psychiatrist

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Educational Activity

Managing Transitions in Care and Adherence to Improve Outcomes in Schizophrenia

John Lauriello, MD, and Diana O. Perkins, MD

Published: March 26, 2019

CME Background

Supported by an educational grant from Alkermes, Inc.

To obtain credit for this activity, study the material, answer the posttest, and complete the evaluation.

Objective

After completing this educational activity, you should be able to:

  • Ensure that patients are receiving continuous antipsychotic treatment by monitoring adherence and making provisions to cover potential gaps in treatment
  • Use evidence-based dosing and switching strategies to incorporate long-acting injectable antipsychotics into the treatment plan
  • Address somatic and psychiatric comorbidities in the treatment plan of patients with schizophrenia
  • Practice effective treatment-planning and decision-making techniques to more successfully manage diverse patients with evolving needs over their lifespan
  • Understand the pharmacology of current and evolving treatments for schizophrenia and how this translates into clinical benefit

Financial Disclosure

The faculty for this CME activity and the CME Institute staff were asked to complete a statement regarding all relevant personal and financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosures are as follows:

The Chair for this activity, Dr Lauriello, has received grant/research support from Sunovion, Otsuka, Janssen, and Alkermes; is on the advisory panel for Alkermes, Janssen, Osmotica, Otsuka, Reckitt Benckiser, Sunovion, and Teva; has received speaker’s honoraria from Roche; and has received travel expenses from Alkermes. Dr Perkins is a consultant for Sunovion and Alkermes, and has received other financial or material support from American Psychiatric Association Publishing. The opinions expressed herein are those of the faculty and do not necessarily reflect the opinions of the CME provider and publisher or the commercial supporter.

Accreditation Statement

The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 2 hours of Category I credit for completing this program.

Release, Review, and Expiration Dates

This activity was published in March 2019 and is eligible for AMA PRA Category 1 Credit™ through March 31, 2021. The latest review of this material was December 2018.

Statement of Need and Purpose

Many individuals with schizophrenia experience numerous relapses, ongoing symptoms, and impairment. Clinicians can take steps to improve the care they provide to patients with schizophrenia. Optimal, aggressive treatment and careful monitoring need to begin during the first episode and continue without interruption, which will require transitional periods or potential gaps in service to be anticipated and planned for. Clinicians must better monitor a common cause of relapse, nonadherence, and offer strategies to improve adherence. Long-acting injectable (LAI) antipsychotics have the potential to reduce relapse and rehospitalization for many patients with schizophrenia, but they are underused. Clinicians need information on identifying candidates for LAI treatment, educating patients about switching, and how to safely transition from oral to LAI formulations. To further enhance patient care, clinicians must address somatic and psychiatric comorbid conditions. Patients with schizophrenia have complex and differing needs, and care providers need to assess each patient individually to determine the best course of treatment and adjust care as patients’ needs change. Treatment algorithms and decision models have been proposed to guide patient management, and clinicians would benefit from a review of these tools as well as the evidence on newer treatments. This activity was designed to meet the needs of participants in CME activities provided by the CME Institute of Physicians Postgraduate Press, Inc., who have requested information on LAIs in schizophrenia.

Disclosure of Off-Label Usage

The chair has determined that, to the best of his knowledge, metformin is not approved by the US Food and Drug Administration for the treatment of metabolic side effects or weight gain.

Review Process

The faculty members agreed to provide a balanced and evidence-based presentation and discussed the topics and CME objectives during the planning sessions. The faculty’s submitted content was validated by CME Institute staff, and the activity was evaluated for accuracy, use of evidence, and fair balance by Dr Lauriello and a peer reviewer who is without conflict of interest.

Acknowledgment

This Webcast was derived from the planning teleconference series “Managing Transitions in Care and Adherence to Improve Outcomes in Schizophrenia,” which was held in July and August 2018 and supported by an educational grant from Alkermes, Inc.

John Lauriello, MD
Department of Psychiatry, University of Missouri, Columbia, Missouri

Diana O. Perkins, MD
Department of Psychiatry, University of North Carolina, Chapel Hill

Introduction

Faculty Introduction

Publisher’s Welcome

Patient Perspectives

“When my son was 20, he was admitted to the hospital; that’s when they said okay, you have schizophrenia. Now he is 23. Last time he became psychotic he ended up stabbing us. He has been transferred from jail to a facility, and his new doctor wants to change his medication. I try to be as involved as I can, but I do not believe that—and I apologize in advance to the physicians that do listen—that the physicians are listening to the caregivers enough because we are on the front lines, and we know when our loved ones are compensating, and they can hold it together sometimes for a 15-minute med check. It is very important when a mom or a caregiver goes in there and says, ‘You need to listen to me because we live with it 24/7, and we know the warning signs,’ and if the physician would have listened to me, I would not have been stabbed.” (Anonymous, oral communication, August 2018).

