Long-acting Injectable Antipsychotic Medication Research Articles

Clinical, Quality of Life, and Health Care Utilization Outcomes of Switching the Administration Route of Antipsychotic Medications Among People With Schizophrenia Spectrum Disorder: A Systematic Review and Meta-Analysis.

Using long-acting injectable (LAI) antipsychotic medications can improve the outcomes of patients with schizophrenia, such as reducing symptom severity and hospitalization risk. However, the outcomes of switching from oral to LAI antipsychotic medications are unclear. The purpose of this review is to provide a summary of the clinical, quality of life, and health care utilization outcomes of switching from oral to LAI antipsychotics among patients with Schizophrenia Spectrum Disorder. We thoroughly searched the PubMed, Scopus, PsycInfo, and CINAHL databases. To conduct the meta-analysis, we used the Comprehensive Meta-Analysis Program. Forty-one articles met our inclusion criteria. After switching to LAIs, symptom severity, the number of rehospitalizations, emergency department visits, and overall health care costs were reduced. Also, social functioning significantly improved. However, no differences were observed in the frequency of outpatient visits. Pharmacy costs were increased between pre- and post-LAI initiation. Our findings support evidence that changing the route of administration of antipsychotic medications from oral to long-acting intramuscular injections can improve the clinical, quality of life, and health care utilization outcomes in people with schizophrenia. Health care practitioners might consider encouraging LAI use earlier during treatment for schizophrenia for better clinical outcomes and to reduce health care utilization associated with treatment.

Multi-level barriers and facilitators to implementing evidence-based antipsychotics in the treatment of early-phase schizophrenia.

Long-acting injectable (LAI) antipsychotic medications and clozapine are effective yet underutilized medical therapies in early intervention services. The purpose of this study was to conduct a pre-implementation evaluation of contextual determinants of early intervention programs to implement innovations optimizing LAI antipsychotic and clozapine use within a shared decision-making model. Semi-structured interviews explored barriers and facilitators to implementing LAI antipsychotics and clozapine in early intervention services. Participants were: prescribers (n = 2), non-prescribing clinicians (n = 5), administrators (n = 3), clients (n = 3), and caregivers (n = 3). Interviews were structured and analyzed using the Consolidated Framework for Implementation Research (CFIR 2.0). Participants were supportive of using LAI antipsychotics, despite barriers (e.g., transportation, insurance coverage), while most were unfamiliar with clozapine (Innovation). Critical incidents (e.g., COVID-19) did not interfere with implementation, while barriers included lack of performance measures; stigma affecting willingness to take medication; and clozapine considered to be a "last resort" (Outer Setting). Treatment culture was described as client-centered and collaborative, and most participants indicated LAI antipsychotic use was compatible with clinic workflows, but some were in need of resources (e.g., individuals trained to administer LAI antipsychotics; Inner Setting). Participants on the healthcare team expressed confidence in their roles. Family education and collaborative decision-making were recommended to improve client/family engagement (Individuals). Participants related the importance of tracking medication compliance, addressing client concerns, and providing prescribers with updated guidelines on evidence-based treatment (Implementation Process). Results may guide implementation strategy selection for future programs seeking to optimize the use of LAI antipsychotics and clozapine for early-phase schizophrenia, when appropriate.

Long-Acting Injectable Antipsychotic Medication Use in Youth: A Systematic Review of the Literature Along with MedWatch Safety Data and Prescriber Attitudes.

