Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers
Abstract
Objective:
Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States.
Methods:
The authors conducted a secondary analysis of the 2020–2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing.
Results:
Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming.
Conclusions:
Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.
HIGHLIGHTS
•
Long-acting injectable antipsychotic medications (LAIAPs) are a safe, effective, and underprescribed treatment modality for patients with chronic psychotic and affective disorders.
•
Using data from the 2020–2021 National Mental Health Services Survey (N-MHSS), this study investigated the characteristics of outpatient mental health care service providers in the United States that prescribed LAIAPs for patients.
•
Approximately 70% of outpatient mental health care service providers surveyed in the N-MHSS did not prescribe LAIAPs, including >40% of facilities with a treatment program specifically for patients with serious mental illness.
•
Additional work is needed to design and scale clinical service delivery models to improve prescription of LAIAPs in the outpatient setting.
An estimated 47.6 million adults in the United States have a mental illness, and an estimated 11.4 million have a chronic psychotic or affective disorder, such as schizophrenia and bipolar disorder (1). These illnesses represent a significant cause of morbidity and mortality in the United States and cost the health care system >$150 billion annually (2–5). The mainstay pharmacological treatment for chronic psychotic or affective disorders remains antipsychotic medications. The development of effective long-acting injectable antipsychotic medications (LAIAPs) represents a remarkable advance in care for patients with chronic psychotic or affective disorders.
For patients with a chronic psychotic or affective disorder, LAIAPs have some advantages over oral antipsychotic regimens. Interruptions in antipsychotic therapy are associated with deterioration in function, psychiatric hospitalization, and possible community disruption (6, 7). Patients with a chronic psychotic or affective disorder who use LAIAPs are up to 20% less likely to discontinue medications than those taking oral regimens (8). A recent meta-analysis reported that patients with schizophrenia had nearly twice the odds of medication adherence (≥80% days adherent) when using an LAIAP than when using oral regimens (9). Because the use of LAIAPs provides greater privacy than use of oral antipsychotics and does not require adherence to daily pill regimens, LAIAPs are also associated with less stigma among some patients (10, 11). Use of LAIAPs is also associated with decreased rates of psychiatric hospitalization and emergency department utilization (9, 12). Correspondingly, growing research supports the efficacy of using LAIAPs early in the disease course, including after first-episode psychosis (FEP) (13–15).
Eight LAIAPs have been approved by the U.S. Food and Drug Administration (FDA) for treatment of schizophrenia in the United States: aripiprazole lauroxil, aripiprazole monohydrate, fluphenazine decanoate, haloperidol decanoate, olanzapine pamoate, paliperidone palmitate, extended-release risperidone, and risperidone microspheres. Risperidone microspheres and aripiprazole monohydrate also have FDA approval for treatment of bipolar disorder. LAIAPs have few serious adverse effects, with the most reported adverse event being injection site soreness, and LAIAPs’ risk for metabolic syndrome is equivalent to that of oral antipsychotics (16–19).
Despite the well-documented efficacy and safety of LAIAPs, their prescription in clinical practice to patients with a chronic psychotic or affective disorder remains suboptimal (20–23). A recent Medicaid claims analysis found that only 13% of patients with such disorders were prescribed an LAIAP (24). This finding underscores the need for a better understanding of the prescription of LAIAPs in outpatient mental health care settings to minimize barriers to care.
In this study, we sought to quantify prescription patterns of LAIAPs by U.S. outpatient mental health care service providers. Given the role of LAIAPs in improving outcomes, increasing LAIAP utilization is an important part of psychiatric care. Identifying gaps in LAIAP prescription may reveal opportunities for innovation to better meet the needs of patients. Our objectives were to determine the percentage of U.S. outpatient mental health service providers prescribing LAIAPs, identify the most commonly prescribed LAIAPs among outpatient mental health care service providers, and ascertain the factors associated with the likelihood that an outpatient mental health service provider prescribes LAIAPs.
