Dr. Craig Chepke, member, Board of Directors, The CURESZ Foundation, Private Practice Psychiatrist, and Adjunct Assistant Professor of Psychiatry, University of North Carolina School of Medicine
Long-Acting Injectable Antipsychotics: Empower Yourself
A mentor once offered me the advice that “if you never ask, you rarely get.” But someone can’t ask for something they don’t know exists. The American Psychiatric Association guidelines for the treatment of schizophrenia support the use of Long-Acting Injectable antipsychotics (LAIs) “if a patient prefers such treatment or if they have a history of poor or uncertain adherence1.” However, the unfortunate truth is that most people with schizophrenia are not even aware that LAIs exist. How would a clinician know if a person living with schizophrenia would prefer treatment with an LAI if they never offered the person that option? Knowledge is power—but only if you are empowered to benefit from it.
The guidelines may be correct that LAIs are a mainstay for those with a history of poor adherence, but they are so much more than that. LAIs can liberate people from the burden of daily pill regimens and ensure 24-hour guaranteed medication levels in the body. Published studies also show they may reduce the risk of relapse, hospitalization, and even death2. Furthermore, treatment of any chronic illness with daily medication is uncertain and riddled with poor adherence, regardless of diagnosis! The rate of nonadherence in schizophrenia is estimated to be 45%-80%, comparable to that of coronary heart disease and asthma3. The availability of LAI options for other areas, such as osteoporosis and contraception, are considered revolutions in convenience and effectiveness. Rather than associating LAI antipsychotics with the stigma of the “last resort,” we should celebrate that schizophrenia is one of the select few conditions for which we are fortunate to have LAI options!
All too often in life, people make snap judgments based on incomplete information or fickle emotions. Sometimes these decisions send us down a path that makes it harder to get back on track with each passing day. Schizophrenia is an insidious illness, directly impairing a person’s insight— the awareness and understanding of the seriousness of their psychosis and need for treatment. Antipsychotics help maintain this insight. The body eliminates most oral antipsychotics from their system so quickly that if someone has a bad couple of days and forgets or doesn’t want to take their medication for just a short time, the amount in the system could fall below an adequate level. In turn, one’s ability to decide to get back on medication could be impaired. Straying from a consistent medication regimen essentially takes the power to make decisions about treatment away from the person and gives it to the disease.
Daily oral medication requires one to fight this battle 365 days a year. While potentially exhausting to the person, brain disorders like schizophrenia persist. Metaphorically speaking, psychotic disorders are relentless in seeking a crack in the person’s resolve. And each successive missed day of oral medication can make it seem more enticing not to start retaking it. However, LAIs keep the medication levels consistent for a month or longer. The number of times someone must fight to stay on their medication can be reduced to as few as 12, 6, or 4, or just 2 times a year. Even if a scheduled injection is missed, LAIs can offer a longer protection period than oral meds before the therapeutic effect is lost4. LAIs are like insurance for your commitment to pursue treatment, giving you a second chance to remain well and avoid rehospitalization.
All psychiatric clinicians have room to expand their usage of LAIs in their practice— even strong advocates like me. I vividly recall a time several years ago that I put a stack of brochures for an LAI in the waiting room of my office. One day, I saw a patient I’ve worked with for a long time who had done quite well on an oral antipsychotic. When it was time for her appointment, she stormed into my office, clutching the brochure. She waved it animatedly towards me and asked, “I didn’t know I could just get my medication once a month— why didn’t you ever offer this to me before?” I was speechless because I had no excuse— there’s no reason I shouldn’t have at least offered it to her. If your clinician has not discussed LAIs with you, empower yourself to start that discussion. Take back the choice about your treatment from your illness!
- Keepers, GA, et al. “The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia.” American Journal of Psychiatry 177.9 (2020): 868-872.
- Kishimoto, T, et al. “Long-acting injectable versus oral antipsychotics for the maintenance treatment of schizophrenia: a systematic review and comparative meta-analysis of randomized, cohort, and pre-post studies.” The Lancet Psychiatry (2021).
- Buckley, P. F., et al. “Adherence to mental health treatment.” New York: Oxford University Press 1 (2009): 53-69.
- Correll, Christoph U., et al. “Pharmacokinetic characteristics of long-acting injectable antipsychotics for schizophrenia: an overview.” CNS drugs (2021): 1-21.