When people living with schizophrenia might switch to long-acting injectables

For many living with schizophrenia, remembering a daily pill can be a barrier to long-term treatment success. In a recent U.S. Medicare sample, only one-third of patients consistently adhered to their oral antipsychotic regimen and nearly 80% discontinued treatment over time. That’s why long-acting injectables (LAIs) are an important tool in our field.

Partnering with a patient to switch from a daily oral medication to an LAI is a nuanced decision-making process. It takes careful consideration with the individual of their needs, goals and circumstances. It also means thoughtful discussion about potential benefits and risks to ensure they feel confident about the change.

Primary care providers (PCPs) are increasingly finding themselves on the front lines of mental health care. Even if behavioral health isn’t specifically offered through their practice, the reality is that many patients bring mental health questions to their primary care visits. Complicated by the ongoing shortage of psychiatry providers, PCPs can become the ones helping patients take those first steps toward treatment, and they may encounter patients who could benefit from LAIs.

Here are key factors I keep in mind when working with patients to determine together whether an LAI is the right fit.

1. Convenience

To me, the biggest advantage of an LAI is convenience. Research suggests that up to 60% of individuals with schizophrenia demonstrate some level of nonadherence to oral antipsychotics. With an LAI, consistency for that medication shifts to, as an example of a dosing schedule, one scheduled clinic visit each month instead of 30 daily choices. Many LAIs are available in different dosing intervals, such as weekly, monthly or every few months, so there are options to assess during decision-making.

In my experience, LAI medications are generally available and covered. While this will vary by state, insurance plan, formulary design or prior authorization requirements, I do find that my patients who prefer an LAI are able to receive one.

2. Side effect profile

Oral medications can be associated with gastrointestinal side effects like nausea, vomiting or diarrhea. Because LAIs bypass the stomach, patients may experience fewer of these issues. Some also report less sedation or fatigue compared with oral formulations. In another U.S. Medicare analysis of more than 150,000 patients, LAIs were associated with significantly lower risks of antipsychotic discontinuation, psychiatric hospitalization and treatment failure compared with oral antipsychotics. While side effects aren’t eliminated entirely, and may differ in type or scope compared with oral medications, the different pharmacokinetics of LAIs can make them more tolerable for patients.

3. Transportation

A patient may be open to trying an LAI at any course in their treatment experience, but if they can’t reliably get to the clinic for monthly or bimonthly injections, the plan won’t succeed. For that reason, access and logistics are always part of the conversation. Variable dosing schedules across types of LAIs, with approved formulations covering ranges from as short as every two weeks to up to every six months, need to be a part of the conversation relative to visit frequency, as well as efficacy over the dosing interval, which can impact stability between visits. For example, aripiprazole lauroxil has been shown in clinical research to deliver therapeutic levels of medication consistently throughout the full dosing interval.

4. Lifestyle factors

To distinguish conversations about convenience, referring mainly to the act of taking a daily pill, I try to learn from patients about the lifestyle factors that capture the rhythm of their day-to-day life. For patients who want to minimize tasks that disrupt their routines, an LAI can offer structure and reliability, ensuring consistent therapeutic coverage even when life is unpredictable. Taking lifestyle into account helps determine whether the built-in consistency of an LAI will reduce stress and better align with a patient’s natural routine.

5. Family and care partner involvement

For care partners and loved ones involved in day-to-day treatment management, the logistics associated with monitoring and ensuring daily medication adherence can become a source of tension. That dynamic can strain relationships and place an emotional burden on everyone involved. Introducing LAIs can reduce conflict and allow families and care partners to spend more energy on encouragement and other forms of support rather than medication enforcement.

6. Reducing self-imposed stigma

Many patients describe taking a pill every day as a daily reminder of their illness. This can reinforce feelings of stigma or self-consciousness. For some, switching to an injection lessens that burden. Instead, they can focus on their lives between visits. I’ve heard from patients that this shift alone helps them feel less defined by their schizophrenia diagnosis.

7. Increasing insight into the illness

Schizophrenia is often described as a “low-insight” disease, and in my clinical experience that’s true. Many patients may not initially believe they are ill or don’t connect their symptoms to a need for medication. But when patients remain on medication long enough to experience improvement, they often report changed understanding of their condition. LAIs create an opportunity for patients to feel well more consistently, providing them an important window to see the connection between adherence and self-perceived well-being, which in turn motivates continued treatment.

8. Provider touchpoints

LAIs inherently build in structured provider contact around a set administration date, and I value those regular check-ins. Even when the injection itself takes just minutes, the scheduled visit creates consistent opportunities to observe a person’s appearance, mood and functioning, which can all be indicative of how well their symptoms are currently managed, and to check in on ongoing or needed counseling or social support. By contrast, patients taking oral medications may go months between appointments unless they proactively reach out or experience a crisis, increasing the risk of unnoticed symptom emergence or other stressors.

Between injections, additional touchpoints may occur based on clinical need. For newly switched patients, best practice often includes one or more check-ins during the first dosing cycle to reinforce education, monitor response and address any logistical barriers.

Moving forward with LAIs

Switching to an LAI is a holistic decision. Factoring in the aforementioned considerations helps make the transition to LAIs successful for appropriate patients.

I’ve seen how this approach can contribute to a person’s sense of stability, strengthen the patient-provider relationship and empower patients to focus on goals beyond their diagnosis. In real-world U.S. Medicare data, LAIs were associated with a 26% to 45% lower risk of treatment failure compared with oral antipsychotics, reinforcing the value of this approach in sustaining long-term recovery.
While no one treatment is right for everyone, I encourage my colleagues to consider LAIs early in treatment conversations and more often across their practices, elevating these medications as a standard of schizophrenia care rather than a down-the-line intervention. Switching ideal candidates to LAIs will create more opportunities for our patients to live fuller, healthier lives.

Additionally, the decision to initiate an LAI or start any treatment plan should never be viewed as final. It should sit within an ongoing dialogue between patient and provider. Regular conversations allow for continual assessment of efficacy, tolerability, lifestyle fit and personal preferences.

As our field continues to evolve, the potential for improving outcomes, grounded in consistent, appropriate medication choices and adherence, only grows. Our responsibility is to ensure patients understand those options and feel supported in choosing the path that best fits their lives.

Melissa Malinoski, PA, is a fully licensed and certified physician assistant specializing in mental health and addiction medicine at multiple outpatient sites across west Michigan through Samaritas, a large nonprofit organization headquartered in Detroit. She has 10 years of full-time clinical experience treating children, adolescents and adults, with particular expertise in bipolar disorder and substance use disorders. Melissa has a strong passion for teaching and has precepted PA students from Chatham University during their clinical psychiatry rotation for the past six years, earning “Psychiatry Preceptor of the Year” honors in both 2022 and 2023.