Long-Acting Injectables and a Team-Driven Approach for Schizophrenia Treatment

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Schizophrenia is one of the most severe and complex chronic mental health conditions. In the US, an estimated 2.4 million American adults live with the disease in a given year.¹ As clinicians, we witness firsthand the challenges that individuals living with complex mental health conditions face. For many, this begins with receiving an accurate diagnosis and goes on to include a lifetime of assessing the long-term disease management options that work for them.

Since their introduction in the 1950s, antipsychotics have undergone meaningful evolution,² and today, they are the standard of care for the treatment of schizophrenia, helping to stabilize symptoms, reduce the risk of relapse, and contribute to patients’ overall wellness goals. Antipsychotics are available in both oral and long-acting injectable (LAI) formulations. The distinctions between different approved antipsychotics and their formulations, as well as appropriateness for a given patient, are important considerations in treatment decision-making.

The Role of LAIs

Adherence is critical in the management of schizophrenia.³ Research suggests correlations between inconsistency in medication utilization and exacerbated risk factors related to treatment effect, relapse, rehospitalization, and other downstream outcomes. While specific metrics for nonadherence vary, there is broad awareness that individuals living with schizophrenia commonly experience challenges related to their medication schedule. For example, a lack of insight into the disease, concerns about adverse effects, and challenges related to daily dosing requirements may impact individual adherence. In addition, external factors that may impact a patient’s ability to take their medication as prescribed may include age, socioeconomic status, and educational background.³

Health care providers who become aware that a patient is having difficulty, for any reason, with taking their oral medication as prescribed may wish to consider an LAI, such as aripiprazole lauroxil (Aristada), as a treatment option. With dosing intervals ranging from 2 weeks to 6 months and directly administered in a health care setting by a qualified professional, LAIs may provide advantages over oral therapies,⁴ as related to questions of medication adherence. Specifically, patients, health care providers, and even loved ones serving as caregivers may find reassurance in the knowledge that dosing is consistent over a period of time. Moreover, alleviating the need for daily decision-making and recollection about a particular medication schedule may open the door to more conversation and exploration of additional wraparound services and support, including attention to self-care and counseling.

One study observed that treatment with an LAI reduced rates of hospital readmission by 29%, when compared with treatment with oral antipsychotic medications, with an even more dramatic outcome of 58% when measuring repeated readmissions.⁵ Given the progressive and often cyclical nature of schizophrenia, as well as high personal and systemic costs, it is clinically important to think about tactics that may reduce circumstances that require recurrent hospitalization.

Nevertheless, despite data supporting LAIs in the treatment of schizophrenia, stigma and lack of information and awareness regarding their use persist. For example, injections are often viewed as a treatment for the most severe or late-stage cases despite research supporting their use early in the disease and as long-term, maintenance treatment. These misconceptions may prevent some providers and patients from selecting an LAI as a treatment option, especially early in disease.

In my experience, much of the hesitation with LAIs stems from clinicians' assumptions about patient preferences, including perceived fear of injections, or presumptions about insurance coverage or other monetary obstacles. I have found that employing a collaborative, team-based approach that includes all health care team members working in sync with the patient leads to greater success in addressing these concerns.

Treatment Conversations Through a Team-Based Approach

In our practice, we foster a collaborative care environment to address barriers to treatment with LAIs. When the entire care team plays a role in developing and executing a care plan, it builds trust and engagement. Shared decision-making that includes health care providers, patients, and caregivers helps ensure alignment with desired goals.

We have found the following steps support open communication related to treatment choices and objectives:

-Involve the whole team in decision-making. Psychiatrists, advanced practice providers (APPs), nurses, case managers, front-office staff, and pharmacists all add value, insights, and support along a patient’s treatment journey.

For example, pharmacists can help address concerns about medication access by identifying patient assistance programs and prescription availability. Together, we can verify whether a patient's insurance covers the treatment and seek out vouchers or other types of aid when needed. In my experience, this sort of collaboration can help alleviate the practical worries faced by patients and their families.

