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Jarurin Pitanupong, M.D.*, Apinan Karakate, M.D.*, Laddaporn Tepsuan, M.D.**, Grittin Sritrangnant, M.D.***
*Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, ailand, **Songkhla Hospital, Mueang
Songkhla District, Songkhla, 90110, ailand, ***Songkhla Rajanagarindra Psychiatric Hospital, Mueang Songkhla District, Songkhla, 90110, ailand.
Attitudes Toward Long-Acting Injectable
Antipsychotics among Schizophrenia Patients in
Southern Thailand: A Multihospital-Based Cross-
Sectional Survey
ABSTRACT
Objective: To identify the attitudes toward long-acting injectable antipsychotics (LAIs) among schizophrenia at
three psychiatric outpatient clinics in Southern ailand from February to April 2021.
Materials and Methods: A study was conducted at three psychiatric outpatient clinics. All patients, who met the
criteria of having schizophrenia based on ICD-10 criteria, aged 20-60 years were included. e questionnaires
utilized were:1) Demographic information, 2) Prole of schizophrenia disorder, and 3) Attitude, knowledge, and
satisfaction towards LAIs. All data were analyzed using descriptive statistics.
Results: ere were 259 participants who completed the questionnaires. From the participants, 39% had a history
of being treated with LAIs. A quarter of them felt LAIs made them feel stigmatized (26.3%), that they lost autonomy
(24.7%), and embarrassed (16.6%). e reasons for refusing to receive LAIs were not fear of needles or pain at the
injection site (49%), but rather that LAIs had more adverse eects than oral medications (47.9%). Half of them
(51.8%) knew that they must continue to use LAIs, even though their symptoms had improved as LAIs played an
important role by improving their symptoms (68.8%), and preventing relapse (51.8%). ey were satised about
having been involved in the decision making of using LAIs for their treatment (63.6%), having information on the
risk-benets from LAIs provided to them (72.3%), and the cost of LAIs (75.2%).
Conclusion: Before deciding to prescribe LAIs, we should ensure that all patients receive information about the risks,
and benets of LAIs, boosting acceptance for this formulation and mitigating concerns about patient autonomy
reduction and stigmatization.
Keywords: Antipsychotics; attitude; knowledge; long-acting injectable; schizophrenia (Siriraj Med J 2022; 74: 193-201)
Corresponding author: Jarurin Pitanupong
E-mail: pjarurin@medicine.psu.ac.th
Received 2 October 2021 Revised 24 October 2021 Accepted 9 February 2022
ORCID: https://orcid.org/0000-0001-9312-9775
http://dx.doi.org/10.33192/Smj.2022.24
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
INTRODUCTION
Schizophrenia is a mental illness aecting about
0.7% of adults globally.
1
It is a long-term chronic disease,
has residual symptoms and functional impairment.
erefore, using integrated treatment strategies; in terms
of medication, psychosocial interventions,
2
including
psychiatric rehabilitation, and decreasing stigmatization
for schizophrenia are essential to both lessen the burden
for family members and improve patients’ quality of life.
3-5
In the past, the core concept of schizophrenia
management was a combination of ensuring patients
gain insight, medical treatment, and the teaching of
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essential community-living skills, so as to integrate
patients back into society.
6
Moreover, occupations and
employment can reduce stigma and promote quality of
life.
4-6
Although, some schizophrenia patients gain insight
well, the truth of this illness makes them suer from
stigmatization. Because of this, patients usually deny or
refuse medication, which in turn makes them relapse.
4
In addition, the relapse rate aer the rst episode of
schizophrenia (FES) is high, oen due to non-adherence
with medication.
7
Presently, antipsychotic medications play an eective
role in schizophrenia symptom control and relapse
prevention;
1,7
however, non-adherence to medication is still
a major problem in the treatment of schizophrenia,
8
and
is one of the most important predictors for relapse rates
of more than 80% within 5 years.
9
Although, treatment
response is better in FES than in multi-episode patients,
10
and within one-year response rates of about 87%, relapse
rates are still high;
9
therefore, long-acting injectable
antipsychotics (LAIs) have a role for promoting adherence
to medication
1,7
in schizophrenia patients who having
poor drug compliance.
