HOLLYWOOD, FLA. – Many American psychiatrists have a bias against long-acting injectable antipsychotic medications, which constitutes a major barrier to broader use of this often advantageous form of therapy, investigators asserted at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.
"There’s a lot of anti-shot sentiment in the U.S., particularly on the part of doctors. They think that the therapeutic alliance will be negatively impacted by talking about an injection. Many of my patients have never been told that there is such a thing as injectable medicines," according to Dawn I. Velligan, Ph.D., professor of psychiatry and director of the division of schizophrenia and related disorders at the University of Texas Health Science Center at San Antonio.
She has participated in studies involving structured observation of psychiatrist-patient encounters that she found revealing – and troubling.
Dr. Dawn Velligan
"When doctors do offer a long-acting injectable agent, they’re so uncomfortable about doing it that they stutter and are just clearly uncomfortable. You can see it in linguistic fluency measures. Not only that, but they lead with the modality, rather than the potential benefit. They’ll say, ‘You don’t want a shot, do you?’ Well, of course not. What kind of a question is that? A doctor never starts out by saying, ‘I have these horse pills, and they’re really hard to take.’ They start out by explaining what this medication is going to do for your recovery, and then they mention that they’re horse pills and are hard to swallow," Dr. Velligan said.
Roughly 50% of patients are poorly adherent to oral antipsychotic therapy. Nonadherence results in higher rates of relapse, hospitalization, and disability. When asked, most psychiatrists will say they consider long-acting injectables (LAIs) the way to go when patients are nonadherent. Unfortunately, however, they are not good at all at identifying nonadherent patients.
"They don’t have any idea. I think doctors prescribe antipsychotic medication in an atmosphere of unclear adherence. So what they’re doing is raising the dose and raising the dose. I think they don’t know how much to prescribe," Dr. Velligan declared.
She was on a National Institute of Mental Health–sponsored expert panel that concluded all of the standard methods of assessing adherence are error prone (J. Psychosom. Res. 2010;69:591-9). For example, studies show that patient self-report vastly overestimates adherence and that clinicians are poor at judging the level of adherence. Plasma and urine analysis provide good quality information only about the last 4-5 days, not the past 30-60 days. "Smart" pill containers with electronic monitoring technology don’t work if the patient opens the bottle and forgets to put the top back on. Pill counts work only if the patient remembers to bring in his bottles. And pharmacy records, too, are unreliable in assessing adherence.
"I have people who are 100% adherent, but they haven’t picked up their pills from the pharmacy in 7 months because they had a bunch of pills left over from all the times that they weren’t adherent before," she observed.
An LAI offers numerous potential advantages for the prescriber. For one, it eliminates guesswork about compliance status.
"If patients with a prescription for oral therapy come in and they’re not looking well, you don’t know how much of their medication they’ve been taking. It’s an enormous crap shoot, yet we do it every single day," Dr. Velligan charged.
LAI therapy also alerts the psychiatrist when nonadherence starts, and it’s invaluable in disentangling efficacy from problem adherence.
"If I’m giving you an injection and you’re not doing well and you’ve shown up every time for your shots, this medicine is not working so well. It’s not the right antipsychotic for you," she explained.
Together with Dr. Martha Sajatovic, a psychiatrist at Case Western Reserve University in Cleveland, Dr. Velligan has developed what they call the NOB (individuals Not receiving Optimum Benefit from antipsychotic medication) checklist. It’s intended for implementation by overburdened clinicians in community mental health centers. A "yes" answer to any of the five simple questions (see below) should alert the provider that LAIs might in this case help in clinical decision making and improve patient outcomes.
In a separate presentation, Dr. Steven G. Potkin presented a detailed analysis of 69 recorded psychiatrist-patient community mental health center office visits involving 22 patients being treated with oral antipsychotics and 38 on LAIs. Prescribers spent merely a mean 2% of the visit time discussing adherence with their patients. Moreover, psychiatrists made decisions about antipsychotic treatment without patient or caregiver input in two-thirds of the encounters.