As the psychiatric provider for an Assertive Community Treatment (ACT) team,I don’t have the luxury of practicing textbook psychiatry. I work with clients whose lives are often unstable, complex, and unpredictable. In that reality, long-acting injectables (LAIs) like Invega Sustenna, Trinza, Hafyera, Aristada, Abilify Maintena, Asimtufii, Uzedy, Haldol Decanoate, and Prolixin Decanoate aren’t just convenient—they’re essential tools for survival.
Yet despite their clinical value, I continue to face persistent and frustrating barriers—not from the medicine itself, but from the system around it.
Take Invega Sustenna, marketed as a once-monthly injection. For some clients, especially those with Schizoaffective Disorder, that 28-day window is too long. By day 21, I see early signs of deterioration: increased paranoia,agitation, or subtle withdrawal. I adjust the schedule to every three weeks, and it works. But insurance? They won’t cover early administration—because the calendar says it’s not time yet. This turns every proactive clinical decision into a battle with bureaucracy.
Then there's my client on Invega Trinza, the every-three-month option. He doesn’t make it to the full 90 days. I bridge the gap with a Sustenna injection midway, and it keeps him out of the hospital. But insurance refuses to cover both formulations at once—even though this combination is the only thing that’s worked. So I rely on samples, not science, to do my job.
And now we have Hafyera, the newest ultra-long-acting paliperidone injection—marketed as a twice-yearly solution. In theory, it’s a leap forward. But in practice? What if symptoms return in month four or five? What if a client needs a supplemental Sustenna or Trinza injection to maintain coverage until their next Hafyera dose? The answer is always the same: insurance won’t authorize it, because the package insert says six months. Not every client fits that mold. And yet again, I’m left to patch the system with samples and workarounds, not support.
Long-acting injectables (LAIs) have transformed the psychiatric landscape, offering sustained medication delivery for conditions such as schizophrenia,schizoaffective disorder, and bipolar disorder. These formulations dramatically improve medication adherence, reduce relapse rates, and lower hospitalizations.In Assertive Community Treatment (ACT) settings, where client engagement is often unpredictable and adherence is inconsistent, LAIs provide a vital stabilizing force. Yet, despite their clear benefits, LAIs remain under utilized due to a confluence of patient, provider, systemic, and insurance-related barriers.
Barriers to LAI use are multifaceted and deeply entrenched in various domains of psychiatric care:
1. Patient-Level Barriers: Clients often hesitate to consider LAIs due to stigma, needle phobia, and lack of understanding. The association of LAIs with "chronic" or "treatment-resistant"cases can make clients feel as though accepting an injection is an admission of failure or severity (Shrivastava et al., 2012). Additionally, cultural narratives about autonomy and control can fuel fears that LAIs are about compliance rather than collaboration.
2. Provider-Level Barriers: Many clinicians hesitate to initiate LAIs unless clients fail oral regimens, delaying access towhat may be a superior treatment modality (Brissos et al., 2014). Others maylack training or confidence in discussing LAIs effectively or navigating the necessary documentation and authorization requirements. Some providers may perceive LAIs as "last-line" interventions, reinforcing the idea that they should only be introduced after multiple relapses.
Communication challenges also persist between outpatient and inpatient settings. Frequently, I reach out to inpatient teams during client hospitalizations to provide vital background on medication history, prior responses, and adherence issues—to often to receive no reply. This communication gap represents a missed opportunity to initiate or continue LAIsat discharge, when clients are often most receptive to treatment changes. Without this bridge, clients may return to the community on ineffective regimens or be started on oral medications despite past failures.
I know from direct experience that if we can start an LAI in the hospital and maintain it in the community, I have a significantly better chance of keeping that client stable. It’s not a guarantee, but it shifts the odds dramatically in our favor. Discharge without one often leads to a revolving door of nonadherence, relapse, and readmission—something we work tirelessly to break.
Some of the reasons for non-compliance are entirely practical. Though we do medication monitoring during the day, we don’t provide it at night, which is when many of our clients return home—often to unstable environments. Several of the oral antipsychotics we use are extremely sedating, making daytime dosing impractical. If a client is unable to take their medication at night due to environmental chaos or personal safety concerns, adherence falls apart quickly. This is why LAIs matter—they remove the guesswork and give us a reliable foundation to build from.
