Schizophrenia is a heterogeneous disease which follows a highly variable course, but for most patients, it is a chronic relapsing condition. The benefit of antipsychotic drugs in preventing relapses has been shown in relapse prevention studies and intermittent versus continuous maintenance studies. However, poor drug adherence to antipsychotic agents is common in schizophrenia, whether intentional or unintentional. Non-adherence leads to an increased risk of relapse, hospitalization, and self-harm. Relapse also worsens the long-term outcomes of schizophrenic patients.

Psychiatrists can use a range of management techniques to improve adherence, such as psychosocial interventions, programmatic treatments, and pharmacological strategies,

including antipsychotic long-acting injections (LAI). LAIs are an important treatment option for psychiatric disorders, such as schizophrenia and bipolar disorders. They were designed over 50 years ago to promote adherence to antipsychotic drug regimens, but arguably remain stigmatized and underused in some countries and regions.

Recently published international guidelines have recommended LAIs for both patients with demonstrated poor drug adherence and for those who prefer LAIs.[i] LAIs are also recommended for use in any stage of schizophrenia. LAIs showed decreased relapse rates through improved medication adherence. This reduces the risk of toxic relapse and possible subsequent re-hospitalizations. Despite good clinical evidence, and the use of LAIs in clinical practice since the 1960s, LAIs are still not commonly prescribed to patients in many countries, including the USA, Japan, and Taiwan. Psychiatrist and patient attitudes are thus important as they are the ones prescribing and using LAIs respectively. Hence, this study aims to investigate psychiatrist and schizophrenic patient attitudes toward LAIs.

The authors designed a questionnaire with 30 items on psychiatrist attitudes and knowledge of LAIs, and invited psychiatrists in central Taiwan to respond. A questionnaire (10 questions) was also designed and used in interviews of schizophrenic patients in the same area (including outpatients, inpatients, and those in homecare and daycare). The participants’ demographic data and related information were collected (including the potential adverse effects, psychological insights, stigma, fear of injections, beliefs about medication, as well as coercion). The data were then analyzed and discussed.

The sample comprised of 102 psychiatrists (with a response rate of 88.7%). They aged from 26 years old to 68 years old with a length of work in mental health institutes from 1 year to 40 years. In this study, 79.4% were male; 78.4% worked in the psychiatric department of a general hospital and 21.6% worked in a mental hospital; 57.8% were employed in a private hospital and 42.2% were employed in a public hospital. No data was collected from private psychiatric clinics.

All participants had experience prescribing LAIs. More than 90.0% of them had introduced LAIs to schizophrenic patients and/or their family members. In addition, 90.0% of psychiatrists agreed that LAIs are suitable for use in any stage of schizophrenia, and agreed LAIs can reduce relapse and re-hospitalization rates, improve overall economic costs, improve the social functioning of patients, and decrease caregiver burden. The main reasons for prescribing LAIs were to overcome adherence problems and for convenience. Two thirds of respondents thought their patients would accept LAIs, especially after a clinician’s introduction. The majority were also willing to prescribe more LAIs in the future. Their age, gender, work experience, and employer influenced their attitudes toward LAIs. Most of the respondents were concerned that the National Health Insurance might be a barrier to using LAIs.

There is little published data on psychiatrist’s attitudes toward LAIs. Compared to previous related investigations, these results show the majority of the psychiatrists surveyed expressed

positive attitude toward LAIs. During the period in which atypical antipsychotic LAIs have been available, overall LAI prescription rates increased in Taiwan. Most respondents regarded LAIs as offering better adherence and reduced relapse rates, but some remained concern about the acceptability of LAIs to patients (due to injection issues and the image of LAIs). These concerns of psychiatrists are important but could compromise drug choices offered to schizophrenic patients. The National Health Insurance is another important factor relating to the prescription of LAIs in Taiwan but is not a medical issue per se.  

As for schizophrenic patients, 295 patients were enrolled in total. The average age was 45.8 years old, 117 (39.7%) were outpatients, 58 (19.7%) were inpatients, 44 (17.9%) were daycare patients, and 76 (25.8%) were homecare cases. Overall, 122 (52.9%) were male. The average duration of schizophrenia was 21.2 years. The average number of psychiatric hospitalizations was 3.9. In this study, 113 (38.3%) of them had used LAIs, 241 (81.7%) knew about LAIs, and 192 (65.1%) had been suggested to use LAIs. In total, 156 (52.9%) respondents could accept LAIs, but compared with oral formulations, only 74 (25.1%) people preferred using LAIs.

In different settings, the attitudes of the schizophrenic patients differed. Clinic patients had the highest acceptance rate of LAIs (57.1%). Patients who had been informed of this option and were suggested to use LAIs, and who had psychological insight, had a higher acceptance rate of LAIs. Patients who had the experience of using LAIs had the highest acceptance rate.  

In the treatment of schizophrenia, acute and long-term goals must be aligned early on in the treatment plan. Previous studies showed patient preferences for LAIs versus oral antipsychotics vary. Heres et al.[i] reported that patients prefer their current formulation (2007). This study re-confirmed that most patients already taking LAIs do accept them and many prefer this formulation to tablets. Maintenance therapy and relapse prevention are pivotal goals. Relapses are most often related to non-adherence of medication, thus antipsychotic LAIs are highly valuable. Earlier use of LAIs may also benefit the overall disease course and outcomes.

Exploring the thoughts of patients toward LAIs is important. Patients may be willing to accept antipsychotic LAIs when properly informed. Psychiatrists should thus look at these drugs as a good option for treatment, and should consider how to approach patients and involve them in the decision-making process, including the use of antipsychotic LAIs where appropriate.

Some important issues were not explored, including the attitude of nurses and family members toward LAIs; any association between therapeutic alliance and attitudes toward medications; as well as first-generation LAIs versus second-generation LAIs. These issues need to be explored in the future.

This paper was presented as a poster at the 6^th Congress of AsCNP during October 2019.

[i] Heres et al. The attitude of patients towards antipsychotic depot treatment. Int Clin Psychopharmacology 2007; 22:275-282.

[i] The Maudsley Prescribing Guidelines in Psychiatry 13th edition, 2018. Wiley Blackwell, UK