When We Know the Medication Is There: What LAIs Have Taught Me in Practice | LAI Series, Part 1 of 3

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Hi, and welcome to Unpacking Schizophrenia and Bipolar Disorder with Dr.
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Lori Kumar.
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I'm your host, Dr.
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Lori Kumar.
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Now, today I'm starting a three-part series called LAIs in Real Practice.
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Now, why am I doing an entire three-part series on LAIs, you ask?
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It's because I love them.
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I really do not know how else to say it.
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I'm probably their number one fan.
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They are not the only medications I use in practice, and they're not going to be the right option for every client.
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But I have seen LAIs give so many of my clients opportunities that they may have not had otherwise.
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For some, that means more consistency, but for others, it means not having to think about medication every single day.
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And truly, it gives me and the client more time during the appointment to focus on their symptoms and their functioning, even what their relationships look like and what they want their life to look like.
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LAIs have also given me more options as a provider.
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They have changed the way I think about medication exposure, improvement, and what may be happening when symptoms return.
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And honestly, I still think they are underused in our clinical community.
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There's so much about LAIs that I think it's worth talking about.
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And, yes, worth celebrating, that I did not want to fit all of it into one episode.
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So here we are, we're doing three.
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Let's get started.
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LAI stands for long-acting injectable antipsychotic.
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From here, I'll mostly say LAI or injectable, and I'll use those terms interchangeably.
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For this first episode, I want to talk about what injectables have taught me in my actual clinical practice.
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We usually talk about LAIs in terms of adherence.
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Did the client take their medication or did they not?
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And yes, that absolutely matters.
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But that is not the only thing an injectable can tell us.
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It can change how we look at improvement.
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It can change how we think about how symptoms are coming back.
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And it can even help us figure out whether the medication really failed or whether something else was going on.
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In my experience with LAIs, it started way before I started prescribing them.
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Before I was the provider ordering the injectable, I was the nurse standing in the room giving it to the client.
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When I first started giving these medications inpatient, they felt very new to everyone.
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They were new to me, they were new to some of the providers, and they were definitely new to many of our clients.
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There was also something we had to work against from the very beginning.
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In the inpatient psychiatric setting, an injection may already have a negative meaning for the client.
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They may have received an emergency injection during a time when they were severely agitated or aggressive or disturbing the unit.
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In that situation, the idea of an injection may have been connected with them feeling restrained, feeling forced to calm down, or even with losing control over what was happening with their body.
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We started approaching clients and saying, this injection is different.
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This one is supposed to last for a few weeks and help you feel better.
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And that was really difficult for some of our clients to understand.
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Their previous experience told them that an injection was something that happened during an emergency or as a negative consequence.
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And now here we are saying that an injection could also be part of their regular treatment.
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I still remember one of the first times I had administered an LAI.
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Another nurse and I gave two injections at the same time.
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And I'll tell you, it did not feel good for the client, and it did not feel good for me.
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I was following the lead of a more experienced nurse, but after, I remember thinking that there has to be a better way to do this.
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The medication was ordered correctly.
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Technically, we completed the task correctly, but the experience around the injection was not what I wanted for a client.
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And that stayed with me when I became a provider.
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I've now been on both sides of that process.
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I've been the person talking about the injection during the appointment, and I've also been the nurse standing there with the client while they're waiting for the needle.
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These experiences make it easier for me to prepare the client without making it sound more frightening than it needs to be.
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I also started seeing clients stay out of the hospital longer with these injections.
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They were returning for outpatient care more regularly, and some were having better outcomes than expected.
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So the injectable began to mean something different to me too.
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It was not only another way to give medication, it also gave us information that can be very difficult to get when someone is only taking the tablet at home.
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In community mental health, I see many of my clients about every four weeks or so.
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And for those of you who do not know, a lot can happen in four weeks.
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A client may fall asleep before taking their nighttime pill.
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They may forget the morning dose and think it's too late to take it later.
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Or medication maybe needed to take with food and they don't feel like eating that day.
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They may travel, move, lose the bottle.
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Tons of things can happen.
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Some of my clients are out of sight, out of mind.
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And then there are times when someone can take one dose, feel dizzy, and then never take it again.
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And all those things are understandable.
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They're human.
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But I may not find out about any of those things until they come back a month later.
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So when I ask about a medication, I try not to make it sound like a test.
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I may say something like, We are human.
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We all forget things.
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It's not a big deal.
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Walk me through what it was like taking your medication over the last week or two.
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That usually gives me much more information than you took it every day, right?
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As providers, exploring this uncertainty matters.
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A medication can look ineffective when the person may not have been exposed to it consistently.
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We may need to increase the dose or change the medication, or even start talking about treatment resistance.
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But before we do any of that, we have to ask if the medication was actually taken often enough and for long enough to understand what happened.
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There is another part to all of this as well.
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Sometimes our clients are looking for one specific symptom to disappear.
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And sometimes they miss the other things that are beginning to change and improve.
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I want to share a story about one of my clients who showed me this very clearly.
