Schizophrenia is a complex, chronic, and progressive illness that affects about 1.1% of adults in the United States. As with any disease that is challenging to diagnose and treat, supporting patients in navigating their journey requires a thoughtful, compassionate approach, as well as open, honest conversation and collaboration between patients and their care teams.
For people living with schizophrenia, the demands of managing the treatment journey can be overwhelming. It has long been acknowledged in the medical literature that medication adherence in particular can present difficulty for these individuals, with significant short- and long-term clinical implications. Finding a treatment regimen that works and that a patient is willing and able to stay on long term can make a meaningful difference in preventing relapse and associated risks.
Antipsychotic medications are the standard of care in the treatment of schizophrenia. These medications are available in both daily oral and long-acting injectable (LAI) formulations, each of which may have benefits and drawbacks for individual patients. Careful consideration of when and how each option may fit into a patient’s ever-evolving treatment journey is important.
The Clinical Importance of Medication Adherence
The ability of patients to take medications as prescribed is a known concern across many disease states. Whether it's a vitamin, antibiotic, or oral antipsychotic, it is not uncommon for people to, from time to time, forget to take their daily medication. The implications of this oversight will vary from disease to disease and medication to medication.
For those living with a serious mental illness like schizophrenia, the implications of a missed dose can be significant. There are many reasons why someone with schizophrenia may stop taking their medication, including a lack of efficacy, medication adverse effects, or even absence of support. It is also true that a common symptom of schizophrenia is a lack of individual insight into the illness itself, which can complicate a person’s motivation or ability to follow their treatment regimen. Unfortunately, people with schizophrenia who stop taking their medication as prescribed are likely to experience a recurrence of symptoms that can lead to a psychiatric crisis, emergency room visit, or even hospitalization.
Consistent treatment can make a big difference in managing schizophrenia for patients, particularly those facing added challenges like homelessness or housing instability.
LAIs as a Treatment Approach
LAIs are a class of medication designed to deliver an active ingredient slowly over an extended period of time, from weeks to months, depending on the dosing interval. Before introducing an LAI, patients should establish tolerability to the active ingredient by taking the oral form of the drug. Like all medications, LAIs work best when combined with psychosocial support. With LAIs, patients have an opportunity to eliminate the daily burden of remembering to take their medication.
LAIs also provide assurance that a patient has medication on board for the full dosing period. For health care providers, this can mean taking the guesswork out of wondering whether a patient is following their treatment plan. For example, if a patient misses their appointment and administration of their next medication dose, the provider can quickly intervene before symptoms recur.
By supporting medication adherence, LAIs may play a role in supporting patients’ long-term well-being. For example, research shows that LAIs may help reduce the risk of relapse and downstream complications, such as hospitalization or readmission,1 which can be traumatic and detrimental to patients. Several studies also show that the use of LAIs in appropriate patients may lead to better long-term outcomes. These benefits are amplified with the use of LAIs earlier in disease progression.2 Nevertheless, despite their well-understood and studied beneficial outcomes,3 LAIs are still widely underutilized and often offered only for the most severe cases or once oral antipsychotics have failed.
There are a number of reasons why LAIs may not be selected as the first option. For example, clinicians often don't suggest LAIs to patients as a treatment option, fearing resistance from the patient to a change in how their medication is administered or a pushback about the use of needles. Helping a patient consider an LAI may necessitate carefully listening to the patient’s questions and concerns, and having multiple conversations about the potential benefits and risks of this treatment option. If the patient's initial reaction is adverse, follow-up discussions that leverage the practice of motivational interviewing may be helpful.
For example, providers can ask their patients, “Would it be more convenient if you don't have to remember to take your pills daily?” This can help them identify how an LAI may benefit them and present LAIs in a positive light. Even if a patient is resistant to an LAI during the first discussion, a commitment to follow-up discussions is critical in ensuring that patients fully understand and consider all their treatment options and make informed decisions about their care.
About the Author
Brooke Kempf, PMHNP, is based in Terre Haute, Indiana. She is an adjunct lecturer for IUPUI’s PMHNP program and spent 30 years with Hamilton Center, where throughout her career she served as chief nursing officer, psychiatric nurse and outpatient PMHNP provider for medication management for adults with psychiatric illness. Kempf has participated in Pharmaceutical Advisory Boards and is on the Steering Committee for Psych Congress to provide feedback in the development and presentation of education for her peers.
The Role of Pharmacists in Supporting Patients Receiving LAIs
Pharmacists are essential members of the health care team and are often in a position to provide front-line guidance to patients navigating their treatment journey. Like other health care providers, pharmacists can play a crucial role in helping people understand what an LAI is, how it works, and why it may be a treatment option early in the disease (and not a “last resort”).
For example, when discussing LAIs with patients, pharmacists have an opportunity to share information about how LAIs are simply a different method of delivering the same medication they’re already familiar with. By contributing to increased awareness and understanding of LAIs, pharmacists can empower patients to make informed decisions about their treatment.
Pharmacists should also consider familiarizing themselves with the practicalities of LAI administration. In many states, pharmacists can now provide injections, which can remove barriers for patients who may otherwise struggle to access regular care and help bridge treatment gaps, such as for patients in rural or underserved communities.
LAIs are now a treatment option across a variety of disease states, from weight loss to HIV to osteoporosis. This increase in availability and use has led to broad acceptance of LAIs and more positive conversations about this route of administration. As providers, we all have an opportunity to help educate patients and their families about both the benefits and risks of LAIs as a treatment option for serious mental illness and, in turn, help reduce long-standing stigma and resistance around injections in mental health care.
REFERENCES
1. Kim HO, Seo GH, Lee BC. Real-world effectiveness of long-acting injections for reducing recurrent hospitalizations in patients with schizophrenia. Ann Gen Psychiatry. 2020;19,1. doi:10.1186/s12991-019-0254-2
2. Stevens GL, Dawson G, Zummo J. Clinical benefits and impact of early use of long-acting injectable antipsychotics for schizophrenia. Early Interv Psychiatry. 2016 Oct;10(5):365-77. doi:10.1111/eip.12278
3. Vita G, Tavella A, Ostuzzi G, et al. Efficacy and safety of long-acting injectable versus oral antipsychotics in the treatment of patients with early-phase schizophrenia-spectrum disorders: a systematic review and meta-analysis. Therapeutic Advances in Psychopharmacology. 2024;14. doi:10.1177/20451253241257062
