Clues on Why LAI Antipsychotics Are Underutilized in Schizophrenia

COLORADO SPRINGS, Colo. — The belief that long-acting injectable (LAI) antipsychotics for schizophrenia should be reserved for patients with severe symptoms or adherence issues may be contributing to their underutilization, a nationwide survey of psychiatric clinicians suggested.

Among 380 psychiatrists, nurse practitioners, and physician associates who responded to the survey, low LAI prescribers were more likely to say these therapies should only be used for patients with more severe symptoms (50% vs 21% for high prescribers) or with adherence issues (82% vs 50%, respectively; P<0.01 for both), reported Rolf T. Hansen III, PhD, of Teva Pharmaceuticals in Parsippany, New Jersey.

LAIs are underutilized in schizophrenia, according to a pair of poster presentations at the Neuroscience Education Institute Congress, despite evidence showing their use is associated with favorable outcomes. Prior literature has shown that a wide range of barriers stand in the way of broader LAI utilization, including physicians who anticipate refusal, patient needle fears, and hurdles on a system level.

“There’s lots of different reasons that high users are different from low users, such as differences in confidence and motivation; navigating access issues; stress and burnout,” said Hansen.

A significantly higher proportion of low LAI prescribers said patients with schizophrenia increase their level of stress (42% vs 13%), the survey found.

Hansen also said that low prescribers might not be using LAIs due to concerns that their patients might view the switch from oral antipsychotics to LAIs as punishment.

“There are some significant barriers to LAI utilization. It’s clear what the barriers are,” Hansen told MedPage Today. What’s less clear, he said, is how some psychiatrists are successfully navigating these barriers.

In the survey, high-prescribing clinicians tended to manage more patients with schizophrenia on a monthly basis compared with low prescribers (mean 88 vs 27), said they had knowledge of approved LAIs and how to use them (68% vs 26%), and were also more confident about switching stable patients from oral antipsychotics to LAIs (69% vs 29%; P<0.01 for both).

Looking at what triggered initial use of LAIs, 52% of high-prescribing clinicians reported this was due to information about LAIs found in peer-reviewed publications compared with 25% of low-prescribing clinicians (P<0.01), and 37% and 23%, respectively, reported it was due to CME events (P<0.05).

The survey was distributed via direct email to psychiatrists, nurse practitioners, and physician associates from March to July 2022, and 380 valid responses were received. Most respondents (82%) were community based. High prescribers were defined as those who used LAIs for ≥31% of their patients (n=106), and low prescribers were defined as those who used LAIs for ≤14% of their patients (n=130).

Overall, 72% of respondents reported that their perception of LAI use changed during their careers, including 78% of high prescribers and 59% of low prescribers.

On average, clinicians believed that 53% of patients nationwide were nonadherent with oral antipsychotics, but that only 26% of their own patients were nonadherent.

“They really do think there’s a lot more adherence in their population than there is nationwide,” Hansen said. “They know it’s an issue in the country, but it’s not an issue in their practice.”

Hansen did point out that providing LAIs does require more resources and specialized personnel, which was seen as a barrier to initiating the use of the drugs.

“It’s not just one thing. It’s environment, mindset. It’s training. It’s the patient population,” he said.