Demystifying Schizophrenia Treatment: Comparing Medications and Explaining LAIs to Patients

Psych Congress Steering Committee Member, Craig Chepke, MD, FAPA, and Psych Congress Network's Schizophrenia Section Editor, Leslie Citrome, MD, MPH, answer questions regarding schizophrenia treatment from the provider and patient perspective in a recent live Q&A session at the virtual Psych Congress Regionals. On May 6, 2022, Dr Chepke and Dr Citrome led a session titled "Breaking Down the Barriers to Utilizing Long-Acting Injectable Antipsychotics for Schizophrenia Management."

In this podcast, they discuss the difference between risperidone and paliperidone, choosing between risperidone and aripiprazole, and demystifying needles with patients to make them more comfortable during treatment with LAIs.

Saundra Jain, MA, PsyD, LPC, adjunct clinical affiliate, University of Texas at Austin School of Nursing, moderates the discussion.

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Dr Saundra Jain: Les, here's a question. This one actually got a lot of up votes and our attendees are wanting to know what's the difference between Risperidone and Paliperidone?

Dr Leslie Citrome: Well, Risperidone is metabolized Paliperidone. So basically, Paliperidone is the son of Risperidone. Paliperidone has very similar receptor binding affinities to Risperidone. And so, I would say they belong to the same family. When you give Risperidone, you're also giving Paliperidone and generally, there's not much of a difference between the two in terms of their activity as well as the potential for prolactin elevation. It's about the same for both. However, there are some patients out there that seem to do a little better with Risperidone than with Paliperidone. I have no logical explanation for this. When we think back of Risperidone too, it has a relatively short half-life. So it's relatively quick that it turns into Paliperidone. That's to keep that in mind.
Saundra Jain: Okay. Craig, anything that you would add to that?

Dr Chepke: No. Not really. Well, actually, the only thing I might think of is that it could be potentially patients with poor metabolism in Cytochrome P452 D6, which is relatively common in many people. It's certainly, in many psychiatric patients, and those people would have a longer half-life of Risperidone, but still, it's going to get converted over to Paliperidone, eventually. So, that would be the only thing that would strike me as a potential, but nothing I would hang my hat on to say, oh yeah, because of this 2D6 person status, I would give this versus that. Just a theory as to, well, maybe that's why one person responds better, and another didn't. But very close relatives there for sure.

Dr Jain: Okay. So Craig, let me follow up another medication question and this clinician wants to know how do I choose between Risperidone and Aripiprazole?

Dr Chepke: Well, there's a lot of different patient characteristics that you might take into factor, also your own experience. So, for instance, sometimes Aripiprazole, it might be better for someone who has a history of Dystonia or Parkinsonism with a full D2 antagonist because, for some patients, the partial agonist can have some less liability there. Still clearly not none. Still, a good percentage of people will have movement disorders with their Aripiprazole, but that could be one thing based off that patient's past history.
If there were concerns about the QT interval well, Aripiprazole doesn't have a QT prolongation liability. That could be something there. Sometimes efficacy, though. If someone didn't do well with Aripiprazole, but they did better with Risperidone or Paliperidone, that might be a factor. And then, when it comes to LAIs, we'd have to also broaden it to look at well, what are some of the other amenities of care, as Dr. Citrome puts it? Well, if you want something with a longer than two-month injection interval, well, it's not going to be Aripiprazole as of today. And things like in the needle size and various things like that, the injection initiation. So, you have to look at both the molecule itself and then also the delivery system that it's in, in order to make that decision on a patient-by-patient basis.

Dr Jain: All right. Les, I know we've talked about this before, just about the size of the needle, how patients respond to that, and how to introduce that. I'm wondering if you would follow up to what Craig was just talking about and maybe speak more to that point.

Dr Citrome: So, patients don't know what you're talking about when you say I can give you this medicine by injection. And they would have all sorts of things running through their mind. Maybe the needle is this big. They don't know. They have some fears about needles most likely. So, I like to demystify it by showing them the needle, and they see that it is really an inoffensive little needle that, yes, it is a needle, but it's not the super size gigantic needle they had imagined it to be. And I describe it as similar to getting a flu shot, for example, that they most commonly have experienced. I don't say it's like a COVID vaccination shot because those actually hurt for a little while afterward. And the IM antipsychotics certainly are not in that category.

I say it's similar to the regular flu shot. And if I notice they have tattoos, I say those tattoos probably hurt a whole lot more than what we're talking about. And if they have a history of IV drug abuse, they're familiar with needles. And I say, well, what I'm proposing is something actually pretty simple. It just goes into the muscle. Not as complicated as what you did on your own. So I try to put it into familiar terms, make it sound matter of fact, routine, not a mystery. I'll show you the needle, show you the kit it comes in, there's different lengths of the needle depending on where it's going to be injected into. It's a little longer if I have to inject it into your rear because there's more fat there that I have to go through until I hit your muscle. And in the deltoid, it's a shorter needle and it could be also a smaller, narrower needle too.

It all depends on where you want the injection. And by the way, as we're talking about injection site, we all think that they don't want it in their rear, but it's not that they need to take off their pants. In fact, we don't want them to drop their pants. It's in the upper outer quadrant part of their rear that we see routinely anyway because they wear pants so low. So, it's not a mystery location. Plus, in the wintertime, it's much easier to get to than the deltoid. At least where I live in New York, where it gets really cold, and people wear a lot of layers. So, I have this conversation in a lighthearted way, and they make a choice of what they would like

Dr Craig Chepke is a Board-Certified psychiatrist and a Fellow of the American Psychiatric Association. He attended NYU School of Medicine and completed his residency training at Duke University. Dr Chepke is the medical director of Excel Psychiatric Associates in Huntersville, NC as well as a clinical assistant professor of psychiatry at SUNY Upstate Medical University and an Adjunct Associate Professor of Psychiatry for Atrium Health. He is a member of the Huntington Study Group and serves on the board of directors for the CURESZ foundation, a nonprofit organization dedicated to improving the lives of people living with Schizophrenia.

Dr Citrome is clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York, and adjunct clinical professor of psychiatry, Icahn School of Medicine at Mount Sinai in New York City, New York. In addition to his academic positions, he has a private practice in psychiatry in Pomona, New York, and is a volunteer consultant to the Assertive Community Treatment team/Mental Health Association of Rockland County. He is a Distinguished Life Fellow of the American Psychiatric Association and a Fellow of the American Society of Clinical Psychopharmacology where he currently serves as President. Dr Citrome is editor emeritus, International Journal of Clinical Practice where he was editor-in-chief 2013-2019; psychiatry topic editor for Clinical Therapeutics; editor for the American Society of Clinical Psychopharmacology Corner in the Journal of Clinical Psychiatry; section editor for psychopharmacology for Current Psychiatry; and also serves as an editorial board member for several other medical journals.