Objectives: Long-acting injectable (LAI) antipsychotic medications are being prescribed to children and adolescents along a broad age range from 2 to 17 years old. However, there is no U.S. Food and Drug Administration (FDA) approved indication for the use of any LAI in a pediatric population. The goal of this article is to perform a systematic literature review regarding the use of LAIs in a pediatric population, to obtain pediatric LAI safety data, and to survey prescriber attitudes regarding LAI use in youth. Methods: A search for relevant articles between June 1986 and June 2021 was conducted. Safety data were obtained from FDA MedWatch postmarketing adverse event reports regarding LAI use in children and adolescents. A survey of practicing Child and Adolescent Psychiatrists in Wisconsin was done regarding the use of LAIs in youth. Results: The predominant reasons for LAI use in youth were illness severity and treatment noncompliance. Twenty-six of 30 identified studies and reports favored LAI use in youth, but were of low to very low quality. Overall, 587 FDA MedWatch reports between June 1986 and June 2021 were identified. Most adverse events occurred in modest numbers. Extrapyramidal symptoms accounted for 18% of all MedWatch reports, neuroleptic malignant syndrome accounted for 3% of all reports, and deaths accounted for 2% of all reports. The concern for safety was reflected in prescriber survey results along with a recognition that LAIs can be helpful to target severe psychiatric symptoms and address treatment noncompliance. Conclusions: No randomized controlled studies were found. Identified published studies and reports were of low to very low quality. However, it appeared reasonable that the use of LAIs in a select group of pediatric patients can be helpful to target severe psychiatric symptoms and to enhance treatment compliance.

Schizophrenia and Heart Health: Are Antipsychotics a Friend or Foe?

Schizophrenia is one of the most disabling of the psychiatric diseases. The Brief Psychiatric Rating Scale Extended (BRSE) is used to evaluate the severity of psychiatric symptoms. Long-acting injectable (LAI) antipsychotics are commonly used and are preferred over oral antipsychotic medications. A two-center-based cross-sectional study was performed on 130 patients diagnosed with schizophrenia or schizoaffective disorder based on the International Classification of Diseases 10 criteria. We studied the relation between the development of cardiovascular risk factors and the antipsychotic medication that was administered in these patients. Our study demonstrates strong links between several cardiovascular risk factors and the duration of psychosis; the duration of the LAI antipsychotic treatment; the duration between the onset of the disease and the start of LAI antipsychotic treatment; and the use of specific LAI antipsychotic medications.

Assessing the impact of long-acting injectable compared to oral antipsychotic medications on readmission to a state psychiatric hospital.

People living with schizophrenia spectrum disorder (SSD) have a higher death rate which is caused, in part, by poorer adherence to treatment as compared to those with other mental illnesses. Using long-acting injectable antipsychotic (LAI) medications can improve medication adherence and reduce hospitalizations for people living with SSD but are often underutilized. As compared to oral antipsychotic medications provided to patients with SSD at discharge from a psychiatric hospitalization, being provided with an LAI antipsychotic medication may reduce subsequent rehospitalization. Specifically, patients discharged on an atypical or second-generation LAI medication are less likely to be readmitted to the hospital when compared to those discharged on a typical first-generation oral medication. Because LAI antipsychotic medications are often underutilized as treatment options, the study findings suggest that this modality may be considered for patients with SSD when being discharged from a psychiatric hospitalization. Ideally, psychiatric-mental health nurses can educate patients about indications, benefits, and risks of using atypical or second-generation LAI antipsychotic medications during hospitalization and at discharge prevent the risk for future rehospitalizations. INTRODUCTION: People living with schizophrenia spectrum disorder (SSD) have poorer medication adherence compared to those with other mental illnesses. Long-acting injectable antipsychotic (LAI) medication use is associated with greater adherence, reduced re-hospitalizations, and improved recovery outcomes when compared to oral formulations. To compare LAI antipsychotic medication use versus oral formulations on readmission to an inpatient hospital. Medical records (N = 707) from a state psychiatric hospital in the southern region of the United States were reviewed. Controlling for demographic variables, logistic regression analyses were used to examine LAI compared to oral formulations on readmission. Compared to patients discharged with oral antipsychotic medications, those with LAIs had a lower proportion of readmission rates in 6-month and 1-year periods, but not 30-day or 2-year periods. When controlling for demographic variables, those discharged with an atypical LAI had significantly lower odds of being readmitted within the 24-year period compared to those discharged on a typical oral antipsychotic. Compared to orals, LAIs do not increase and may mitigate readmissions to psychiatric hospitalization. Psychiatric-mental health nurses and other professionals may recommend LAIs when indicated for those with SSD.

