Schizophrenia: Are Long-Acting Injectable Antipsychotics Better than Oral Meds?

What’s happening – For people with schizophrenia, studies have found that using long-acting injectable (LAI) antipsychotic drugs may improve overall treatment adherence compared to using oral antipsychotics. However, a recent review in CNS Drugs that looked at the different formulations of LAI antipsychotics illustrates that not all options in this category are created equal. Some details that impact the effectiveness of LAI antipsychotics include: how the medication is delivered in the body, where it is administered, and interactions with other medications.

The details – Read the full study by Correll et al in CNS Drugs.

Why it’s complicated – Since different LAIs achieve different results, clinicians need to understand these differences and select the best fit for their patient’s specific needs. In addition to looking at the medication profile, it’s also important to take into account the person’s health history and other medications they take. The dose equivalent of any oral antipsychotic drugs taken by the patient previously must also be examined to titrate the LAI appropriately.

The perspectives –

  • Another study in the Journal of Psychiatric Research explores the association between using LAI antipsychotics and the odds of withdrawing consent in schizophrenic trials. Researchers found that the rate of withdrawal was higher in people using the LAI-aripiprazole than those using a placebo. However, the overall rate of withdrawal was still similar to that among patients using other types of LAI antipsychotics.
  • In a separate study, in the Journal of Affective Disorders, researchers looked at patients diagnosed with bipolar mania who were discharged from a hospital stay with prescribed LAI antipsychotics or oral antipsychotics to determine if the time before rehospitalization would differ. They discovered that those taking LAIs had a much longer period before their next admission than those taking the oral medication. First-generation and second-generation LAIs did not appear to impact the results.
  • The journal International Clinical Psychopharmacology reported that using LAIs in people with schizophrenia leads to improved outcomes compared to using oral medications. The LAIs reduced the need for other treatments in addition to reducing hospital admissions.

The conversation –

  • @PsychiatricNews (APA news) shares: “Combing clinical data from 68 separate studies, a research team has estimated the most effective dose for 19 different antipsychotic medications, including both oral and long-acting injectable (LAI) formulations…”
  • @CMEInstitute (a CME provider) says: “LAI antipsychotics can be a powerful strategy in helping patients to receive ongoing benefit from treatment….”
  • @HeidiTaipale (an assistant professor of psychiatric epidemiology) tweets: “Long-acting injectable antipsychotics (LAIs) were almost two times more likely in Sweden (22%) than in Finland (13%). This difference is due to more common use of first-generation LAIs in Sweden. On the contrary, clozapine is used more likely in Finland (22% vs. 15%).”

In practice – A clinical primer to first- and second-generation antipsychotics.

Depression, Hypertension, and Healthcare Disparities in African American Women

What’s happening – African American women of lower socioeconomic status who suffer from hypertension may be at elevated risk of experiencing co-existing depression. Yet, little research has delved into the relationship, prompting researchers affiliated with Johns Hopkins Bloomberg School of Public Health to explore the connection. They administered questionnaires to a group of women with hypertension between the ages of 18 and 45 years to understand how hypertension affects their lives, their attitudes toward medication, and how they rate their depression symptoms.

The team discovered that depression rates were higher among women who had not completed high school and those with chronic health conditions who smoke. Their findings should serve as a reminder to clinicians to screen African American women with hypertension for signs of depression and to refer them to mental health services as needed.

The details – Read the full study by Gabriel et al in JAMA Psychiatry.

Why it’s complicated – When people experience discrimination on a regular basis, the chronic psychosocial stress it causes can lead to a variety of health conditions, including hypertension and depression. A group of researchers looking at three coding scales determined that the type of coding used can impact the classifications and associations among factors with significant indicators in African American women’s mental and physical health.

