Medication adherence is a challenge for many patients, especially with chronic diseases, such as schizophrenia. Long-acting injectable antipsychotics (LAIs) rather than oral medication may be a way to encourage engagement and retention in treatment, thereby improving outcomes1, especially if LAIs are offered using shared decision-making and motivational interviewing techniques, as discussed in this ECNP Virtual 2020 presentation by Patricia Marcy (Northwell Health, New York, USA).
Why is engagement a challenge?
Need for continuous and long-term treatment to prevent relapse2 and ensure successful outcomes3 can be particularly hard for individuals experiencing first episode and early-phase psychosis. Young patients face significant psychosocial issues related to personal identity, relationships and educational and occupational goals, which may have been disrupted by their illness4.
Many patients are willing to try an LAI, but how they are offered them matters5,6
Many patients are willing to try an LAI5, but how they are offered them matters6. Common reasons for preferring oral medication are5:
- avoiding injections
- comfortable with tablets
- not wanting to visit a health institute for treatment
- control over when/how much medication
An online survey of patients with recently diagnosed schizophrenia showed most had some willingness to try an LAI, and 53% rated willingness as >50%5. Success is more likely if the clinician can uncover underlying resistance and address the root issue(s)6, encouraging patients to consider benefits of LAIs5:
- not needing to remember daily medication
- more convenient
- less worried about relapse
- not having to take tablets in front of others
Success is more likely if the clinician can uncover underlying resistance and address the root issue(s)6
The psychiatrist can take a punitive approach, using fear tactics, or a positive approach, stressing potential personal gains for the patient. In an observational study7, the initial acceptance rate was 33% (11/33) when LAIs were presented in a predominantly negative light, whereas in a post-visit interview, 96% (27/28) were willing to try LAIs after a positive presentation.
Techniques to encourage engagement
Techniques are available to help healthcare providers think creatively about encouraging patient engagement
Healthcare providers may wish to think creatively about encouraging patient engagement, and techniques that are available to help. Hear more about supporting shared decision making in schizophrenia here.
Shared decision-making recognises that clinicians and patients bring different but equally important, knowledge and expertise to the process8. The clinician provides input on disease aetiology, treatment options, and prognosis, whilst the patient contributes their preferences, values, experiences, and circumstances.
Motivational interviewing motivates the patient in making positive changes. For instance, the GAIN model9 was developed to address patient acceptance of, and adherence to LAI treatment and involves Goal setting; Action planning; Initiate treatment; Nurturing motivation. Click to read more on the GAIN model.
Engaging patients in clinical practice
Using LAIs in clinical practice requires engagement and education of patients and mental health team members10, as both may have negative beliefs and experiences regarding LAIs.
A recently concluded study in the US, in a real-world clinical setting, demonstrated that high levels of LAI uptake can be achieved, even in early-phase patients11,12. The primary aim of this cluster-randomised trial was to compare the use of an LAI with usual care, in reducing the risk of hospitalization in early-phase schizophrenia (1st episode or <5 years antipsychotic treatment), and included a prescriber training program. For sites randomised to LAI therapy, only 14.4% of 576 potential participants declined because they would not consider LAIs, and 91% of the final sample of 234 participants accepted ≥1 LAI injection 11,12. The use of LAIs significantly delayed time to first hospitalisation (hazard ratio 0.56; 95% confidence interval 0.35 to 0.92; p=0.02) compared with clinician’s choice11,12.