Methods
This secondary analysis of publicly available and anonymous administrative data was deemed nonhuman subjects research and was exempted from oversight by the institutional review board of the Biological Sciences Division of the University of Chicago.
Data Sources
The main data source was the annual National Mental Health Services Survey (N-MHSS) conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) (25). The N-MHSS is distributed to the directors of all known outpatient and inpatient mental health service providers in the United States. The survey excludes independent practitioners, jails and prisons, and any mental health care facilities operated by the U.S. Department of Defense. U.S. Department of Veterans Affairs (VA) facilities are included. SAMHSA reported a response rate of 89% for the 2020–2021 N-MHSS (25). Data were collected between March 26, 2020, and January 18, 2021 (25).
Outcome measures.
The 2020–2021 N-MHSS included a series of items inquiring specifically about the use of antipsychotics, including both oral medications and LAIAPs. The instrument asked directors to indicate whether their facility prescribed any antipsychotics (oral or LAIAP). Facility directors indicating “yes” completed a follow-up item that listed nearly all FDA-approved antipsychotics, including six LAIAPs (excluding aripiprazole lauroxil and long-acting risperidone), and respondents indicated whether each was prescribed at their facility. We classified a service provider as prescribing LAIAPs if the response indicated that at least one LAIAP was used.
Facility characteristics.
The N-MHSS included a series of items inquiring about the characteristics of the facility. Variables included in this study were facility type (residential treatment center for adults, other residential treatment, community mental health center [CMHC], certified community behavioral health clinic [CCBHC], partial hospitalization or day program, outpatient mental health facility, multisetting mental health facility, VA, or other), location of the facility (U.S. state), and ownership (private for-profit, private nonprofit, or public). We also included survey items that asked facility directors to indicate whether their facility had a specific program for patients with serious mental illness, whether their facility had a specific program for patients with FEP, and whether the facility provided court-ordered treatment for patients (all yes or no). Finally, we included three items from the N-MHSS that asked for the types of payment a service provider accepted for services, including whether private insurance, Medicaid, and Medicare were accepted (all yes or no). Inpatient mental health care facilities (psychiatric hospital or a psychiatric unit of general hospitals) and providers exclusively serving children were excluded. VA facilities were also excluded because the N-MHSS does not distinguish between inpatient and outpatient VA service providers.
Statistical Analysis
First, we calculated frequencies and descriptive statistics to describe study variables. The first set of analyses focused on examining provider characteristics associated with the likelihood that a provider prescribed any antipsychotic. The second set of analyses examined the characteristics associated with the likelihood of specifically prescribing LAIAPs among the subgroup of service providers who indicated that any antipsychotic medication was prescribed. Within each set of analyses, bivariate binomial logistic regressions were used, followed by multivariable binomial logistic regressions for each dependent variable (prescribing any antipsychotic or prescribing specifically LAIAPs), with all provider characteristics as covariates. We estimated ORs in bivariate regression analyses and adjusted ORs (AORs) in multivariable analyses. An additional set of descriptive analyses was conducted at the level of facility type to evaluate the characteristics of each type of outpatient service provider that was associated with prescription of any antipsychotic agent and specifically with prescription of LAIAPs. All data were analyzed with IBM SPSS, version 27; a p<0.05 was considered statistically significant.
Results
A total of 12,275 facility directors responded to the 2020–2021 N-MHSS. We excluded 78 responses because they were from providers outside of the 50 states and the District of Columbia. Of the remaining responses, 2,171 were removed because they were from directors of inpatient mental health care facilities. An additional 590 were removed because they were responses from directors of outpatient service providers serving children, and three were removed for missing facility type. Thus, the final analytic sample included 9,433 outpatient mental health care service providers in the United States.
