Effective Communication Strategies to Implement LAIs Into Treatment Plans

In this video, Sanjai Rao, MD, DFAPA, Associate Clinical Professor of Psychiatry, Associate Residency Training Director, University of California, San Diego, shares effective communications strategies for clinicians to implement long-acting injectables (LAIs) in their patients’ treatment plans.

Dr Rao recently spoke in a Psych Congress Elevate session titled “Clinical Profile and Considerations for Use of a Long-Acting Injectable Treatment in Adults With Schizophrenia” and he shares more insights on this topic here:

LAIs Offer Opportunity for Increased Medication Adherence in Patients With Schizophrenia

Read the transcript:

Hi, I'm Sanjai Rao. I'm a clinical professor of psychiatry at the University of California, San Diego, and an attending psychiatrist at the San Diego VA.
My practice is centered around acute care and inpatient psychiatry, and I have the good fortune of being able to work with residents and medical students every day. That's most of what I do. I practice clinical inpatient psychiatry in the setting of training residents and medical students.

I also have the good fortune of being able to participate in events such as this.

Communication strategies for clinicians talking to patients who might potentially consider an LAI. This is one of the most important things that you can do to put someone on the path to an LAI.

To frame this, I want you to think about how you've been trained to think about LAIs. This is going to be very generational. If you were trained recently, you're probably more likely to think of LAIs as the viable option, even earlier in the treatment course of schizophrenia.

If you were trained a while back, like I was, you were probably taught that LAIs are for the sickest of our patients. They're for the patients who've had difficulty taking medications, who've failed a lot of different medications, who have been hospitalized a lot of times. You're at the end of the rope with that.

It's a stark difference in how you think about this. You've got one group of patients who's as sick as they can possibly get who's gone way down the their illness and who now you're thinking about an LAI, versus a paradigm of thinking about putting someone on LAIs much earlier and having them maybe experience the benefit of being on LAIs earlier.

The reason I bring this up is if your mindset is that LAIs are for only the sickest of our patients, that's going to come across in the way that you communicate it to your patient.

Implicitly, you're going to say things to them like, "Hey, you've had a hard time taking medications," or, "Hey, I notice you've been hospitalized a lot because you haven't taken your medications. Maybe we should have you on a long-acting injection."

It's a very well-intentioned way of expressing it. Many patients, if they hear that, what they're going to hear is, "You've been bad. You've failed. You haven't done what you're supposed to do, and so we don't trust you to take your medications. We're going to put you on an injection."

You can imagine that that's not a great message for them to hear or to feel like they're hearing. Not that you're giving them that message, but this is what they often will feel like they're hearing if you approach it that way. What's the alternative?

If we're looking at this from the other framework, that LAIs can be beneficial earlier in treatment, that they're easier to take, that they liberate patients to not have to make a choice on a day-to-day basis, then you can present it that way.

That's the way you can talk to your patients about it, and this is what I do. When I talk to a patient about getting an LAI, the way I usually approach it will be to say something like, "Hey, it seems like you're doing pretty well on this oral medication," whatever that oral medication is.

"I wanted to let you know that we have an option where you can take this medication once a month instead of taking it every day." You would not believe the number of patients whose ears perk up at that.

Some of them have heard of injections, and so what they'll say is, "Oh, do you mean the injection?" I'll say, "Yeah, that's what I mean. There's this injection that you can get once a month."

Some of them have never heard of this, and they're quite frankly very surprised that this option even exists, that you can take a medication once a month, and they want to know more, and they say, "Well, do I still have to take the daily thing?" You say, "No, you don't have to take the daily thing. You can just do it once a month."

Notice there that I didn't lead with, "Let's inject you," because many people, if you lead with that, will have a negative connotation to it. If you think about it, that's not the choice you're offering them.

We have to use an injection because it's the only way we have of getting monthly medications in them. You're offering them the choice between daily and monthly. I would encourage you to frame it that way to begin with, daily versus monthly.

Then, of course, once the patient expresses interest, then you say to them something along the lines of, "I want to let you know, this monthly medication, we don't have it in a pill form, we only have it as an injection. Is that OK with you?"

It's rare that I have patients say they want a monthly medication and then refuse it because it's an injection. One of the reasons is once they get this idea in their head that they only have to take medications once a month, it becomes too attractive to let go of.

Even though it's an injection, even if they might have had some slight trepidation about the injection, they'll often say, "OK, yeah, that sounds fine. It may not have been my first choice, but that sounds fine." A bunch of them say, "Yeah, that's fine. That's no problem. I don't mind doing that."

That's the way I would encourage communication with the patient. Frame the choice with what the actual choice is, doing it every day versus only doing it once a month or once every other month.

Once you frame it in that way and once patients are invested in that, you'll have a much higher take rate, even after you tell them that it's an injection.

Dr. Sanjai Rao is an Associate Clinical Professor of Psychiatry and Associate Residency Training Director at the University of California, San Diego (UCSD), and the Site Director for Residency Training at the VA Medical Center in San Diego, CA.  A lifelong clinician educator, Dr. Rao’s clinical practice is focused on inpatient and acute care at the VA, with an emphasis on teaching practical psychopharmacology to the many trainees he supervises. Dr. Rao coordinates the UCSD Psychiatry Residency curriculum and has received a number of teaching awards based on his clinical and academic work, including the APA Irma Bland Award for Excellence in Residency Teaching.