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Benefits of early LAI use
I want to thank Dr. Nasrallah for his editorial calling for more frequent and earlier use of long-acting injectable antipsychotics (LAIs) in schizophrenia (From the Editor,
In addition to the neuroprotective biologic effects of early LAI usage, I’ve found that many of my FEP patients find great psychological comfort from incorporating LAIs into their treatment plan. The first psychotic break is generally when a person (and their family) feels the most afraid about the future and is in desperate need of hope that they can have a full life—with educational opportunities, sustained employment, meaningful relationships, and more. Just as society has seen the COVID-19 vaccines as a symbol of hope and the first step in overcoming the oppression of living in fear of an uncertain future, we need to help people experiencing FEP find hope in a needle.
Craig Chepke, MD, FAPA
Excel Psychiatric Associates
Huntersville, North Carolina
Reference
1. Chepke C. Drive-up pharmacotherapy during the COVID-19 pandemic. Current Psychiatry. 2020;19(5):29-30.
Dr. Nasrallah responds
Thank you, Dr. Chepke, for your letter confirming full support for using LAIs in schizophrenia. I like the phrase you coined: “hope in a needle.” The early use of LAIs in schizophrenia can provide the same type of hope that the vaccines against the life-threatening COVID-19 virus have generated in our society. Based on my direct observations, I also agree with you that the longer patients with schizophrenia remain on LAIs, the more engaged and happy they are with their progress and the quality of their lives. It is tragic that many patients never had the opportunity to return to their baseline with the early use of LAIs immediately following their first psychotic episode, instead of relapsing again and again due to their inability to adhere completely to their oral medications.
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: LAIs as the standard of care
LAIs as the standard of care
Thank you, Dr. Nasrallah, for reiterating the importance of compliance with pharmacologic management of schizophrenia after FEP (From the Editor,
As you point out in your editorial, the facts are powerful, well-known, undisputed, and yet not adopted in the United States, when in other countries LAIs are first-line care. Yes, LAIs are expensive, but not nearly as expensive as the disabilities caused by noncompliance are to society.
Why isn’t LAI use the standard of care here in the United States? In the United States, there is advocacy for treatment because there’s money in it. There is no good advocacy for preventive care because there’s no immediate money in it. We have another good example of this in the United States: private, for-profit prisons. They have a vested interest in keeping prisons full and building new ones. Patients with FEP are most often treated in the hospital, where a standard of care could easily be established that mandates LAIs as first-tier care. Why is that not so? Who is pushing for it? Who is resisting?
Your editorial inspired me to advocate more strongly. Do you have advice about how to effect policy change? I know administrators respond when we talk dollars and cents, not quality of care. What is the dollar cost of not using LAIs as the standard of care after FEP? Who cares? Who would listen to the numbers?
Edward A. Major, MD, LFAPA
Clinical Professor of Psychiatry
Upstate Medical Center
Syracuse, New York
Dr. Nasrallah responds
Dr. Major, thanks for your message. Establishing a standard of care for the use of LAIs (or any other therapy) is not that simple. It requires well-coordinated collaboration among several stakeholders (clinicians, researchers, payors, advocacy groups, and a national organization such as the American Psychiatric Association). The cost issue is certainly powerful, but the equation works in favor of LAIs because 1 psychiatric hospitalization due to a psychotic relapse costs up to 3 times the annual cost of an LAI medication that can prevent that rehospitalization. In addition, disability comprises the lion’s share of the large indirect costs of schizophrenia (disability payments, lifetime room and board, incarceration and legal costs, and loss of work and generation of taxes). LAIs can save both lives and expenditures, and a lot of suffering by patients and their families. I, too, long to see the emergence of a rational standard of care for schizophrenia using LAIs right after the initial psychotic episode. Oncology and cardiology have standards of care, so why not psychiatry?