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She is a woman in her 30s who experienced several hospitalizations and periods of incarceration.
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One of the first things she told me when I met her was every time I get manic, I go to jail.
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And that was very powerful because she knew she did not want those things to keep happening.
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She understood the consequences, but she was having a difficult time preventing them.
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She had seen several providers and had tried several medications and combinations over the years.
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Some of her medications were started in jail, they were changed by the hospital, and many of her medication trials were stopped after short periods of time because of these transitions.
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When I asked her what had worked, she really couldn't tell me.
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And despite that, she was very open to trying another medication.
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To me, her attitude was, I do not want to keep living like this.
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What else is there?
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She was hearing voices that told her that she was not good enough, that there was no reason to live, and that she should kill herself.
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Thankfully, she did not feel suicidal within herself, but by hearing those things repeatedly, she was having some difficulty knowing where the voices ended and where her own feelings began.
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She also felt very paranoid and had a lot of trouble trusting others.
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Some of that distrust may have been connected with the psychosis, but it's also likely was reinforced by experiences during her repeated hospitalizations and her jail stays.
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And that's why we have to look at the full picture rather than deciding that every symptom comes from one place.
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She was barely leaving the house.
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She was having difficulty with her hygiene, with having an appetite, staying hydrated, difficulty with focus, concentration.
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She was not working.
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Luckily, she did live with her family, but she did not have many responsibilities outside of taking care of herself and staying out of trouble.
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So we started a new medication.
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At our next appointment, she told me the medication was not doing anything.
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The voices are still there.
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And every time I asked about the medication, her answer was always, I still have voices.
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I'm not doing well.
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And that was the marker she was using.
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When I looked at her, she seemed different.
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She was making more eye contact, she was able to focus on the conversation a little bit better.
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She even looked cleaner and a little bit more put together.
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She just seemed lighter.
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Not dramatically better, but there was a little bit of a difference.
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During our first appointment, I had asked her whether she had any responsibility that she could take over.
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I'd often do ask my clients if they have responsibilities like children, pets, something that can get them out and about, feel useful, have a purpose.
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She had mentioned that her family owned a dog.
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At this follow-up visit, I asked whether she had done anything outside of the house.
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She had said she had taken the dog out, but it was only because her family was away and she had no other choice but to do it.
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I wanted to explore this with her, so I asked her to walk me through what happened.
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She said that she put the dog on the leash, they went outside.
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Simple, nothing new, right?
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Then I asked her, had she just let the dog use the restroom and then come back in?
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And she said no.
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I actually walked in for a little bit.
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And as we kept talking, she said that she had gone to the dog park.
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She had stayed there, she let the dog run around a little bit before coming home.
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And I asked her if this is something that she normally would have done.
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She was like, yeah, I probably would have let the dog out, let him sniff, but I probably would have come back home right away.
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I asked her if she still felt like she had to push herself to go to the dog park.
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She said no.
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Then I asked her if she felt like she had to push herself to leave the house initially, and she said yes.
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Then I asked, was it as hard as it normally would have been?
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She thought about it for a moment and said, no, it wasn't.
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When I pointed that out, she had a realization.
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Almost like, oh my gosh, something happened.
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I told clients that improvement does not always feel easier right away.
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Sometimes it just has to feel different.
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She was still hearing voices that still remained important, and we are continuing to work towards improving that.
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But psychotic disorders are not only voices.
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There are also difficulties with attention, with self-care, feeling connected with others, wanting to leave the house, and the ability to complete something that feels impossible.
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She was also beginning to smile when she talked about her family and the way that they looked out for her.
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That connection was easier to see than it had been during the first appointment.
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That dog walk did not prove that the medication was the only reason for the change, but it did give us something else to follow besides the one symptom.
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And because she had only been on the medication for a very short period of time and was not experiencing major side effects, it gave us a reason to continue and see where this went.
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Now, all of this is still during a trial of a tablet, so I was trying to figure out two questions.
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One, was the medication beginning to help?
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And two, was she taking it consistently enough for us to know?
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And I'm hoping there's an injection in the future.
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One of those questions will become much smaller.
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Once the injection is documented, I can confirm when it was given, the dose, and the date.
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That still does not prove that the client has the same medication exposure every moment.
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Some people metabolize medications differently.
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There can be interactions, timing issues, missed injections, and differences in how the medication is absorbed and released.
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But I do know the medication was given, and that changes the beginning of my visit.
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I have a client, a man in his 40s, who initially did very well on the tablet form of the medication.
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He was taking it consistently, his symptoms improved over several months, and we continued.
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Then, one day, he called the nurse.
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He said he started forgetting to take his medication at night.
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And once he missed it a few times, he just started forgetting more and more.
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He was interested in the LAI that we had talked about previously in our appointments, and he wanted to know if this was something that was available to him.
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He was so excited about this, and that's something I didn't expect to see in my career.
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Some clients look at me as though I could not possibly be serious when I mention injection.
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And others, they hear the word injection and they say yes before I even finish my sentence.
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After this phone call, the client moved on to the injectable, and he really liked knowing that he had completed that part of his treatment every month.