Adherence, health care utilization, and costs between long-acting injectable and oral antipsychotic medications in South Carolina Medicaid beneficiaries with schizophrenia.

Schizophrenia and schizoaffective disorder require long-term antipsychotic treatment with antipsychotic medications, but poor medication adherence can lead to increased health care utilization and costs. Long-acting injectable antipsychotics (LAIs) offer potential therapeutic advantages in that they require less frequent dosing and improved medication adherence. South Carolina has the highest adoption of LAIs among US states, making it an ideal population for comparing the effectiveness of LAIs vs oral antipsychotics (OAPs) in treating schizophrenia or schizoaffective disorder. To evaluate the effect of LAIs compared with OAPs on medication adherence, health care resource utilization, and costs among South Carolina Medicaid beneficiaries with schizophrenia or schizoaffective disorder. South Carolina Medicaid beneficiaries with at least 1 claim for an LAI or OAP between January 1, 2015, and December 31, 2018, aged 18 to 65, with at least 2 claims with diagnoses of schizophrenia or schizoaffective disorder were included. Propensity scores (PSs) were calculated using logistic regression adjusting for confounders and predictors of the outcome. We estimated the "average treatment effect on the treated" by employing PS-weighted t-tests and chi-square tests. A total of 3,531 patients met the inclusion criteria, with 1,537 (44.5%) treated with LAIs and 1,994 (56.5%) treated with OAPs. In PS-weighted analyses, the LAI cohort had a greater proportion of days covered than the OAP cohort with a 365-day fixed denominator (69% vs 64%; P < 0.0001), higher medication possession ratio with a variable denominator while on therapy (85% vs 80%; P < 0.0001), and higher persistence (82% vs 64%; P < 0.0001). The average number of inpatient visits and emergency department visits did not significantly differ between cohorts (0.28 hospitalizations, P = 0.90; 3.68 vs 2.96 emergency department visits, P = 0.19). The number of outpatient visits, including visits for medication administration, were greater in the LAI cohort (23.1 [SD 24.2]) vs OAP (16.9 [SD 21.2]; P < 0.0001); however, including the costs for medication administration visits, outpatient costs (per member) were approximately $2,500 lower in the LAI cohort (P < 0.0001). The number of pharmacy visits was greater in the OAP cohort (LAI 21.0 [SD 17.0] vs OAP 23.0 [SD 15.0]; P = 0.006). All-cause total costs were greater in the LAI cohort ($26,025 [SD $29,909]) vs the OAP cohort ($17,291 [SD $25,261]; P < 0.0001) and were driven by the difference in pharmaceutical costs (LAI $15,273 [SD $16,183] vs OAP $4,696 [SD $10,371]; P < 0.0001). Among South Carolina Medicaid beneficiaries, treatment with LAIs for schizophrenia or schizoaffective disorder was associated with greater medication adherence rates. Patients using LAIs had higher drug costs and total costs, but lower outpatient and total nondrug costs compared with those using OAPs.

Retrospective chart review of metabolic screening of patients receiving clozapine and long-acting injectable antipsychotic medications