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: Psychosis and epilepsy
Psychosis and epilepsy
I just read your editorial regarding the devastating consequences of psychotic relapses (From the Editor,
I work in the spheres of psychiatry, epileptology, and whole genome sequencing, and have experienced a psychotic episode myself (in 2013, after temporal lobe resection and overdose). I now consider myself even more lucky to be out the other side! As Governor for South London and Maudsley NHS Foundation Trust (SLaM) and Trustee for Epilepsy Action, many of our patients have psychosis. Some patients with epilepsy even experience postictal psychosis. Just yesterday, we had a call at SLaM regarding patients from a secure unit, and a psychiatric nurse spoke about patients at risk to themselves and others because of their psychotic illness, and how crucial effective long-term care was.
Torie Robinson
CEO, Epilepsy Sparks
Dr. Nasrallah responds
Ms. Robinson, thank you for sharing your story. It is important to note that the neurobiology of the psychosis that may occur with epilepsy may not be as neurodegenerative as the psychosis of schizophrenia. Many neurologic conditions can be associated with psychotic episodes, not only epilepsy. I am glad you overcame your post-temporal lobectomy psychotic episode and have had a very good outcome with high functioning.
Henry A. Nasrallah, MD
Editor-In-Chief
Disclosures
Dr. Chepke is a consultant to and speaker for Janssen Pharmaceuticals, Otsuka Pharmaceuticals, and Alkermes. The other authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.
Benefits of early LAI use
I want to thank Dr. Nasrallah for his editorial calling for more frequent and earlier use of long-acting injectable antipsychotics (LAIs) in schizophrenia (From the Editor,
In addition to the neuroprotective biologic effects of early LAI usage, I’ve found that many of my FEP patients find great psychological comfort from incorporating LAIs into their treatment plan. The first psychotic break is generally when a person (and their family) feels the most afraid about the future and is in desperate need of hope that they can have a full life—with educational opportunities, sustained employment, meaningful relationships, and more. Just as society has seen the COVID-19 vaccines as a symbol of hope and the first step in overcoming the oppression of living in fear of an uncertain future, we need to help people experiencing FEP find hope in a needle.
Craig Chepke, MD, FAPA
Excel Psychiatric Associates
Huntersville, North Carolina
Reference
1. Chepke C. Drive-up pharmacotherapy during the COVID-19 pandemic. Current Psychiatry. 2020;19(5):29-30.
Dr. Nasrallah responds
Thank you, Dr. Chepke, for your letter confirming full support for using LAIs in schizophrenia. I like the phrase you coined: “hope in a needle.” The early use of LAIs in schizophrenia can provide the same type of hope that the vaccines against the life-threatening COVID-19 virus have generated in our society. Based on my direct observations, I also agree with you that the longer patients with schizophrenia remain on LAIs, the more engaged and happy they are with their progress and the quality of their lives. It is tragic that many patients never had the opportunity to return to their baseline with the early use of LAIs immediately following their first psychotic episode, instead of relapsing again and again due to their inability to adhere completely to their oral medications.
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: LAIs as the standard of care
LAIs as the standard of care
Thank you, Dr. Nasrallah, for reiterating the importance of compliance with pharmacologic management of schizophrenia after FEP (From the Editor,
As you point out in your editorial, the facts are powerful, well-known, undisputed, and yet not adopted in the United States, when in other countries LAIs are first-line care. Yes, LAIs are expensive, but not nearly as expensive as the disabilities caused by noncompliance are to society.
Why isn’t LAI use the standard of care here in the United States? In the United States, there is advocacy for treatment because there’s money in it. There is no good advocacy for preventive care because there’s no immediate money in it. We have another good example of this in the United States: private, for-profit prisons. They have a vested interest in keeping prisons full and building new ones. Patients with FEP are most often treated in the hospital, where a standard of care could easily be established that mandates LAIs as first-tier care. Why is that not so? Who is pushing for it? Who is resisting?
Your editorial inspired me to advocate more strongly. Do you have advice about how to effect policy change? I know administrators respond when we talk dollars and cents, not quality of care. What is the dollar cost of not using LAIs as the standard of care after FEP? Who cares? Who would listen to the numbers?
