Reducing the stigma of long acting injectable antipsychotics - current concepts and future developments

Schizophrenia and Heart Health: Are Antipsychotics a Friend or Foe?

Schizophrenia is one of the most disabling of the psychiatric diseases. The Brief Psychiatric Rating Scale Extended (BRSE) is used to evaluate the severity of psychiatric symptoms. Long-acting injectable (LAI) antipsychotics are commonly used and are preferred over oral antipsychotic medications. A two-center-based cross-sectional study was performed on 130 patients diagnosed with schizophrenia or schizoaffective disorder based on the International Classification of Diseases 10 criteria. We studied the relation between the development of cardiovascular risk factors and the antipsychotic medication that was administered in these patients. Our study demonstrates strong links between several cardiovascular risk factors and the duration of psychosis; the duration of the LAI antipsychotic treatment; the duration between the onset of the disease and the start of LAI antipsychotic treatment; and the use of specific LAI antipsychotic medications.

Comparative Safety of Long-Acting Injectable Antipsychotics: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To find the safety of long-acting injectable antipsychotics (LAIs) compared to each other, and/or placebo in the treatment of schizophrenia (SCZ) and/or schizoaffective disorder (SZA).

METHODS

We performed a systematic review and a network meta-analysis of randomized controlled trials (RCTs) comparing the safety of LAIs versus other LAIs or placebo in adults diagnosed with SCZ or SZA. The primary outcomes were treatment emergent adverse events (TEAEs), serious treatment emergent adverse events (STEAEs), and deaths. The secondary outcomes included treatment discontinuations due to adverse events and all-cause discontinuations.

RESULTS

Seventeen RCTs were included (n=7,908). There were no significant differences between LAIs and placebo in the risk of presenting TEAEs. LAIs had a significant lower risk of presenting STEAEs except for aripiprazole. No significant differences in deaths were found. LAIs showed a significant protective effect against all-cause discontinuation, except for haloperidol. Only aripiprazole had a significantly lower risk of treatment discontinuation due to adverse events.

CONCLUSION

We found no significant differences in the risk of presenting TEAEs between LAIs and placebo. The majority of LAIs had a significantly lower risk of presenting STEAEs than placebo. Development of international guidelines for the report of safety outcomes related to antipsychotics especially for LAIs in clinical trials could minimize report and interpretation biases and improve the accuracy of posterior meta-analysis.

Long-acting antipsychotics in the treatment of schizophrenia: opportunities and challenges

INTRODUCTION

Maintenance antipsychotic treatment improves multiple outcomes in people with schizophrenia. These benefits are challenged by medication nonadherence, which is a common occurrence. Long-acting injectable antipsychotic (LAI) formulations were developed to reduce nonadherence and thereby improve outcomes. This narrative review is based on a PubMed search (January 2000 - August 2022) for studies on LAI antipsychotics.

AREAS COVERED

Opportunities and challenges associated with LAIs are reviewed. Advantages, compared to oral antipsychotics (OAs), include improved adherence, reduced relapse and hospitalization risk, delayed and lower relapse risk after stopping treatment, and the ability to differentiate true treatment resistance from 'pseudo'-resistance. Additionally, LAIs are associated with lower all-cause mortality than OAs. LAIs are under-used in many services, partly reflecting negative attitudes, misconceptions, and lack of knowledge among clinicians, patients, and carers. Practical barriers to LAI use include acquisition costs and inadequate service structures to administer/monitor LAI treatment.

EXPERT OPINION

The education and engagement of clinicians, patients and caregivers can assist more informed decision-making regarding LAIs. Future research regarding LAIs should encompass multiple complementary designs, focus on functionality and recovery outcomes, and include groups at high risk of relapse, including those with comorbid substance use disorders and early in the course of schizophrenia.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Attitudes and perceptions about the use of long-acting injectable antipsychotics among behavioral health practitioners

Introduction

Long-acting injectable antipsychotics (LAI-As) are important tools for the treatment of schizophrenia, yet they appear to be underutilized. This study will assess practitioner perceptions of LAI-As to elucidate reasons for underuse and uncover new avenues to increase appropriate use.

Methods

An anonymous electronic survey was developed and actively distributed to behavioral health care practitioners (MD, DO, PA, NP, PharmD, RN, LCSW). Independent t testing and linear regression analysis was used to assess for interactions between survey responses and individual factors.

