Misperceptions and Underutilization of LAIs for Schizophrenia

Transcript: John M. Kane, MD: Why is there so much controversy or hesitation to use long-acting injectable LAI medicines? The evidence is clear, but many clinicians are hesitant. There is a misperception of what it means to recommend a long-acting injectable. It's viewed as coercive or we're taking away the patient's autonomy, and I think that's an unfortunate misperception. We are trying to help the patient achieve more autonomy by giving him or her more control over the illness from which they're suffering. We should not convey that injections are somehow punitive. Unfortunately, many clinicians present this to patients and families in a negative light.

Prescribers highlight the injection more than they promote the benefits. We need to do a better job training everyone how to have these conversations so LAIs are not viewed negatively. There is a tremendous push from prescribers to identify a patient who may not need medicine, or who can use a low dose. It’s confusing because the long-acting injectable is no different than making a decision to use medication, whether it's oral or long-acting. The first decision that needs to be made is, is medication indicated? If it is indicated, then why not use a long-acting formulation? But I think people confuse those issues sometimes.

Henry A. Nasrallah, MD: I have an answer to your question of why are they not being used widely. The reason is ignorance, and it's a very specific type of ignorance. People in the 1970s when Prolixin came to the market as the first long-acting [medication], nobody used it because of attitudes of psychiatrists that, “I let my patient make the decision. I respect the patient's decision to decide what they want.” Without realizing that they have a severe brain disorder that impairs their ability to make decisions, and then it gets worse. There was absolutely no knowledge until 20 years ago that psychotic relapses destroy the brain. They are neurodegenerative. They are damaging to the brain. Nobody knew that in the ’60s, ’70s, ’80s, ’90s; nobody knew that. Long-acting injectables were not taken seriously because they didn't know how serious and devastating psychotic relapses are to the biology of the brain of the patient.

Because of that ignorance they thought of it as an option, let the patient decide. “I don't force myself on the patient. I don't want to be paternalistic. Let the patient exercise their civil liberties.” In other words they destroyed themselves by exercising the wrong decisions for themselves. Only in the last 20 years we realized that, when they started doing MRI scans, repetitively, and realized that the brain was undergoing atrophy with every episode. That’s when we realized how urgent the matter is. Nobody took it urgently. And there is a whole generation of psychiatrists who were trained in the ’60s, ’70s, ’80s, and ’90s who are still practicing, and they still have that same old attitude, that this is an option. And they don't realize how urgent it is to save young people's lives.

Transcript Edited for Clarity