Focused Ethnographic Examination of Barriers to Use of Long-Acting Injectable Antipsychotics

The project was a performance improvement initiative of the Care Transitions Network (CTN) for People With Serious Mental Illness, a Practice Transformation Network funded by the Centers for Medicare and Medicaid Services. The CTN provides training for member facilities. The project’s goals were to identify barriers to LAI use at CTN sites, to provide sites with information about available CTN resources relevant to identified barriers, and to determine topics for future CTN training. The CTN framework allowed the project to be conducted at multiple sites with a central team that performed all interviews and analyses. Facilities received a report presenting the interview insights from their facility and from across the network and information on CTN resources for overcoming barriers identified at the site. Reports presented solely group data to allow participants to raise issues anonymously. Data collection occurred from October 11, 2017, to February 16, 2018.

The prevailing perception was that LAI antipsychotics are most suitable for patients who have a history of nonadherence with oral antipsychotic medications or who have a history of repeated hospitalizations. Most psychiatrists stated that they rarely bring up LAI options with patients, and they do so only if patients have a history of usage of LAI antipsychotics or significant nonadherence and resulting hospitalizations.

Most patients interviewed were unaware of LAI antipsychotics as a treatment option. A few patients knew someone using LAI antipsychotics (who were prescribed them primarily because of a history of nonadherence). In these situations, patients often reported that they observed improvement with LAI treatment. One patient said that observing improvement in others was the reason he was more open to try a LAI formulation when the doctor raised this possibility. When patients who were unaware of LAI options were presented with the features of this method of administration, many of them had a positive assessment of the features, citing specifically the reduced effort and reliance on family members or other support systems to keep track of oral medication intake.

Both psychiatrists and therapists stated that the best time to introduce a patient to a LAI antipsychotic is when he or she is admitted to a hospital because of a psychotic decompensation. Some patients had received short-acting injectable medications while in the hospital. The negative experience of being given a medication against their will generalized for them from short-acting injections to long-acting injections. These patients refused to use LAI antipsychotics and also informed their friends and acquaintances of their experience, thereby dissuading them from using this option as well.

Psychiatrists reported spending 15 minutes on average with each patient. Most psychiatrists (and therapists and administrators) said that was not ideal but unavoidable with the high patient-to-psychiatrist ratio prevalent in mental health clinics. Therapists in the study reported spending 45–60 minutes with each patient. However, therapists did not engage much with patients about their medications. Many therapists were not aware of the benefits or risks of using LAIs, and a few did not even know it was a treatment for psychosis.

Patients reported not feeling emotionally supported when making a decision about starting a new medication. Overall, patients were reluctant to switch medications, and this transition became more difficult if they lacked support. Patients also perceived that they had limited choice in medication decisions. Some psychiatrists acknowledged that they do not have much time during their sessions with the patient to introduce or discuss new treatments, such as LAI antipsychotics. This shortcoming limited the patient’s access to information about LAI formulations.

Most patients said they would prefer to be counseled about new treatments by their therapist, owing to the trust and time they had with their therapist, compared with the psychiatrist. When asked, therapists did not find the patients’ responses surprising and noted that it would certainly be beneficial to discuss matters as important as medication with the most trusted professional. Therapists also noted that they are more likely to detect patient nonadherence because they spend considerably more time with patients than do psychiatrists. Some therapists also noted that some of their patients feign adherence in front of their psychiatrist because they know psychiatrists are the ones charged with making medication changes.

Psychiatrists said they did not think therapists should be having medication conversations, primarily because that is the way it has always been. However, they acknowledged that therapists are in a better position to have the conversation if the therapist is properly trained and not prescribing (only discussing features and benefits). Therapists were generally very willing and felt that medication “consulting” could be part of their continuing education. In current practice, therapists limited their role to only encouraging patients to remain adherent with their medications and communicating incidences of nonadherence to the psychiatrist.

The extent of communication between therapists and psychiatrists about patients varied considerably between clinics and often within clinics as well. The official communication route was through case notes written by therapists and psychiatrists. However, therapists did not know whether psychiatrists read their notes, and some assumed that psychiatrists did not read any notes. One of therapists’ biggest concerns was that psychiatrists would not be aware of a patient’s nonadherence if they did not read the therapist’s notes. Therapists noted that if the clinicians were encouraged to talk outside of work (e.g., in break rooms), then communication regarding patients was likely to improve.

Many psychiatrists interviewed disliked the inability to vary the length of the effect of LAI antipsychotics. They were reluctant to start a trial of an LAI medication, especially if they were not aware of how the it would affect the patient. Psychiatrists noted that all patients do not react to antipsychotic medications in the same way; furthermore, they expressed the belief that patients may react differently to the LAI formulation than they would the oral form, even if both formulations contain the same core molecule. Psychiatrists reported that performing a trial of an LAI antipsychotic was more difficult than with oral medications. Psychiatrists said that it often takes a lot of trial and error to find an antipsychotic medication that patients respond to well. The benefit of oral medications is that the trials can be as short as a few days to evaluate side-effect tolerability. Patients could experience different or worse side effects with an LAI antipsychotic. Furthermore, psychiatrists did not want to wait 1 or 2 months before being able to make dose adjustments if needed to enhance efficacy. Overall, psychiatrists did not feel comfortable giving a patient an LAI antipsychotic unless the patient had used them previously.

Only two of the five outpatient clinics had infrastructure that supported LAI utilization. Barriers identified included that without a sufficient volume of LAI prescriptions, pharmacies did not want to participate in LAI delivery systems, and clinics did not want to provide nurses to administer LAI antipsychotics. Only one of the psychiatrists interviewed administered LAI antipsychotics. The others said that it was not their job to administer medication, that psychiatry is a hands-off practice, and that they intentionally do not administer medications. Nurses had concerns about minimizing the effort required of them to keep track of LAI medications.

There was considerable variability (sometimes within the same clinic) in the perceived ease or difficulty of setting up an LAI program. Some administrators assumed that setting up an LAI program could be done quickly, whereas others described a long and arduous process. Clinics interested in setting up an LAI program had few examples to follow because of the paucity of clinics with LAI programs.

When assessing a new drug, payers were primarily interested in efficacy, followed by price and molecule differentiation. Most payers believed that LAI antipsychotics reduce long-term hospitalization costs through increased adherence, but the substantial cost difference between LAI and oral antipsychotic medication is a barrier to widespread coverage. Payers were not willing to “buy futures” by spending significantly more on LAI antipsychotics to potentially save on later costs. They also commented that the process of helping patients switch to more premium drugs is cumbersome, requiring significant administrative burden on both payer and provider. Some payers also blamed providers for a lack of training or interest in advocating for LAI antipsychotics. Overall, payers believed that LAI formulations have an important role in the future of antipsychotic treatment, although they anticipated the growth to remain slow (largely because of the high treatment cost).