Background/Aims Individuals treated with antipsychotic medications are at risk of developing metabolic syndrome, negatively impacting the quality of life among patients with severe mental illness. The aim of this study was to examine metabolic screening data and determine the prevalence of metabolic syndrome among those who were prescribed clozapine and long-acting injectable antipsychotics. Methods This retrospective chart review looked at 307 patient records who were prescribed clozapine and long-acting injectable antipsychotics as part of a service improvement initiative. Results The prevalence of metabolic syndrome was found to be 60.2% and 49.5% for those on clozapine and long-acting injectable antipsychotics respectively, with no significant difference between groups (χ2 (1, n=198)=2.295, P=0.130). Screening rates were significantly higher for patients receiving clozapine (42.5–96.2%) vs those receiving long-acting injectable antipsychotics (20.5–55.7%). There were significant differences between screening rates and clinical sites; the clozapine clinic had the highest completed screening rate (90.7%). Conclusions Screening of metabolic syndrome is insufficient among patients prescribed long-acting injectable compared to clozapine despite similarly high prevalence. Having a robust screening practice promotes early intervention to prevent metabolic syndrome, reduces the risk of developing comorbid health conditions and premature death, and improves the physical health of patients treated with antipsychotic medications. This study also recommends that service development efforts should target these screening deficiencies to improve the quality of life of patients with severe mental illness.

Predictors of Long-Acting Injectable Antipsychotic Medication Use in Patients with Schizophrenia Spectrum, Bipolar, and Other Psychotic Disorders in a US Community-based, Integrated Health System.

Long-acting injectable (LAI) antipsychotics improve patient outcomes and are recommended by treatment guidelines for patients with limited medication adherence in schizophrenia spectrum, bipolar, and other psychotic disorders. Reports of LAI antipsychotic use in these disorders and if use aligns with treatment guidelines are lacking. This study aimed to report patient characteristics associated with LAI antipsychotic use in these disorders. Retrospective observational study of patients ≥18-years-old with bipolar or psychotic disorders at a large, integrated, community-based health system. Patient demographic and clinical characteristics served as exposures for the main outcome of adjusted odds ratio (aOR) for LAI versus oral antipsychotic medication use from January 1, 2017 to December 31, 2023. There were N = 2685 LAI and N = 31 531 oral antipsychotic users. Being non-white (aOR = 1.3-2.0; P < .0001), non-female (aOR = 1.5; P < .0001), from a high deprivation neighborhood (NDI, aOR = 1.3; P < .0007), having a higher body mass index (BMI, aOR = 1.3-1.7; P < .0009), having a schizophrenia/schizoaffective (aOR = 5.8-6.8; P < .0001), psychotic (aOR = 1.6, P < .0001), or substance use disorder (aOR = 1.4; P < .0001), and outpatient psychiatry (aOR = 2.3-7.5; P < .0001) or inpatient hospitalization (aOR = 2.4; P < .0001) utilization in the prior year with higher odds and age ≥40 (aOR = 0.4-0.7; P < .0001) or bipolar disorder (aOR = 0.9; P < .05) were associated with lower odds of LAI use. Non-white, non-female, age 18-39, and high NDI patients had higher LAI use regardless of treatment adherence markers. Smoking and cardiometabolic markers were also associated with LAI use. Demographic and clinical factors are associated with increased LAI use irrespective of treatment adherence. Research on utilization variation informing equitable formulation use aligned with treatment guideline recommendations is warranted.

Concepts for selection and utilization of psychiatric medications in pregnancy.

Psychiatric illness may develop or relapse during pregnancy, and understanding best practices is paramount. In 2017, the British Association for Psychopharmacology (BAP) consensus guidance on the use of psychotropic medication preconception, in pregnancy, and postpartum was released. The BAP guidelines provide concise evidence and additional insight and flexibility for use of psychiatric medication. Key takeaways of these guidelines are highlighted serving as a concise reference for practitioners. Additionally, practice points, such as recommendations for rapid tranquilization and the role of long-acting injectable antipsychotic medications as well as additional insights to the growing body of literature associated with psychiatric medications in pregnancy since 2017 are summarized. Providers are strongly encouraged to stay up to date to provide optimal care for pregnant patients and their babies.

Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers.

Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States. The authors conducted a secondary analysis of the 2020-2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing. Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming. Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.

Implementing gradual, hyperbolic tapering of long-acting injectable antipsychotics by prolonging the inter-dose interval: an in silico modelling study.

