While schizophrenia is not a common diagnosis treated in the primary care setting, it does come up on occasion, especially when a patient is past the acute phase and in a more “stable” phase of his illness. Medication noncompliance goes hand in hand with the more severe psychiatric disorders, like schizophrenia and bipolar disorder. Really, treatment noncompliance is common in most chronic medical illnesses, like diabetes and hypertension, especially after a few years of treatment. This is why providers treating these disorders should consider long-acting injectable (LAI) medications in this population. It is also important for primary care providers to have some knowledge about LAI, because a patient with a history of schizophrenia who is not compliant with his mental health treatment might still be seeing his primary care provider for other medical concerns.
Studies have shown that in patients with schizophrenia, medication non-adherence (defined as taking the medication less than 80% of the prescribed time) reaches 75% after 2 years of taking a medication. The time course of schizophrenia, specifically time to remission after subsequent relapses, supports the use of LAI. In schizophrenia, it takes longer to achieve remission for each subsequent relapse into a psychotic episode. This statistic makes it that much more important to try to prevent future relapses in patients with schizophrenia.
There are several reasons why LAI are not considered more frequently. Most providers, including psychiatrists, rarely recommend it as a treatment after the first psychotic episode, and only half of psychiatrists recommend it after several episodes. Patients have concerns related to pain at the injection site, possible side effects, and burden of having to come into the medical office to receive their medication. Providers also have concerns related to insurance coverage and staffing issues.
LAI medications have been shown to be superior to oral antipsychotic medications in preventing psychiatric hospitalizations, taking medication non-adherence into consideration. The rates of longer term side effects, including metabolic effects and longer term extrapyramidal symptoms) are the same between oral antipsychotics and LAI, there is a lower risk of acute side effects, like sedation, orthostasis, and acute dystonia, with LAI compared to oral antipsychotics.
The first-generation antipsychotics available in injectable form include haloperidol (Haldol) and fluphenazine (Fluphenazine). The second-generation antipsychotics currently available in injectable form are risperidone (Risperdal Consta), paliperidone (Invega Sustenna: available in 1-month and 3-month formulations), olanzapine (Zyprexa Relprevv), aripriprazole (Abilify Maintena). It is important that patients are on the respective oral version of the medication in the initial stage while the LAI is loading into the system.
This information helps to support the argument to consider using LAI not just in stable patients with schizophrenia, but also in patients still in the acute phase. Here are some tips for talking with patients about the option of LAI. It is important to not say anything about compliance and adherence, to avoid the patient perceiving judgment. Instead one could ask “Would it be easier for you to take medication once a day or once a month?” and then following up with something like “We have the medication you are taking in a monthly version. Unfortunately it is not available in a pill, only an injection (avoid the word shot too!). Is that okay with you?”
In summary, medication non-adherence is the greatest single factor contributing to relapse risk in schizophrenia. Poor adherence starts at the onset of schizophrenia and is the norm, leading to functional decline. Patients should hear about depot options as early as possible and be educated about their benefits, including in their primary care setting.