Chapter 1: Strategies for Ensuring Continuous Care From the First Episode Through the Patient’s Life

Video 1.1. The Problem of Nonadherence


Implementing reliable strategies can help physicians monitor adherence. Here are recommendations from Dr Lauriello and Dr Perkins:

  • Ask patients detailed questions such as how many pills they take each day and on how many days over the past month they did not take any medication.
  • Have an open, nonjudgmental attitude and recognize that, in most cases, it is a patient’s choice whether or not to take medications.
  • Work with patients to determine the reasons for not taking medications and what physicians could do better.
  • Use pharmacy data to detect gaps in medication refills, which would indicate nonadherence, because patient/carer reports are often unreliable.
  • Enlist a family member to help supervise medication adherence.
  • Assist the patient with useful monitoring strategies such as a pill box, smart phone reminders, electronic monitoring devices, or pharmacy blister packs.
  • Discuss adherence as part of all patients’ routine medical management.

Reference: Byerly et al 2008

In the next video clip, Dr Perkins and Dr Lauriello discuss the importance of keeping the medication regimen as simple as possible for the patient, which can be done with LAIs, as well as other potential benefits of these formulations

Video 1.2. Reasons Patients May Prefer LAIs


Barriers to clinicians offering patients LAI antipsychotics:

  • Clinicians aren’t familiar with LAIs.
  • Offices lack resources to administer LAIs (eg, staff, refrigeration).
  • Insurance issues may arise.

References: Caroli et al 2011; Citrome 2013; Correll et al 2016; Heres et al 2006; Jaeger et al 2010; Patel et al 2003

In this clip, a patient, Anne, describes the barrier that has prevented her from ever trying LAI treatment, despite experiencing numerous relapses. Dr Lauriello and Dr Perkins then discuss how Anne’s case illustrates that having a “battle plan” for how a patient takes a medication once they’ve left the hospital is key.

Video 1.3. Identifying Treatment Barriers


Some perceived advantages and disadvantages of LAI antipsychotics are the following:

  • Advantages:
    • No need for daily antipsychotic, which may offer both convenience and elimination of a daily reminder of illness
    • Ease of tracking adherence
    • Stable blood drug levels, which may minimize side effects
    • More peace of mind for carers
    • Reduced risk for relapse/rehospitalization
  • Disadvantages:
    • Low acceptance of shots
    • Injection-site complications
    • Reduction in patient autonomy
    • No rapid dose adjustment
    • Cost differences
    • Side effects may appear to occur more than with oral agents due to actually taking the medication

References: Correll et al 2016; Kane et al 2013

In the following clip, the mother of a man with schizophrenia discusses why her son recently decided to switch to LAI treatment, and Dr Lauriello and Dr Perkins respond by explaining that patients may have a number of reasons for prefering LAI treatment, but, as Dr. Lauriello points out, patients will never have the opportunity to try these treatments if clinicians do not discuss them.

Video 1.4. Considering Patient Preferences

Case Practice Question

Ray is 26 years old and has just been released from the hospital following a relapse. He has come for his follow-up appointment accompanied by his mother, which he is irritated about because he feels like she is meddling in his life. Ray’s mother reports that this was his third relapse in as many years and she isn’t sure why. Which of the following would be the most helpful strategy for addressing Ray’s relapses?

  1. Ask Ray’s mother if he has been filling his prescriptions.
  2. Ask Ray if he has times when he either forgets to take the medication or decides to miss or stop altogether.
  3. Increase the dose of Ray’s medication because the current dose has not been strong enough to prevent his relapses.
  4. Advise Ray’s mother to withdraw herself from Ray’s treatment process because her involvement seems to be counterproductive.

Preferred Response is B.

Explanation: Clinicians often fail to inquire in depth about a patient’s adherence to the prescribed medication, which is problematic because adherence is very closely related to relapses. The questioning must be more than “Are you taking your medication?” It should include nonjudgmental questions about Ray’s use of the medication. In-depth questioning may reveal that Ray doesn’t feel the medication is helping, has intolerable side effects, or is too complicated to take every day. Although checking pharmacy records may be useful for detecting medication gaps or non-fills, patient/carer reports are unreliable. Increasing the medications without understanding Ray’s adherence could expose him to higher than optimal doses. Finally, understanding the family dynamics between Ray and his mother may be helpful but should not lead to excluding his mother from the treatment process.