3. Systemic and Logistical Barriers: Infrastructure limitations—including refrigeration needs, medication storage,documentation burdens, and staffing requirements—make LAI implementation more difficult in under-resourced settings. A systematic review highlighted how administrative hurdles and inadequate care coordination contribute significantly to underuse (Stovall et al., 2024). COVID-19 further exposed system weaknesses, with a third of clients reporting disruptions to their LAI regimens during the pandemic (Stroup et al., 2022).
4. Insurance and Policy Barriers: Perhaps the most significant barrier is the inflexible insurance infrastructure that prioritizes cost control over clinical nuance. For example, Invega Sustenna is labeled for monthly use, yet clients with schizoaffective disorder often deteriorate by day 21. Adjusting to a 3-week interval prevents decompensation,but insurers routinely deny early dosing. Similarly, clients on Invega Trinza who require supplemental Sustenna doses by the second month are left vulnerable when overlapping medications are denied. Hafyera, marketed as a six-month option, lacks built-in safety nets for earlier symptom recurrence, and insurance policies fail to accommodate such variability.
Even older LAIs such as Risperdal Consta, which require a three-week or al overlap and are dosed biweekly, face resistance from payers. Newer formulations like Uzedy and Asimtufii, while promising in design, still encounter prior authorization hurdles and formulary delays. The use of rapid-initiation agents like Aristada Initio is frequently denied, undermining efforts to quickly stabilize high-risk clients.
Across formulations, the message from payers is consistent: dose by calendar, not by symptom. Yet serious mental illness does not follow fixed cycles.
Adding to these challenges, some LAI manufacturers restrict provider access to the full range of samples—particularly in terms of dose and formulation. This creates a major barrier in real-world settings, where flexibility is key. In ACT, we often have only a brief window to offer an LAI before a client changes their mind. If I don’t have the medication in-hand at the moment of engagement, I may lose the opportunity entirely. This is why having the full range of treatments and doses available is critical.
One client comes to mind who had been prescribed oral Invega but was notoriously difficult to engage in the community. Every time I saw him, I brought a sample of Sustenna and revisited the conversation about stability,independence, and long-term benefits. Eventually—after many attempts—he agreed. Because I had the sample with me, I administered it immediately. That was a year ago. He has continued to take it monthly with no hospitalizations, nolegal issues, and consistent community functioning. This is exactly the kind of success story that hinges on access and timing—not just intent.
But in ACT work, we can’t afford that rigidity. My clients aren’t “every 28 days” people. They’re real people with real variability—metabolic differences,complex trauma, substance use, medication sensitivity, and erratic access to care. When a medication starts to wear off early, I see it first—not the insurance company. I shouldn't need to prove relapse in order to prevent it. Providers see early symptom return, declining insight, and renewed psychosis well before a scheduled injection date—but must often wait for a full relapse to justify intervention.
Solving the underutilization of LAIs requires more than access—it demands targeted, evidence-based strategies to increase both provider comfort and client acceptance.
1. Motivational Interviewing (MI): MI is a powerful tool to explore ambivalence and build trust. A single MIsession combined with psychoeducation doubled LAI acceptance rates and reduced hospitalizations over an 18-month period (Bröms et al., 2020). In ACT, we integrate MI into nearly every visit—validating the client’s fears while reframing LAIs as empowerment rather than control. We value motivational interviewing deeply on our ACT team—not just as a clinical tool, but as a philosophy. Our documentation templates allow us to explicitly identify MI as a selected intervention, ensuring that the practice is intentional, not incidental.
We also spend a considerable amount of time refining this skill. As part of Chesapeake Integrated Behavioral Healthcare (CIBH), we are fortunate to have institutional support for ongoing professional development. CIBH invests financially in training to ensure we are delivering care that is both evidence-based and person-centered. Most recently, we completed required training on Collaborative Documentation in Behavioral Health, which reinforces the principles of transparency, shared language, and client empowerment—core values that overlap significantly with MI. These investments translate directly into better client outcomes and stronger therapeutic alliances. In ACT, weintegrate MI into nearly every visit—validating the client’s fears while reframing LAIs as empowerment rather than control.
2. Shared Decision-Making (SDM): Clients are more likely to commit to a treatment they helped shape. SDM builds therapeutic alliance, improves satisfaction, and leads to greater treatment adherence (Rosen et al., 2024). In practice, this means presenting LAIs early and honestly—without waiting for failure on orals.
