Early Initiation of LAI Therapy for Schizophrenia

Transcript: John M. Kane, MD: Sanjai, what’s your opinion on how early we should initiate a long-acting formulation?

Sanjai Rao, MD: I would do it at the beginning of their illness, for all the reasons that we’ve highlighted. The longer you wait, the more chance they relapse, the more likely that relapse affects cognitive function and brain tissue. It will be harder and longer to get them back.

One example is the VA [Veterans Affairs] hospital system, where I work. The VA is not fond of spending large amounts of money on medication. However, over the last several years, the VA has been a leader in encouraging usage of long-acting medication. It’s 1 of our performance metrics.

They determine what percentage of our patients with schizophrenia are on long-acting injections [LAIs]. This is a closed hospital system that’s paying for all the medication and choosing to pay for a more expensive medication, out of recognition that it saves you on the back end. I have no difficulty starting a long-acting injection at any time in a treatment course. This proves what the expected outcomes are, starting an LAI early.

John M. Kane, MD: That’s very important. At some point we should approach our patients with a much clearer message. We tell them, “This is the way we treat your illness.” As Henry was emphasizing, if it were a family member he would say, “This is the way I would treat you if you were my son or daughter.” Clinicians can go a long way in terms of outlining a treatment plan that is considered routine. If you go to a cancer hospital, someone is going to suggest a particular protocol for treating that type of cancer. If someone is admitted to a psychiatric hospital, we could tell them, this is the way we treat your illness. We start with an oral medicine while you’re in the hospital, and then we’re going to switch you to a long-acting. This conveys a very different message from the way it’s often presented.

Sanjai Rao, MD: Our colleagues in Europe do much better than we do at initiating. They do it more often and earlier than we do. I don’t think it’s because long-actings work only in Europe.

Henry A. Nasrallah, MD: I would be lucky if 1% of the psychologists in the United States are using long-acting injectables in the first episode. Nobody is doing it. They keep delaying it as a last resort. This last-resort mantra should be destroyed. It’s the first option to save lives. Delaying a long-acting injectable is a recipe for disaster for the majority of the patients.

Erin C. Crown, PA-C: Suggesting LAIs with confidence is important. This is how we do it, and it’s the best treatment. When we went into community mental health centers and listened to how doctors made offers of long-acting injection, we found that they’re not very confident. “You don’t really want this, do you?” It’s all about presentation and confidence.

Henry A. Nasrallah, MD: That’s the impediment in American psychiatry, why they are underutilized—the lack of conviction by the psychiatrists, nurse practitioners, and physician assistants about the importance and the life-saving potential of using LAIs.

Transcript Edited for Clarity