Gradual, hyperbolic tapering has been proposed as a method to reduce the risk of withdrawal effects and potential relapse of an underlying condition by minimising disruption of existing equilibria. We applied hyperbolic tapering principles in silico to long-acting aripiprazole to generate regimens for withdrawal in clinical practice. We derived thresholds for taper rates using existing studies and consensus. Using pharmacokinetic data for aripiprazole long-acting injectable antipsychotic (ALAI), we conducted in silico modelling to examine the impact of abrupt cessation of long-acting injectable antipsychotic (LAI) medication and the effect of prolonging inter-dose interval on plasma aripiprazole levels and consequent D2 occupancy. We also modelled transitions from LAI medication to oral medication. Regimens were designed to afford a rate of reduction between 5 and 12.5 percentage points of D2 occupancy per month. Abrupt discontinuation of ALAI was shown to lead to a maximal D2 occupancy reduction of 16.8 percentage points per month; prolongation of the inter-dose interval of ALAI produced a slower reduction. Specifically, hyperbolic tapering was afforded by prolongation of a 400 mg ALAI inter-dose interval from 4 to 7 weeks, before reducing the dose to 300 mg ALAI. This could then be administered at up to 4-week (for 6% maximal D2 occupancy change), 6-week (9% change) or 7-week (11% change) intervals. Switching to oral medication - 5, 2.5 and 1.25 mg for the three regimens, respectively - is required for ALAI to complete full cessation to prevent too rapid a reduction in D2 occupancy. Oral medication should probably be maintained at a consistent dose for 3-6 months before further reductions to account for residual LAI being concurrently eliminated. Hyperbolic dose tapering is possible with ALAI through prolongation of the inter-dose interval and may reduce the risk of relapse compared to abrupt discontinuation of LAI medication.

Planning for Future Is Critical to Protecting Our Profession and Americans’ Mental Health

Planning for Future Is Critical to Protecting Our Profession and Americans’ Mental Health

Psychiatric hospitalisation before and after commencing long-acting injectable antipsychotic medication: a mirror-image study.

Treatment adherence is an important predictor of outcomes in schizophrenia, related disorders and bipolar disorder, and may be improved by the use of long acting injectable (LAI) antipsychotic medication. Past research on the efficacy of LAIs is mixed with randomised controlled trials showing similar benefits to oral medication, and naturalistic studies showing advantages to LAIs. Psychiatric hospital bed-nights and admissions were compared before and after commencement of an LAI, using a retrospective cohort study with a mirror-image design. Total bed-nights and hospital admissions for each patient were compared for the same time period before and after commencing the LAI. Subgroup analyses were also conducted. Mean bed-nights decreased from 47.1 pre-LAI to 14.3 post-LAI, and median bed-nights from 24.5 to 0.0. Mean hospital admissions decreased from 1.7 pre-LAI to 0.7 post-LAI, and median admissions from 1.0 to 0.0. In our cohort, LAI treatment was associated with a significant reduction in bed-nights and total admissions to psychiatric hospitals. The findings of the current study are consistent with the results of previous naturalistic studies of LAI treatment for patients with psychotic disorders and bipolar disorder.

Systematic review of community pharmacist administration of long-acting injectable antipsychotic medications

