Behavioural Providers Turn to Long-acting Injectables to Boost Adherence, Decrease Burden
Medication adherence is a critical issue for behavioural health providers. This is especially true for patients with serious mental illness.
More than half of patients with schizophrenia are nonadherent to medication, and 50% of patients with depression and 44% of patients with bipolar disorder are nonadherent to medication, according to a meta-analysis.
In order to help boost medication adherence and help patients improve their condition, many providers are looking to use long-acting injectables. Previous research has connected long-acting injectables to fewer psychiatric hospitalizations, suicide attempts and overall hospitalizations in patients with schizophrenia. Still, operational hurdles and provider comfort with the medications have posed obstacles.
“Long-acting injectables predict much better outcomes. So everything from fewer hospitalizations and fewer ED visits to [reduced] symptom burden,” Scott Fears, chief medical officer at Amae, told Behavioral Health Business. “Obviously, [patients are] compliant with the meds because they’re getting the shot, but they’re showing up to appointments. The outcomes in a regular outpatient clinic are really superior. I think for us, even though we’re doing intensive care and we can get good results with pills, there’s a lot of advantages even in our clinic.”
Los Angeles-based Amae Health is focused on unifying disparate parts of the health care system that treat people with serious mental illness (SMI). In April, it received $15 million in Series A funding.
Long-acting injectables are medications that can be given as a shot and released slowly and over time. In some cases, the medication must only be administered every six months, though most long-acting injectables need to be administered every four to eight weeks.
Several different types are used in behavioural health care. In the mental health space, there are more than a dozen antipsychotic medications available in the U.S. The majority of these medications are indicated for treating schizophrenia, and several are also indicated for bipolar disorder maintenance.
Long-acting injectables can also be used to treat substance use disorder. For example, there are long-acting injectables containing naltrexone and buprenorphine, which are used to treat opioid use disorders.
The opportunity for long-acting injectables
For the right patient, long-acting injectables can remove some of the burden of managing the condition.
“There’s a lot of advantages to it. One is you don’t have to think about a pill, you don’t have to think about medications every day, which can truly be a hassle,” Fears said.
He noted that many patients with SMI feel ambivalent about taking medications. However, when offered an easy alternative to daily pills, many are open to long-acting injectable treatments.
The other major positive of long-acting injectables is the potential decrease in side effects of the medications.
“There tends to be less side effects with the long-acting injectables. So when you’re taking the pill form, most of them are pretty sedating,” Fears said. “Especially once we get up to, more than low doses. And they also tend to have cognitive side effects, [such as] feeling dulled or kind of foggy. Those side effects in long-acting injectables tend to be quite a bit better. So instead of taking a pill and getting sedated and then it wears off and then you take another and you’re kind of oscillating up and down through the 24 hour period, with the long-acting injectables it’s much steadier, so you don’t get that prominent sedation or prominent cognitive effects.”
While long-acting injectables are often prescribed by mental health specialists, there could also be an opportunity for primary care providers to help with the adoption of these medications. PCP involvement could be beneficial for patients with mental health conditions who tend to use primary care as their go-to.
“There’s a population of patients that wind up in primary care that don’t go to the community mental health center, they got fired or they don’t like it. For whatever reason, they consider the primary care practice their home,” Virna Little, cofounder and special advisor of advocacy and research at Concert Health, told BHB. “Educating the providers [about] long-acting injectables is helpful because it reduces the difficulty of caring for those patients in primary care. It helps to be able to manage them. … I don’t think it is really addressed enough in primary care settings and I also think they’re underutilized in the community mental health settings.”
Concert Health is a virtual collaborative care platform integrating primary and behavioural health. In 2022, the company raised $42 million in Series B funding. While Concert Health does not use long-acting injectables, the provider has, in certain instances, recommended that primary care providers use them.
Providers aren’t the only ones keen for more long-acting injectables to be used in care, payers are also beginning to see the benefits.
“I think insurance companies are realizing that even though these medications are expensive, the return on investment has been proven quite rigorously that outcomes are better when you have [long-acting injectables],” Fears said. “I think they’re moving towards it. In the past there was a bit of a barrier. I think it’s much less of a barrier now.”
Limitations of long-acting injectables
While much of the research on long-acting injectables is promising, adoption is still relatively low. One of the main reasons for that is provider barriers.
“A lot of psychiatrists just aren’t comfortable giving shots,” Fears said. “They are used to writing a prescription and sending someone off. There’s not a lot of services available to give people shots. So I think that’s a big part of it…. But the other reason is that the individuals that would benefit the most from this are individuals with chronic psychotic disorders. And as we know that the mental health system for that population is broken.”
Many patients who start in the inpatient setting get long-acting injectables before leaving. However, when they continue in their care to an outpatient setting, the majority of patients stop receiving long-acting injectables, Fears said.
It takes education to get clinicians to use long-acting injectables widely. At Amae, a big focus was on upskilling clinicians so that they could offer long-acting injectables to patients.
Ujjwal Ramtekkar, chief medical officer at LifeStance, noted that typically, behavioural health prescribers have training in long-acting injectables. Still, there needs to be a whole-team approach to administering these types of medications.
“Some of the administration also requires nursing support,” Ramtekkar said. “We also need to make sure that the labs are being done appropriately, so folks have to really follow the evidence-based care guidelines of getting the baseline labs observations after injecting it, making sure that they are continuously planning for any acute side effects or any reactions that might happen.”
While long-acting injectables could be a great tool for curbing medication adherence burden and managing conditions, providers warn that these medications alone aren’t sufficient for treating behavioural health conditions.
“Long-acting injectables are great, but let’s not forget that mental health treatment is holistic, wraparound integrated care. We can’t lose sight of that,” Fears said. “What I wouldn’t want to happen is to say, ‘Hey, here’s your six-month shot; I’ll see it twice a year, and good luck and hope everything goes okay.’ For us it is, ‘Here’s your shot. We know the meds on board. This is convenient.. and we get to work on all these other things now, the community building exercise, diet and all of that.'”
Read Laura Lovett's original article here.
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