Results

A total of 146 survey responses were collected from September 3, 2020 to March 17, 2021. On average, participants thought that LAI-As were slightly underutilized in practice. The mean estimated patient acceptance rate for LAI-A therapy was 38.6% ± 29.5% (range = 0%-100%). Participants who were <40 years of age and those with a psychiatric pharmacist at their practice site had significantly higher estimated acceptance rates. The highest-rated barriers to LAI-A use were related to negative patient attitudes, lack of patient education, and access issues (eg, transportation, cost). Respondent characteristics including age, gender identity, geographic location, practice setting, and the presence of a psychiatric pharmacist significantly influenced the perceived impact of these barriers.

Discussion

Behavioral health practitioners generally believed that LAI-As were underused, and only one-third of their patients would be accepting of the therapy. Several barriers were perceived as frequently impacting LAI-A use, but these were reduced by the presence of a psychiatric pharmacist. Understanding practitioner perceptions can assist with increasing the use of LAI-As.

Switch from Olanzapine Long-Acting Injectable to its Oral Equivalent during COVID-19 Pandemic: a Real World Observational Study

Schizophrenia is a psychiatric condition with chronic evolution, one of the most disabling diseases. The main cause for the disease's progression is considered to be the lack of compliance with the treatment. Long-acting injectable antipsychotics (LAIs) are an important treatment option for patients with schizophrenia. Olanzapine long-acting injection (OLZ-LAI) is a pamoate monohydrate salt of olanzapine that is administered by deep intramuscular gluteal injection. The aim of this paper is to report the effects of a sudden and unplanned switch from olanzapine long-acting injectable to oral olanzapine in remitted patients with schizophrenia due to restrictions caused by the COVID-19 pandemic. An observational study conducted in the Clinical Hospital of Psychiatry and Neurology of Brasov, Romania between April 2020 and March 2021. 27 patients with OLZ-LAI were entered into the study. Of 27 cases, 21 patients preferred to be switched to oral olanzapine (77.77%). Only 6 patients continued with the long-acting formulation. The main reason for the initiation of olanzapine pamoate in all the patients was non-adherence to oral medication (80.95%), and the mean age of starting LAI olanzapine was 36.42 years (SD ± 10.09). Within the following 12 months after switching from olanzapine LAI to OA, 15 patients (71.42%) relapsed, and 12 were admitted to the emergency psychiatric unit. The COVID-19 pandemic has brought multiple disservices to current medical practice. Sudden and unplanned switch from olanzapine long-acting formulation to oral olanzapine was followed by the high rate of relapse in remitted schizophrenia.

Calling for policy actions to increase access to long-acting antipsychotics in low-income and middle-income countries

Schizophrenia-spectrum disorders are associated with substantial impairment and disability. Lack of treatment adherence is a major issue, especially in low- and middle-income countries (LMICs). Despite growing evidence supporting second-generation long-acting antipsychotics (LAIs) as an effective strategy to ensure continued maintenance treatment in schizophrenia, access to these technologies has been very limited in constrained-resource settings. Including second-generation LAIs in national and international essential medicines lists and evidence-based guidelines, promoting public health-oriented patent pooling and extending their availability to primary health care settings, are key actions that should urgently be implemented to increase access to long-acting technologies. Implementing these policy actions can pragmatically improve treatment adherence, ultimately tackling schizophrenia-related impairment and disability in LMICs, which can be regarded as a global health priority.

Development and Evaluation of a Web-Based Educational Toolkit on the Knowledge, Attitudes, and Practices of Psychiatric Prescribers Regarding Long-Acting Injectable Antipsychotics

BACKGROUND

Long-acting injectable antipsychotics (LAIs) are unique and effective pharmacological treatment options for schizophrenia that are underutilized in clinical practice. Research surrounding prescriber barriers to the underuse of LAIs are limited to a few seminal studies which identified psychiatric prescriber barriers to the use of LAIs as knowledge deficits, uninformed attitudes, and poor prescribing practices. There is a gap in the literature regarding effective educational interventions to target the identified psychiatric prescriber barriers to the use of LAIs.

AIMS

The study aimed to develop a web-based educational toolkit that would positively affect the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs.

METHODS

A one-group, before and after design with a convenience, purposive sample of 17 psychiatric prescribers to assess the knowledge, attitudes, and practices (KAP) using a 20-item KAP questionnaire before and after a presentation of a web-based educational toolkit about LAIs was chosen.

RESULTS

The web-based educational toolkit slightly improved the total and three subscales KAP scores of psychiatric prescribers. However, only the difference in total KAP scores was found to be statistically significant.

CONCLUSIONS

The developed and evaluated web-based educational toolkit could provide a foundation for positive change to psychiatric prescribers' KAP regarding LAIs.

