Data Raise Question: Why Aren't Long-Acting Injectable Therapies Tried Earlier in Schizophrenia?

A medical affairs official with Janssen said physicians may not bring up the option of a long-acting injectable for fear of disrupting the doctor-patient relationship.

Medication adherence is a problem when treating any chronic condition, but nowhere is the challenge greater than in cases of severe mental illness. Patients diagnosed with schizophrenia or bipolar disorder may so dislike the side effects of medications, especially antipsychotics, that they may skip doses or stop taking them abruptly, often without telling their physician. Recently, 44% of patients admitted doing so in a survey reported at the recent US Psychiatric and Mental Health Congress.

When patients with severe mental illness don’t take medication as prescribed, the results are predictable: repeat trips to the emergency department (ED), inpatient stays, and outpatient care that may include weeks of intensive therapy. So, what can be done to stop this pattern?

Other data presented at the recent Psych Congress meeting point to an option that authors of the studies say deserves more attention: long-acting injectable therapy, or LAIs. With this option, patients receive injectable doses of medication in the physician’s office; these occur every 2 weeks to 3 months, and the care team is not reliant on patients being willing to take pills—or remembering to take them. Multiple antipsychotics are available in an injectable formulation, from older formulations such as olanzapine to newer ones like paliperidone palmitate, sold by Janssen in a 1-month dose as Invega Sustenna and in a 3-month dose Invega Trinza.

The need for a different option for patients with acute schizophrenia is seen in analyses involving Medicaid beneficiaries with schizophrenia. In a study using 10 years’ worth of data from 6 states1 and in another study of adults with schizophrenia treated across a large US healthcare system, authors found:

  • Among all Medicaid recipients, those with schizophrenia had 74% more inpatient stays and 92% more long-term stays. This translated into 15.8 times more mental health stay days each year, compared with patients not diagnosed with schizophrenia.
  • The Medicaid patients with schizophrenia incurred $14,087 in higher medical costs annually, compared with other Medicaid patients.
  • Within the health system studied, 44.3% of the Medicaid recipients with schizophrenia had some type of inpatient stay, and 64.9% had some type of ED visit.

Despite these results, recent research on patients within the Veterans Health Administration shows that medication adherence is extremely poor, with an 83.5% discontinuation rate. A third (33.8%) of patients had a relapse following an inpatient stay. This is of concern to health systems, as Medicare now evaluates them on their ability to prevent readmissions within 30 days, and the most seriously ill mental health patients are typically disabled and enrolled in Medicare and Medicaid. Yet only 9% of the patients who discontinued their first therapy switched to LAI therapy.

The VHA study found that annual per patient total healthcare costs for patients with schizophrenia were $40,989; almost all of this was attributed to medical costs.2

The studies were funded by Janssen Scientific Affairs.

Why do so many physicians wait until patients with schizophrenia fail on oral medication before trying an LAI? Ed Kim, MD, MBA, therapeutic area leader for schizophrenia, US Medical Affairs, Janssen, said in an email to The American Journal of Managed Care® that clinicians may assume, incorrectly, that their adult patients with schizophrenia will refuse an LAI. Because these clinicians want to maintain the physician-patient relationship, they may never offer this option.

“In fact,” Kim said, “there is research indicating that patients are actually fairly open to considering LAIs when provided information about this treatment option.”

Because LAIs are currently reserved for those with poor adherence or multiple relapses, Kim said it may take years before physicians try an injectable medication, despite evidence that these formulations offer benefits. When using an LAI for the first time, Kim said it’s not necessary for adult patients to be titrated up to a given dose of oral therapy before switching to the injectable version, “although it is recommended that they have previously tried and tolerated the oral version.”

For guidance in starting LAIs earlier in treatment, Kim recommended a resource from the National Council for Behavioral Health, “Guide to Long-Acting Medications.”

Asked if there are consent issues involved with these formulations, Kim said, “LAIs are an important treatment option that all too often are not offered to adults living with schizophrenia. We believe it’s important to help adults living with schizophrenia understand all of their treatment options, including the benefits and risks of each option, so they can truly make an informed treatment decision.”


  1. Lafeuille MH, Patel C, Pilon D, et al. Prevalence, incidence, and economic burden of schizophrenia among Medicaid beneficiaries. Presented at the US Psychiatric and Mental Health Congress; San Diego, California; October 3-6, 2019; Poster 212.
  2. Patel C, Huang A, Wang L, Paliwal Y, Joshi K. Journey of Veterans Health Administration population with recent schizophrenia diagnosis: a real-world analysis of treatment patterns and healthcare burden. Presented at the US Psychiatric and Mental Health Congress; San Diego, California; October 3-6, 2019; Poster 215.

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