Facility Characteristics
The most common type of outpatient service provider included in this analysis was outpatient mental health facilities (52.1%), defined on the N-MHSS as facilities that “provide only outpatient mental health services to ambulatory clients, typically for less than three hours at a single visit” (25). The most common ownership type of service providers was private nonprofit organizations (65.1%). Regarding availability of specific services, 52.5% offered a specific program for individuals with serious mental illness, 17.6% offered a specific program for those with FEP, and 59.0% offered court-ordered treatment (Table 1).
| Characteristic | N | % |
|---|---|---|
| Facility type | ||
| Residential treatment center | 857 | 9.1 |
| Community mental health center | 2,546 | 27.0 |
| Certified community behavioral health clinic | 336 | 3.6 |
| Partial hospitalization or day treatment facility | 415 | 4.4 |
| Outpatient mental health facility | 4,913 | 52.1 |
| Multisetting mental health facility | 366 | 3.9 |
| Facility ownership | ||
| Private for-profit organization | 1,895 | 20.1 |
| Private nonprofit organization | 6,138 | 65.1 |
| Public agency or department | 1,400 | 14.8 |
| Serious mental illness program | ||
| Yes | 4,932 | 52.5 |
| No | 4,467 | 47.5 |
| First-episode psychosis program | ||
| Yes | 1,658 | 17.6 |
| No | 7,741 | 82.4 |
| Court-ordered treatment | ||
| Yes | 5,559 | 59.0 |
| No | 3,866 | 41.0 |
| Accepts Medicaid | ||
| Yes | 8,595 | 91.7 |
| No | 777 | 8.3 |
| Accepts Medicare | ||
| Yes | 6,514 | 69.5 |
| No | 2,858 | 30.5 |
| Accepts private insurance | ||
| Yes | 7,621 | 81.3 |
| No | 1,751 | 18.7 |
a
Data were missing for some categories, so Ns may not sum to the total.
Prescription of Any Antipsychotic
We found that 59.3% (N=5,590) of outpatient mental health care service providers prescribed any antipsychotic medication (oral or LAIAP). Of these providers, CCBHCs were the facility type that most frequently prescribed antipsychotics as treatment for patients (80.1%) (Table 2). Compared with outpatient mental health facilities, residential treatment (57.5%, OR=1.22, p=0.008), CMHCs (70.1%, OR=2.11, p<0.001), CCBHCs (80.1%, OR=3.67, p<0.001), and multisetting mental health facilities (66.1%, OR=1.76, p<0.001) were significantly more likely to prescribe antipsychotics. More service providers owned by a public agency (79.6%) prescribed antipsychotics than those with private ownership, and private nonprofit (59.6%, OR=1.94, p<0.001) and publicly owned (79.6%, OR=5.20, p<0.001) providers were more likely to prescribe antipsychotics compared with providers under private for-profit ownership.
| Any antipsychotic (N=5,590)b | Any LAIAP (N=2,885)c | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Characteristic | N | % | OR | 95% CI | p | AOR | 95% CI | p | N | % | OR | 95% CI | p | AOR | 95% CI | p |
| Facility type | ||||||||||||||||
| Outpatient mental health facility (reference) | 2,584 | 52.6 | 1,155 | 44.7 | ||||||||||||
| Residential treatment center | 493 | 57.5 | 1.22 | 1.05–1.41 | .008* | 1.43 | 1.21–1.70 | <.001* | 263 | 53.3 | 1.41 | 1.16–1.71 | <.001* | 1.75 | 1.41–2.18 | <.001* |
| Community mental health center | 1,784 | 70.1 | 2.11 | 1.91–2.34 | <.001* | 1.25 | 1.12–1.40 | <.001* | 1,116 | 62.6 | 2.05 | 1.81–2.32 | <.001* | 1.46 | 1.27–1.67 | <.001* |
