Adherence in the real world

Adherence rates are poor

In the USA, adherence rates to antipsychotic medications are less than 40%. Simply increasing adherence by 20% would afford not only fiscal but also clinically-therapeutic benefits. Can long acting injectable antipsychotic (LAI) agents help attain this goal, Dawn Velligan, University of Texas Science Centre at San Antonio, San Antonio, Texas, USA, wondered.

Can LAIs help adherence?

Dr Velligan described the Multi-level facilitation of long-acting AntiPsychotic (MAP) initiative currently being tested in 4 clinics in the USA. MAP is a behavioral intervention tool targeted not only at patients, but also at clinicians and administrators. It seeks to aid in the identification of patients, who would benefit from LAI and, through improved adherence, so aid their outcomes and better utilize resources. For example, patients can watch filmed footage of a peer specialist that guides them through shared decision-making, outlining the types of questions a patient should be asking their clinician about their care plan; administrators learn how appropriate use of LAIs may improve outcomes and care quality.

MAP is a behavioral intervention tool targeted at patients, who would benefit from LAI clinicians and administrators

Physicians receive academic detailing, which explains clearly the benefits of LAI therapy. Too often, it would appear, clinicians are not offering this option to patients – mainly because clinicians think that an injectable won’t be acceptableby the patient.

Clinicians uncomfortable – patients amenable

Clinicians are not comfortable with suggesting use of an injectable and want to avoid the discussion, it appears. However, Dr Velligan showed that, by emphasizing the benefits and convenience of the therapy first and then adding “By the way, this involves a monthly injection” as an ‘add-on’, patients are usually receptive to this strategy.

Patients are open to the use of LAIs

5-point check list aids in identifying those that might benefit from LAIs

To further aid the identification of patients who might benefit, clinicians were also offered a simple 5-point checklist called the “NOB” (individuals Not receiving Optimum Benefit from antipsychotic medication) checklist. So, how did these fare at the four test clinics where use of the NOB checklist alone (two clinics) or in conjunction with the MAP package of support materials (two clinics) was compared?

The NOB checklist was useful in identifying individuals who are not only likely to receive offers of LAIs but also to accept them

The NOB checklist was useful in identifying individuals, who are not only likely to receive offers of LAIs but also to accept them. Implementation was challenging – as Dr Velligan said, “Asking 5 questions was too hard, but it did make a difference.” However, in the MAP treatment clinics, patients were asking for injections.

Offer patients choice

The MAP program may increase use of LAIs even in clinics that use a fair amount at baseline and the use of NOB alone may increase the offers and use of LAIs. She concluded, “When oral and injectable medicines exist, why not offer all patients a choice? Don’t we often do that with antibiotics and steroids?”

When oral and injectable medicines exist, why not offer all patients a choice?

Gaining expert consensus on LAI use

In the MAP program, expert detailing videos were included in the materials offered to clinicians. But experts also need to gain knowledge on how others utilize LAIs. Martha Sajatovic, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA, outlined the process underlying the formation of consensus guidelines for use of LAIs in patients with schizophrenia, schizoaffective disorder and bipolar disorder.

An online survey asking a total of 50 questions on how experts identify patients, initiate therapy and conduct maintenance therapy in their patients was sent to 42 experts (24% of those invited to participate). Of these, 34 (81%) completed the questionnaire. Respondents were asked to rate options using a 9-point scale; consensus was determined statistically.

LAIs are suitable where poor adherence, high-risk behaviors and limited support exist

LAIs use should be considered earlier in the course of the disease

Most experts acknowledged that adherence cannot be reliable determined in standard clinical settings. Individuals with known poor adherence, those with a history of high-risk behaviors and those with limited support may be ideal candidates for LAIs. The consensus was that LAIs use should also be considered earlier in the course of the disease.