Adherence Strategies in Schizophrenia Care

When I treat adult patients with schizophrenia, I do not focus on reactively treating a relapse but, rather, on proactively working to prevent nonadherence. To do this, we need to make adherence achievable and understandable. It is human nature to be nonadherent—no one is able or expected to do something 100% of the time—even in the best of circumstances.¹ Adherence can be even more difficult when faced with the fact that having to take schizophrenia medication can cause patients to experience feelings of lack of control, otherness, and oftentimes a disbelief that the medication is even needed.¹

In my experience, achieving symptomatic stability for adults living with schizophrenia can result in positive psychosocial interactions, increased self-care, and the improved ability to engage in leisure activities, education, or employment. However, when an individual with schizophrenia stops taking medication as prescribed without the direction of a healthcare provider, this can often result in relapse.² Repeated relapse may have an impact on the brain and alter the course of the disease trajectory.^3,4 However, I’ve also seen it result in an erosion of the patient’s support network and self-worth, as well as increased self-stigma, which is when people internalize public stigma and stereotypes and apply these to themselves. Repeated relapse is associated with poorer functionality and quality of life, which successful maintenance can treat.⁵

Beyond the positive personal benefits of finding a comprehensive treatment plan that works for the adult living with schizophrenia by keeping them more symptomatically stable and functional, caregivers and the healthcare system also benefit. A comprehensive treatment plan entails providing psychoeducation, group and/or individual psychotherapy, and medication treatment to the patient, supplemented as needed by case management and help from a supported employment and education specialist. If the patient allows this, family psychoeducation may also be provided. In the context of patients’ nonadherence and symptomatic instability, caregivers can become worn down, feel stressed, and may miss work in order to stay at home looking after their loved ones. With the right treatment plan, caregivers and patients have the chance to focus on the positive and productive aspects of their relationship. 

The healthcare system also benefits when adults living with schizophrenia find the right treatment plan. While long-acting injectables (LAIs) might be more expensive than oral medications, we know from pharmacoeconomic data that healthcare utilization or costs were significantly reduced in some studies of LAIs.^2,6

LAIs can reduce how often an individual needs to think about receiving their antipsychotic medication, potentially from 365 to 12 times a year or less.⁷ LAIs are associated with delayed time to relapse, and can be used to empower patients to have more autonomy from their illness instead of facing a daily reminder of their illness by having to take an oral medication. In addition, some studies have shown that patients on LAIs have less treatment discontinuation versus those on oral antipsychotics.^7,8,9

The way I present LAIs as a treatment option to my patients is through a seat belt analogy. Every time you get into a car, you wear a seat belt, not because you are going to be in a car crash, but because the events of life are uncertain and the seat belt offers greater assurance that you’ll be safer if something does happen. For adults living with schizophrenia, an LAI can act as their seat belt and delay time to relapse due to medication nonadherence, specifically in patients with a history of nonadherence to their oral medication regimen.^9,10 I also understand people fear the unknown. Because of this, I recommend that my patients give LAIs a try. After a trial period, if they don’t like the treatment, that’s OK, since they determined whether that specific treatment was right for them, based on their own experience with the LAI.

In my opinion, healthcare providers (HCPs), like people living with schizophrenia, need more experience with LAIs in order to determine if they are right for their patients. For HCPs, they need more education on LAIs to have meaningful and important conversations with patients around treatment choice—after all, only a convinced HCP can be convincing. Within the database of clinical evidence and recent guidelines and guidance, like the American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, the Florida Best Practice Psychotherapeutic Medication Guideline for Adults, and the National Council for Behavioral Health Guide to Long-Acting Medications, HCPs are now being advised to consider LAIs across the illness course and HCPs can feel empowered to take a stance recommending this treatment option. 

I believe we need to continue to educate HCPs on the new evidence, guidelines, and guidance, so they feel comfortable recommending LAIs. In my opinion, we need to destigmatize LAIs, as they are no longer a last-resort treatment option, and evaluate the growing body of clinical evidence more progressively. I try to promote with my patients proactive rather than reactive treatment, which in my opinion entails the ideally shared paradigm of ensured maintenance antipsychotic care with an LAI before and not after a relapse or nonadherence, using LAIs as a safety belt on the journey through life in cases where a schizophrenia relapse may intervene. While we are moving in the right direction, I believe that there is still more work to be done.
 

Christoph Correll is Professor of Psychiatry at The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA. Furthermore, he is Chair of the Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité Universitätsmedizin Berlin, Campus Virchow, Berlin, Germany. This article reflects Dr Correll’s own experience and opinions and was developed in joint collaboration by Janssen Pharmaceuticals, Inc., and Dr Correll. He has been paid an honorarium for his time. 
 

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