| Certified community behavioral health clinic | 269 | 80.1 | 3.67 | 2.79–4.83 | <.001* | 2.21 | 1.65–2.95 | <.001* | 163 | 60.6 | 1.89 | 1.46–2.44 | <.001* | 1.43 | 1.09–1.87 | .01* |
| Partial hospitalization or day treatment facility | 218 | 52.5 | 1.00 | .82–1.22 | .97 | 1.50 | 1.20–1.88 | <.001* | 70 | 32.1 | .58 | .43–.78 | <.001* | .85 | .62–1.17 | .33 |
| Multisetting mental health facility | 242 | 66.1 | 1.76 | 1.41–2.12 | <.001* | 1.94 | 1.52–2.47 | <.001* | 118 | 48.8 | 1.17 | .90–1.52 | .25 | 1.26 | .95–1.67 | .11 |
| Facility ownership | ||||||||||||||||
| Private for-profit organization (reference) | 819 | 43.2 | 273 | 33.3 | ||||||||||||
| Private nonprofit organization | 3,656 | 59.6 | 1.94 | 1.74–2.15 | <.001* | 1.51 | 1.34–1.69 | <.001* | 1,852 | 50.7 | 2.05 | 1.75–2.40 | <.001* | 1.56 | 1.31–1.85 | <.001* |
| Public agency or department | 1,115 | 79.6 | 5.20 | 4.43–6.09 | <.001* | 3.43 | 2.89–4.09 | <.001* | 760 | 68.2 | 4.26 | 3.52–5.17 | <.001* | 3.07 | 2.49–3.78 | <.001* |
| Treatment for serious mental illness | ||||||||||||||||
| No (reference) | 2,063 | 46.2 | 801 | 38.8 | ||||||||||||
| Yes | 3,497 | 70.9 | 2.84 | 2.61–3.09 | <.001* | 2.07 | 1.87–2.28 | <.001* | 2,080 | 59.5 | 2.31 | 2.07–2.58 | <.001* | 1.86 | 1.64–2.11 | <.001* |
| First-episode psychosis program | ||||||||||||||||
| No (reference) | 4,310 | 55.7 | 2,153 | 50.0 | ||||||||||||
| Yes | 1,250 | 75.4 | 2.44 | 2.17–2.76 | <.001* | 1.58 | 1.38–1.80 | <.001* | 728 | 58.2 | 1.39 | 1.23–1.58 | <.001* | 1.03 | .89–1.18 | .71 |
| Court-ordered treatment | ||||||||||||||||
| No (reference) | 2,010 | 52.0 | 879 | 43.7 | ||||||||||||
| Yes | 3,549 | 63.8 | 1.66 | 1.52–1.80 | <.001* | 1.25 | 1.13–1.37 | <.001* | 1,999 | 56.3 | 1.66 | 1.48–1.85 | <.001* | 1.25 | 1.10–1.41 | <.001* |
| Accepts Medicaid | ||||||||||||||||
| No (reference) | 308 | 39.6 | 107 | 34.7 | ||||||||||||
| Yes | 5,243 | 61.0 | 2.38 | 2.05–2.76 | <.001* | 1.15 | .97–1.36 | .11 | 2,769 | 52.8 | 2.09 | 1.64–2.66 | <.001* | .94 | .72–1.23 | .65 |
| Accepts Medicare | ||||||||||||||||
| No (reference) | 1,112 | 38.9 | 343 | 30.8 | ||||||||||||
| Yes | 4,439 | 68.1 | 3.36 | 3.07–3.68 | <.001* | 2.41 | 2.17–2.69 | <.001* | 2,533 | 57.1 | 2.98 | 2.59–3.43 | <.001* | 2.38 | 2.02–2.81 | <.001* |
| Accepts private insurance | ||||||||||||||||
| No (reference) | 885 | 50.5 | 433 | 48.9 | ||||||||||||
| Yes | 4,666 | 61.2 | 1.54 | 1.39–1.71 | <.001* | 1.21 | 1.07–1.37 | .003* | 2,443 | 52.4 | 1.14 | .98–1.31 | .08 | .97 | .82–1.15 | .74 |
a
Multivariable analyses of likelihood of an outpatient service provider utilizing any antipsychotic therapy and specifically long-acting injectable antipsychotic medications (LAIAPs). Analyses of the likelihood a service provider prescribed LAIAPs were conducted only among the subset of respondents who indicated that their facility prescribed any antipsychotic therapy. In multivariable analyses, all independent variables were included in a single model, and adjusted ORs (AORs) are presented.
b
Percentages represent the proportion of service providers within each category offering any antipsychotic medication; total Ns for each category (used as denominators) are shown in Table 1.
c
Percentages represent the proportion of service providers within each category offering any LAIAP among those offering any antipsychotic medication.