3. Family Engagement: Educating and involving families reduces resistance and stigma. Clients supported by informed family members are more likely to initiate and maintain LAI therapy (Rosen et al., 2024).
4. Clinician Training and Audit Feedback: When providers understand the evidence, know the formulations, and feel supported by their systems, LAI prescribing improves. Structured education,coupled with review of prescribing trends, enhances adherence to best practices(Gray, 2011; Rosen et al., 2024).
5. Customized Adherence Approaches: Combining LAIs with interventions like Customized Adherence Enhancement (CAE)has shown success in improving outcomes for bipolar disorder and other complex conditions (Levin et al., 2021). These strategies can be tailored and scaled in community mental health settings.
6. Financial Incentives: Though controversial, modest financial incentives improved LAI adherence in randomized trials (Priebe et al., 2013). Incentivizing stability—rather than crisis—deserves consideration in future care models.
The clinical utility of LAIs is not in question. What is in question is why so many clients cannot access them the way they need to. To fix this, we must push for:
At South Chesapeake Psychiatry, we treat people, not timelines. LAIs are notjust medications—they’re often the bridge between crisis and stability. But for too many clients, systemic rigidity stands in the way. We must demand a shiftin how LAIs are authorized, supported, and implemented. Because textbook psychiatry doesn’t work in the field—and my clients can’t afford to wait for relapse just to justify care.
Brissos, S., Veguilla, M. R., Taylor, D., & Balanza-Martinez, V. (2014).The role of long-acting injectable antipsychotics in schizophrenia: A critical appraisal. Therapeutic Advances in Psychopharmacology, 4(5), 198–219.https://doi.org/10.1177/2045125314540291
Bröms, G., Cahling, L., Berntsson, A., & Öhrmalm, L. (2020).Psychoeducation and motivational interviewing to reduce relapses and increase patients’ involvement in antipsychotic treatment: Interventional study. BJ Psych Bulletin, 1–4. https://doi.org/10.1192/bjb.2020.28
Correll, C. U., Citrome, L., Haddad, P. M., Lauriello, J., Olfson, M.,Calloway, S. M., & Kane, J. M. (2016). The use of long-acting injectable antipsychotics in schizophrenia: Evaluating the evidence. Journal of Clinical Psychiatry, 77(Suppl3), 1–24. https://doi.org/10.4088/JCP.15032su1
Gray, R. (2011). Applying motivational interviewing techniques to the initiation of long-acting injectable antipsychotics. Journal of Psychiatric and Mental Health Nursing, 18(2),150–155. https://doi.org/10.1111/j.1365-2850.2010.01645.x
Gupta, S., Duxbury, J., Ward, T., & Jones, J. (2020). Motivational interviewing and psychoeducation for improving attitudes toward LAI antipsychotics: A randomized trial. Schizophrenia Research,222, 405–412.https://doi.org/10.1016/j.schres.2020.05.008
Levin, J. B., Krivenko, A., Sax, K. W., et al. (2021). Long-acting injectable antipsychotic medication plus customized adherence enhancement for patients with bipolar disorder and poor medication adherence. The Primary Care Companion for CNS Disorders, 23(5).https://doi.org/10.4088/PCC.20m02790
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
Priebe, S., Yeeles, K., Bremner, S. A., et al. (2013). Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: Cluster randomised controlled trial. BMJ,347, f5847. https://doi.org/10.1136/bmj.f5847
Rosen, C., Hrouda, D., & Lamberti, J. S. (2024). Increasing use of long-acting injectable antipsychotics: Review of barriers and strategies for improvement. Frontiers in Health Services,3, 1385398.https://doi.org/10.3389/frhs.2024.1385398
Shrivastava, A., Johnston, M., & Bureau, Y. (2012). Stigma of mental illness-1: Clinical reflections. Mens Sana Monographs, 10(1),70–77. https://doi.org/10.4103/0973-1229.91552
Stovall, C., Hill, R., & McNamara, M. (2024). Barriers to long-acting antipsychotic use: A systematic review. Frontiers in Health Services, 3, 1385398.https://doi.org/10.3389/frhs.2024.1385398
Stroup, T. S., Kane, J. M., Muench, J., et al. (2022). Effects of theCOVID-19 pandemic on LAI antipsychotic treatment continuity: A multi site survey. Psychiatric Services, 73(9),978–985. https://doi.org/10.1176/appi.ps.202100531
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