Chapter 2: Understanding the Psychopharmacology of LAI Antipsychotics

As Dr Lauriello explains in the next clip, to fully understand the psychopharmacology of LAI antipsychotics, clinicians must be familiar with the different carriers and their unique characteristics that have been used to create these long-acting formulations.

Video 2.1. Evolution of LAI Antipsychotics

What are microspheres?

Microspheres are a novel drug delivery system that are being used in a number of therapeutic areas. The microspheres consist of biodegradable polymers that are hydrolyzed and metabolized by the body. In the case of risperidone LAI, the active risperidone molecules are embedded in microspheres of glycolic acid-lactate copolymer. These remain in a dry, powder form until they are mixed with an aqueous suspension just prior to injection. The dried microspheres slowly fill with water and begin to swell until they begin to fall apart. As they fall apart, the embedded risperidone crystals start to be released, usually around 3 weeks after the injection. According to Dr. Lauriello, this new technology was a game changer because, for the first time, a long-acting second-generation antipsychotic was available. This new formulation, however, had drawbacks. Injections needed to be given every 2 weeks, but the microspheres took around 3 weeks to begin to break down and release medication. Patients, therefore, were having to receive their second injection before any benefit from the first injection was evident. In addition, the injections needed to be kept refrigerated, which was a challenge for some clinics.

References: Hyon 2000; Kane et al 2003

Since the development of risperidone LAI, additional LAI formulations of atypical antipsychotics have become available. Dr Lauriello summarizes these in the next clip.

Video 2.2. Available LAIs


LAI formulations vary greatly in certain pharmacologic characteristics. Therefore, clinicians must be familiar with the following information for each agent:

  • How long after the first injection is therapeutic effect achieved?
  • How frequently must injections be given?
  • Is initial oral supplementation required?
  • How long until steady state blood levels are reached?

Reference: Correll et al 2016

In the video below, Dr Lauriello and Dr Perkins discuss how the more steady blood levels, in this case provided by risperidone microspheres, translate into clinical benefit for the patient.

Video 2.3. Benefits of Steady Blood Levels

Reference: Eerdekens et al 2004

When considering pharmacokinetic differences between oral and LAI formulations of the same antipsychotic, clinicians must be aware that a steady state is reached with an oral medication after 4 or 5 half-lives, but with an LAI, steady state may not be achieved until after 4 or 5 injections. Thus, instead of taking days, it may take months, but the patient should see a big difference in terms of the medication’s dose-related side effects. However, as Dr Perkins and Dr Lauriello point out, new side effects may emerge once patients begin LAI treatment because they are receiving their medication more consistently. They may not have been experiencing the side effect while taking oral antipsychotics because they were only partially adherent.

Of course, Dr Lauriello and Dr Perkins emphasize that drug half-lives may be very different in the brain versus in the blood. The effect of a particular drug in the brain, at the receptor level, is what is most important in psychiatric illness, and this can vary from patient to patient. Dr Lauriello and Dr Perkins discuss this topic in the next clip, and present audio from a patient who is apprehensive about LAI treatment because of the negative experiences of an acquaintance.

Reference: Sheehan et al 2012

Video 2.4. Pharmacokinetic Considerations


In the next segment, Dr Lauriello and Dr Perkins discuss the importance of understanding the details of each medication to help you choose how to approach each patient’s treatment regimen.

Video 2.5. Important Differences Between LAIs

What’s new on the horizon for LAI antipsychotics?

  • Aripiprazole lauroxil now has a loading dosing system for starting treatment or re-starting treatment after a missed dose; the system comprises a single-dose, immediate-release LAI, a ‘regular’ LAI, and a 30-mg oral pill.
  • A new, subcutaneous formulation of risperidone was approved by the FDA in July 2018 for the treatment of schizophrenia in adults. This new formulation requires no oral supplementation and injections are given monthly. Dr Lauriello explained that subcutaneous injections have the potential to be less painful and provide greater delivery accuracy than intramuscular injections, and they could, at some point, allow for self-administration.
  • Different delivery methods for LAIs may become available.
    • Implants may offer 6-month efficacy, and, unlike injectable formulations, could be removed if treatment needed to be discontinued or adjusted
    • Intranasal administration might provide a non-invasive means of more effectively delivering medication across the blood-brain barrier.
    • Liquid antipsychotic delivery might be preferred by or easier to administer to some patients.