11,12
However, in many countries,
fewer than 20% of schizophrenia patients receive LAIs.
The rate of LAIs usage among schizophrenia at the
psychiatry department of the Faculty of Medicine, Prince
of Songkla University, in 2018, was 12.7%.
13
e reason
for this low prescribing rate of LAIs may be the patient
attitudes and reluctance to accept depot treatment.
10
Despite good clinical evidence, depot treatment rates
are still low across countries,
7
and depot antipsychotics
are only seldom prescribed for patients with FES.
12
Currently, some systematic review studies have reported
that patients have generally positive attitudes toward LAIs
compared with oral medication.
14-17
Additionally, it is
generally considered that providing adequate information
to patients and having a therapeutic relationship with the
psychiatrist, which includes a shared decision-making
processes, can promote a positive image to depot injections.
7
Although, some previously reviewed literature found that
LAIs are associated with a better outcome, as a reduction
of re-hospitalization and better adherence, schizophrenia
patients are particularly fearful of being stripped of their
autonomy when treated with LAIs, and that the injections
may be painful. Moreover, the lack of adequate information
given to patients may be a reection of their negative
attitudes towards LAIs. Providing adequate information
on LAIs can help promote positive attitudes, especially
as LAIs don’t particularly increase the risk of side-eects
such movement disorder.
11
erefore, to enhance the use
of LAIs, psychiatrists could improve their practice, by
providing patients with more information regarding the
dierent forms of available treatment during the early
stages of this illness.
12
In addition, the availability of the
deltoid route of administration would oer increased
choices in LAIs administration, and may be perceived
as more respectful and less socially embarrassing.
16
e
aim of this study was to identify the prevalence of LAIs
usage, attitudes, and satisfaction toward LAIs among
schizophrenia outpatients, as this may provide useful,
basic knowledge for enhancing the use of LAIs.
MATERIALS AND METHODS
Aer being approved by the Ethics Committee of the
Faculty of Medicine, Prince of Songkla University (REC:
63-521-3-4) and Rajanagarindra Psychiatric Hospital
(SKPH.IRB.COA 1/2021), this cross-sectional study
was conducted at the three listed psychiatric outpatient
clinics: Songklanagarind Hospital, which is an 800-bed
university hospital serving as a tertiary referral center in
Southern ailand, Songkla Hospital, which is a 508-bed
provincial hospital, and Songkhla Rajanagarindra Psychiatric
Hospital, which is a 200-bed psychiatric hospital serving as
a referral center in Southern ailand. All schizophrenia
outpatients, who had an appointment and were followed
up at three psychiatric outpatient clinics; from February
to April 2021, were invited to participate in the study. To
be included, they had to meet the criteria of being adult
schizophrenia outpatients by their psychiatrists and their
case les were selected in the medical register, based on
the following criteria: ICD-10 code F20.0-F20.9, aged
20-60 years, agreeing to participate in the study, able to
understand and use the ai language well and to complete
all of the questionnaires. Patients who had more than
one psychiatric diagnosis or comorbidity, did not wish
to participate or decided to withdraw from the study
and/or lacked mental capacity (judged by an outpatient
psychiatric nurse) to complete all of the questionnaires,
were excluded. We tried to calculate a sample size to
determine the minimum number of subjects to enroll
in our study. Following a literature review we could not
nd any information from studies about the prevalence of
patient attitudes in regards to long-acting antipsychotic
injections, in ailand. erefore, we simply identied
all patients with an appointment and we followed them
up during that period.
Data collection
All of the eligible schizophrenia outpatients were
approached by the research assistant for recruitment,
and were provided with an information sheet; which
delineated the rationale for the study and the allotted time
to complete the survey. All eligible participants had at
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least 20-30 minutes to consider whether to participate in
the study or not. Participants willing to collaborate were
invited to a private location to complete the questionnaire,
and were informed that they could stop at any time if
they felt distressed, uneasy or were unwilling to perform
any further. All participants were allowed to nish and
return the questionnaires immediately, or at a later time.