* p<0.05.
Providers with specific programs for patients with serious mental illness (OR=2.84, p<0.001) and FEP (OR=2.44, p<0.001) and those providing court-ordered treatment (OR=1.66, p<0.001) were more likely to prescribe antipsychotics compared with facilities without such programming (Table 2). Regarding accepted payments, providers accepting Medicaid (OR=2.38, p<0.001), Medicare (OR=3.36, p<0.001), and private insurance (OR=1.54, p<0.001) were more likely to prescribe antipsychotics compared with programs not accepting each reimbursement source.
These trends remained largely unchanged in the multivariable analyses, except for the likelihood of partial hospitalization programs utilizing antipsychotic agents, which was statistically significant (AOR=1.50, p<0.001) (Table 2). Descriptive analyses were repeated at the level of provider type (see Table S1 in the online supplement to this article). Trends identified in the analyses of the overall group of outpatient service providers remained largely unchanged in the provider-level analyses.
LAIAP Prescription
Of facilities prescribing any antipsychotic medications (N=5,590), 51.6% (N=2,885) prescribed any LAIAP. Thus, 30.6% of outpatient mental health care service providers in the overall sample prescribed LAIAPs. CMHCs had the highest rate of LAIAP prescription (62.6%) (Table 2). Compared with outpatient mental health facilities, residential treatment programs (OR=1.41, p<0.001), CMHCs (OR=2.05, p<0.001), and CCBHCs (OR=1.89, p<0.001) were more likely to use LAIAPs, and partial hospitalization and day programs were less likely to use LAIAPs (OR=0.58, p<0.001).
Private nonprofit ownership (50.7%, OR=2.05, p<0.001) and public ownership (68.2%, OR=4.26, p<0.001) were associated with greater likelihood of prescribing LAIAPs, compared with private for-profit ownership (Table 2). Providers with specific programs for patients with serious mental illness (59.5%, OR=2.31, p<0.001) and FEP (58.2%, OR=1.39, p<0.001) and those providing court-ordered treatment (56.3%, OR=1.66, p<0.001) were more likely to prescribe LAIAPs compared with facilities without such programming. Providers accepting Medicaid (52.8%, OR=2.09, p<0.001) and Medicare (57.1%, OR=2.98, p<0.001) were more likely to prescribe LAIAPs compared with programs that did not accept these payments.
In multivariable analyses, the trends of the univariate comparisons were largely unchanged, with some notable exceptions (Table 2). Namely, the relationships between prescribing LAIAPs and partial hospitalization and day program facility type, prescribing LAIAPs and having programming specifically for FEP, and prescribing LAIAPs and accepting Medicaid as payment were no longer statistically significant. Finally, in the repeated descriptive analyses of outpatient service providers that indicated any antipsychotic therapy was prescribed at their facility, trends in the percentages of these service providers indicating use of LAIAPs were stable (see Table S2 in the online supplement ).
Specific LAIAP Agents
Among all outpatient service providers indicating that their facility prescribed any LAIAP (N=2,885), paliperidone palmitate (N=2,243, 77.7%) was the most commonly prescribed LAIAP, and olanzapine pamoate (N=855, 29.6%) the least commonly prescribed (Figure 1).
Discussion
A robust body of evidence supports the benefits and safety of LAIAPs for patients with chronic psychotic or affective disorders such as schizophrenia and bipolar disorder (9, 12, 16, 26–29). LAIAPs are an essential component of the array of interventions that improve quality of life and outcomes for people with such disorders (12). Prescription of LAIAPs in outpatient settings is important for maintaining stability of treatment and to promote recovery and quality of life for patients who need chronic antipsychotic therapy.
