Schizophrenia: Switching to a Long-Acting Injectable

John M. Kane, MD: In my opinion we should start the conversation about long-acting formulations, long-acting injectable formulations, before the first relapse. I think we should be talking about it when we begin to treat the illness. Because if we wait until after the first or second or third relapse, we’ve already lost half the battle. I think the number of relapses that someone experiences early in the course of the illness can have a big impact on the ultimate outcome over the long term. We really want to try to help the patient get this illness under control as well and as rapidly as possible so they can achieve as good a quality of life as they can.

I think at the very beginning of the illness—as we’re doing psychoeducation, as we’re explaining the nature of the illness and the need for continued medication, which is not easy to convince people of—we should explain that there are many advantages to using long-acting formulations and that this is the way we treat your illness, this is what we recommend. We’re going to start with oral medicine and then we’re going to switch to the long-acting formulation. So it becomes part of the patient’s expectation and not that a year later after 1 or 2 relapses somebody says, “Well, maybe we should put you on a long-acting formulation.” I think that’s a very different scenario. If it’s something that someone views as part of the treatment plan from the very beginning, I think it’s a lot easier.

We have to take advantage of different techniques in communicating with our patients. And one is motivational interviewing, understanding the individual goals that particular patient has and how can we help them achieve those goals. In many cases a relapse will interfere with the achievement of those goals. So we can help them to understand the potential benefits of the medication and ensure that they’re getting the medication in the context of achieving their goals, and the motivational interview is an attempt to bring those different concepts together.

Sometimes we hear from clinicians that they think it’s too complicated to switch from oral medicine to a long-acting formulation. I don’t think that’s true at all. I think we know a lot about the right conversions. We have someone on oral medicine, we have a sense of what the right dose is, we found over time that they might be vulnerable to certain adverse effects. We try to adjust the dose appropriately, and then we switch to a long-acting formulation. It can be quite straightforward. I think we have good guidelines. It’ll depend on the specific drug. Each drug has a different dose, potentially different injection intervals. But the information is there, and I think it’s relatively straightforward. And the investment that the clinician makes in doing that transition will pay off over the long term.

People sometimes say, “Well, what if I need to do x, y, or z for the next week or two? Sometimes I need to supplement with oral medicine.” It’s really a very minor challenge in terms of thinking about the long-term course of a patient’s illness. So I don’t think that switching from oral to an injectable formulation should be an obstacle at all. We have to help patients feel comfortable doing this. I think the harder part is the conversation that they need to have with the patient. And when we ask clinicians, “What are the obstacles,” one of the most frequent answers is, “Oh, the patient said no. The patient doesn’t want it, that’s why I don’t use it.” And then when we talk to the patient they often say, “Well nobody really explained that to me. I wasn’t even aware that this was really an option.”

A lot of it breaks down in terms of the conversation between the clinical team and the patient, and not just the physician, not just the prescriber, but the entire clinical team needs to be onboard. Because if I have a therapist who says, “Oh, John, you don’t need to take injections. I know you’re taking your medicine,” that can undermine what the prescriber has been trying to discuss with the patients. I think the entire clinical team needs to be onboard. They need to be comfortable. They need to understand the rationale. They need to be able to answer any questions that the patient might have. And I believe very strongly that we need to make this a much more routine part of treatment.

So if we said to a patient, “This is the way we treat your illness.” This is like when you go to a cancer hospital and they have a protocol: this is the kind of cancer you have, this is how we treat your illness. I think we need to take a similar approach and say, “Well, this is the illness you have. We want to use medication because we think it’s going to be very, very helpful to you. We’re going to start with an oral medicine and then we’re going to switch to a long-acting formulation. This is the way we treat your illness.” I think that would go a long way to helping foster much greater utilization.