Participants could submit the questionnaires via two
options: by dropping them in a secure box at the front
of the clinic upon leaving, or by returning them later by
placing them in a secure box located at the Psychiatry
Department and/or Unit. erefore, protecting respondent
condentiality.
Instruments
1) Personal and demographic information: inquiries
around areas related to age, gender, marital status, religion,
education, income, occupation, and history of physical
illnesses.
2) Prole of schizophrenia disorder: the number
of hospital admissions, duration of illness, and history
of injection experience.
3) Self-rating questionnaires to evaluate attitude,
knowledge, and satisfaction toward LAIs: 4 tools. e
Drug Attitude Inventory (DAI-30) containing 30 questions
concerning the aspects of the patient’s perceptions
and experiences of treatment.
18
e Satisfaction With
Antipsychotic Medication scale (SWAM scale) containing 33
questions evaluating the patient’s beliefs, patient’s concerns,
and other aspects of treatment; including social support
and information regarding the patients.
19
A questionnaire
from a study in Nigeria;
20
and a questionnaire from a
study in Croatia.
21
Our tool consisted of 15 questions,
in 3 domains: attitude, knowledge, and satisfaction.
e response to each question ranged from disagree;
neutral; agree, and strongly agree. is questionnaire’s
modication and content validity was reviewed by 5
psychiatrists; the content validity (CVI) score was 0.8.
A pilot study was conducted with 20 volunteers; thus,
Cronbach’s alpha was 0.8.
Statistical analysis
Descriptive statistics; such as frequency, percentage,
proportion, mean, and standard deviation (SD) were
calculated. Chi-square tests were used in regards to the
comparison of ‘knowledge’, ‘attitude of schizophrenia
patients who received LAIs’ and ‘no experience of receiving
LAIs’. e analyses were conducted using R version 3.4.1
(R Foundation for Statistical Computing). Statistical
signicance was dened as a p-value of less than 0.05.
RESULTS
Demographic characteristics
From February to April 2021, 262 schizophrenia
patients attended all three Psychiatric Clinics, and 259 of
them agreed to collaborate and complete the questionnaires.
e response rate was 98.9%. e majority of participants
were male (62.5%), Buddhist (74.9%), and unmarried
(82.2%). Overall, their mean age was 41.2 ± 10.9 years,
and their median income (IQR) was 9,000 (4,000-15,000)
baht, per month. Fiy-three participants (20.5%) reported
having history of physical illness (Table 1). e most
common physical illness were diabetes mellitus (32.7%),
hypertension (25%), and dyslipidemia (21.2%). No
statistically signicant dierence in demographic data
was detected between the participants, according to the
three hospitals.
Prole of schizophrenia disorder
For all the participants, their mean (S.D) duration
of illness was 139.8 (104.5) months. e majority of
participants (58.3%) reported having a history of inpatient
admission; with the mean (S.D) number of admissions
at 2.6 (2.4). No statistically signicant dierence in
the prole of schizophrenia was observed between the
participants, according to all three hospitals. 101 (39%)
participants had a history of being treated with LAIs
(Table 2), with the most common LAIs received being
conventional LAIs; there were only 5 (4.9%) participants
who had received novel LAIs.
However, a statistically signicant dierence in the
history of psychiatric inpatient admission was detected
between the participants who had received and those who
had no experience of receiving LAIs. Of all participants
who received LAIs, 75% of them had history of psychiatric
inpatient admission; whereas, 52.6% of participants who
had no experience of receiving LAIs had a history of
psychiatric inpatient admission (Table 3).
Knowledge and attitude toward long-acting injectable
antipsychotics
In regards to knowledge and attitude toward LAIs,
the majority of participants knew that LAIs played an
important role and improved their symptoms (68.8%),
and that they must continue to use LAIs even though
their mental health was improved (51.8%). ey also
knew that LAIs prevented symptom relapse (51.8%).
However, 64 (24.7%) participants felt that LAIs made
them feel a loss of autonomy, and 68 (26.3%) participants
reported feeling stigmatized due to LAIs. Only 98 (37.8%)
participants felt that LAIs were more convenient than oral
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TABLE 1. Demographic characteristics (N = 259).
