Stabilizing Treatment
“While we recognize that there are some patients for whom it is clinically prudent to switch to an oral medication, there are others for whom that change would be deeply destabilizing,” the APA statement said. “Individuals with serious mental illness are at much higher risk of morbidity and mortality even when provided continuous, stabilizing treatment; withdrawal of this treatment would likely increase their risk of physical and psychiatric decompensation.”
Maintaining an effective treatment and established course of therapy during uncertain times is particularly important. The pandemic has knocked out critical support structures for many veterans, who may not be able to see family members, access group sessions, or meet with therapists in person. They may be experiencing multiple disruptions in previously finely tuned schedules that kept them feeling grounded and safe. For some, keeping their pharmacotherapy consistent may be essential.
The VA endorses that patient-centric approach to care for veterans with schizophrenia. The patient handout, “Managing Schizophrenia During the Coronavirus Pandemic: Maintaining Your Recovery,” tells veterans that “[l]iving with schizophrenia or related conditions, like schizoaffective disorder, requires being a full and active participant in your own treatment. That’s especially true during the COVID-19 pandemic, which can bring about some new challenges in managing your recovery.”
The APA also noted that LAI may reduce the risk of COVID-19 for some patients. “For many with severe and chronic mental illness, the use of these long-acting formulations can reduce personal suffering and distress, especially in a pandemic; for others, it has also reduced disorganized or impulsive behaviors that put them at risk of physical injury, aggression, utilization of emergency rooms or incarceration. LAI can also help ensure adequate level of functioning and cognitive processing which would enable these patients to practice social distancing in a pandemic.”
LAI are available in a number of formulations providing coverage from two weeks to three months. Facilities looking to reduce the number of visits veterans with severe mental illness need to make could safely consider switching to options that use the same medication but provide extended coverage or increasing time between injections, according to the APA and the Substance Abuse and Mental Health Services Administration. Switches of this type might include shifting veterans using Invega Sustenna to Trinza or migrating those on receiving Aristada injections monthly to a six weeks or bi-monthly schedule.
For some veterans, the right decision during the pandemic might still be to switch to daily oral medications, despite concerns about adherence, if the risk of contracting COVID-19 is too great or the thought of coming in for an injection is too distressing for the patient, said. Andrew J. Saxon, MD, director of the Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, and professor in the department of psychiatry and behavioral health at the University of Washington School of Medicine, both in Seattle,
“It comes down to a specific decision about each patient,” Saxon told U.S. Medicine. “What are the risks of COVID transmission if the patient comes to the clinic versus what are the risks of relapsing and getting into serious problems if they don’t come to the clinic and get an injection?”
- Keepers G, Fochtmann LJ, Anzia JM, Benjamin S, et. Al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. Published Online:1 Sep 2020. The American Journal of Psychiatry, Vol. 177, Issue 9. Pages 868-872. https://doi.org/10.1176/appi.ajp.2020.177901