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Engaging patients with schizophrenia in decision-making to improve outcomes

Medication adherence is a challenge for many patients, especially with chronic diseases, such as schizophrenia. Long-acting injectable anti-psychotics (LAIs) rather than oral medication may be a way to encourage engagement and retention in treatment, thereby improving outcomes1, especially if LAIs are offered using shared decision-making and motivational interviewing techniques, as discussed in this ECNP Virtual 2020 presentation by Patricia Marcy (Northwell Health, New York, USA).

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 patients11,12. 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 (1st 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.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. Kane JM, Correll CU. J Clin Psychiatry 2019;17:80:IN18031AH1C.
  2. De Hert M, et al. CNS Drugs 2015;29:637-58.
  3. Llorca P-M. Psychiatry Res 2008;161:235-47.
  4. Malla AK, et al. Can J Psychiatry 2005;50:881-91.
  5. Bridges JF, et al. Patient Prefer Adherence 2018;12:63-70.
  6. Potkin S, et al. BMC Psychiatry 2013;13:261.
  7. Weiden PJ, et al. J Clin Psychiatry 2015;76:684-90.
  8. https://www.kingsfund.org.uk/sites/default/files/Making-shared-decision-...
  9. Lasser RA, et al. Psychiatry (Edgmont) 2009;6:22-7.
  10. Correll CU. J Clin Psychiatry 2014;75:e25.
  11. Kane JM, et al. J Clin Psychiatry 2019;80:18m12546.
  12. Kane JM, et al. JAMA Psychiatry 2020;e202076.
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