Case-Based Psych Perspectives: Treating Schizophrenia in the Era of COVID-19

CASE-BASED PERSPECTIVES

For more information, see the video series at https://www.psychiatrictimes.com/case-based-psych-perspectives/treating-schizophrenia-in-the-era-of-covid-19.

There are many barriers to the successful treatment of schizophrenia, shared Bryce Reynolds, MD. In addition to patients’ lack of insight about their disease, schizophrenia is associated with cognitive deficits, social isolation, and cultural stigmas. Patients also face lack of motivation, transportation difficulties, and financial issues. These barriers are particularly relevant when addressing treatment adherence, especially with oral medications, and it can be difficult to truly assess adherence to oral medications.“We can’t absolutely guarantee that the person is consistently taking their PO [oral] medication,” stressed Reynolds. In his experience, there are generally 4 underlying reasons when symptoms worsen in a patient who previously achieved effective symptom management. He explained, “One is a decrease in adherence—the others are a medical comorbidity, a substance abuse comorbidity, or a major stressor that may cause an increase in their symptoms, even if they’re on their medication.”

The use of a long-acting injectable antipsychotic (LAI) medication can help overcome the clinical challenges associated with treating schizophrenia, especially adherence. There is an important pharmacokinetic benefit of LAIs, he explained. If a patient on a LAI does not receive an injection on schedule, there is “some additional time where [the LAIs are] still at a therapeutic serum level.” Compared with oral antipsychotic medications, LAI medications offer an extended time to relapse or decompensation. Reynolds emphasized that a longer time to relapse provides patients with benefits such as, “the ability to work and sustain housing and socialization and employment and going to school [for longer periods of time].” Since adherence is a known component for patients who use an LAI, Reynolds noted their contribution to an episode of decompensation is clearer.

Hannah Phillips-Hall, MSN, PMHNP-BC, who joined Reynolds in the discussion, added she is able to identify the possible cause more readily when a patient who is on an LAI decompensates.

Guideline-Recommended Schizophrenia Management with LAIs

Guidelines for the treatment of patients with schizophrenia from the American Psychiatric Association (APA) were updated in 2020 and emphasize a patient-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments. Reynold’s summarized the APA guidelines and recommendations updates for LAI treatment in 3 applications: if it is preferred by the patient; if the patient has a history of poor adherence to oral therapy; and/or the patient’s future adherence to oral medications is questionable or uncertain in the judgment of the provider.

Both Reynolds and Phillips-Hall noted that offering a LAI upfront would be advantageous for several populations in which adherence to oral therapy is uncertain, such as for those with a history of substance use disorder, and those who are homeless or lack transportation to a pharmacy. Reynolds explained, “There is a benefit that the APA has recognized [in] getting them on LAIs, even before you see adherence issues. In fact, in my practice, the first day that I see them is the day that I offer a LAI to them.”

Phillips-Hall added, “Having those [APA] guidelines further validates [the use of LAIs] for the purpose of reimbursement and approval.”

There is an opportunity to implement early treatment with LAIs, which the faculty noted may improve treatment success. For instance, a patient who is diagnosed in their late teens or early 20s may go through 4 cycles of PO medications before they are offered an LAI at age 38. “[In essence], we wait until [their disease] gets really bad before we bring out the tool that perhaps could have kept them from getting bad in the first place,” Reynolds said. Phillips-Hall agreed, noting that offering a LAI upfront is a better way to set up newly diagnosed patients for success versus waiting for them to experience treatment failure with several oral medications.

Patient-Focused Care and Shared Decision Making

Reynolds emphasized the importance of correcting patient misconceptions and empowering them with choices about their treatment using motivational interviewing. Through his own use of this interview technique, Reynolds has identified 4 common patient-reported barriers to LAI treatment selection: 1) feeling that they have no control over the medication schedule, as they would with a pill or tablet; 2) a negative experience with a first-generation oil-based product (eg, knots at site of administration); 3) association of injections with being restrained in the emergency department (ED) during acute episodes of agitation; and 4) fear of injection-associated pain. Understanding these concerns allows clinicians to better address them. Reynolds finds it helpful to “normalize” his patients’ feelings by expressing his understanding of their fears. He then discusses LAIs in the context of the patient’s personal life goals, and points out how their current oral regimen is not helping them achieve their personal goals.

“Some studies show that 60% of people will take LAIs if presented [to them] well. That’s an extremely high number,” Reynolds said. As part of this presentation, the faculty suggested offering a short-term trial of an LAI, as it may help patients feel a greater sense of control over their treatment. “When patients are involved in a collaborative way to make an informed decision, many of them [try the LAI],” Reynolds explained. Since LAIs are available in several administration schedule options, Phillips-Hall noted it empowers the patient to choose how frequently they receive their medicine. Reynolds added that only having to receive medication 4 times a year has been very appealing to some of his patients.

Sesame oil-based first-generation antipsychotic LAIs are associated with more injection site pain, which can be also be addressed. Reynolds and Phillips-Hall indicated that injection-associated pain and discomfort can often be minimized by using second-generation antipsychotic LAIs, or by using an LAI with a small injection volume or decreased administration frequency.

Opportunities to Address Adherence During the COVID-19 Pandemic

As a result of the coronavirus disease (COVID-19) pandemic, patients with schizophrenia have experienced a reduction in their access to care as well as medication access challenges. Therefore, they experienced difficulty maintaining medication adherence. Given reduced office hours in many health care settings, it may be difficult for patients who are decompensating to receive medication adjustments from their provider or pick up their prescription from the pharmacy. For patients on oral medications, Phillips-Hall tries to make sure she prescribes a 90-day supply if their insurance will accommodate such. However, she also noted that the increased availability of, and insurance coverage for, telehealth services as a result of COVID-19 has been a silver lining in patient care.

Although there are additional safety risks associated with in-office visits for administration of LAIs during COVID-19, the faculty noted that routine safety measures can help mitigate the risk of exposure. Improvements in adherence with LAIs may help prevent hospitalizations, which in turn may prevent inadvertent exposure to the COVID-19 virus. “With the COVID risk, you want to limit that risk of hospitalization and going to the ED [due to] the exposure they may have in the ED,” said Reynolds.

Phillips-Hall added that COVID-19 has helped patients and families be more open-minded toward use of LAIs.

Reynolds added, “during the pandemic, LAI administration has been suspended in some areas where it’s identified as an elective procedure. The APA is encouraging hospitals and facilities to continue the use of LAIs for patients at high risk and [to] consider it a necessary procedure.”

Closing Advice

When offering advice to community psychiatrists treating patients with schizophrenia, Reynolds said, “All it takes is a little compassion and using the right tools, and I would say LAIs are absolutely one of those right tools.” ❒

For more information, see the video series at https://www.psychiatrictimes.com/case-based-psych-perspectives/treating-schizophrenia-in-the-era-of-covid-19.