Exploring the Challenges and Opportunities Offered by LAIs in Schizophrenia and Bipolar Disorder

In this video, Christoph U. Correll, MD, explains the importance of medication adherence in patients taking antipsychotics, how long-acting injectables (LAIs) improve adherence, and strategies for educating patients on LAIs.

Read the transcript:

Hello, everyone. My name is Dr. Christoph Correll. I am Professor of Psychiatry and Molecular Medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York, as well as Professor of Child and Adolescent Psychiatry at the Charitè University Medicine in Berlin, Germany.

Treatment of schizophrenia has evolved, and we are still fighting a very severe illness. Sixty-seven years after the serendipitous discovery of chlorpromazine, all of our known and approved treatments are still dopamine-based.

We're trying to decrease the net effect of dopamine flow. By treating patients with this kind of antipsychotic treatment, we can get good results in many patients. However, we also know that patients—either because they're forgetting, maybe because they do not accept that they have illness, or they think that when they are better, this will stay—do not always take the medication as prescribed.

Not taking medication is associated with a huge risk of relapse. Relapse is associated with a huge risk of not doing well in the long run. More relapses are associated with more symptoms and suffering. They're associated with more suicide attempts.

More relapses are associated with a shrinkage of the gray matter. There is less brain to rehabilitate. More relapses are also associated with less treatment response. Patients who have responded before, 1 in 6 to 1 in 7 patients, will not respond as well to antipsychotic treatment after a relapse—secondary treatment resistance.

There is personal suffering, and there is cost to families, patients, and societies. So we must prevent relapses, and relapses are mostly preventable by having a short, continuous treatment with antipsychotics.

How do we achieve that? Data suggests that long-acting injectable medications have the highest chance of doing this. Multiple meta-analyses have suggested that long-acting injectable antipsychotics are superior to oral antipsychotics in terms of prevention of relapse, prevention of hospitalization, continuation of treatment, functionality, and also reducing the risk of mortality.

In April, a Lancet Psychiatry meta-analysis, including all 3 designs—randomized controlled trials, cohort studies, and pre/post studies, or mirror image studies—in almost 400,000 patients has shown that, in each design, mostly in pre/post studies, taking the patient as their own control, which is very much like in clinical care, but also in cohort studies, and in randomized controlled trials, long-acting injectable antipsychotics are superior to oral antipsychotics in preventing relapse and hospitalization.

Therefore, it's important to actually offer these medications. We also know that long-acting injectables are the only way to actually know exactly the week, the day, the hour when a patient becomes nonadherent. These medications, these formulations of antipsychotics, are not only a treatment tool, they're also an information tool.

That is important, because once we know somebody is not covertly, but for us, then, overtly nonadherent, we can do something about it. We can get family members to work with us to get patients back, and we can really address the nonadherence and the potential reasons which could be anosognosia, not acknowledging one has an illness.

It could be substance abuse, that people feel that they don't want to counter the effect of substances with antipsychotics. It could also be cognitive, failure to remember to take medications. It could be beliefs that need psychoeducation. that after one is fine, you can just drop the medication. And it can also be side effects that we need to know about, inquire about, monitor, and maybe address with either other comedications or changing the underlying antipsychotic.

Even when patients stop an antipsychotic, when it's a long-acting injectable, the first relapse and the time to relapse is enormously lengthened, again, opening the window of opportunity for us to get patients back into care.

How do we offer long-acting injectables? It takes some time. It takes some skill, but it's no rocket science. It doesn't take session after session. Psychoeducation about the value of long-acting injectables is not a one-shot deal, where you talk an hour about it.

You may bring it up for a couple of minutes in one session and then follow up afterwards. You may involve family members who you have educated to further talk to the patient about it. You may involve peer counselors who actually have experienced the benefit of long-acting treatments and can communicate this much better to patients in a more believable way than we can.

Patients often say, "You do the talk. I do the walk," but other patients have done the walk, too, and can then suggest taking a long-acting injectable and trying it out.

Data suggests that 70 percent or more of patients have never been offered an LAI when they're afflicted with schizophrenia, and the rates are much higher in people with bipolar disorder, where the antipsychotic is one building block, but often not the only one, because you can also require further mood-stabilizing treatments for either antimanic or antidepressant capacity that the LAI might not provide alone.

What is the key to offering long-acting injectables? It is motivational interviewing, borrowed from the substance use community, which means in a nutshell that we're trying to motivate someone to make a change that helps them achieve their goals, not necessarily ours.

In order to understand what their goal is, we need to ask open-ended questions, try to be understanding and not judgmental, but listening for our way in to communicate that symptom stability and lack of relapse is more likely to get patients what they want.

They may not want total cessation of symptoms. They may not be interested in negative symptom pathology, because they just don't care. But they may be interested in having enough money to buy cigarettes, even though that's obviously not a good health aspect, but they want something.

They may want interaction with people. They want maybe to stay in the basement, where the parents have them, and you can make the link. "Last time you had a relapse, you were almost thrown out. You were on the streets."

They may want to function and have some degree of quality of life. That degree of quality of life can be challenged a lot by relapse and ongoing symptoms, but we need to listen carefully. That degree of quality of life and functioning can also be impaired by side effects.

Research suggests that particularly brain-dulling side effects—cognitive attenuation, sedation— but also weight gain and sexual side effects really interfere with quality of life and well-being, plus depression. We need to monitor and ideally also treat depression. There are antipsychotics that have antidepressant capacity, which we can also bring to bear.

In essence, it is always important in people with a chronic illness to have maintenance care. Maintenance care in people with schizophrenia and bipolar disorder, which at the moment is still a lifelong disease, once people have had at least a second episode.

If they have the illness, we even after the first episode know that they need maintenance treatment, and we should offer long-acting injectables, because they have the best chance of benefiting the patient in terms of symptoms, in terms of functional outcome. Thank you very much for your attention, and I hope that this was helpful.