BackgroundLong-acting injectable antipsychotic (LAIA) medications offer an effective treatment option for patients with serious mental illness. Despite demonstrated clinical safety and efficacy as well as increased adherence and less frequent administration compared with daily oral regimens, LAIAs remain underutilized in clinical practice. With legislation allowing pharmacists to administer injectable medications in 48 U.S. states, community pharmacies are uniquely positioned to serve as an access point for patients with serious mental illnesses to receive LAIA injections. ObjectiveThis study aimed to conduct a systematic review of the health and economic benefits and costs of community pharmacist administration of LAIA medications. MethodsA systematic search of the literature published from January 1996 to April 2022 was conducted across 3 databases (Embase, PubMed, and Scopus Plus). Publications describing pharmacist administration of LAIA medications in outpatient settings were included. Publications that examined the use of LAIAs but did not involve a pharmacist administering the medication were excluded. ResultsOf 2261 publications reviewed, we identified 8 publications (4 articles and 4 abstracts) that met our inclusion criteria, of which only 7 included results. Four studies reported high medication adherence achieved by patients receiving pharmacist-administered LAIAs. Two publications surveyed patient satisfaction with pharmacist administration of LAIAs in community pharmacy settings. One study found pharmacists’ mixed attitudes regarding LAIA administration and time and safety barriers to offering the service. ConclusionWe found very little evidence on the impact of pharmacist administration of LAIAs on patient outcomes. This review highlights the need to generate greater evidence on the health and economic benefits as well as financial models for pharmacists to administer LAIA medications in outpatient and community pharmacy settings. Such evidence could support more community pharmacists to offer LAIA medications and contribute to the shift toward value-based care.

Effectiveness of More Personalized, Case-Managed, and Multicomponent Treatment for Patients with Severe Schizophrenia Compared to the Standard Treatment: A Ten-Year Follow-Up.

Case management is a model of personalized intervention in people with severe mental illness. To explore the treatment adherence and effectiveness of patients with severe schizophrenia (Clinical Global Impression Severity, CGI-S ≥ 5) undergoing treatment in a community-based, case-managed program (CMP) with an integrated pharmacological and psychosocial approach compared with the standard treatment, an observational, ten-year follow-up study was conducted on patients treated in mental health units (MHUs) or a CMP (n = 688). Treatment discontinuation, hospitalizations, suicide attempts, and antipsychotic (AP) medications were recorded. Clinical severity was assessed with the CGI-S. Adherence to the CMP was higher than adherence to standard treatment (p < 0.001). There were fewer hospitalizations and suicide attempts in the CMP (p < 0.001). The clinical severity decreased more in the CMP (p < 0.005). Long-acting injectable (LAI) antipsychotic medication was more closely related to these outcomes than oral antipsychotics (APs) were (p < 0.001). Patients with severe schizophrenia in an integrated CMP recorded higher treatment compliance and better outcomes compared with standard care. Treatment with LAI APs was linked to these outcomes. A personalized combination of case management and LAI AP medication was more effective in these patients than standard treatment and oral APs.

Case Series Evaluating the Use of Combined Long Acting Injectable Antipsychotics in Three Patients Within Forensic Services

AimsAntipsychotic polypharmacy is a relatively common practice, despite a lack of robust evidence. In 2018, the National Clinical Audit of Psychosis evaluated the treatment of 8000 patients with a diagnosis of schizophrenia or schizoaffective disorder, and found 10% were receiving non-clozapine antipsychotic polypharmacy. This included 432 patients receiving one oral &amp; one long acting injectable (LAI) antipsychotic and 2 patients receiving two LAI antipsychotics. An audit within our service, found that 24 of 88 (27%) inpatients were receiving non-clozapine antipsychotic polypharmacy. Of these, 3 were prescribed two LAI antipsychotics. A literature review found very limited evidence supporting the use of combined LAI antipsychotics, with publications relating to a total of 18 cases. Presented here is a case series, reviewing the use of LAI antipsychotic polypharmacy in three patients within Devon Partnership Trust.MethodsThe case series reports on three male inpatients, who are under the care of secure services within Devon Partnership Trust. All are currently prescribed two LAI antipsychotics. Two have a diagnosis of treatment resistant schizophrenia and one of schizoaffective disorder. All are complex, necessitating recurrent or lengthy admissions, and present with significant risk to others when unwell. In each case, there have been trials of multiple antipsychotics, but only one has had a previous trial of clozapine.ResultsPublished case reports highlight the positive effects of LAI polypharmacy, noting an improvement in mental state and lack of adverse effects. The cases presented here show significant variability, with one patient improving significantly, the second to a lesser extent, and the third remaining under high level observations.All cases are complex with decisions taken on a background of high risk, after multiple failed trials of medication.Although no specific adverse effects were reported, none of the patients regained sufficient insight to engage in treatment decisions and physical health monitoring. It is therefore difficult to quantify the adverse effect burden and weigh this against perceived efficacy.ConclusionCombined LAI antipsychotic medication is a possible treatment option in complex individual cases. Prescribing decisions are based on perceived clinical benefit, and the evidence base remains limited, with little understanding of long-term effects or consequences.Unlike high dose antipsychotics, there is no formalised guidance for prescribing combined LAI antipsychotics. Treatment targets and review processes were not always explicit. A more robust approach, would provide greater clarity around the practice and aid with future decision making.