TABLE 2. Prole of schizophrenia disorder (N = 259).
Demographic characteristics Number (%)
Gender
Male 162 (62.5)
Female 97 (37.5)
Religion
Buddhism 194 (74.9)
Islam/Christianity/Other 62 (23.9)
No answer 3 (1.2)
Marital Status
Single/Divorced 213 (82.2)
Married 39 (15.1)
No answer 7 (2.7)
Education level
Secondary school/below 99 (38.2)
High school/diploma 92 (35.5)
Bachelor’s degree or above 64 (24.7)
No answer 4 (1.5)
Occupation
Employee/Agriculture 68 (26.3)
Government employees ofcer/state Enterprise ofcer/Private company employee 32 (12.4)
Merchant/Personal business 37 (14.3)
Unemployed/Student 118 (45.6)
No answer 4 (1.5)
Having income
No 127 (49.0)
Yes 127 (49.0)
No answer 5 (1.9)
Having physical illness
No 199 (76.8)
Yes 53 (20.5)
No answer 7 (2.7)
Schizophreniaprole Number(%)
Having history of inpatient admission
No 97 (37.5)
Yes 151 (58.3)
Not answer 11 (4.2)
Having history of being treated with injectable antipsychotic agents
No 89 (34.4)
Yes 170 (65.6)
Type of injectable antipsychotic agents
Short-acting injectable antipsychotics 69 (26.6)
Long-acting injectable antipsychotics 53 (20.5)
Both 48 (18.5)
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TABLE 3. e demographic characteristics comparison between a group of being treated with LAIs or not.
History of being treated with LAIs
Chi2
Demographic characteristics Total Yes No
P-value
(n=259) (n=101) (n=158)
Gender 0.054
Male 162 (62.5) 71 (70.3) 91 (57.6)
Female 97 (37.5) 30 (29.7) 67 (42.4)
Education level 0.006
Secondary school/below 99 (38.8) 49 (50.0) 50 (31.8)
High school/diploma 92 (36.1) 33 (33.7) 59 (37.6)
Bachelor’s degree or above 64 (25.1) 16 (16.3) 48 (30.6)
Occupation 0.78
Employee/Agriculture 68 (26.7) 29 (29.6) 39 (24.8)
Government employees ofcer/ 32 (12.5) 12 (12.2) 20 (12.7)
state Enterprise ofcer/
Private company employee
Merchant/Personal business 37 (14.5) 12 (12.2) 25 (15.9)
Unemployed/ Student 118 (46.3) 45 (45.9) 73 (46.5)
Religion 0.024
Buddhism 194 (75.8) 67 (67.7) 127 (80.9)
Islam/Christianity/Other 62 (24.2) 32 (32.3) 30 (19.1)
Marital Status 0.095
Single/ Divorced 213 (84.5) 88 (89.8) 125 (81.2)
Married 39 (15.5) 10 (10.2) 29 (18.8)
Having income 0.302
No 127 (50.0) 53 (54.6) 74 (47.1)
Yes 127 (50.0) 44 (45.4) 83 (52.9)
Having physical illness 0.637
No 199 (79.0) 77 (81.1) 122 (77.7)
Yes 53 (21.0) 18 (18.9) 35 (22.3)
Having history of admission < 0.001
No 97 (39.1) 23 (25.0) 74 (47.4)
Yes 151 (60.9) 69 (75.0) 82 (52.6)
medications. However, more than half of the participants
(61.8%) felt that their families accepted LAIs treatments.
e reasons for refusing to receive LAIs did not appear
to be due to a fear of needles or pain at the injection site
(49%), but due to a belief that LAIs had more adverse
eects than oral medications (47.9%) (Fig 1).
From a comparison between 101 participants who
had experienced receiving LAIs and 158 participants
who had no experience in receiving LAIs, statistically
signicant dierences in knowledge, and attitude were
identied between these two groups. In regards to the
knowledge of LAIs, participants who had experience in
receiving LAIs had higher percentages of knowledge in
connection to LAIs improving their symptoms (79.6%)
and that they must continuously use them even though
their mental health had improved (65.3%) than the
participants who had no experience of receiving LAIs who
had percentages of knowledge at 63.5%, 40.8%, respectively.
