LAIs Offer Opportunity for Increased Medication Adherence in Patients With Schizophrenia

Sanjai Rao, MD, DFAPA, suggests it is “unrealistic” to expect patients with schizophrenia to perfectly adhere to daily medications and proposes long-acting injectables (LAIs) offer a treatment plan that leads to a greater opportunity for medication adherence.

In this video, Dr Rao, who recently spoke in a Psych Congress Elevate session titled “Clinical Profile and Considerations for Use of a Long-Acting Injectable Treatment in Adults With Schizophrenia” offers insight to clinicians on how LAIs differ from other treatment options in regards to medication adherence for patients with schizophrenia.

Read the transcript:

Q: Medication adherence can be a challenge for patients with schizophrenia. How do LAIs differ from other treatment options?

A: Medication adherence in schizophrenia is, for many patients, the whole ball game. We know from treating patients as inpatient that a lot of them will respond to particular medications as an inpatient.

By the time they leave the hospital, they look like they're doing quite well. After they leave the hospital, they come back and, at some point, have decompensated. What's going on there?

You've already demonstrated that pharmacologically, a particular medication works, and so the most likely thing is that once they leave, they're not taking that medication again.

We don't have to guess at this. There is an extensive body of work out there which demonstrates how challenging medication adherence is for our schizophrenia patients.

You can go all the way back 20 years to the CATIE study showing adherence rates of about a quarter once you get a year and a half out, and that even within about six months, you've got 50 percent or so patients who discontinued their medications.

When you look at things that way, it almost makes no sense to talk about nonadherence, because nonadherence is the default condition.

Usually, if you talk about non something, that should be the exception to the norm, but nonadherence in schizophrenia is the norm. It's medication adherence to oral medications that would be the unusual thing to see in schizophrenia.

If that is your situation, you can, of course, be frustrated with that and you can think about the unfairness of that or however else you want to characterize it, or you can think about, if this is the problem, if patients have a hard time taking their medications, but the medications in many cases actually do get them better, then how do you go about dealing with that?

In my mind, the single most effective way of dealing with that is to allow patients to not have to make the choice as often as we force them to make the choice. What do I mean by that?

If you're giving someone an oral medication for schizophrenia, by default, you are telling them, "This is what you have to do every day, every week, every month, every year, for as long as we can imagine." 365 times a year, or more if you have chosen to give them a twice-a-day medication.

"You have to make this choice to take your medication. Oh, by the way, on any given day that you don't make that choice, either because you didn't want to make that choice or maybe just because you forgot, that could potentially screw up your entire treatment and you could end up being hospitalized again."

That's how we treat most of our patients with schizophrenia. Something like 85 percent of our patients with schizophrenia are on oral medication. This is what 85 percent of our schizophrenia patients face. This is the choice that they face every single day. What's the alternative?

The alternative is you can say to them, "Look, how about if you only had to make this treatment choice once a month, or once every two months, or once every three months? Wouldn't that be a lot easier for you? I think for me, personally, it would be a lot easier. If I had to take a medication every single day, I would much prefer to, instead of that, just take it once a month."

That is what I think is the true choice that we're offering our patients and is the fundamental nature of adherence and nonadherence in schizophrenia.

Expecting someone to do something every single day when they have a chronic degenerative cognitive condition, I don't think is realistic. Everybody out there, you know that it's not realistic as well.

If you've ever taken a course of antibiotics or more than one course of antibiotics, I'd be very surprised if you've never missed a dose. If you think about why you missed that dose, it's probably along the lines of, "I forgot," or, "I left my bottle at home," or, "I felt better."

Think about how many times you've heard those exact reasons from your patients with schizophrenia, and reflect back on the fact that even you, as a healthcare professional, could mess this up every once in a while.

Think about how unrealistic it is to expect our patients to never mess this up once in a while and how much better it could be if, instead, we didn't force them to make that choice every day, that we could liberate them to make that choice once a month, or every two months, or every three months.

Dr Sanjai Rao is an Associate Clinical Professor of Psychiatry and Associate Residency Training Director at the University of California, San Diego (UCSD), and the Site Director for Residency Training at the VA Medical Center in San Diego, CA.  A lifelong clinician educator, Dr Rao’s clinical practice is focused on inpatient and acute care at the VA, with an emphasis on teaching practical psychopharmacology to the many trainees he supervises. Dr. Rao coordinates the UCSD Psychiatry Residency curriculum and has received a number of teaching awards based on his clinical and academic work, including the APA Irma Bland Award for Excellence in Residency Teaching.

Dr. Rao received his undergraduate degree from Stanford University, California, his medical degree from the University of California, San Diego, completed his residency at UCSD, and is board certified in general psychiatry and consult-liaison psychiatry. He is also the Immediate Past President of the San Diego Psychiatric Society and an APA Distinguished Fellow.