Under Prescribing LAIs: Understanding Why

Peter Salgo, MD: In your experience, Rahn, do you think LAIs [long-acting injectables] are under prescribed? 

Rahn Bailey, MD, DFAPA: I’d say 4 things. No. 1, we’re having a very good discussion about that. They are under prescribed for a variety of reasons, and we’ve made that point very clear. I think Henry said 10%. I’ve always written in the 15%-to-20% range, but the numbers are definitely much lower than they should be. Second, not only are LAIs under prescribed, but we have data arguing that we should probably use—I think it was only mentioned once today—Clozaril has a greater risk of suicide or psychotic aggression. We often are afraid because the blood draw is an important part of that acculturation to really push the envelope and use best-in-class choice along that line as well. If we begin to appreciate that, the analogy is the same for the use of LAIs first line.

The third thing is this issue of when to use them. Part of the strategy has to be, if we’re going to move toward using them more regularly, arguing against what are the reasonable rationales that many doctors learn early in their career not to use them. That’s this issue that the only way to use them is tertiary, once you fail something else, or you wait to use them once there has been some long history of noncompliance, or what have you. The point was made and we regularly discussed the fact that they’ve been used for a long time much more assertively in Europe than here. We probably should not have so much of a distant approach. This is going to be an area that European psychiatrists get better than us. Reading data from both sides of the pond, so to speak, will also help many of our younger and midcareer doctors.

My final point is that the position regarding long-term outcomes is key. That’s the issue of having high expectations by doctors in our patients and what can occur. I want my patients to have the same 3 things that I have in life: a decent clean place to live, some work or some vocation that I feel respected in, and hopefully a family that loves me. We shouldn’t think that patients have to have a setting where they don’t have that. I know Joe Avelino is in California and can probably teach us better about this, but I haven’t been in a place where the state wants me to discharge persons to homelessness. 

In my entire career—I’ve been doing this in 4 or 5 other states—1 of the goals is to get them stable, and then we work very diligently to get them discharged to a place where they’re likely to be successful: a clean, decent halfway house and they have SSI [Supplemental Security Income], some funding, and theoretically a way to make sure they’re medication compliant. Putting all that together speaks to this overarching issue of why LAIs first line can be best for many more patients.

Peter Salgo, MD: When I was considering where we were going to go with this discussion, I was considering asking, “What are the demographics among patients that should make you consider an LAI vs an oral agent? But after listening to you folks, I’m not sure there are any demographics that would make you prefer an oral agent over an LAI. Or am I missing something here? Why would you not offer everybody a therapy that prevents recrudescence of this disease? It’s easier to use for the patient, it’s less costly to society, it gets patients out of the hospital and keeps them out. Where’s the downside? What am I missing? Is anybody going to tell me I’m crazy? That’s a strange question to ask a psychiatrist, but go ahead.

Rahn Bailey, MD, DFAPA: I’ll jump in again. I’ll be brief. I’m a 56-year-old man with high blood pressure for the last 20 years, and I wish there was an LAI that I could take once a month, let alone like a Trinza every 90 days and 1 becoming even longer than that. I often argue to my patients—because I speak about myself quite a bit to patients—it makes the situation pretty real. Although my grandmother at age 95 was on 4 antihypertensives, the reality is that she lived to age 95 and saw her kids graduate from college and her son be a grand physician. Treatments can help. But taking them is what’s key, and she had the ability to take them regularly; otherwise, she probably would have had an MI [myocardial infarction] or a stroke well before she was age 95, maybe when she was in her fifth, or sixth, or seventh decade. The reality for us is that LAI is a remarkable advantage for psychiatrists. It would give patients a chance to be compliant with medicines for a longer period that would let them have a more successful overall life.

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Transcript Edited for Clarity