References: Aristada package insert 2018; Citrome 2018; Clinicaltrials.gov 2018; Clinicaltrials.gov 2014; Shah et al 2016; Papazisis and Siafis 2018

In the following segment, the faculty discuss the main concepts clinicians need to consider when selecting the best available antipsychotic agent and formulation for each patient.

Video 2.6. Matching Patients to the Best Available Treatment


In addition to factors such as efficacy, side effects, and dosing intervals, Dr Perkins recommends that clinicians talk with patients about their personal preferences for medication, and what their concerns are about one formulation or another. Exploring medication options with a patient (just as doctors discuss, for example, various forms of birth control) could improve adherence and therefore enhance recovery.

References: Das et al 2014; Shuler 2014

Case Practice Question

Connie is a 43-year-old woman with schizophrenia, diabetes, and high blood pressure. Her multiple health issues require a complicated medication regimen. She has been prescribed risperidone along with the antidepressant sertraline for her psychiatric symptoms, but you suspect she may not be taking either. You want to start a long-acting antipsychotic but are not sure how to choose. Which one of these is not a factor you should consider?

  1. What has her response been to oral risperidone in the past, especially when her adherence was monitored?
  2. Is coming to the clinic difficult for her?
  3. Has she been adherent to her other oral medications, which may indicate she is a poor candidate for LAI treatment?
  4. Has she had side effects from oral risperidone?

Preferred Response is c.

Explanation: The fact that many patients will continue to take some oral medication should not rule them out for an LAI. In fact, reaching stable and consistent dosing of the antipsychotic may help eliminate the need for other psychotropic medications and help simplify the medication regimen. Before prescribing an LAI to a patient, the clinician must know the patient’s history with the oral formulation of the medication, including efficacy and side effects. In Connie’s case, if oral risperidone was effective for her but she was only partially adherent, then using risperidone microspheres or paliperidone palmitate are logical choices. However, if risperidone seemed to have suboptimal effectiveness, when adherence was monitored, switching to another medication (eg, aripiprazole or olanzapine LAI) may be indicated. The same logic should be followed for the side effects; if oral risperidone was well tolerated, then an LAI would be a good choice, but the LAI should not be prescribed if she experienced significant side effects such as extrapyramidal symptoms (EPS) or elevated prolactin. Finally, clinicians should explore how easily the patient can make it to the clinic because this can be helpful when selecting medications. For example, if Connie has limited transportation, paliperidone palmitate may be superior to risperidone microspheres since it can be given monthly and eventually even every 3 months.

Chapter 3: Treating the Whole Patient, With Special Considerations for Comorbid Conditions

In this segment, Drs Lauriello and Perkins hear from a woman who is worried that her grown son with schizophrenia is not having his medical issues addressed.

Video 3.1. Balancing Psychiatric and Medical Health Needs


Because the time during patient visits is limited, clinicians must prioritize what will be addressed in the appointment, such as medication adherence, comorbid conditions, and the possible need for referrals. Comorbid conditions have to be distinguished from medication side effects, which can be a diagnostic challenge because they share many common symptoms. Therefore, clinicians must assess patients for these symptoms at baseline and record changes at each visit. Dr Perkins recommends using a checklist or assessment tool that addresses common antipsychotic side effects, which will enable clinicians to identify the side effects that are most bothersome to the patient, or most likely to lead to the development of comorbid conditions if not addressed.

References: Dott et al 2001; Kozumplik et al 2009; Weiden and Miller 2001

In the next video, Dr Lauriello and Dr Perkins discuss specific side effects in more detail, and explain how side effect burden must be determined on a patient-by-patient basis.

Video 3.2. Addressing Side Effects

Managing Side Effects

Dr Lauriello noted that, although prescribing patients an antipsychotic without side effects such as weight gain and movement problems would be ideal, sometimes patients respond only to particular medications. In those cases, instead of switching antipsychotics, the side effects must be treated with targeted strategies to prevent or manage comorbid conditions.

Weight gain. Drs Lauriello and Perkins recommend talking with patients about lifestyle changes (eg, healthy diet, exercise) to help minimize weight gain and metabolic side effects from antipsychotics. However, managing one’s diet and exercise is particularly challenging for a patient who has acute psychosis, is in the early stages of recovery, or is an adolescent. For some patients, metformin can be used off-label to minimize weight gain.