Evaluation of patient satisfaction and perceptions of a long-acting injectable antipsychotic medication administration service in a community-based pharmacy during the COVID-19 pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic, restrictions, and social distancing requirements for medical offices reduced scheduling availability and increased virtual televisits by providers. COVID-19 restrictions created a barrier to health care access for patients who are being administered long-acting injectable antipsychotics (LAIs) in an already vulnerable population. ObjectiveTo describe an LAI medication administration service at a community-based pharmacy during the COVID-19 pandemic, to evaluate patient satisfaction with the administration of LAIs by a pharmacist service in a community-based pharmacy during the COVID-19 pandemic, and to compare the patient’s perceptions of receiving LAIs in a community-based pharmacy with those in another setting previously used for medication administration. Practice descriptionIndependent full-service community-based pharmacy. Practice innovationImplementation of an LAI administration service after an increase in provider referrals of patients to the community-based pharmacy during the COVID-19 pandemic. Evaluation methodsA 4-month prospective convenience sample study conducted to evaluate the LAI medication administration service. The survey containing 32 questions was adapted with permission from a previous survey administered in a large grocery store chain to a similar population. Survey results were reported using descriptive statistics. ResultsEleven patients completed the survey. A total of 82% of patients strongly agreed that they felt comfortable with receiving this service at the community-based pharmacy and were satisfied with the privacy during the service. Seventy-one percent of patients who received this service elsewhere strongly agreed the LAI medication administration service was more convenient than a similar service received elsewhere, yet only 18% of patients strongly agreed that the community-based pharmacy was near their work or home. ConclusionA medication administration service for LAIs was developed in a community-based pharmacy, and patients were satisfied with the service. Further research needs to be completed to evaluate health outcomes and financial implications of this service for the patient and health care system.

An interventional pilot of customized adherence enhancement combined with long-acting injectable antipsychotic medication (CAE-L) for poorly adherent patients with chronic psychotic disorder in Tanzania

BackgroundChronic psychotic disorders (CPD) impose a particularly significant burden in resource-limited settings. Combining long-acting antipsychotic medication (LAI) with a customized adherence enhancement intervention (CAE-L) has potential to advance care.MethodsNineteen adults ≥ age 18 with CPD who self-reported missing ≥20% of antipsychotic medication within the last month were stabilized on oral haloperidol prior to transitioning to monthly haloperidol decanote for 25 weeks. Outcome evaluations were conducted at baseline and Week 25. Primary outcomes were oral medication adherence assessed via the Tablet Routines Questionnaire (TRQ) and LAI injection frequency. Secondary outcomes included CPD symptoms measured by the Brief Psychiatric Rating Scale and Clinical Global Impressions, functioning evaluated using the Social and Occupational Functioning Scale, and medication attitudes assessed with the Drug Attitudes Inventory.ResultsMean sample age was 38.79 (SD = 9.31) with 18 individuals completing the study. There was one serious adverse event, a relapse into substance use, not deemed study-related. Mean endpoint LAI dosage was 65.79 mg (SD = 22.38). TRQ mean scores were 21.84 (SD =13.83) and 12.94 (SD = 11.93) at screen and baseline respectively. For only two individuals who were on concomitant oral medication at 25 weeks, TRQ change was not calculated. LAI injection frequency was 100%. Medication attitudes scores significantly improved from 7.89 (SD = 2.72) to 9.83 (SD = 0.52) (p = .001.) Changes in CPD symptoms and functioning were non-significant.ConclusionsCAE-L appears to be preliminarily feasible and acceptable in Tanzanians with CPD.Trial registrationThe study was registered on ClinicalTrials.gov (NCT04327843) on March 31, 2020.