Regarding attitude toward LAIs, the participants who
had an experience of receiving LAIs had less percentage
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of negative attitude and of feeling embarrassed and
stigmatized than the participants who had no experience
of receiving LAIs. Additionally, they were more likely
to have families accepting LAIs treatment (78.2%) than
the residual group who had no experience of receiving
LAIs (51.3%) (Fig 2).
Satisfaction toward long-acting injectable antipsychotics
Of all 101 schizophrenia patients who had an
experience of receiving LAIs, the majority of them (63.6%)
thought that they were involved in the decision or choice
of LAIs treatments. Despite this, they were satised with
the provided information of the risk-benets from LAIs,
type, and cost of LAIs that they received (72.3%, 64.3%,
and 75.2% respectively). Regarding LAIs causing any
adverse eects, 41 (40.6%) participants agreed that LAIs
caused adverse eect, whereas, 40 (39.6%) participants
disagreed with LAIs causing any adverse eects (Fig 3).
Fig 1. Knowledge and attitudes toward LAIs (N = 259).
Fig 2. Comparison of knowledge, attitude of schizophrenia patients who received LAIs (N=101) or no experience of receiving LAIs (N = 158).
*p-value<0.05, **p-value<0.001
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DISCUSSION
In clinical practice, the advantages and disadvantages
of LAIs are still controversial. A better understanding of
attitudes toward LAIs would likely enhance their acceptance
and use in patients with schizophrenia. e objective of
this study was to evaluate the attitudes of schizophrenia
patients in regards to LAIs. In our study, there were 101
(39%) participants receiving LAIs. Furthermore, patients
who received LAIs had favorable attitudes about LAIs
in regards to: being involved in the decision or choice of
treatment, family acceptance, ecacy, relapse prevention,
type, and cost. However, participants who were receiving
LAIs had a higher frequency of past psychiatric inpatient
admission than the participants who had no experience
of receiving LAIs.
According to the number of patients who received
LAIs, this survey found a higher rate than the study in
Japan
22
that found twenty-nine (18.2%) participants
were on LAIs. However, another study from Australia
showed that more than half of schizophrenia patients were
receiving LAIs prescriptions.
23
e reason for the dierent
rates of LAIs prescription might be the same as shown in
previous studies; that LAIs prescriptions by psychiatrists
and the patients’ preference for LAIs depended on their
preference of antipsychotic treatment in terms of their
attitude and experience with the formulation.
10
Some
psychiatrists frequently assume that patients with a FES
would not recognize depot medication, and that depots
were mostly suitable for chronic patients.
8
However, a
recent study from several European countries found
physicians willing to accept the usage of LAIs, and that
having a positive attitude toward LAIs could inuence
the acceptance and usage of them to treat patients with
schizophrenia.
24
is study found that most patients had favorable
attitudes towards LAIs, in regards to their cost. e
reason might be that most prescriptions of LAIs in this
study were of the conventional type, which incurred less
economic burden to the patient and their family than a
novel type.
Attitudes toward LAIs in this study identified
that, the participants had favorable attitudes toward
LAIs concerning ecacy because LAIs improved their
symptoms (68.8%), and assisted them to prevent relapse
(51.8%). ey did not fear needles, being injected, or
pain (49%). is nding was the same as a prior study
that identied that the expectation of relapse prevention
was signicantly related with patients’ acceptance of
LAIs.
22
Moreover, some studies revealed that patients
receiving LAIs prescribing rated their current medication
useful and helpful, even among patients lacking insight.
23
Choosing the appropriateness of
LAIs treatment, providing
information of risks and benets, and side eects from
LAIs to patients might enhance the recognition and
acceptance of this formulation, among schizophrenia
patients. Besides, the discrepancy between the psychiatrists’
and patients’ opinions regarding the suitability of LAIs
treatment was signicantly associated with symptom
severity, expectations about relapse prevention, beliefs
that LAIs are painful, and LAIs providing a reduced
range of antipsychotic choices.
