Institutional Best Practices for Treating Schizophrenia - Episode 9
Henry Nasrallah, MD, and Rahn Bailey, MD, DFAPA, discuss how to switch a patient from oral to a long-acting injectable antipsychotic from their own experience.
Peter Salgo, MD: Give me a little tutorial. If you’ve got a patient on oral agents and you want to switch this patient to a long-acting agent, how do you go about it? The nuts and bolts: What do you do? Where do you start?
Rahn Bailey, MD, DFAPA: A few things. The data make it very clear that we should have a transition. You shouldn’t do it cold turkey, so to speak. Very often we’ll decrease by half the oral, give the long-acting injectable [LAI] a chance to kick in, and then as the patient responds, wean the oral. That has psychological and physiological aspects to it because the patient was enjoying their medications, it was actually very good, they don’t lose it immediately. In addition, it gives us the time to do a lot of patient education about what this medication is likely to do and why it’s better. This whole discussion about whether LAIs are efficacious is clear, but it’s our job to do the education and make sure the patient appreciates all the other downstream benefits that we discussed earlier, so it’s likely to be better for them.
I’m often amazed—I talk to patients, and I’ll recognize that my students have seen them. My junior faculty would always acknowledge that all LAIs are not just once a day. Where I trained, we had Prolixin caprate every 2 weeks and Haldol at every 4 weeks. Now we have 2-month and 90-day options. When patients hear about that and really do a value-added judgment consideration, very often the value for the LAI increases. The big issue is that we have to accept that it’s good. We have to recultivate ourselves. Joe Avelino mentioned earlier that we have long-term doctors and new doctors. I’m surprised by how many of our new doctors, very often in training, pick up ways of old, passing on a lot of those considerations. Conversations like this are essential. We’ve got to make sure we stop those considerations and change how we educate young doctors and educate patients about the value of LAIs for the long term.
Peter Salgo, MD: I want to go back to something we touched on earlier. We have good protocols, but while the doctors are out there cowboying on their own, in cardiology—I’m going to use Henry’s analogy because I like it—somebody comes in with an MI [myocardial infarction]. Perhaps you’re going to put that patient on a calcium channel blocker, a beta-blocker, or an anti-cholesterol medication. It’s all in the literature. You wouldn’t have a cardiologist say you had an MI, but in my practice, all I do is have you eat prune juice. I’ve been practicing for 35 years, that’s what I’m going to do. Why do we allow practitioners to do this with psychiatric illness, when we don’t allow them to do it with other physiological derangement?
Henry Nasrallah, MD: Very good question. There are no guidelines, no protocols, no algorithms that apply to everybody. Cardiologists and other specialties have very fixed algorithms and they don’t deviate from them. They’re all evidence based. They’re proven, and if you deviate drastically, you’ll get a sanction. You have to do the right thing for your patient. In psychiatry, you can do whatever you want. Nobody follows guidelines, even though the evidence is massive that patients do better with long-acting injectables. The problem is that there’s a very regrettable therapeutic lionism in psychiatry about schizophrenia. Low expectations. They don’t think that there’s hope for them from day 1. ‘Oh, you’re schizophrenic? Forget it. It doesn’t matter. No matter what I do, you’re going to be disabled.’ That is the most destructive attitude that psychiatrists can have, because they never try to treat them as aggressively as they should with LAIs or anything else. Lower the expectation and the patient feels it, and they certainly are very disheartened and stigmatized by it.
Peter Salgo, MD: OK. We’re going to transition somebody from oral agents to long-acting agents. You said you might start with a half dose and what have you. How do you monitor? What are the landmarks you’re looking for, the metrics, to know when to step up the LAIs and come down on the oral agents? How do you measure that?
Henry Nasrallah, MD: Everybody has their own way, Peter. I’ll let Joe and Rahn talk about their methods.
Rahn Bailey, MD, DFAPA: We use the LAIs at Kedren hospital in Los Angeles. Many patients come in from the Los Angeles County ER [emergency department]—or what’s called the exodus, the crisis center—or Harbor-UCLA Medical Center. Most have failed oral choices, so we’ll start them on orals in the ER when we first get them here. We try to transition them to an LAI. We have about a 30-day length of stay, so we can get them well and stable and get through all the legal issues. Joe mentioned a lot of legal challenges with a finite civil commitment process. I’m new to California. I’ve been places where there was an infinite time period for civil commitment, so I had to work through that entire process. For us, once they have started, part of our discharge plan is to communicate with their outpatient team. We’re trying to grow an outpatient practice in our hospital, which will allow better continuity of care. But at this point, the initial consideration is to make the referral when they get to outpatient, and then they have an ongoing communication process about what symptoms they started with. Then when relapse comes into play, it’s often the same symptoms that got them in the hospital last time. Those are the ones the practitioner should be looking for very carefully. If that’s likely to begin, they may at that point take either a higher dose or augmentation.
One thing I would argue is that sometimes patients think LAIs are a must. We’ve had patients very often, across most of my career, who need to be chased with oral as well if indicated, if the LAI by itself is not likely to work fully for them. The key, though, is to not have a mindset that the patient can’t get better because they have schizophrenia. As was just said, if the patient’s expectations are higher, as well as their family, they could be symptom-free, and it’s our job to keep pushing the envelope to get them to that place.
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Transcript Edited for Clarity