Engaging patients with schizophrenia in decision-making to improve outcomes

Why is engagement a challenge?

Need for continuous and long-term treatment to prevent relapse² and ensure successful outcomes³ can be particularly hard for individuals experiencing first episode and early-phase psychosis. Young patients face significant psychosocial issues related to personal identity, relationships and educational and occupational goals, which may have been disrupted by their illness⁴.

Style matters

Many patients are willing to try an LAI, but how they are offered them matters

Many patients are willing to try an LAI⁵, but how they are offered them matters⁶. Common reasons for preferring oral medication are⁵:

• avoiding injections
• comfortable with tablets
• not wanting to visit health institute for treatment
• control over when/how much medication

An online survey of patients with recently diagnosed schizophrenia, showed most had some willingness to try an LAI, and 53% rated willingness as >50%⁵. Success is more likely if the clinician can uncover underlying resistance and address the root issue(s)⁶, encouraging patients to consider benefits of LAIs⁵:

• not needing to remember daily medication
• more convenient
• less worried about relapse
• not having to take tablets in front of others

Success is more likely if the clinician can uncover underlying resistance and address the root issue(s)

The psychiatrist can take a punitive approach, using fear tactics, or a positive approach, stressing potential personal gains for the patient. In an observational study⁷, initial acceptance rate was 33% (11/33) when LAIs were presented in a predominantly negative light, whereas in a post-visit interview, 96% (27/28) were willing to try LAIs after a positive presentation.

Techniques to encourage engagement

Techniques are available to help healthcare providers think creatively about encouraging patient engagement

Healthcare providers need to think creatively about encouraging patient engagement, and techniques are available to help.

Shared decision-making recognizes that clinicians and patients bring different, but equally important, knowledge and expertise to the process⁸. The clinician provides input on disease etiology, treatment options, and prognosis, whilst the patient contributes their preferences, values, experiences, and circumstances.

Motivational interviewing motivates the patient in making positive changes. For instance, the GAIN model⁹ was developed to address patient acceptance of, and adherence to, LAI treatment and involves: Goal setting; Action planning; Initiate treatment; Nurturing motivation.

Engaging patients in clinical practice

Using LAIs in clinical practice requires engagement and education of patients and mental health team members¹⁰, as both may have negative beliefs and experiences regarding LAIs.

High levels of LAI uptake can be achieved, even in early-phase patients

A recently concluded study in US, in a real-world clinical setting, demonstrated that high levels of LAI uptake can be achieved, even in early-phase patients^11,12. The primary aim of this cluster-randomized trial was to compare use of an LAI with usual care, in reducing the risk of hospitalization in early-phase schizophrenia (1^st episode or <5 years anti-psychotic treatment), and included a prescriber training program. For sites randomized to LAI therapy, only 14.4% of 576 potential participants declined because they would not consider LAIs, and 91% of the final sample of 234 participants accepted ≥1 LAI injection. Use of LAIs significantly delayed time to first hospitalization (hazard ratio 0.56; 95% confidence interval 0.35 to 0.92; p=0.02) compared with clinician’s choice.

Educational financial support for this Satellite symposium was provided by Otsuka Pharmaceutical Europe Ltd and H.Lundbeck A/S.