John M. Kane, MD: When we look at the studies that have compared oral antipsychotics to the long-acting injectable formulations, there are different kinds of studies that have been done. They each have their advantages and disadvantages. But when we look at all of the data as a whole, I think it’s pretty compelling that we can reduce the risk of relapse and hospitalization by using long-acting formulations. I think the challenge has been that many clinicians are not comfortable, or comfortable enough, having these conversations with patients. Sometimes it’s presented in a more pejorative or negative way. “You haven’t been taking your medicine, so we’re going to put you on injections.” I think that’s the wrong message. I think the message has to be, “Look, we want you to get the benefit of the medication, and we believe that the way we can have the greatest likelihood of succeeding in that is for you to be receiving injections on a regular basis, because that makes it much easier for you to be able to get the benefit of the medication.”
I think we need to present it in a much more normalized fashion. There should not be a stigma associated with injections, the way some people see it. It shouldn’t have a stigma, just as some people stigmatize nonadherence. “You’re a bad patient.” I think that’s a mistake. I think we have to say, “Nonadherence is normal; it’s human nature. The question is, what do we do to help you overcome that problem?” This is where the use of long-acting medicines comes in. I think we have to help our colleagues do a better job of explaining to patients the potential benefits, and not presenting it in a negative way. I think if we can present it more routinely as a real advantage, that would be very, very helpful.
I think there are several advantages in the use of long-acting formulations. First, we know that they can help reduce the risk of nonadherence. They also give the clinical team much better awareness of what is happening. When someone’s taking oral medicine, if the patient stops it, we don’t necessarily know. They’re not going to call us up and tell us. If someone misses their scheduled injection of a long-acting formulation, we know immediately that the person is now missing their medicine, and we can try to do something about it. We can do a home visit or call the family or do whatever we think is appropriate, because we know. We also have some time to intervene, because the medicine is not out of their system immediately. We have some time.
Another factor is family. If you have had a relative or a son or a daughter who’s had a psychotic episode and you had to call the police to take that person to a hospital against their will because they had lost insight or because they’d become aggressive or violent, it’s really a traumatic experience for everybody. When the individual affected by the illness has to be taken to a hospital against their will or admitted to an emergency room, for the family, it’s a traumatic experience. When that person leaves the hospital and they’re better, the family members are going to be very concerned as to whether or not they’re taking their medicine.
This can become a source of tension in the family. “Did you take your medicine?” “Oh, leave me alone. I’m a grown-up, leave me alone.” “No, I need to know, did you take your medicine?” If someone is receiving long-acting formulations, then that question is off the table. It eliminates a lot of tension in the family. It eliminates uncertainty on the part of the clinical team.
When someone relapses, sometimes we don’t know whether they’ve relapsed despite taking the medication or they’ve relapsed because they stopped taking the medicine. We can’t always figure that out. When someone’s receiving a long-acting injectable formulation, it’s very clear if they’ve relapsed despite taking the medication. These are very important advantages. Another advantage is that we have better control over the actual dosage because we’re giving it prudentially, and there’s a much better correlation between the dose and the blood level that we’re going to achieve. We have more sustained control over that blood level.
In addition, if someone were to stop taking the medicine, particularly with the formulations that are now given less frequently, we know that the person will still be, to a large extent, protected from relapse for quite some time after they’ve received their last injection. That can also be very valuable because it gives us time to intervene, time to do something.