Extrapyramidal symptoms. The principle of treating extrapyramidal symptoms (EPS) is the same for first-generation or second-generation antipsychotics, although second-generation antipsychotics in general are associated with fewer EPS than first-generation antipsychotics. If a patient is experiencing some EPS, the symptoms will need to be treated because EPS can be related to long-term tardive dyskinesia risk. With second-generation LAIs, the first step would be to lower the dose of antipsychotic medication rather than adding another treatment for the movement symptoms. Valbenazine and deutetrabenazine are available to treat tardive dyskinesia.

References: Pringsheim et al 2017; Hendrick et al 2017; de Silva et al 2016; Divac et al 2014; Salem et al 2017; D’Souza and Hooten 2018; Touma and Scharff 2018

Frequently, patients with serious mental illness end up incarcerated, which is a poor setting in which to receive mental health treatment. In the following clip, Dr Lauriello discusses a study that explored the potential advantages of LAI treatment in these individuals, many of whom also had comorbid substance abuse.

Video 3.3. LAIs for Incarcerated Patients

The PRIDE Study Conclusions:

  • The study enrolled 450 individuals with a recent history of incarceration and a diagnosis of schizophrenia. More than half (60%) of the population was identified as having concurrent substance abuse. Substance abuse is common in patients with schizophrenia and is associated with a number of negative outcomes including poor adherence, greater impairment and symptom burden, and increased suicidality and hospitalizations.
  • After 15 months of treatment, the investigators found that LAI paliperidone significantly delayed treatment failure compared with daily oral antipsychotics.
  • Less treatment failure occurred with LAI treatment than oral treatment, even among patients who misused or abused substances.

References: Alphs et al 2015; Alphs et al 2016; Kim et al 2016; Lynn Starr et al 2018

Viewing patients holistically is key to improving their medication adherence and health outcomes. Watch the following clip as the doctors discuss this topic.

Video 3.4. Holistic View of Treatment

Case Practice Question

Amy is a 34-year-old single woman with a diagnosis of schizophrenia who was recently discharged from the county jail after an incarceration for trespassing. Which of the following statements is not true?

  1. Recent studies show that patients with schizophrenia who are incarcerated are not likely to have a co-occurring substance use problem.
  2. Long-acting antipsychotics have been shown to be more effective at delaying treatment failure than oral antipsychotic medications in patients with a recent history of incarceration.
  3. Substance use is associated with earlier relapse in patients with schizophrenia.
  4. Patients with schizophrenia are more likely to be victims of a crime than to commit a crime.

Preferred Response is A.

Explanation: As demonstrated by the PRIDE study, paliperidone LAI was superior to oral antipsychotics in time to relapse among a population of recently incarcerated individuals, many of whom had comorbid substance abuse. Substance use is a contributor to early relapse, and it has been noted that patients with schizophrenia are more likely victims of crime than perpetrators of crime.

Chapter 4: Successful Decision-Making and Treatment Practices for Managing Patients with Schizophrenia

In the following clip, Dr Perkins discusses the traditional medical model. Hear why one of her current patients told Dr Perkins she was “fired” by a previous psychiatrist.

Video 4.1. Limitations of the Medical Model


Next, Dr Lauriello and Dr Perkins explain that a collaborative approach, in which the patient partners with the clinicians to make treatment decisions, is more likely to lead to recovery.

Video 4.2. Benefits of a Collaborative Model


Working in the collaborative model is easier, according to Dr Perkins, if clinicians understand the health belief model, which describes components that affect patients’ likelihood of adhering to treatment. The model has 3 main components:

  • Perceived threat (patient’s perceptions of the severity of the illness, risk of relapse, and cues to act, such as the experience of symptoms)
  • Perceived benefits of treatment (patient’s experience of decreased symptom severity/frequency, ability to return to previous levels of functioning)
  • Perceived barriers to treatment (patient’s experience of side effects, difficulty obtaining treatment due to cost or transportation issues, lack of family support, stigma)

The cause of a patient’s nonadherence can generally be traced back to an issue in one of these 3 areas.

References: Becker 1974; Rosenstock 1974

Although with effective treatment, patients should experience prolonged symptom-free periods, schizophrenia is still a chronic disorder. This can be a disheartening fact for patients. In the next segment, Dr Lauriello and Dr Perkins suggest ways to tactfully address this topic with patients.