Attitudes and Willingness to Accept Long-Acting Injections for Patients With Schizophrenia in Beijing: A Cross-Sectional Investigation Based on Samples From the Communities

Background: Schizophrenia has brought a serious disease burden to China. Under the background that community rehabilitation has become the mainstream treatment model, the long-acting injection (LAI) can better prevent recurrence. Some districts in Beijing have also issued policies. This article aims to find out patient's current attitudes toward LAI and provide policy suggestions.

Methods: Some patients with schizophrenia in the communities are selected, while the survey format is face-to-face conversation. The content of the self-made questionnaire includes patients' willingness and reasons for accepting LAI treatment. Descriptive statistics, t-test and F-test are used to process the data from questionnaire surveys.

Results: About 10% of respondents have had experience using LAI and the current utilization rate is 2.4%. Respondents' willingness to accept LAI is generally low (only 18.1% are willing). The main reason for willingness is no need to take medication every day, while the main reasons for unwillingness are high cost, fear of injection and lack of understanding.

Conclusion: Beijing community patients are not very optimistic about LAI's cognition and willingness. Medication habits play an important role in their medication selection decisions. Intervention such as educate clinicians and patients about LAI and provide free injections to patients can be imposed. The promotion of LAI still has a long way to go.

Treatment strategies in management of schizophrenia patients with persistent symptoms in daily practice: a retrospective study

OBJECTIVES

One-third of the patients with schizophrenia show treatment resistance and literature on the effectiveness of interventions in patients with persistent symptoms is conflicting. This study aimed to assess clinical preferences of clinicians in those showing treatment resistance to antipsychotics and to determine correlates of interventions.

METHODS

Treatment strategies applied in the patients with schizophrenia in daily practice were inquired retrospectively. Those showing poor response to at least two antipsychotics and were administered a clinical intervention in a University Hospital between January and September 2018 were included. Clinical correlates of distinct interventions were evaluated.

RESULTS

The most common intervention (47%) was transition to a long-acting injectable antipsychotic (LAIA) and the second most common (22%) was addition of a second/third oral drug to on-going oral therapy. Switching to clozapine was more effective on positive symptoms comparing with the other interventions (p < 0.01). LAIA therapy showed a superiority over oral antipsychotic interventions at improving positive symptoms, except clozapine (p < 0.01).

CONCLUSIONS

LAIA administration and oral antipsychotic augmentation were the most common interventions in the patients with persistent symptoms. Clozapine was related to better clinical improvement in the present study and it might be administered as a second-line treatment in schizophrenia.Key pointsEffectiveness of the treatment strategies in schizophrenia patients with persistent symptoms is not satisfactory to meet expectations of the clinicians yet. Clozapine still seems to be the best option to provide a favourable improvement in TRS.LAIA and oral AP combination are used frequently in schizophrenia for persistent psychotic symptoms and targets of the combination therapies in daily practice needs to be clarified.The most common intervention was transition to a LAIA (47%) in the study and none of the patients administered LAIA had used a long-acting AP before the intervention. High rate of treatment nonadherence in schizophrenia is an important reason for common LAIA preference in the patients with persistent symptoms.Growing evidence indicates that clozapine can be used as a second-line treatment in schizophrenia, and thus, there is an urgent need to increase clozapine use in the patients with persistent symptoms in clinical practice.

Antipsychotic use among persons with schizophrenia in Sweden and Finland, trends and differences

OBJECTIVES

To compare the differences in prevalence of antipsychotic and adjunctive pharmacotherapy use among individuals with schizophrenia between Sweden and Finland during 2006-2016.

METHODS

Nationwide register-based data were utilized for constructing two separate cohorts: all persons in Finland with a diagnosis of schizophrenia treated in inpatient care during 1972-2014, and persons in Sweden aged 16-64 with recorded diagnoses of schizophrenia in inpatient or specialized outpatient care, sickness absence or disability pension during 2005-2013. The prevalence of use was assessed as a point prevalence on 31 October each year 2006-2016, based on drug use periods modelled with the PRE2DUP method. In 2016, the Finnish cohort included 37,780 persons and Swedish cohort 25,433 persons.

RESULTS

The most commonly used antipsychotic in 2016 was oral olanzapine in both countries (22.7% [95% CI 21.6-22.4] in Finland, 20.9% [20.4-21.4] in Sweden), followed by clozapine which was more frequently used in Finland (22.0%, 21.6-22.4) than in Sweden (14.8%, 14.4-15.3). Long-acting injectable (LAI) use was almost two times more likely in Sweden (21.6%, 95% CI 21.1-22.1) than in Finland (12.8%, 12.5-13.1), a difference which was due to more common use of FG-LAIs in Sweden. A four-fold difference was observed in Z-drugs use (19.9% in Sweden versus 5.0% in Finland).

