Clinical Summary: Utilization of Long-Acting Injectable Antipsychotics and Clozapine in Coordinated Specialty Care: Data From EPINET
Many patients in early phase schizophrenia still relapse and are hospitalized despite coordinated specialty care, and 2 evidence-based medication strategies that can reduce this risk—long-acting injectable antipsychotics and clozapine—are often hard to implement in routine clinics. For psychiatrists treating first-episode psychosis, the key issue is not just whether these treatments work, but whether patients are actually getting them consistently across programs.
Key Findings
- Of the 5,324 participants, 1,261 (23.7%) received an LAI at any point in their treatment, while 297 (5.6%) received clozapine.
- Across the 8 EPINET hubs, the proportion of patients receiving LAIs ranged from 5.0% to 37.5%, and clozapine ranged from 1.7% to 9.0%, showing marked between-program variation.
- Across all 113 clinics, the proportions receiving LAIs ranged from 0.024 to 0.60 and clozapine ranged from 0.005 to 0.33.
- Males had higher rates than females for both LAIs (logOdds=1.11, SE=0.099, P<.00001) and clozapine (logOdds=0.83, SE=0.17, P<.00001).
- African Americans had higher rates than Whites on LAIs (logOdds=0.47, SE=0.079, P<.000001), while clozapine differences were nonsignificant (logOdds=−0.29, SE=0.16, P=.067).
In coordinated specialty care for early phase schizophrenia and related disorders, both long-acting injectable antipsychotics and clozapine are used inconsistently, with striking clinic-level variation that is not explained away by sex, ethnicity, or race. Programs should treat low use of these evidence-based options as an implementation problem, not simply a patient-mix issue.
Practice Implications
- Review your clinic’s own rates of LAI and clozapine prescribing against the EPINET ranges of 5.0% to 37.5% for LAIs and 1.7% to 9.0% for clozapine across hubs, and 0.024 to 0.60 for LAIs and 0.005 to 0.33 for clozapine across clinics.
- Use an LAI trial when adherence is uncertain before labeling persistent psychosis as treatment resistant, consistent with the article’s discussion that LAIs provide a conclusive assessment of medication adherence.
- If clozapine prescribing is rare in your setting, examine workflow barriers the article identifies, including mandatory hematological monitoring, intensive side-effect management, clinic resources, and prescriber expertise.
- Audit whether prescribing discussions are occurring equitably across patient groups, since males were more likely to receive both LAIs and clozapine and African Americans were more likely than Whites to receive LAIs.
