RESEARCH WEEKLY: Barriers to Access to Long-Acting Injectable Antipsychotic Medications
Long-acting injectable (LAI) formulations of medications are effective in increasing medication adherence for all people. Their promise is especially important for people with severe mental illness who may struggle with adhering to daily oral antipsychotic formulations. Adherence to prescribed psychotropic medications is essential to prevent decompensation and promote recovery from symptoms for people with severe mental illness.
Despite being available for more than 40 years, LAI antipsychotic medications continue to be extremely underutilized by prescribers and patients. The United States significantly lags behind other developed countries in their prescription and utilization.
Barriers to utilization of LAIs in the United States have previously been studied, although mainly through surveying clinicians or patients. In an article published in Psychiatric Services this month, researchers from New York State utilized an ethnographic approach to examine barriers to using LAI medications from a wider range of perspectives. By interviewing participants in a discussion format with probing questions and then coding the responses into thematic areas, researchers were able to gain a more expansive view of barriers to use of LAI antipsychotic medications.
Study results
Researchers conducted a total of 79 interviews that included patients, psychiatrists, nurses, therapists, clinic administrators, and representatives from an insurance company, pharmaceutical company and professional organization. Below are the top seven themes that resulted as contributing to the low usage of LAI antipsychotic medications:
- Eligibility – There is an understanding among psychiatrists that LAI antipsychotic medications should only be used for patients who have a history of non-adherence to oral antipsychotic medications. As a result, most patients interviewed were unaware that LAI medications were a viable treatment option.
- Inpatient use – Outpatient clinicians who were interviewed felt that the best time to introduce someone to a LAI antipsychotic medication was during an inpatient stay. As well, patients who received an injection against their will while hospitalized were traumatized by that experience and refused to try a LAI formulation.
- Medical decision support – There is very little time in an average psychiatrist appointment to provide decision support on different treatment options, according to the results. Therapists interviewed reported having more time to spend with each patient and therefore felt that medication consulting could be an additional part of their practice.
- Communication between clinicians – The interview results indicated that communication between different providers, such as therapists and psychiatrists, about individual patients varied by setting. Psychiatrists may not know about medication adherence issues of patients unless they read the therapist’s case notes.
- Pharmacological profile –Psychiatrists report being reluctant to start a trial of LAI medication due to the length of time that must pass before dose adjustments can be made.
- Infrastructure – Clinics require appropriate infrastructure to administer LAI antipsychotics, including nursing staff to administer the medication and lab testing.
-
Payer issues – There is a substantial cost difference between oral and LAI antipsychotic medications and “payers were not willing to ‘buy futures’ by spending significantly more on LAI antipsychotics to potentially save on later costs,” according to the results.
The study authors conclude that the entire mental health treatment team must be involved in providing information and decision support to patients to consider LAI antipsychotic medications as a treatment option.
Note: As with many aspects of life during the COVID-19 pandemic, there are additional barriers to receiving LAI antipsychotic medications for people with severe mental illness during these times. See the Treatment Advocacy Center recommendations on ensuring access to treatment for people with severe mental illness here.
