. Tell them that this is the best way to treat this illness. If they say, “I don't like injections,” tell them, “I can take you downstairs to the pediatrics department, and I'll show you young children with juvenile diabetes getting 3 injections a day. And you can't take 1 injection a month, of which I would change to 1 injection every 3 months after we adjust the dose for 3 or 4 months?”

Then I give them the argument about less medicine with injectable [therapy]. It becomes a sense of relief from all the hassles of taking pills. “This is the best way to avoid coming back to the hospital, which you don't like, obviously. And this is the best way to make sure that you can go back to school, work, and keep your friends. Otherwise, here's what happens if you relapse again.” And I tell them stories of patients I've had. I show them MRIs that I have proving how the brain shrivels. Show and tell works with some of these young people. “This is what happens if you relapse again. This is the best bet you have to minimize the risk of relapse.” I do everything I can. And if they still refuse, at least I sleep well at night.

Dawn I. Velligan, PhD: What's really important too, John, is thatthere is only one Henry, Erin, and Sanjai. We need to change prescriber behavior. We have to keep LAIs in what the providers are prescribing. In the clinics that I've worked with we use a very brief checklist, 5 things. Is a person not doing as well as they want? Do they say they're missing doses? Have you tried more than 1 antipsychotic? Have you thought about long-acting? Did you offer it? We try to keep it in their minds constantly. We’ve found that can be very helpful. Also approaching patients and having someone beside the provider explaining to patients about LAI and show a video about shared decision-making, and how long-acting can fit in, can be really helpful. We need to get the frontline providers to do it.

Transcript Edited for Clarity