A Psychiatric Pharmacist on Breaking the Stigma Around Injectable Antipsychotics

For people living with serious mental illnesses like schizophrenia, long-acting injectable (LAI) antipsychotics can offer real advantages: consistent medication levels over weeks or months, and one less daily decision to manage. Yet many patients are never offered this option, or only hear about it after repeated relapses or hospitalizations, framed less as a genuine choice and more as a consequence.

We spoke with Michael McGuire, Pharm.D., a psychiatric pharmacist and professor at Belmont University, about why that gap persists. McGuire points to a surprising root cause: it often has less to do with what patients want and more to do with how comfortable clinicians feel prescribing and managing LAIs in the first place. He walks through the training gaps behind that hesitation, what current clinical evidence and guidelines actually recommend, and how patients can advocate for themselves in a conversation their own provider may not be fully equipped to lead.

Many patients with serious mental illness are never offered a long-acting injectable antipsychotic as an option. How much of that comes down to their clinician simply not having enough training or confidence with these medications?

Michael McGuire, Pharm.D.: Many people living with serious mental illnesses, such as schizophrenia, often are not offered LAI until late in their treatment journey, if at all. I think a lack of sufficient clinician training on LAIs during the education and training of psychiatrists, nurse practitioners, physician assistants, pharmacists and other mental health professionals plays a significant role in why these treatments are often not discussed or offered.

Most providers naturally become comfortable using medications they are exposed to during training, so the lack of training often leads to less real-world experience, which in turn impacts confidence with these medications. For example, if someone trains in a health care setting that routinely uses one or two oral medications to treat schizophrenia, those may be the only products they feel prepared to leverage once they enter clinical practice, instead of considering other treatment modalities, such as LAIs.

In addition to a lack of exposure, additional challenges with prescribing an LAI include understanding how to start it, how to determine the appropriate dosage and what to do if an injection is late or missed. There are also practical questions about insurance coverage, storage, where the injection can be administered, how to administer it and necessary follow-up. When clinicians do not receive enough instruction in all of these areas, they may avoid the option entirely because they do not feel comfortable managing the entire process.

There seems to be a persistent belief among some providers that long-acting injectables are a last resort. Where does that misconception come from, and what does the evidence actually say?

MM: Despite publication of the 2025 International Guidelines for Algorithmic Treatment [INTEGRATE], which recommend LAIs as an option early in the treatment journey [including in response to the first episode of psychosis], and many years of clinical evidence demonstrating the potential benefits of LAIs for appropriate patients, they are still often viewed through a narrow historical lens and discussed primarily in the context of “nonadherence.” For example, a clinician may be taught to consider LAIs only after a patient has had trouble taking their oral medication as prescribed, experienced multiple relapses or returned to the hospital due to a return of their symptoms. Over time, this can create the impression that an injectable is a consequence or a measure of last resort rather than simply another way to deliver effective treatment.

There is ample clinical evidence that supports viewing LAIs as an important treatment option for people early in their treatment journey and for those who are stable and looking for the convenience of taking one less pill each day. LAIs are effective antipsychotic treatments that can provide consistent medication exposure over the full dosing period [from weeks to months, depending on the medication selected] and remove the need to make a pill-taking decision each day. For some patients, LAIs may support stability and reduce the risks associated with missed doses.

Patients are often assumed to be resistant to the idea of injectable medications. How accurate is that assumption, and what do patients actually say when long-acting injectables are presented to them properly?

MM: I think as clinicians we sometimes assume patients will hear “injection” and immediately say no, so we avoid even asking them, but this has not been my experience. Some patients simply are not interested in making a medication change, and that is completely valid. But many are more open to a conversation than providers may expect.

What is critical is that LAIs are presented properly. The way providers introduce LAIs makes a huge difference in how receptive a patient may be to the option. If an LAI is presented as, “You have not been taking your medication, so now we have to give you a shot,” it can feel like a punishment or like control and autonomy are being taken away. However, when LAIs are presented as a choice, many patients are open [to them]. Some like the idea of having one less pill to remember each day, while others like knowing one of their medications is taken care of for an extended period of time. Not every patient will choose an LAI; however, every patient deserves the opportunity to consider it as a treatment option.

If a patient suspects their doctor is not very familiar with long-acting injectable options, what can they do to have a more informed conversation about whether it might be right for them?

MM: A patient can begin by asking a very direct question: “Are there any long-acting versions of the medication I am taking or other LAIs that might be appropriate for me?” That opens the conversation without assuming that an injectable is necessarily the right choice.

From there, patients should ask the same questions they would ask about any treatment: What are the benefits and risks? What is the schedule for taking/receiving the medication? Will my insurance cover it? A medication may look good on paper, but it also has to fit into the patient’s actual life.

If the provider does not have experience with LAIs, that does not have to end the discussion. The clinician may be able to consult a psychiatric pharmacist, another mental health provider or a clinic with broader experience administering these medications. Some providers may also be comfortable prescribing an LAI but may not have the staff or resources to administer it in their own practice. In these cases, patients may need to receive the injection at another location, but that should not prevent them from considering the treatment — many LAI manufacturers offer patient-support services that can help identify an appropriate injection site. Patients should feel empowered to get the information they need to make an informed decision.

What would better training on long-acting injectables actually look like in practice, and how would that change the treatment options available to patients living with serious mental illness?

MM: Improved training on LAIs needs to go beyond a lecture describing which products are available. Clinicians need practical experience working through the patient scenarios they will encounter where an LAI may be appropriate. This includes learning how to identify patients who may benefit from an LAI, how to present the option without stigma and how to initiate different medications safely and effectively. Providers should practice dose conversions, oral overlap, loading strategies and missed-dose protocols. They also need to understand injection technique, administration schedules, storage requirements, insurance barriers and ongoing monitoring.

Documentation and care coordination have to be part of this education as well. When a patient moves settings of care, for example, every team needs to know exactly which medication was given, the dose, the administration date and when the next dose is due. Incomplete information can result in delayed treatment or, in some cases, receiving an unnecessary additional dose of the LAI.