How to Talk With Patients About LAIs Early on in Schizophrenia Treatment Plan

In this video, Jonathan M. Meyer, MD, voluntary clinical professor of psychiatry, University of California, San Diego, provides insight on initiating long-acting injectables (LAIs) in the schizophrenia treatment plan early and how to discuss this with patients. "Talking [with patients] about LAIs should really start on day 1 of the diagnosis," says Dr Meyer.

Stay tuned for part 2 where Dr Meyer will discuss correctly initiating LAIs after deciding to use them in the treatment plan.

Read the transcript:

Hello. My name is Dr Jonathan Meyer. I'm a clinical professor of psychiatry at the University of California, San Diego, and a psycho-pharmacology consultant to a number of state hospital and first-episode psychosis programs. I'm here to talk about how to get your schizophrenia patient started on a long-acting injectable antipsychotic. And I think most of you appreciate the fact that patients on LAIs obviously have much better adherence to treatment and typically have lower rehospitalization rates and better functional outcomes.

What I'm going to talk about specifically really is 2 things. How do you have the conversation around LAIs and then how do you actually initiate the medication?

The first part is that talking about LAIs should really start with day 1 of the diagnosis.

In the past when I train, we often reserved LAIs for those who were "Nonadherent." Well, we've come to recognize that the majority of patients with chronic illnesses like schizophrenia are nonadherent with oral medication. But most importantly, the big idea which has come through over decades of research is that when patients relapse, they may no longer respond as well to the same medication, meaning relapse may be a disease-modifying event. And who has the most to lose when they relapse?

Well, it's often the first episode patient. They have the most brain because they haven't relapsed multiple times. They still often have family connections. They have friends, maybe they have aspirations if possible about going back to school or working. We want to try to preserve all of that as much as possible. LAI should be framed for all patients as something of convenience and something of benefit, not as a punishment and especially for somebody in their first episode, letting them know that potentially they could have a medication, which they could get as a shot every 1 month, 2 two months, maybe every 3 months or even more, often alleviates the constant reminder of their illness, which happens when you have to take a pill every day. Let people know that these options exist.

If I have schizophrenia, how do I know what the medications are? How do I know that even LAI technologies exist? Let people know what the options are in terms of frequencies. And of course, we often preferentially will try to steer first-episode patients in particular, but really all schizophrenia patients towards molecules, which have LAI options. Again, try to frame the conversation as one of benefit and not one of punishment. Don't make it a one-time event. There will be people who will refuse an LAI despite your elegant discussions, but don't see that as the end of the story.

Try to keep the conversation open—especially if people have shown themselves to be having difficulties with oral medication adherence, it's a great time to bring it back up again.

"We have another way to do this." "There might be another option." "Maybe it'll be easier for you to get the medication this way." "You won't have to fill prescriptions on a regular basis." "You won't have to worry about forgetting your pills or taking your pills on a daily basis and keep reminding them there might be a different way to go."

Often patients when they sense that you're really trying to help them will finally agree to do a lot of things like take clozapine for example, with all of its baggage, and the same is true for LAIs, but people don't know that these options exist unless you tell them. And most importantly, don't just accept no, as the end of the discussion. Keep the conversation open, letting them know that we feel like there's a better way, and try to address any of their concerns such as the discomfort from the injection frequency or anything else that they may have on their mind.

Stay tuned for part 2 where Dr Meyer will discuss correctly initiating LAIs after deciding to use them in the treatment plan.

Jonathan M. Meyer, MD, is a voluntary clinical professor of psychiatry at University of California, San Diego, and a distinguished life fellow of the American Psychiatric Association. Dr Meyer is a graduate of Stanford University and Harvard Medical School, finished his adult psychiatry residency at LA County-USC Medical Center and completed fellowships there in Consultation/Liaison Psychiatry and Psychopharmacology Research. Dr Meyer has teaching duties at UC San Diego and the Balboa Naval Medical Center in San Diego, and is a psychopharmacology consultant to the California Department of State Hospitals, and to the first episode psychosis programs at Balboa Naval Medical Center in San Diego and in the State of Nevada.

Dr Meyer has lectured and published extensively on psychopharmacology and is the sole author of the chapter on the "Pharmacotherapy of Psychosis and Mania" for the last 3 editions of Goodman & Gilman's The Pharmacological Basis of Therapeutics. Along with Dr. Stephen Stahl he is co-author of the Clozapine Handbook published by Cambridge University Press in May 2019, and The Clinical Use of Antipsychotic Plasma Levels released in September 2021 by Cambridge University Press.