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He would organize his appointments around the clinic.
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He might see me, come again for his injection, meet a different time with his case manager, and he gave him things to do during the month, and it gave us the opportunity to see him several times within the treatment team.
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Sometimes the client tells the nurse something that did not come up during my appointment.
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And sometimes the case manager, they notice something about the client withdrawing or not caring as much about themselves.
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The additional contact can help us build a better picture over time for the client.
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When the injectable is going well, the client comes in, receives it, and they don't have to repeat that decision every single day about the medication.
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That can change their confidence.
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And it changes my attention too.
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With the tablet, my first question is often, how are you taking it?
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But with the LAI, I can look at the administration record, confirm, and move on.
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Now we get to spend all of that time talking about their symptoms, quality of life, their work, their sleep, and other ways that the client would like to improve their overall quality of life.
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So for me, this is where the injectable becomes more than just the adherence tool.
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But it is also important not to become too confident just because the injection was given.
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A client can still become unwell.
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And when that happens, we have to decide what the injection is doing and what it is not doing.
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So this is where it gets difficult.
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I had a client who had been stable on the same medication for years.
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For work, she drove one of those very large buses, and she was doing very well, working consistently, and she was one of my strongest advocates for the injection.
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Then her sister died, and her sister's two children came to live with her.
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This transition was very difficult.
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One child was damaging the things in her house, and the other was staying out late and getting into trouble.
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And my client was grieving too.
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She was working full time, trying to parent them, and eventually had to take a second job because money became tight.
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And at first, during our meetings, she kept saying, I'm stressed out, Dr.
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Kumar.
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But I got this, I can handle it.
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She was not reporting voices or any clear psychiatric symptoms.
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But she was sleeping less, and you could see the stress was staying with her.
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We talked about changing the medication or the dose, but she did not want to.
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That dose had worked for her for years.
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She trusted it.
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Eventually, she was hospitalized with psychosis.
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When she came back into my office, she felt like the injectable had let her down.
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And honestly, I understood why.
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She had received it consistently and still ended up in the hospital.
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But the medication was not the only thing that had changed.
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Her entire life had changed.
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Eventually, the children went to live with another family member.
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She was able to take ownership of her home again, rebuild her routine, and return back to baseline.
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She also continued benefiting from that same injection.
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If we had immediately called the medication a failure and abandoned something that had worked for years, we may have lost a good option.
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Now, sometimes the medication is the problem, but one hospitalization does not automatically give me that answer.
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I still want to know what changed with sleep, stress, was there any substances involved, relationship troubles, or the client's environment?
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That is also why I use the word relapse very carefully.
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The next episode may not look exactly like the last one because the client and their life are not exactly the same.
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There's another part to this.
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An injectable cannot make the wrong medication the right medication.
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Before I move someone from the tablet to the injectable, I want to know that the medication itself is helping and that the client can tolerate it.
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We do not need perfection, but I do want enough experience to know that we are moving in the right direction and that the client is not having major problems with side effects, including sedation, restlessness, tremor, or involuntary movements.
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I usually explain it to them this way.
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I am so happy you are interested in the LAI.
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But we first need to make sure that you respond well to the medication and that it fits your needs before starting a longer acting version.
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Once we administer the injection, we cannot simply remove it the next morning.
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We have to monitor what happens next.
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That is why follow-ups matter, especially when the LAI is started in the hospital.
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The outpatient team needs to know when it was given, what was given, when the next dose is due, and where the client will actually receive it.
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And even after all of that, an LAI can still not solve every adherent's problem.
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Some people still miss their injection appointments.
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It could be because of transportation or work, or maybe they no longer feel like they need the medication anymore.
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If that keeps happening, I do have to ask my clients whether this medication plan actually fits their lifestyle.
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Sometimes a tablet is more accessible if the client is not coming to the clinic to receive their injection.
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So after all of this, there are really three things that I want to leave us with.
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The first is that we have to be careful about saying that a medication failed when we are not sure how consistently it was taken.
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It is not about blaming the client, it is more so about making sure our interpretation includes what actually happened with the medication.
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The next thing is that even when we know the medication was given, we still have to look at the whole person and what changed around them.
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The medication may need to change, but I do not want us to move so quickly that we miss the person while we are looking at the medication.
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And the last thing is probably the simplest.
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The medication itself still has to be right.
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The injectable changes how it is delivered, but it does not fix or change the medication if it's not already helping or if the client cannot tolerate it.
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LAIs have not made psychiatric treatment simple.
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I do not think any medication can do that.
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But the LAI has made one part of the picture clearer.
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And sometimes that is enough to change what I ask next.
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The companion newsletter takes these same ideas and puts them into a more structured clinical framework.
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And in part two of the series, we're going to move into the actual LAI conversation, what clients may be responding to when they hesitate, what we may be communicating without realizing it, and how we can explain the option without making someone feel pushed.
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I'm Dr.
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Lori Kumar, and this is Unpacking Schizophrenia and Bipolar Disorder.
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Thank you for spending time with me.