Why Long-Acting Injectables Deserve Our Attention in Schizophrenia Care

For all the progress we've made in psychiatry, schizophrenia remains a complex condition with gaps in access to care and medication adherence. Inconsistent use of antipsychotic medication is a longstanding, well-documented challenge, but what’s harder to accept is how often we miss the opportunity to improve patient engagement in treatment when durable, trusted options are available.

Long-acting injectables (LAIs) support adherence, reduce hospitalizations, and improve long-term outcomes. Yet, only about 14% of people with schizophrenia nationwide are on an LAI.1 That’s far below where we should be, especially considering the clinical and societal consequences of repeated relapse.

Why adherence matters

Taking antipsychotic medication as prescribed can be difficult. Symptoms like paranoia and trouble with logical thinking can interfere with a person’s ability to consistently follow a treatment plan.2 On top of that, many navigate stigma, unstable housing, comorbid conditions, and other access barriers.

These aren’t just social challenges—they’re clinical risks that can undermine adherence. As providers, we often lack real-time visibility into whether patients are taking their medication as prescribed, making it harder to intervene early when things begin to slip.

Research shows that individuals with schizophrenia die, on average, about 20 years earlier than the general population, much of it due to unnoticed or unmanaged physical health comorbidities. 3 Baseline cognitive function deteriorates with every relapse, making recovery harder each time.

While relapse can occur during any treatment, not taking the medication as prescribed increases the risk of symptom recurrence requiring acute hospitalization or other intervention. This is where LAIs can make a real difference, offering therapeutic coverage, reducing the chances of missed doses, and providing a clear signal to providers when a patient has disengaged. If a patient misses their injection appointment, that can be an early warning sign and give us the opportunity to reassess before a full relapse occurs.

A 2024 online Harris Poll survey of US psychiatric healthcare providers, conducted on behalf of Alkermes, Inc., reinforces this clinical reality: nearly half of responding providers (41%) cited concern about patients’ ability to take and stay on their schizophrenia medication.4 It’s no surprise then that nearly 9 in 10 (88%) in the same survey reported that minimizing treatment switching and supporting long-term adherence are essential to effective care.

Debunking the myths: What’s really standing in our way?

When I speak with other providers about LAIs, there are two objections that I often hear: patients are afraid of needles and access and coverage may be limited. Both of these objections are increasingly outdated, and in many cases, simply untrue.

Today, LAIs are broadly covered across insurance types and are increasingly available on preferred formularies. The logistical and coverage-related barriers that once limited LAI use—prior authorizations, reimbursement issues, or a lack of available administration sites—have largely been addressed. In many areas, they can be administered not only in psychiatric settings but also through primary care offices, outpatient clinics and designated injection sites. Put simply, many of the systemic hurdles that once made LAI prescribing difficult have been significantly reduced.

Fear of injections is often overstated. Most patients aren’t nearly as worried about the injection itself as many providers assume. When I ask patients with schizophrenia why they have not tried an LAI, most say they were never informed that LAIs were an option. When they are told about LAIs, many wish they had known earlier in their treatment journey.

The way we present LAIs matters

We’ve all heard the phrase “meeting the patient where they are.” When it comes to LAIs, that starts with how we introduce them. Too often, the conversation happens late in a person’s treatment experience, such as after multiple relapses or hospitalizations. As a result, an LAI can almost feel like a punishment or a last resort.

When we introduce LAIs early and frame them positively, patients tend to respond differently. If you say to someone, “We have an option that doesn’t require you to take medication every day—it’s once a month, or even once every 2 or 3 months, and it’s 1 less thing you have to worry about in your care,” that can be incredibly motivating. The conversation becomes about empowerment, not compliance.

Studies show LAI acceptance rates can jump from 50 – 60% to 90% when framed with a focus on autonomy, simplicity, and opportunity.5 That’s a staggering difference that only requires a shift in how we communicate.

What can happen when we get it right

I once worked with a young man who had been hospitalized 5 times in 5 months. He was aggressive, agitated, and caught up in the legal system. His family was overwhelmed as standard treatments hadn’t worked as hoped and he wasn’t staying on his oral medications. Every month, like clockwork, he ended up back in the hospital.