22
Moreover, mental health professionals are required
to have a range of competencies to assist patients handle
their medication eectively; and when clinicians and
patients make a joint decision then they are both more
likely to adhere to the treatment plan. Good practice in
the administration of LAIs that points on where and when
they should be given and administration techniques is
Fig 3. Satisfaction of schizophrenia patient toward LAIs (N = 101).
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therefore very important. Clinician ability for talking
with patients concerning their medication, including the
exchange of data, monitoring the eects of medication,
and planning choices in advance about treatment, in
the event of a crisis should also be scrutinized.
25
is
study revealed that the patients felt LAIs were not more
convenient than oral antipsychotics (42.1%) and also had
more adverse eects than oral antipsychotics (47.9%).
Concerning autonomy and stigmatization, our
results indicated that even though more than half of the
participants (63.6%) were involved in the choice of LAIs
and had family acceptance for LAIs treatment (61.8%);
a quarter of them (24.7%) regarded LAIs treatment as
something that was limiting their autonomy, caused
them to be stigmatized (26.3%), and made them feel
embarrassed when seen by others to be taking LAIs
(16.6%). A previous study showed that patients, more
than psychiatrists, felt that LAIs restricted patient
autonomy.
15
erefore, psychiatrists and the patients’
caretakers should be concerned about these ethical issues;
especially regarding coercion. In addition, minimizing
the patients’ feelings of coercion by providing complete
information to all patients in a therapeutic relationship,
which includes a shared decision-making processes, could
also reduce the negative image, being embarrassed by,
and the stigmatization attached to depots.
8,17
Finally, as the destinations of schizophrenia treatment
are to manage symptoms, prevent relapse, and enhance
both functioning and quality of life, the recommendations
should include: 1) adopting a patient-centered approach;
2) selecting medications based on a balanced risk-benet
assessment, including a point on addressing symptoms
related to the agents; 3) considering LAIs as an alternative
to oral medications, as they offer benefits; such as,
uncovering poor adherence, and reduced relapse risk;
and 4) implementing psychosocial interventions that
have been proven to be eective in enhancing adherence
and overall outcomes.
26
Strengths and limitations
is study had both strengths and limitations worth
mentioning. To our knowledge, this is the only study on
this topic conducted in Southern ailand over the past
decade. However, this study had some limitations as it
was a cross-sectional survey and utilized self-administered
questionnaires; therefore, some misunderstanding
regarding the intended meaning of the questions may
have taken place. Another drawback was that our data
was quantitative, the sample size, and that participants
were only schizophrenia outpatients in lower, Southern
ailand. Hence, its ndings may not fairly represent
the situation of schizophrenia patients throughout the
country. Henceforward, studies are recommended to
enclose a larger number of schizophrenia patients, with
age group and gender dierences from other hospitals
in ailand. erefore, a more comprehensive, multi-
centered research study should be performed. Moreover,
other studies should retain more qualitative or in-depth
methods.
CONCLUSION
Before deciding to prescribe LAIs formulations, the
schizophrenia patient’s attitude, and knowledge needs
to be considered. is is particularly relevant as the
care for schizophrenia is focused on symptom control,
relapse prevention, and optimizing their quality of life.
Clinicians should ensure that patients receive access to
information such as the risks and benets of treatment
with LAIs, helping to improve the acceptance and use
of such formulations and addressing any concerns that
LAIs treatment is limiting their autonomy or causing
stigmatization.
ACKNOWLEDGMENTS
All authors would like to acknowledge the participants
for their willingness to oer information and the nursing
sta of the psychiatric clinic for providing space at the clinic
as well as facilitating a number of operational aspects in
the study. We would like to also acknowledge Associate
Professor Hutcha Sriplung, and the research assistants;
Nisan Werachattawan and Kruewan Jongborwanwiwat, for
their assistance. e English of this article was proofread/
edited by the Oce of International Aairs, Faculty of
Medicine, Prince of Songkla University.
Disclosure statement: e authors declare no conict
of interest.
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