Edward A. Major, MD, LFAPA
Clinical Professor of Psychiatry
Upstate Medical Center
Syracuse, New York
Dr. Nasrallah responds
Dr. Major, thanks for your message. Establishing a standard of care for the use of LAIs (or any other therapy) is not that simple. It requires well-coordinated collaboration among several stakeholders (clinicians, researchers, payors, advocacy groups, and a national organization such as the American Psychiatric Association). The cost issue is certainly powerful, but the equation works in favor of LAIs because 1 psychiatric hospitalization due to a psychotic relapse costs up to 3 times the annual cost of an LAI medication that can prevent that rehospitalization. In addition, disability comprises the lion’s share of the large indirect costs of schizophrenia (disability payments, lifetime room and board, incarceration and legal costs, and loss of work and generation of taxes). LAIs can save both lives and expenditures, and a lot of suffering by patients and their families. I, too, long to see the emergence of a rational standard of care for schizophrenia using LAIs right after the initial psychotic episode. Oncology and cardiology have standards of care, so why not psychiatry?
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: Psychosis and epilepsy
Psychosis and epilepsy
I just read your editorial regarding the devastating consequences of psychotic relapses (From the Editor,
I work in the spheres of psychiatry, epileptology, and whole genome sequencing, and have experienced a psychotic episode myself (in 2013, after temporal lobe resection and overdose). I now consider myself even more lucky to be out the other side! As Governor for South London and Maudsley NHS Foundation Trust (SLaM) and Trustee for Epilepsy Action, many of our patients have psychosis. Some patients with epilepsy even experience postictal psychosis. Just yesterday, we had a call at SLaM regarding patients from a secure unit, and a psychiatric nurse spoke about patients at risk to themselves and others because of their psychotic illness, and how crucial effective long-term care was.
Torie Robinson
CEO, Epilepsy Sparks
Dr. Nasrallah responds
Ms. Robinson, thank you for sharing your story. It is important to note that the neurobiology of the psychosis that may occur with epilepsy may not be as neurodegenerative as the psychosis of schizophrenia. Many neurologic conditions can be associated with psychotic episodes, not only epilepsy. I am glad you overcame your post-temporal lobectomy psychotic episode and have had a very good outcome with high functioning.
Henry A. Nasrallah, MD
Editor-In-Chief
Disclosures
Dr. Chepke is a consultant to and speaker for Janssen Pharmaceuticals, Otsuka Pharmaceuticals, and Alkermes. The other authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.
Benefits of early LAI use
I want to thank Dr. Nasrallah for his editorial calling for more frequent and earlier use of long-acting injectable antipsychotics (LAIs) in schizophrenia (From the Editor,
In addition to the neuroprotective biologic effects of early LAI usage, I’ve found that many of my FEP patients find great psychological comfort from incorporating LAIs into their treatment plan. The first psychotic break is generally when a person (and their family) feels the most afraid about the future and is in desperate need of hope that they can have a full life—with educational opportunities, sustained employment, meaningful relationships, and more. Just as society has seen the COVID-19 vaccines as a symbol of hope and the first step in overcoming the oppression of living in fear of an uncertain future, we need to help people experiencing FEP find hope in a needle.
Craig Chepke, MD, FAPA
Excel Psychiatric Associates
Huntersville, North Carolina
Reference
1. Chepke C. Drive-up pharmacotherapy during the COVID-19 pandemic. Current Psychiatry. 2020;19(5):29-30.
Dr. Nasrallah responds
Thank you, Dr. Chepke, for your letter confirming full support for using LAIs in schizophrenia. I like the phrase you coined: “hope in a needle.” The early use of LAIs in schizophrenia can provide the same type of hope that the vaccines against the life-threatening COVID-19 virus have generated in our society. Based on my direct observations, I also agree with you that the longer patients with schizophrenia remain on LAIs, the more engaged and happy they are with their progress and the quality of their lives. It is tragic that many patients never had the opportunity to return to their baseline with the early use of LAIs immediately following their first psychotic episode, instead of relapsing again and again due to their inability to adhere completely to their oral medications.