Video 4.3. A Day-By-Day Approach


Once patients understand the need for potentially long-term treatment, Dr Lauriello and Dr Perkins explain that that treatment will be different for every patient, and must reflect the patient’s goals and preferences. In the next video, they discuss this process.

Video 4.4. Using the Health Belief Model to Keep Patients Engaged in Treatment


As Drs Lauriello and Perkins stated, clinicians must make sure to maintain connections with the patient even if LAI antipsychotics afford longer times between visits than oral prescriptions. Whether through calls, emails, or health portals, clinicians need to keep connected to the patient and treatment team. Issues that should be continually monitored include:

  • metabolic changes
  • substance abuse
  • functional status
  • adherence

In the final video, Drs Lauriello and Perkins offer concluding remarks and reflect on the role that mental health providers have to play in promoting their patients’ overall health.

Video 4.5. “More Than Just Prescribers”

Case Practice Question

Scott is a 24-year-old man who was diagnosed with schizophrenia when he was 19. His first few years of treatment were marked by frequent periods of nonadherence, often resulting in hospitalizations, and a general attitude of resentment and hostility towards his treatment providers. A little over a year ago, his attitude changed dramatically when he became interested in a young woman that he met through a friend. He started LAI treatment, which he has found very effective. Since he started LAI treatment, he has consistently come for his monthly injections, and at previous visits he has reported that his relationship with the young woman was going well, he had gotten a part-time job, and he was considering a couple of college courses. At his next visit, he stated that he and his girlfriend had been fighting and she said she wanted to break up with him. He missed his last appointment and is now a few days late for his injection. Considering the components of the health belief model, what would be the best strategy to re-engage Scott in treatment?

  1. Allow Scott to remain non-adherent long enough that his symptoms begin to return and remind him of the severity of his disorder and the need for treatment
  2. Because his adherence and engagement in treatment has improved so much until recently, suggest he switch back to oral antipsychotics which may be more convenient now that his schedule is more demanding
  3. Remind Scott of all the benefits he has experienced since he has become adherent, such as being able to have a romantic relationship
  4. Work with Scott to identify new goals that will motivate him to remain engaged in treatment

Preferred Response is d.

Explanation: In this scenario, allowing Scott to relapse is both unnecessary and dangerous, considering many of his previous relapses resulted in hospitalizations. Oral medications are unlikely to improve his adherence because the act of getting the injections was never reported to be an inconvenience and is unlikely to be the cause of his nonadherence. Furthermore, reminding him of his relationship that has just ended probably will not have a positive effect on his outlook or willingness to resume treatment. However, the relationship was, originally, the factor that seemed to have the most power to motivate Scott to be adherent. In terms of the health belief model, he saw the possibility of the relationship as a benefit of treatment. Once the relationship ceased to be an incentive, Scott disengaged from treatment. Thus, working with Scott to identify a new goal, such as continuing his college courses, or pursuing a new relationship, could provide him with the motivation to continue treatment.

Clinical Points

  • Regularly assess treatment adherence using a reliable method.
  • Always strive to keep the medication regimen as simple as possible.
  • Do not hesitate to discuss LAI treatment options, because some patients may prefer these formulations.
  • Ensure that a patient will actually be able to access a given treatment before prescribing it, particularly a LAI.
  • Use a collaborative treatment model to involve patients in decision-making and goal setting.
  • Consider pharmacology of a particular drug, and use characteristics such as efficacy, side effect profile, and dosing interval to select the best agent for a particular patient.
  • Keep in mind that injectable antipsychotics may have added benefit in certain patient populations, including those with a history of substance abuse or incarceration.
  • Stay informed about emerging delivery systems because many agents currently being developed hold great promise for improving treatment outcomes.
This CME activity is expired. For more CME activities, visit cme.psychiatrist.com.
Find more articles on this and other psychiatry and CNS topics:
The Journal of Clinical Psychiatry
The Primary Care Companion for CNS Disorders