CONCLUSION

Potential explanations for the observed discrepancies include differences in national treatment guidelines, methods of data collection, patient characteristics and/or attitudes towards treatment among both patients and physicians.

Comparing Long-Acting Antipsychotic Discontinuation Rates Under Ordinary Clinical Circumstances: A Survival Analysis from an Observational, Pragmatic Study

BACKGROUND

Recent guidelines suggested a wider use of long-acting injectable antipsychotics (LAI) than previously, but naturalistic data on the consequences of LAI use in terms of discontinuation rates and associated factors are still sparse, making it hard for clinicians to be informed on plausible treatment courses.

OBJECTIVE

Our objective was to assess, under real-world clinical circumstances, LAI discontinuation rates over a period of 12 months after a first prescription, reasons for discontinuation, and associated factors.

METHODS

The STAR Network 'Depot Study' was a naturalistic, multicentre, observational prospective study that enrolled subjects initiating a LAI without restrictions on diagnosis, clinical severity or setting. Participants from 32 Italian centres were assessed at baseline and at 6 and 12 months of follow-up. Psychopathology, drug attitude and treatment adherence were measured using the Brief Psychiatric Rating Scale, the Drug Attitude Inventory and the Kemp scale, respectively.

RESULTS

The study followed 394 participants for 12 months. The overall discontinuation rate at 12 months was 39.3% (95% confidence interval [CI] 34.4-44.3), with paliperidone LAI being the least discontinued LAI (33.9%; 95% CI 25.3-43.5) and olanzapine LAI the most discontinued (62.5%; 95% CI 35.4-84.8). The most frequent reason for discontinuation was onset of adverse events (32.9%; 95% CI 25.6-40.9) followed by participant refusal of the medication (20.6%; 95% CI 14.6-27.9). Medication adherence at baseline was negatively associated with discontinuation risk (hazard ratio [HR] 0.853; 95% CI 0.742-0.981; p = 0.026), whereas being prescribed olanzapine LAI was associated with increased discontinuation risk compared with being prescribed paliperidone LAI (HR 2.156; 95% CI 1.003-4.634; p = 0.049).

CONCLUSIONS

Clinicians should be aware that LAI discontinuation is a frequent occurrence. LAI choice should be carefully discussed with the patient, taking into account individual characteristics and possible obstacles related to the practicalities of each formulation.

Controversies Surrounding the Use of Long-Acting Injectable Antipsychotic Medications for the Treatment of Patients with Schizophrenia

Schizophrenia is a serious mental illness that requires continuous and effective long-term management to reduce symptoms, improve quality of life, and prevent relapse. Oral antipsychotic medications have proven efficacy for many patients taking these medications; however, a considerable number of patients continue to experience ongoing symptoms and relapse, often due to lack of adherence. The advent of long-acting injectable (LAI) formulations of antipsychotic medications provided an opportunity to improve treatment adherence and overall patient outcomes. Despite data to support LAI efficacy, safety, and improved adherence over oral formulations, there are several misconceptions about and barriers to LAI implementation within a standard of care for patients with schizophrenia. Areas of resistance around LAIs include (1) doubts regarding their benefits outside of improved adherence, (2) questions regarding their prescribing to a broader population of patients with schizophrenia, (3) when to initiate LAIs, (4) concerns regarding the safety of LAIs in comparison with oral medication, and (5) the most effective ways to educate healthcare providers, patients, and caretakers to enable appropriate LAI consideration and acceptance. Here, we discuss these key controversies associated with LAIs and provide supportive evidence to facilitate LAI use in a manner that is constructive to the clinician-patient relationship and successful treatment.

Rating Opportunity for Long-Acting Injectable Antipsychotic Initiation Index (ROLIN)