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: LAIs as the standard of care
LAIs as the standard of care
Thank you, Dr. Nasrallah, for reiterating the importance of compliance with pharmacologic management of schizophrenia after FEP (From the Editor,
As you point out in your editorial, the facts are powerful, well-known, undisputed, and yet not adopted in the United States, when in other countries LAIs are first-line care. Yes, LAIs are expensive, but not nearly as expensive as the disabilities caused by noncompliance are to society.
Why isn’t LAI use the standard of care here in the United States? In the United States, there is advocacy for treatment because there’s money in it. There is no good advocacy for preventive care because there’s no immediate money in it. We have another good example of this in the United States: private, for-profit prisons. They have a vested interest in keeping prisons full and building new ones. Patients with FEP are most often treated in the hospital, where a standard of care could easily be established that mandates LAIs as first-tier care. Why is that not so? Who is pushing for it? Who is resisting?
Your editorial inspired me to advocate more strongly. Do you have advice about how to effect policy change? I know administrators respond when we talk dollars and cents, not quality of care. What is the dollar cost of not using LAIs as the standard of care after FEP? Who cares? Who would listen to the numbers?
Edward A. Major, MD, LFAPA
Clinical Professor of Psychiatry
Upstate Medical Center
Syracuse, New York
Dr. Nasrallah responds
Dr. Major, thanks for your message. Establishing a standard of care for the use of LAIs (or any other therapy) is not that simple. It requires well-coordinated collaboration among several stakeholders (clinicians, researchers, payors, advocacy groups, and a national organization such as the American Psychiatric Association). The cost issue is certainly powerful, but the equation works in favor of LAIs because 1 psychiatric hospitalization due to a psychotic relapse costs up to 3 times the annual cost of an LAI medication that can prevent that rehospitalization. In addition, disability comprises the lion’s share of the large indirect costs of schizophrenia (disability payments, lifetime room and board, incarceration and legal costs, and loss of work and generation of taxes). LAIs can save both lives and expenditures, and a lot of suffering by patients and their families. I, too, long to see the emergence of a rational standard of care for schizophrenia using LAIs right after the initial psychotic episode. Oncology and cardiology have standards of care, so why not psychiatry?
Henry A. Nasrallah, MD
Editor-In-Chief
Continue to: Psychosis and epilepsy
Psychosis and epilepsy
I just read your editorial regarding the devastating consequences of psychotic relapses (From the Editor,
I work in the spheres of psychiatry, epileptology, and whole genome sequencing, and have experienced a psychotic episode myself (in 2013, after temporal lobe resection and overdose). I now consider myself even more lucky to be out the other side! As Governor for South London and Maudsley NHS Foundation Trust (SLaM) and Trustee for Epilepsy Action, many of our patients have psychosis. Some patients with epilepsy even experience postictal psychosis. Just yesterday, we had a call at SLaM regarding patients from a secure unit, and a psychiatric nurse spoke about patients at risk to themselves and others because of their psychotic illness, and how crucial effective long-term care was.
Torie Robinson
CEO, Epilepsy Sparks
Dr. Nasrallah responds
Ms. Robinson, thank you for sharing your story. It is important to note that the neurobiology of the psychosis that may occur with epilepsy may not be as neurodegenerative as the psychosis of schizophrenia. Many neurologic conditions can be associated with psychotic episodes, not only epilepsy. I am glad you overcame your post-temporal lobectomy psychotic episode and have had a very good outcome with high functioning.
Henry A. Nasrallah, MD
Editor-In-Chief
Disclosures
Dr. Chepke is a consultant to and speaker for Janssen Pharmaceuticals, Otsuka Pharmaceuticals, and Alkermes. The other authors report no financial relationships with any companies whose products are mentioned in their letters, or with manufacturers of competing products.