When a patient is due for an Aristada injection, we make sure we have the medicine in the office and are prepared to administer it. We are transparent about what will happen during the appointment, which conveys respect to facilitate a more positive experience.

-Embrace a patient-centric mindset. Everyone who walks through our doors feels valued and important. We build trust. We look at patients as our clients, to whom we owe excellent service. It is our job to give them all the options. To that end, we introduce LAIs as an option as appropriate, even as early as the initial visit, emphasizing patient choice and considerations related to convenience and consistency in treatment.

If the idea of a needle produces anxiety, we show the patient the needle sizes and then walk them through every step, letting them know we support them. Focusing on the longer-term benefits can help manage fears. We provide patients and their attendant caregivers with all available details about the medication they are receiving, so they are making an informed choice. It is important for everyone involved to feel knowledgeable about the decision, weighing factors like adverse effects or injection discomfort as well as efficacy.

-Foster open communication. As part of our patient-centric approach, we encourage patients to articulate their goals, preferences, and concerns openly to help alleviate anxiety. I spend the first few minutes of every visit talking to the client about what has been happening in their life and their goal for that day's visit. It is essential to ensure that the patient's goals align with the treatment plan, to help nurture a sense of empowerment and ownership in their treatment journey.

This is critical to reducing the paternalistic dynamic often seen in mental health care, which can become a barrier to patients accepting or adhering to treatment.

We aim to operate as a partner to our clients. Rather than immediately or reductively telling them what to do, we look for common areas where our goals align and build from there. We find that when patients feel a part of the decision-making team, they are more likely to adhere to the treatment plan. This sense of empowerment is particularly important for those managing a chronic illness like schizophrenia.

-Continuous monitoring and adjustment. Regular assessments of treatment efficacy are essential to see if adjustments are necessary. Therapeutic drug monitoring allows us to objectively measure the drug's presence in the body and adjust as needed. This aids in ensuring adherence and also strengthens the patient's trust in the treatment process. Knowing that the patient receives consistent dosing with an LAI, we can more easily monitor whether the medication works effectively and iterate accordingly.

-Mitigate financial barriers. Patients and their families understandably have questions about the costs associated with their treatment. As discussed previously, our team works closely with pharmacists to explore all avenues for financial assistance. Prior authorization issues can be challenging, but we have found proactive collaboration between the provider and pharmacy can streamline the process, ensuring that cost does not impede access to treatment.

Concluding Thoughts

As psychiatric health care providers, our role extends beyond prescribing medication to ensuring patients can access targeted, effective care. For individuals living with schizophrenia, that can include a disease management plan that includes treatment options that best fit their needs, lifestyle, and goals, working within the framework of a team-based approach.

Shared decision-making can empower those living with schizophrenia to take control of their treatment, paving the way to improving their outcomes. By building robust and supportive care teams and fostering open communication, we can ensure that more patients benefit from the consistency and convenience of LAIs.

Dr Hicks is founder of the C-Trilogy Comprehensive Clinical Care/C-Trilogy Outreach.

References

1. Fleischhacker WW, Arango C, Arteel P, et al. Schizophrenia--time to commit to policy change. Schizophr Bull. 2014;40 Suppl(Suppl 3):S165-S194.

2. Abou-Setta AM, Mousavi SS, Spooner C, et al. First-generation versus second-generation antipsychotics in adults: comparative effectiveness. Agency for Healthcare Research and Quality (US). AHRQ Comparative Effectiveness Reviews. 2012 Report No:12-EHC054-EF.

3. Guo J, Lv X, Liu Y, et al. Influencing factors of medication adherence in schizophrenic patients: a meta-analysis. Schizophrenia (Heidelb). 2023;9(1):1-8.

4. Morris MT, Tarpada SP. Long-acting injectable paliperidone palmitate: a review of efficacy and safety. Psychopharmacol Bull. 2017;47(2):42-52.

5. 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).