The Changing Viewpoint: Schizophrenia Treatment

One of my first jobs following my residency and fellowship was working part-time at Safe Haven, a shelter and treatment center for people who are homeless and living with mental illness. This was 20 years ago, and for the first time I was exposed to new treatment options that I had not encountered before in my other practice settings, including long-acting injectable (LAI) medications. As time progressed, newer LAIs became available. While this form of treatment was not widely used, as I gained more experience with LAIs, I observed that many adults living with schizophrenia who were successful outside of the center were those who had been on LAIs.

At Safe Haven, patients received medication reminders while in the treatment center, but once they left, their daily care was now their own, or a caregiver’s, responsibility. Based on my experience, this type of transition can lead to one of the key challenges in schizophrenia treatment—nonadherence.¹ There are many factors that can lead to nonadherence, including lack of a strong support network and care team, lack of resources to assist in following a treatment plan properly, and the need for repeated reminders to continue consistent treatment, which can be in the form of a daily medication.² Adherence is difficult, and when care and support aren’t stable, this dynamic can result in increased stress and angst.

What results is a cyclical experience–hospitalization, stabilization, and relapse.³ In fact, according to one Medicaid claims analysis, after a psychiatric hospitalization, 49% of patients are nonadherent to their antipsychotic medication within 6 months of discharge.⁴ Relapses impact adults living with schizophrenia and their families, and have significant economic consequences, as repeated relapses escalate healthcare costs.^5,6

During my time at Safe Haven, I observed that those treated with LAIs and later discharged received their antipsychotic medication consistently. They did not need that daily treatment reminder. I’ve seen the impact LAIs have firsthand. In my experience, LAIs reduce the risk of hospitalizations as well as schizophrenia-related complications and comorbidities, and decrease medical resource use. I have seen, and continue to see, the positive personal, societal, and economic outcomes associated with LAIs. 

Today, the work that I do is very different from what most other providers do. I work with the Institute of Human Services as the only street outreach psychiatrist in Hawaii treating patients who are homeless and living with mental illness. I also work at Adventist Health Castle serving as a psychiatric hospitalist and am the medical director of the hospital’s Behavioral Health Services. The combination of these experiences has afforded me the opportunity to see and treat a wide range of adults living with schizophrenia—whether it’s patients who are not stable and are regularly admitted to the ER, patients who have been homeless for years without treatment, recently diagnosed young adults, or people who have been living with the chronic brain disorder for a while and are deteriorating without proper treatment.

In each of these scenarios, where patients are at different points in their journeys with schizophrenia, I’ve found that LAIs offer a strong pharmacologic option. We owe it to our patients to present all treatment options, including the benefits and risks, and encourage them to be cooperative with treatment. 

Previously, healthcare providers (HCPs) were very conservative about using LAIs since many of us were trained to believe this treatment type should be reserved for the most severe cases. However, as time progresses and more clinical evidence is made available, LAIs have been proven to be effective treatments for adults with schizophrenia and can help address adherence issues patients can be facing with oral medications.^7,8

In my opinion, the best thing about the updated guidance and guideline from the National Council for Behavioral Health Guide to Long-Acting Medications and the American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia is the shift in mindset and approach to exploring treatment options. The way people view LAIs is changing compared to 10 or even 5 years ago, but there is still more education needed as LAIs remain underused.⁹ It’s my hope that more practitioners will familiarize themselves and become more comfortable with recommending LAIs for appropriate patients.
 

Chad Koyanagi, MD, serves as a psychiatric hospitalist at Adventist Health Castle and was recently appointed medical director of the hospital’s Behavioral Health Services. He works part-time in an administrative position for the Department of Human Services MedQuest office, helping to set the tone for mental health services in the state of Hawaii by reviewing Medicaid plans. For the past 10 years, Dr. Koyanagi has served as one of the 3 psychiatric providers for the Institute of Human Services and its large homeless clientele. This article was developed in joint collaboration by Janssen Pharmaceuticals, Inc., and Dr. Chad Koyanagi.
 

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