Background: Schizophrenia is a severe psychiatric condition with devastating consequences for the individual's functionality and leading to severe disability. Lack of insight and non-adherence to treatment remain the most important factors in the progression of the disease to chronicity. Despite their proven effectiveness in preventing relapses, reducing morbidity and mortality, long-acting injectable antipsychotics (LAIs) are still underused. One of the causes invoked is the lack of guidelines or protocols for initiating LAIs. Objective: The aim of this article is to present Rating Opportunity for Long-Acting Injectable Antipsychotic Initiation Index (ROLIN), a clinician-rated index that rates the important factors of the disorder across seven items: age, duration of illness, relapses, antipsychotic treatment response, family support, antipsychotic existing formulation and adherence. Method: A retrospective study in which all patients with schizophrenia discharged on oral antipsychotics without LAIs treatment lifetime were evaluated with ROLIN for opportunity for LAIs initiation. Results: Of 225 consecutive patients, 126 patients (56%) had a strong indication for initiating LAI (score between 25 and 35). Kolmogorov-Smirnov test was used for checking the normal distribution of values (95% CI for the mean = 9.5781 to 20.4219; 95% CI for the median = 6.5920 to 24.8161; SD = 9.7907; Coefficient of Skewness = 0.0743; Coefficient of Kurtosis = -1.1377). Conclusion: This paper proposed an instrument designed to improve treatment in schizophrenia using a simple conceptual model which integrates important predictors of good or poor outcomes.

Ingestible Sensors and Medication Adherence: Focus on Use in Serious Mental Illness

Background: Poor medication adherence is a major public health concern. Patients living with a serious mental illness (SMI) commonly present with non-adherence to their medication regimen, which can lead to relapse and hospitalizations. The high rates of antipsychotic non-adherence continue to persist despite several interventions and medication advances. This review evaluates the possible role of the ingestible sensor technology for medication adherence in different conditions, with a focus on use in the SMI schizophrenia. Methods: Literature searches were conducted in July 2019 in the PubMed database. Results: In small studies of ingestible sensor use, the average adherence ranged from 73.9% to 88.6% for SMI and ≥ 80% for cardiac and transplant (99.4%) patients. In SMI studies, patients were clinically stable, and the majority had a clinical global impression severity of “mild disease”. Patients generally experienced relatively minor dermatological adverse effects related to wearable sensor use. Conclusions: A medication with an ingestible sensor may help provide real-time objective medication-taking adherence information for clinicians. However, further studies are needed to understand the impact of use on adherence and improvement on treatment outcomes with the ingestible sensor technology.

The Gut Microbiome and Treatment-Resistance in Schizophrenia

The effect of antipsychotic medication is poor in 30-40% of patients with schizophrenia; treatment resistance is usually met with shifts to new drugs or drug augmentation strategies or a trial of clozapine. The purpose of this review was to examine the potential role of intestinal bacteria in the bioavailability of antipsychotic medication and the possibility that parenterally administered antipsychotics might be able to overcome treatment resistance. Databases were searched with appropriate terms to locate relevant papers dealing with the effect of antipsychotic drugs on the gut microbiome and the effect of bacterial metabolizing enzymes on antipsychotic drugs. Also searched were papers addressing the various current parenteral formulations of antipsychotic drugs. Sixty-five recent pertinent papers were reviewed and the results are suggestive of the premise that there is a drug refractory form of psychosis for which the composition of gut bacteria is responsible, and that parenteral drug administration could overcome the problem.

Reasons for initiating long-acting antipsychotics in psychiatric practice: findings from the STAR Network Depot Study

BACKGROUND

Long acting injectable (LAI) antipsychotics have been claimed to ensure treatment adherence and possibly reduce the daily burden of oral formulations. So far, only surveys investigating the theoretical prescribing attitudes of clinicians have been employed. On this basis, we aimed to investigate reasons for prescribing LAIs in a real-world, unselected sample of patients.

METHODS

The STAR Network Depot Study is an observational, multicentre study consecutively enrolling adults initiating a LAI over a 12-months period. Clinical severity was assessed with the Brief Psychiatric Rating Scale, and patient's attitude toward medications with the Drug Attitude Inventory 10 items. Psychiatrists recorded reasons for LAI prescribing for each study participant. Responses were grouped into six non-mutually exclusive categories: aggressiveness, patient engagement, ease of drug taking, side-effects, stigma, adherence.

RESULTS

Of the 451 patients included, two-thirds suffered from chronic psychoses. Improving patient engagement with the outpatient psychiatric service was the most common reason for prescribing LAIs (almost 80% of participants), followed by increasing treatment adherence (57%), decreasing aggressiveness (54%), and improving ease of drug taking (52%). After adjusting for confounders, logistic regression analyses showed that reasons for LAI use were associated with LAI choice (e.g. first-generation LAIs for reducing aggressiveness).

CONCLUSION

Despite the wide availability of novel LAI formulation and the emphasis on their wider use, our data suggest that the main reasons for LAI use have remained substantially unchanged over the years, focusing mostly on improving patient's engagement. Further, clinicians follow implicit prescribing patterns when choosing LAIs, and this may generate hypotheses for future experimental studies.