Overall, a low percentage (30.6%) of outpatient mental health care service providers prescribed LAIAPs, and only 51.6% of the outpatient facilities prescribing any antipsychotics (long-acting injectable or oral) prescribed LAIAPs. This finding may be explained by the relatively greater logistic requirements to administer LAIAPs than oral regimens. Prescribing LAIAPs requires available staff time, training, facility space, and administrative time to coordinate schedules and payments (23, 30). For providers without large populations of patients requiring long-term antipsychotic maintenance therapy, the necessary clinical infrastructure may be impractical.
LAIAPs are also increasingly recognized as an important component of early recovery–oriented care, which may be jeopardized by interruptions in treatment that are more likely with oral antipsychotic regimens (8, 9, 12–14, 31, 32). However, we found that only 58.2% of service providers with FEP programs prescribed LAIAPs (13–15). Early initiation of antipsychotic therapy that promotes adherence is a crucial component of recovery from early psychosis. This approach not only improves symptomatic stability but also may mitigate long-term neurodegeneration by preventing relapse (33–35).
The NIMH has published guidelines detailing coordinated specialty care (CSC) for FEP, which highlight an interdisciplinary approach to supporting patients (36, 37). An estimated 360 clinics are classified as CSC providers by the NIMH, compared with 1,658 that indicated on the N-MHSS that FEP programming was available (36, 37). However, the N-MHSS does not inquire about the specific components of this programming, so it is unclear whether providers who indicated their facility offered FEP programming met all CSC criteria, which likely explains this disparity. Importantly, the CSC guidelines do not specifically mention prescription of LAIAPs (36, 37). As evidence grows supporting the benefits of early initiation of LAIAPs, increasing their availability will be an important area of consideration in designing outpatient services for patients early in their disease course (13–15).
We note two interesting findings related to facility type and LAIAP prescription. First, partial hospitalization and day programs were the least likely facility type to prescribe LAIAPs. This level of care may often be transitional for patients being discharged from inpatient psychiatric units before returning to a less-intense psychiatric follow-up schedule. Because some LAIAPs (such as haloperidol decanoate and paliperidone palmitate) require two initiation doses, both of which may not be given in the hospital, the ability to seamlessly continue the injection series in the outpatient setting is paramount to decreasing the risk for decompensation after discharge (30). Previous work has found that up to 60% of patients who begin an LAIAP series did not receive the follow-up dose as an outpatient (38, 39).
Second, the percentage of CCBHCs prescribing LAIAPs was relatively low (60.6%). CCBHC models are innovating and expanding and are premised on integration of mental health care, primary care, case management, and peer-support services (40). Some CCBHCs also have an onsite pharmacy, which may allow for easier administration of LAIAPs. However, implementation of such a model would require training for pharmacists to detect changes in mental health status and timely engagement of psychiatric care providers (41). Given the inherent multidisciplinary approach of the CCBHC model, these clinics may be opportune outlets to expand LAIAP use with adequate training and communication among all treatment team members (42, 43).
Another possible strategy for increasing the use of LAIAPs is the expansion of the types of service providers in which patients can receive these medications to include pharmacies (44). As of 2021, 48 states (excluding New York, Rhode Island, and Washington, D.C.) allowed pharmacists to administer LAIAPs, with eight states requiring a physician-pharmacist collaborative practice agreement (45). Retail pharmacies are ubiquitous in the United States and already administer immunizations, and the more convenient operating hours of pharmacies may also increase utilization of LAIAPs. Studies of pharmacists and patients, although limited, have reported satisfaction with obtaining LAIAPs from community pharmacies, with good medication adherence; however, additional work is needed to inform further scale-up (46–48).
The finding that olanzapine pamoate was the least frequently prescribed LAIAP is not surprising, given the black box warning concerning postinjection delirium and sedation syndrome and the need for a period of monitoring by specially trained clinicians (49). Thus, the number of outpatient service providers capable of administering this medication is likely significantly lower than for other LAIAPs, which require minimal additional infrastructure to administer.
