Practical Advice on Long-Acting Injectables in Schizophrenia

Peter L. Salgo, MD: Are there any other suggestions, you as an experienced clinician, can give our audience about how to start this conversation? What do you say to patients? How does it happen?

John M. Kane, MD: Sure. First you’re going to do psychoeducation, explaining the nature of the illness. You’re going to explain the treatment options, the risks, the benefits, and so forth. Once you get the message across that medicine is a very important component of the treatment for schizophrenia, then the conversation has to be, “Okay, I’ve worked with many, many patients like you, and I know how difficult it is to take medicine on a regular basis. I’ve had many, many patients who’ve been rehospitalized because they stop their medicine, or they weren’t taking it regularly. I’d really like to work with you to avoid that, therefore I’m going to suggest that we start a long-acting formulation very soon. Right now, you were just admitted to the hospital. I’m not going to start it today. We’re going to start it just before you leave the hospital, or we’re going to start it when you are being treated in the outpatient clinic.” That way you’re setting an expectation. You’re saying to the patient, “This is the way we treat your illness. This is what you can expect down the road.”

Peter L. Salgo, MD: You’re not dropping it on them at the last minute.

John M. Kane, MD: That’s right, where 2 years later someone says, “Oh gee, I think you should be getting this formulation,” and they’re like, “What?”

Peter L. Salgo, MD: That’s what you say to patients. We know that physicians are slow to adopt anything. Let’s turn it around again. What do you say to physicians who should be adopting the long-acting injectables? How do you describe that to them?

John M. Kane, MD: Right. I think we want to have a similar conversation. “Look, you have decided for your patient that medicine is recommended. That’s what you want. The reason that is, is there have been meta-analyses showing that if you compare antipsychotic drugs to placebo in the prevention of relapse in schizophrenia, the number needed to treat is 3. It doesn’t get any better than that in medicine. It is a very powerful effect. Once you’ve reached that conclusion, you’re communicating that to the patient, then you want to work with the patient to do everything you can to ensure that they’re going to get those benefits of that medicine.”

Peter L. Salgo, MD: Right. I have my own theory as to why it takes 10 years or more to adopt these things. I think it’s generational. I think us old guys have to go away, and I think the kids have to come on and start doing the new stuff. But that’s just me.

John M. Kane, MD: We’ll see.

Peter L. Salgo, MD: I don’t have any proof for that.

John M. Kane, MD: We’ll see.

Peter L. Salgo, MD: I know I’m perfect, but the rest of us old guys, you know?

John M. Kane, MD: It’s an empirical question, we’ll see.

Peter L. Salgo, MD: It’s an empirical question.

John M. Kane, MD: The other thing to communicate to the physicians, in addition to that message, is to better teach them how to have the conversation. We’ve done role-playing with doctors. I’ll play the patient, and I’ll sit with the doctor and he or she will offer me a long-acting formulation. I’ll say something, and we’re going to train them. OK, well, how do you respond to that? You need to be prepared to answer frequently asked questions. You need to be comfortable with that. You need to be comfortable when the patient tells you to go blankety blank because they don’t want injections.

Peter L. Salgo, MD: But I’m a doctor. I should simply say something, and that patient should listen to me. How 19th century.

John M. Kane, MD: Yes, that is very 19th century.

Peter L. Salgo, MD: When we had almost nothing to offer anyone.

John M. Kane, MD: Yes. The other thing is you want to work with the rest of the clinical team.

Peter L. Salgo, MD: Who is that clinical team, by the way?

John M. Kane, MD: There could be social workers, psychologists, nurse practitioners, rehabilitation counselors, and peer counselors. There could be a pretty broad team in many cases. We believe in coordinated care where there are many disciplines participating. The doctor cannot do everything. We need to make sure that everybody on the team understands this and is on board. This is because if I’m a patient and I have a therapist who’s a social worker, I probably have a closer relationship with that person than I do with the prescriber, right?

Peter L. Salgo, MD: Right.

John M. Kane, MD: So, if that person says, “Oh, I know you’re adherent, you don’t need to take these injections.” We’re done, you know what I mean? We’ve got to make sure that person is also on board and understands what’s going on here.

Peter L. Salgo, MD: It’s very close to the idea that you should never treat your family.

John M. Kane, MD: Well, yes, that’s true.

Peter L. Salgo, MD: That’s the point. You need to treat people as patients, and it’s why doctors as patients are just bad outcomes.

We talked about all kinds of ways to encourage the use of the right medicines, these long-acting injectables. What about in the hospital setting itself—hospital administrations, pharmacy administrators—how can they smooth the path here?

John M. Kane, MD: I think they can help in a number of ways. First, they can help by obviously making sure these are on the formulary, making sure they understand how they need to be delivered, and stored, and so forth. I think if the hospital can also make people available to give the injections that would be helpful. A lot of psychiatrists are not going to give the injections themselves. If they have to, that may be a deterrent. If a hospital can provide nursing to do that, and if they can set up an injection clinic so that patients have easy access, that can be extremely helpful. Having guidelines within the hospital can be helpful. But also making sure that the clinicians, and here I’m talking about all the clinicians, not just the prescriber, that the clinicians have adequate training in what this is all about and how to communicate the message.

Peter L. Salgo, MD: Most hospitals that I know have an injection clinic for something. So why not for this?

Transcript edited for clarity.