Management of Schizophrenia with Long-Acting Injectable Antipsychotic Medications: An Assessment of the Educational Needs of Clinicians.

PurposeSchizophrenia is a chronic and serious mental disorder characterized by disturbances in thought, perception, and behavior that impair daily functioning and quality of life. Long-acting injectable (LAI) antipsychotic medications may improve long-term outcomes over oral medications; however, LAI antipsychotic medications are often only considered as a last resort late in the disease course. This study sought to assess current clinical practice patterns, clinicians’ attitudes, and barriers to the use of LAI antipsychotic medications as well as identify unmet educational needs of psychiatric clinicians in managing patients with schizophrenia.MethodsA survey was distributed via email to 2330 United States-based clinicians who manage patients with schizophrenia; 379 completed the survey and were included for analysis. The survey included five patient case-based scenarios, with seven decision points. Data were analyzed with qualitative and quantitative methodologies.ResultsClinicians were most confident in determining when to initiate treatment and least confident in transitioning to injectable therapy or administering injectable therapy. Clinicians cited nonadherence, and not wanting to take daily medicine or the “hassle” of frequent treatment, as key factors for which patients were most suitable for an LAI antipsychotic medication. Patient nonadherence was considered the most important barrier to optimal management of patients with schizophrenia. A clinician’s perception of relapse was a strong driver of whether or not the clinician would discuss/recommend an LAI antipsychotic medication.ConclusionThis study suggests that clinicians may be reluctant to discuss or recommend switching patients to an LAI antipsychotic medication if they are perceived as doing well on current therapy. These results will inform future research and continuing education that aims to improve the confidence, knowledge, and competence of clinicians who provide care for patients with schizophrenia who may benefit from treatment with an LAI antipsychotic medication and clinicians who may be more likely to routinely offer an LAI antipsychotic medication to their patients.

Long-Acting Injectable Antipsychotic Medications in Pregnancy: A Review.

Long-acting injectable antipsychotic medications (LAIs) are an evidence-based treatment option for people with severe mental illness. While women with severe mental illness who are prescribed LAIs can become pregnant, there is a dearth of research examining the safety of these medication formulations during pregnancy. This article summarizes available literature on the use of LAIs in pregnancy to help inform clinical decisions and guide future research. PubMed literature searches were completed using combinations of keywords including "antipsychotic" and "long-acting injectable" or "depot," or generic or brand names of LAIs with "pregnancy." Pregnancy outcomes were compared across studies. Twelve relevant case reports of 13 pregnancies were identified. Six cases did not report any negative birth or infant outcomes, including prematurity, infants being born small for gestational age, congenital anomalies, and extrapyramidal symptoms. No cases reported abnormal Apgar scores, infants being born large for gestational age, or negative long-term developmental outcomes after exposure to LAIs during pregnancy. Cesarean section rate was comparable to the general population. Specific adverse outcomes included one infant with multiple congenital anomalies, 3 infants with minor congenital anomalies, and one infant with possible extrapyramidal symptoms. One infant was born prematurely, one infant was born small for gestational age, and 2 infants were born both prematurely and small for gestational age. There is little research specifically examining the use of LAIs in pregnancy, so risks must be extrapolated from studies on oral antipsychotics in pregnancy. While the few published case reports examining LAIs in pregnancy somewhat align with research examining oral antipsychotics, these findings are inconclusive due to the inherently limited nature of case reports. Further investigation into the use of LAIs in pregnancy is warranted.