For some people, a pill is just a pill.
For Tyler, a 26-year-old Silicon Valley resident, medication helps him maintain his livelihood. “I’m at a job where I do a lot of customer service,” he says, asking to withhold his last name to protect his privacy. “I need to be up and happy.”
Tyler was diagnosed three years ago with bipolar disorder, a mental illness that causes extreme mood swings marked by emotional highs (mania) and lows (depression). To help manage his bipolar depression, he was prescribed a daily antipsychotic pill. But if he missed a pill, he sometimes experienced mood swings and fell behind at work.
His psychiatrist knew of an alternative, and suggested that Tyler try taking the medication as an injection that could last for a month. Some studies have shown that these injections, known as long-acting injectable antipsychotics, can improve medication adherence and reduce relapse and hospitalizations. He referred Tyler to San Jose’s Garcia Pharmacy, which runs a clinic where patients can receive injectable antipsychotics to treat conditions including bipolar disorder, schizophrenia and schizoaffective disorder. Depending on the drug, the injections can last from two weeks to three months.
Tyler is glad he made the switch. “I feel more even-keeled and steady,” he says.
California is one of 39 states that allow pharmacists to provide injections beyond immunizations, according to the National Community Pharmacists Association. A dearth of data makes it unclear how many community pharmacies throughout the state offer long-acting injectable antipsychotics. Yet Kelly Lee, a board-certified psychiatric pharmacist and associate dean of the UC San Diego’s pharmacy school, says that from what she’s seen, it’s uncommon for community pharmacists in California to provide such injections. One potential barrier, she believes, is that they may not feel comfortable treating patients with mental illness.
Santa Clara County offers long-acting injectable antipsychotics at nine pharmacies and clinics. The county doesn’t charge co-pays for the injections, which it has offered since 2004. About 300 Medi-Cal patients currently receive the treatment, according to county spokeswoman Laurel Anderson.
Tropicana opened in 1970 as a retail pharmacy in San Jose. But during the ’80s and ’90s, large chain pharmacies cut the number of independent counterparts—often pharmacist-owned small businesses—in the U.S. by half. Tropicana survived by shifting from serving retail consumers exclusively to also serving long-term care centers, such as nursing homes and residential facilities for people with severe mental illness.
Ten years ago, when long-acting injectable antipsychotics came on the market, a couple of local private psychiatrists wanted their patients to try it. To avoid the overhead costs of buying and administering the drugs themselves, they asked Tropicana to provide the injections instead, says James Wong, Tropicana’s owner. Tropicana agreed, making it one of the first privately-held pharmacies in California to offer the treatment.
Seeing an opportunity to also add this as a service for its residential facility clients, the pharmacy turned part of its space into a long-acting injectable antipsychotic clinic. In 2016, when Tropicana’s retail pharmacy closed, Wong bought Garcia Pharmacy, shifted the clinic there, and then merged it with Tropicana’s long-term care unit into a single business entity.
The clinic, which operates at Garcia Pharmacy from 10am to 5pm every Wednesday, serves about 100 to 120 patients referred there by psychiatrists and residential facilities. Most of them are covered by Medi-Cal and aren’t charged co-pays. Others are covered by Cal MediConnect—California’s program for patients on both Medi-Cal and Medicare—or by private insurance.
Lapsing on antipsychotic meds isn’t just an individual health problem; it can also create considerable public expense. An estimated 40 percent to 90 percent of people with schizophrenia—one of Medi-Cal’s most expensive conditions to treat—don’t take their oral antipsychotic medications, an oversight that studies show can lead to relapse and hospitalization. Additionally, some research has shown that non-adherence to antipsychotic medications is linked with homelessness and unemployment.
Research suggests that enhancing access to long-acting injectable antipsychotics may ultimately benefit taxpayers and others who pay for health care of patients with mental illness. Anderson says that Medi-Cal patients on long-acting injections have lower rates of emergency hospitalizations.
Injectable antipsychotics aren’t without controversy, however. Critics argue that they prevent patients from exercising their free will to reduce or stop their medication, especially when the injections are court-ordered. Concerns also exist that establishing separate injection sites could fragment care by adding another party for doctors and other caregivers to communicate with.
Hien Hoang, a registered nurse at Tropicana, said the pharmacy takes measures to help coordinate care. After each injection, Tropicana faxes the patient’s doctor to confirm the injection and includes any information the patient shares, such as side effects they’re experiencing, before storing this information in a database.
Several studies have estimated that about 10 percent of people with schizophrenia in the U.S. are prescribed long-acting injectable antipsychotics. But the rate is up to three times higher in countries such as the U.K. Some researchers think physician practices account for the difference. U.S. psychiatrists tend to prescribe long-acting injections as a last resort for patients who’ve repeatedly relapsed because they didn’t take their oral meds. But in some European countries, doctors tend to prescribe shots as a first-line treatment.
Patient preferences also affect whether someone is prescribed this treatment, according to Dr. Victor Chen, a psychiatrist who started practicing at Valley Health Center in Gilroy in 2014 and left last month to pursue an out-of-state opportunity.
“My sense is that the majority of county doctors believe in the injectables, but a lot of us have trouble convincing patients,” he says, noting that he can only venture a guess.
Patients’ reasons for refusing injections, Chen says, range from the physical pain and stigma of injections to paranoia. He cautions that the injections aren’t appropriate for everyone. Some patients need to take particular antipsychotics that don’t have injectable versions, and patients who have good results with oral antipsychotics often don’t need to switch to an injectable. According to the county, most Medi-Cal patients on long-acting injections have schizophrenia or schizoaffective disorder, tend to be between 35 and 45 years old and are three times more likely to be male than female.
Chen says the most vulnerable populations such as the homeless and formerly incarcerated are among the most likely to struggle with adherence and thus, in his view, could benefit from long-lasting injections the most. But in his experience, they’re often the least likely to try this treatment. He reports greater success getting patients with stronger support networks to try the injections. “If the patient is younger and living at home,” he explains, “I can work with the parents to convince the patient.”