In month 6, he was referred to our clinic and we talked about LAIs. He was skeptical at first, but we took the time to build rapport, explained the benefits and worked through the process together.

After his first injection, he stayed out of the hospital. One month turned into 2, and 2 turned into 6. Eventually, he was able to get his legal concerns resolved, start his own business, and improve relationships with his family. He even began reminding us about his upcoming appointments!

Stories like his serve as a reminder of what’s possible when we lead with evidence-based care and pair the right treatment with the right support. This kind of progress that supports both symptom control and broader quality-of-life improvements mirrors what many healthcare providers say they prioritize. In the Harris Poll survey, 94% of providers said improving quality of life is just as important as managing symptoms when evaluating treatment success.

If we want better outcomes, we have to do better

The American Psychiatric Association’s (APA) treatment guidelines recommend earlier use of LAIs in schizophrenia than we commonly see in this country. Many countries in Europe, and even some US states, have much higher utilization rates.6 In South Carolina, LAI use is approaching 60%, with goals up to 80%. These aren’t theoretical targets—they’re achievable realities.7 We need to reposition LAIs not as niche or last-resort options but as foundational components of schizophrenia treatment. That starts with early conversations, motivational framing, patient education, and provider accountability. At just 14% utilization, the system is falling short.

The Harris Poll survey indicates that a strong majority of prescribing providers (91%) value treatments that support long-term maintenance. Clinicians tend to lean towards treatment options that have existing, supportive data and are included in clinical guidelines, with only 31% identifying themselves as early adopters of new treatments.

LAIs are not a case where more evidence is needed. The clinical efficacy data and guidelines are already established.

When we step back and consider LAIs holistically as a treatment category, the foundation is already in place. They are well-supported by clinical research, embedded in updated APA guidelines and accessible through most insurance plans. In other words, the evidence and infrastructure are there. What’s missing is action.

This is one of the rare areas in psychiatry where we have the tools; we just need to use them. The question isn’t whether LAIs work—it’s whether we’re ready to treat them like the standard of care they already are.

References

1. Reymann S, Schoretsanitis G, Egger ST, Mohonko A, Kirschner M, Vetter S, Homan P, Seifritz E, Burrer A. Use of Long-Acting Injectable Antipsychotics in Inpatients with Schizophrenia Spectrum Disorder in an Academic Psychiatric Hospital in Switzerland. J Pers Med. 2022 Mar 11;12(3):441. doi: 10.3390/jpm12030441. PMID: 35330441; PMCID: PMC8955244.

2. What if Schizophrenia? American Psychiatric Association. https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia#:~:text=Positive%20symptoms%20(those%20abnormally%20present,school%20performance%20and%20reduced%20motivation. Accessed July 8, 2025.

3. Peritogiannis V, Ninou A, Samakouri M. Mortality in Schizophrenia-Spectrum Disorders: Recent Advances in Understanding and Management. Healthcare (Basel). 2022 Nov 25;10(12):2366. doi: 10.3390/healthcare10122366. PMID: 36553890; PMCID: PMC9777663.

4. New National Survey of Healthcare Providers Offers Insights Into the Dynamic and Challenging Treatment Journey for People Living With Schizophrenia or Bipolar I Disorder. Alkermes. March 27, 2025. https://investor.alkermes.com/news-releases/news-release-details/new-national-survey-healthcare-providers-offers-insights-dynamic. Accessed July 8, 2025.

5. Weiden PJ, Roma RS, Velligan DI, Alphs L, DiChiara M, Davidson B. The challenge of offering long-acting antipsychotic therapies: a preliminary discourse analysis of psychiatrist recommendations for injectable therapy to patients with schizophrenia. J Clin Psychiatry. 2015;76(6):684-690. doi:10.4088/JCP.13m08946

6. Treatment of Patients with Schizophrenia. Guideline Central: American Psychiatric Association. January 30, 2024. https://www.guidelinecentral.com/guideline/307794/pocket-guide/307921/#section-anchor-308255. Accessed July 8, 2025.

7. Cai C, Kozma C, Patel C, et al. Adherence, health care utilization, and costs between long-acting injectable and oral antipsychotic medications in South Carolina Medicaid beneficiaries with schizophrenia. J Manag Care Spec Pharm. 2024;30(6):549-559. doi:10.18553/jmcp.2024.30.6.549