References

  1. Alphs L, Mao L, Lynn Starr H, et al. A pragmatic analysis comparing once-monthly paliperidone palmitate versus daily oral antipsychotic treatment in patients with schizophrenia. Schizophr Res. 2016;170(2-3):259–264. PubMed CrossRef
  2. Alphs L, Benson C, Cheshire-Kinney K, et al. Real-world outcomes of paliperidone palmitate compared to daily oral antipsychotic therapy in schizophrenia: a randomized, open-label, review board-blinded 15-month study. J Clin Psychiatry. 2015;76(5):554–561. PubMed CrossRef
  3. Aristada [package insert]. Waltham, MA: Alkermes, Inc; 2018.
  4. Becker MH. The Health Belief Model and personal health behavior. Health Educ Monogr. 1974;2(4):324–508. CrossRef
  5. Byerly MJ, Nakonezny PA, Rush AJ. The Brief Adherence Rating Scale (BARS) validated against electronic monitoring in assessing the antipsychotic medication adherence of outpatients with schizophrenia and schizoaffective disorder. Schizophr Res. 2008;100(1-3):60–69. PubMed CrossRef
  6. Caroli F, Raymondet P, Izard I, et al. Opinions of French patients with schizophrenia regarding injectable medication. Patient Prefer Adherence. 2011;5:165–171. PubMed CrossRef
  7. Citrome L. New second-generation long-acting injectable antipsychotics for the treatment of schizophrenia. Expert Rev Neurother. 2013;13(7):767–783. PubMed CrossRef
  8. Citrome L. Sustained-Release Risperidone via Subcutaneous Injection: A Systematic Review of RBP-7000 (PERSERIS™) for the Treatment of Schizophrenia. Clin Schizophr Relat Psychoses. 2018;12(3):130–141. PubMed CrossRef
  9. Clinicaltrials.gov. Study in stabilized schizophrenic patients to evaluate the pharmacokinetics of risperidone and 9-hydroxy (OH)-risperidone when risperidone is administered from a polyurethane implant. 2014. Available at: https://clinicaltrials.gov/ct2/show/NCT01774435. Accessed December 12, 2018.
  10. Clinicaltrials.gov. Randomized, double-blind, placebo controlled, multi-center and tolerability of RBP-7000 in schizophrenia patients. 2018. Available at: https://clinicaltrials.gov/ct2/show/NCT02109562?term=subcutaneous&cond=Schizophrenia&rank=2. Accessed December 12, 2018.
  11. Correll CU, Citrome L, Haddad PM, et al. The use of long-acting injectable antipsychotics in schizophrenia: evaluating the evidence. J Clin Psychiatry. 2016;77(suppl 3):1–24. PubMed CrossRef
  12. D’Souza RS, Hooten WM. Extrapyramidal symptoms (EPS). StatPearls website. https://www.ncbi.nlm.nih.gov/books/NBK534115/. Updated November 14, 2018. Accessed December 12, 2018.
  13. Das AK, Malik A, Haddad PM. A qualitative study of the attitudes of patients in an early intervention service towards antipsychotic long-acting injections. Ther Adv Psychopharmacol. 2014;4(5):179–185. PubMed CrossRef
  14. de Silva VA, Suraweera C, Ratnatunga SS, et al. Metformin in prevention and treatment of antipsychotic induced weight gain: a systematic review and meta-analysis. BMC Psychiatry. 2016;16(1):341. PubMed CrossRef
  15. DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42(3):200–209. PubMed CrossRef
  16. Divac N, Prostran M, Jakovevski I, et al. Second-generation antipsychotics and extrapyramidal adverse effects. Biomed Res Int. 2014;2014:656370. PubMed CrossRef
  17. Dott SG, Weiden P, Hopwood P, et al. An innovative approach to clinical communication in schizophrenia: the approaches to schizophrenia communication checklists. CNS Spectr. 2001;6(4):333–338. PubMed CrossRef
  18. Eerdekens M, Van Hove I, Remmerie B, et al. Pharmacokinetics and tolerability of long-acting risperidone in schizophrenia. Schizophr Res. 2004;70(1):91–100. PubMed CrossRef
  19. Ereshefsky L, Mascarenas CA. Comparison of the effects of different routes of antipsychotic administration on pharmacokinetics and pharmacodynamics. J Clin Psychiatry. 2003;64(suppl 16):18–23. PubMed
  20. Hendrick V, Dasher R, Gitlin M, et al. Minimizing weight gain for patients taking antipsychotic medications: the potential role for early use of metformin. Ann Clin Psychiatry. 2017;29(2):120–124. PubMed
  21. Heres S, Hamann J, Kissling W, et al. Attitudes of psychiatrists toward antipsychotic depot medication. J Clin Psychiatry. 2006;67(12):1948–1953. PubMed CrossRef