Although they are effective and safe, LAIAPs are not the sole method of symptom control and relapse prevention for patients with chronic psychotic or affective disorders. Daily oral antipsychotic regimens remain a mainstay in the treatment of patients with these disorders and arguably offer more options for patients, given the greater number of available medications compared with LAIAPs. However, many of the newer oral antipsychotic agents are patented and more expensive. The same is true about the patented LAIAPs, which may be more difficult to obtain for patients because of insurance formulary restrictions and costs. However, we found that many outpatient mental health care service providers that used any LAIAP did not prescribe even relatively inexpensive, generic LAIAPs, such as haloperidol decanoate (39.8% did not use) and fluphenazine decanoate (53.6% did not use) (Figure 1). This finding may indicate that clinical infrastructure is a greater limiting factor than affordability in the use of LAIAPs.
Finally, although some studies have identified decreased perceptions of stigma about mental illness and treatment among patients using LAIAPs, others have found that some patients have stigmatized views of LAIAPs because of the belief that these medications are reserved for patients with very severe illness (10, 50). This perception is partially connected to the dissemination of these medications at specialized LAIAP clinics, which further underscores the need to broaden availability of these agents within the community rather than restrict them to specific clinics.
The findings of this study should be interpreted in the context of several limitations. The use of self-reported, cross-sectional survey data is inherently subject to limitations of recall and accuracy in reporting. Although the N-MHSS is distributed to many service providers, it may not be fully inclusive of all outpatient venues for psychiatric care in the United States. Notably, one group excluded from the N-MHSS is private and independent outpatient psychiatry practices, representing an important area of future study regarding use of LAIAPs. Furthermore, the N-MHSS does not quantify the number of patients seeking care at a facility or the number who are prescribed an LAIAP, so an outpatient facility may have been classified as prescribing LAIAPs even if very few of these medications were prescribed to patients. Examination of the facility characteristics associated with greater frequency of LAIAP use would be an interesting and important area for future study. Facility leadership, provider training, and patient education on LAIAPs as a treatment option may also be necessary to improve use of LAIAPs for appropriate patients.
Similarly, in the 2020–2021 N-MHSS, antipsychotic medications were the only specific group of psychotropic agents included; therefore, it was not possible to perform analyses based on whether a service provider prescribed any other psychotropic agents (e.g., antidepressants or mood stabilizers). However, an outpatient facility that prescribes psychotropic medications without also prescribing antipsychotics would likely provide incomplete treatment for mental illness because it would exclude many medication combinations commonly used for pharmacotherapy. Relatedly, data about the availability of samples from pharmaceutical companies or about manufacturer rebates reducing prices for patients who need an LAIAP are not captured by the N-MHSS and may also influence the availability of LAIAPs in the outpatient setting. Further study is needed to better understand the administrative and financial factors that may be limiting LAIAP prescriptions and to inform new service delivery models to increase the use of LAIAPs.
An additional limitation was the exclusion of facilities focused predominantly on substance use, which are not surveyed in the N-MHSS. The companion study, the National Survey of Substance Abuse Treatment Services, does not include questions about whether a facility prescribes LAIAPs for patients with co-occurring substance use and chronic psychotic disorder diagnoses.
Conclusions
An important aspect of care for patients with chronic psychotic or affective disorders is treatment with antipsychotic therapy. LAIAPs represent a notable step forward in care for these patients, and their use is broadly supported by a body of evidence indicating improved outcomes at both patient and system levels. Outpatient prescription of LAIAPs is an important component of recovery-oriented care for people experiencing a first episode of psychosis, as is maintenance therapy for patients with chronic mental illness. We found that approximately 70% of outpatient mental health care service providers surveyed in the N-MHSS did not prescribe LAIAPs. Expanding use of LAIAPs may be one important step in reducing relapse and improving quality of life for patients with chronic psychotic or affective disorders.
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Information & Authors
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Received: 17 November 2022
Revision received: 8 January 2023
Accepted: 24 February 2023
Published online: 12 April 2023
Published in print: November 01, 2023
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Competing Interests
Dr. Bunting reports receiving research funding from Gilead Sciences, Inc. The other authors report no financial relationships with commercial interests.
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