The perspectives –

  • Johns Hopkins Medicine shares additional research that finds minority women are twice as likely to experience a major depressive episode as men. Yet African American women are only half as likely to seek mental health treatment as Caucasian women.
  • Mental Health America reveals that 13.4% of the population identifies as Black or African American, and more than 16% of them report experiencing mental illness over the past year.
  • Prevention ran an article on the increased mental health challenges facing Black women during the pandemic and delved into the many barriers – including lack of research in this area and cultural and financial roadblocks –that can hamper access to treatment.

 The conversation –

  • @One_Health_In (information hub) tweeted about the Gabriel study, noting: “In this study of low-income African American women with uncontrolled hypertension, more than half had symptoms of #depression that was associated with less than high school #education, chronic conditions and #smoking.”
  • @AAPolicyForum (a think tank) shares: “Black women are battling misogynoir and its related health impacts, compounded by the economic fallout @ the near-invisible mental health catastrophe that has only been exacerbated by COVID.”
  • @BlackWomensRJ (a reproductive rights organization rights) says: “Black women are more likely than white women to experience a common mental illness such as anxiety disorder or depression. White people, however, are twice as likely as Black people to be receiving treatment for mental health issues.” They shared an article titled “The Black Girl’s Guide to Seeking Therapy for the First Time.”

In practice – The American Psychiatric Association recently issued an apology statement for its support of structural racism in psychiatry. Danielle Hairston, MD, and Racquel Reid, MD, share their take on the apology.

Pandemic Practice Management

Mental Health Providers Share How They Are Managing High Client Demand

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Motivational Interviewing Can Improve Psychosis Outcomes

What’s happening – Do people with psychosis have better outcomes when motivational interviewing (MI) and psychoeducation are included as part of the treatment plan? A recent interventional study explored this question. Participants included people diagnosed with schizophrenia or schizoaffective disorder who were taking oral antipsychotics and had not yet tried long-acting injectable (LAI) antipsychotics. Their findings reveal that patients who received psychoeducation with MI may be more involved in their own treatment. They also may have a reduced chance of relapsing.

The details – Read the full study by Broms et al in BJPsych Bulletin.

Why it’s complicated – A related study in Frontiers in Psychiatry reports that there are significant differences in the effectiveness of motivational interviewing depending on the tool and technique used. While therapists must build a trusting and empathetic relationship with patients in order to prompt them to change, the type of conversational techniques employed was strongly tied to the response. Therapists who posed reflections and asked questions regarding taking medication as directed led to “patient change talk” about 70% of the time while using patient affirmations and emphasizing the control patients have over their lives only led to patient change talk 6% of the time. These insights may help therapists use MI to their full advantage.

The perspectives –

  • A Clinical Psychology Review paper looking at 199 empirical studies that incorporated MI skills or tools demonstrated a wide variation of outcomes depending on what was used. The authors offer recommendations on which tools to use in different case scenarios.
  • A piece on Cureus looks at the link between suicide and medication adherence in people with schizophrenia and identifies that MI plays an important role in exploring patient’s attitudes toward medications and encouraging adherence.
  • A paper published in Psychotherapy Research examines the effectiveness of using motivational interviewing in people with social anxiety disorder prior to CBT. They discovered that when the therapist used a predicted MI approach during the session, the patient talked more about changing behavior. Yet the client behaviors were not directly linked to the outcomes of the CBT session.

The conversation –

  • @morriseric (director of the La Trobe University Psychology Clinic) tweets: “How Counseling Based on Acceptance and Commitment Therapy and Supported with Motivational Interviewing Affects Levels of Functional Recovery in Patients Diagnosed with Schizophrenia: A Quasi-Experimental Study.”
  • @MelindaHohman (professor and author) shares: “Is training #motivationalinterviewing the same in different countries? This interesting study found some difference…”

In practice – This comprehensive guide provides an overview to motivational interviewing techniques geared toward clinicians and other HCPs. See also how MI is being used in pain management on our sister site and a related Q&A below.

Psy-Q: This Week's Challenge

Is motivational interviewing being integrated enough in the mental health care field? Ravi Prasad, PhD, answers.

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Last Updated: Apr 20, 2021