By Gina Shaw

Despite evidence of their efficacy and improved adherence compared with oral antipsychotic therapy, uptake of long-acting injectable antipsychotics (LAIs) remains relatively low, with some data suggesting prescribing rates can be as low as 10% in the United States (Ther Adv Psychopharmacol 2014;4[5]:198–219). At the 2023 Psych Congress, multiple abstracts and presentations addressed the underlying factors behind their relatively low utilization.

In the Determining Clinician factors for Implementing LAIs and Defeating Barriers (DECIDE) survey, which involved interviews with 380 psychiatric clinicians across the United States, including 295 physicians and 85 nurse practitioners/physician assistants, survey authors included a hypothetical interaction between a psychiatrist and a 38-year-old woman with schizophrenia who was nonadherent to her oral antipsychotic therapy (OA) for the participants to review.

In that scenario, the psychiatrist first presented the LAI option to the patient this way: “Well, um, there have been some studies showing that patients may respond better to long-acting injectable treatment … rather than having to take medication every day, you would only need a shot every so often. [So I] wanted to at least mention to you so that you would … you know … know that it’s an option.”

When the patient responded, “I think I can be better at taking my regular medication. I don’t really like needles,” the psychiatrist immediately said, “That’s fine, it’s a big decision! I wouldn’t want to push anything like this on you.”When presented with this dialogue, 60% of survey respondents felt that the clinician did not provide enough information on the benefits of LAIs; 29% felt that the clinician seemed hesitant/reluctant to bring up LAIs; and 15% felt that the clinician gave up too early, reported DECIDE lead author Dawn Velligan, PhD, the Henry B. Dielmann Chair of the Department of Psychiatry and director of the Division of Community Recovery, Research and Training at the University of Texas Health Science Center, in San Antonio. 

But when respondents were grouped by their general attitudes and preferences toward LAI use, those who were early users of LAIs were more likely to feel that the clinician in the case gave up too early compared with clinicians who were LAI-hesitant (18% vs 9%; P>0.05), Dr. Velligan reported.

The equivocal-sounding introduction from the psychiatrist may seem unrealistic, but it is in fact based on an observational study conducted by Dr. Velligan and a team of colleagues, in which they observed interactions at 10 community health centers that offer LAIs (J Clin Psychiatry 2015;76[6]:684-690).


“We found that when offering these medications, clinicians start by talking about the modality,” Dr. Velligan explained. “Doctors never do that with oral agents: they don’t start out by saying ‘I have these pills that are very big and hard to swallow. But with LAIs, they start by describing the shot rather than what the treatment offers. Overall, 91% of presentations focused on the modality while only 9% focused on the benefits.”

In the recordings, clinicians also often appeared hesitant in offering the LAIs, Dr. Velligan added. “They used a lot of ‘ums’ and ‘maybes’ and other equivocal language, and then they gave up very quickly if the patient raised any question or objection.” 

Perhaps not surprisingly, 11 of 33 recommendations for LAIs (33%) were accepted during the discussion; but in post-visit interviews conducted by study investigators, 27 of 28 patients (96%) who seemed to decline the initial recommendation said they actually would be willing to try LAI treatment.

“The other issue is that clinicians tend to reserve LAIs for people who they think will be nonadherent, and for those patients who have failed in oral treatments multiple times,” Dr. Velligan said. “In another specialty—cardiology, for example—no one would do that, waiting until a patient failed on other medications over and over before giving them a medication that they know reduces rates of relapse and rehospitalization and improves mortality.” 

She noted that 82% of clinicians who were low LAI users believed LAIs to be reserved for patients with adherence issues (compared with 50% of high LAI users), and 50% of low LAI users thought they were to be used for patients with more severe symptoms, compared with 21% of high LAI users.

Overall, the DECIDE findings underscore that there is a substantial percentage of psychiatric clinicians who remain uncomfortable with prescribing LAIs, Dr. Velligan said. “They don’t know what options are available, how to prescribe these agents, how to switch between them, and how to navigate the barriers that come up in terms of insurance and prior authorization. And many do not understand that by putting in a little bit of effort up front, in the long run their practice will become easier to manage.”

Dr. Velligan reported consulting positions and/or advisory board relationships with Alkermes, Boehringer Ingleheim, Indivior, Janssen, Otsuka and Teva Pharmaceuticals.