  22. Hyon SH. Biodegradable poly (lactic acid) microspheres for drug delivery systems. Yonsei Med J. 2000;41(6):720–734.PubMed CrossRef
  23. Jaeger M, Rossler W. Attitudes towards long-acting depot antipsychotics: a survey of patients, relatives and psychiatrists. Psychiatry Res. 2010;175(1-2):58–62. PubMed CrossRef
  24. Kane JM, Eerdekens M, Lindenmayer J-P, et al. Long-acting injectable risperidone: efficacy and safety of the first long-acting atypical antipsychotic. Am J Psychiatry. 2003;160(6):1125–1132. CrossRefPubMed
  25. Kane JM, Kishimoto T, Correll CU. Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies. World Psychiatry. 2013;12(3):216–226. PubMed CrossRef
  26. Kim E, Correll CU, Mao L, et al. Once-monthly paliperidone palmitate compared with conventional and atypical daily oral antipsychotic treatment in patients with schizophrenia. CNS Spectrums. 2016;21(6):466–477. PubMed CrossRef
  27. Kozumplik O, Uzun S, Jakovljević M. Psychotic disorders and comorbidity: somatic illness vs. side effect. Psychiatr Danub. 2009;21(3):361–367.  PubMed
  28. Living with schizophrenia: people’s experience of the condition. SANE website. http://www.sane.org.uk/uploads/living-with-schizophrenia-final-uk_am_0414_0121_vcertification_1-2.pdf. Published May 2014. Accessed December 12, 2018.
  29. Lynn Starr H, Bermak J, Mao L, et al. Comparison of long-acting and oral antipsychotic treatment effects in patients with schizophrenia, comorbid substance abuse, and a history of recent incarceration: an exploratory analysis of the PRIDE study. Schizophr Res. 2018;194:39–46. PubMed CrossRef
  30. Malo S, Aguilar-Palacio I, Feja C, et al. Different approaches to the assessment of adherence and persistence with cardiovascular-disease preventive medications. Curr Med Res Opin. 2017;33(7):1329–1336. PubMed CrossRef
  31. Papazisis G, Siafis S. The added value of liquid antipsychotics: the case of quetiapine [published online ahead of print November 2, 2018]. Curr Clin Pharmacol. PubMed CrossRef
  32. Patel MX, Nikolaou V, David AS. Psychiatrists’ attitudes to maintenance medication for patients with schizophrenia. Psychol Med. 2003;33(1):83–89. PubMed CrossRef
  33. Pringsheim T, Kelly M, Urness D, et al. Physical health and drug safety in individuals with schizophrenia. Can J Psychiatry. 2017;62(9):673–683. PubMed CrossRef
  34. Rosenstock IM. Historical origins of the Health Belief Model. Health Educ Behav. 1974;2(4):328–335.
  35. Salem H, Nagpal C, Pigott T, et al. Revisiting antipsychotic-induced akathisia: current issues and prospective challenges. Curr Neuropharmacol. 2017;15(5):789–798. PubMed CrossRef
  36. Shah B, Khunt D, Misra M, et al. Non-invasive intranasal delivery of quetiapine fumarate loaded microemulsion for brain targeting: formulation, physicochemical and pharmacokinetic consideration. Eur J Pharm Sci. 2016;91:196–207. PubMed CrossRef
  37. Sheehan JJ, Reilly KR, Fu D-J, Alphs L. Comparison of the peak-to-trough fluctuation in plasma concentration of long-acting injectable antipsychotics and their oral equivalents. Innov Clin Neurosci. 2012;9(7-8):17–23. PubMed
  38. Shuler KM. Approaches to improve adherence to pharmacotherapy in patients with schizophrenia. Patient Prefer Adherence. 2014;8:701–714. PubMed CrossRef
  39. Subotnik KL, Nuechterlein KH, Ventura J, et al. Risperidone nonadherence and return of positive symptoms in the early course of schizophrenia. Am J Psychiatry. 2011;168(3):286–292. PubMed CrossRef
  40. Touma KTB, Scarff JR. Valbenazine and deutetrabenazine for tardive dyskinesia. Innov Clin Neurosci. 2018;15(5-6):13–16. PubMed
  41. Weiden PJ, Miller AL. Which side effects really matter? Screening for common and distressing side effects of antipsychotic medications. J Psychiatr Pract. 2001;7(1):41–47. PubMed

Volume: 80

Quick Links:

References

RECENT ARTICLES
ACADEMIC HIGHLIGHTS
Jordan F. Karp and others

INFORMATION FROM INDUSTRY
ORIGINAL RESEARCH
Alice Demesmaeker and others

CASE REPORT
Tej Joshi and others

CLINICAL AND PRACTICAL PSYCHOPHARMACOLOGY
Chittaranjan Andrade