Patient Selection for LAIs in Schizophrenia

Patient factors taken into consideration when prescribing long-acting injectables (LAIs) to reduce onset of psychotic episodes in schizophrenia.

Henry Nasrallah, MD: I admit that I am one of the very strong advocates for long-acting injectables for all patients. The reason is that schizophrenia is conducive to nonadherence. It’s very hard for people who suffer from schizophrenia to remember to take their medication because they have cognitive deficits. They do not recognize that they need the medication because they have lack of insight, and they are not able to initiate an action because they have negative symptoms, or avolition. Because many of them abuse substances, alcohol and drugs are very common now in patients with schizophrenia, so it’s very hard to remember to take their prescription medication when they are drunk or stoned.

I regard all patients to be at risk for nonadherence. Because I’m a schizophrenia researcher, I try to convince every patient to go on a long-acting injectable as soon as possible, ideally at the first episode. Many psychiatrists may not do that initially, which, in my opinion, is regrettable. The earlier we begin, the better the patient’s brain will be because every psychotic episode damages brain tissue. That’s why I like to use it as early as possible, but many clinicians wait for patients to prove that they are nonadherent. One, 2, 3, 4, 5 admissions to the hospital, and then they think, “Maybe I should put the patient on a long-acting injectable.” By the time a patient has 3, 4, or 5 admissions, many of them have been disconnected from their families, many of them have been incarcerated and sent to prison, many of them have become homeless, or many of them have committed suicide.

I don’t want to wait for those bad outcomes to occur before I use long-acting injectables. One of the mandatory reasons why we should use long-acting injectables very early is not only the brain tissue damage that occurs with the psychotic episode, but if the patient commits a violent act in the first episode. There are a few patients like that but not many. We know that whenever a patient becomes psychotic, they will repeat the same symptoms. If they commit a violent act in the first episode, we absolutely must protect them from relapsing because they’re going to commit a violent act again when they become psychotic. That’s the nature of some patients who are in their teens. They abuse a lot of alcohol and drugs. These young people must be given long-acting injectables because they tend to neglect their medication, they don’t believe they need it, and so on.

For patients who don’t have a family support system, they’re isolated. It would be far better to use a long-acting injectable than to delegate the heavy responsibility of taking a medication every single day, every week, every month, every year, for the rest of their life. It’s much better to deliver the medication parenterally, and they don’t have to take any pills. I have seen remarkable benefits from that in my own patients when we give them a long-acting, second-generation injectable. You can see the steady and continuous improvement and return to baseline in most of the patients.

Transcript Edited for Clarity

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