Psychopharmacology & The Human Aspect of LAIs

A single comment before surgery sticks for decades: “You must be pretty sick.” It was said after noticing an insulin pump, and it reveals a mistake we make all the time in mental health care. We treat certain treatment tools as proof of failure or severity, instead of seeing them as smart choices that can make day to day life easier. From that story, we step into the most misunderstood part of psychopharmacology: the adherence conversation. 

We talk about why missed doses are not automatically “resistance,” why forgetting is human, and why taking medication can feel like waking up to a diagnosis every morning. We also get practical about what helps: empathy before education, and motivational interviewing that starts with permission and curiosity. You’ll hear language you can use right away to explore ambivalence, uncover what an option represents to a patient, and move from persuasion to partnership. 

Then we dig into long acting injectables, including common fears about injections, the stigma attached to “shots,” and why LAIs can be less about control and more about freedom. We explore recovery-oriented care, the ripple effects on families who carry the reminder burden, and why offering evidence-based options earlier, including in first episode psychosis, may prevent relapse and protect a person’s life trajectory. 

If you care about medication adherence, shared decision-making, and reducing stigma in psychiatric treatment, this one will change how you frame choices. What treatment option might you be saving for later that deserves a place in today’s conversation?

Transcript

Insulin Pump And Misread Signals

SPEAKER_00 0:07

Hi, and welcome to the human side of psychopharmacology. I'm Dr. Sandra Jan. Today I'd like to begin with a story from nearly 30 years ago. I was waiting to go into surgery for a shoulder procedure when the orthopedic surgeon noticed my insulin pump. He looked at me and said, Oh, you wear an insulin pump. You must be pretty sick. I smiled and said, Actually, my diabetes is very well managed because of the pump. His comment reflected what I think is a common misunderstanding. That needing a device like an insulin pump must mean the illness is especially severe. But in my case, the pump wasn't a sign that my diabetes was poorly managed. It was one of the reasons it was so well managed. My endocrinologist and I had talked through the options, multiple daily injections or pump therapy. And together, we chose the approach that offered the best possible management and the one that fit most naturally into my lifestyle. I wasn't using a pump because I had somehow failed daily injections. I was using it because it was the treatment that made the most sense for a condition that I was going to be managing every day for the rest of my life. And over the years, I've often wondered why don't we think about psychiatric treatment the same way? Today, I'd like us to explore what I think may be one of the most misunderstood conversations in healthcare, the adherence conversation. We often think about adherence as something patients either are or aren't. Adherent, non-adherent, reliable, unreliable. But what if it's more complicated than that? What if the question isn't, why won't people take their medications? But rather, how can we better support them in managing conditions they live with every single day? Because daily medication works beautifully for many people. And for others, it doesn't fit quite as well. My pump wasn't a sign that I was sicker or that another treatment had failed. It was simply the option my clinician and I decided was best for me. You know, that experience has stayed with me because treatment decisions aren't only about what works clinically. They're also about what fits

Fear, Needles, And Learning Support

SPEAKER_00 3:05

the person and the life they're living. And living with diabetes has taught me something else. Taught me a lot about needles, and there's quite a story there. You know, as a kid, when my mother would take me to see the pediatrician, if there was even a hint that a shot might be involved, as soon as she would get out of the car, I would speed around the inside of the car, locking all the doors from the inside. You know, back then there were manual locks, so I've just dated myself. But eventually, of course, my mother would get me out of the car. We'd go into the doctor's office. And if shots were on the agenda, I want you to know it often took more than one person to hold me still. So imagine my reaction all those years later when I was diagnosed with type 1 diabetes. You know, my first thought wasn't, wow, how am I going to manage this disease? Here was my first thought. Oh my goodness, that's going to involve shots. I remember way back then, this is what I thought. I can't do this. But I want you to know, all these decades later, I did it and I'm still doing it. And it's not because someone handed me a brochure or they reminded me of all the terrible things that could happen if I didn't take care of myself. I did it because of a kind and compassionate nurse who sat with me for hours. This is what we did. We practiced injections using an orange. She answered all my questions. She gave me time. She gave me attention. And little by little, I began to believe that I could do something that I had once thought absolutely impossible. It was that conversation, that interaction, that quite literally, it saved my life. Fear did not mean that I somehow lacked insight. My hesitation didn't mean that I was unmotivated. And my need for support certainly didn't mean that I had failed in any way. Sometimes what people need most is information. And sometimes they need options. Sometimes they need someone who's willing to sit beside them long enough to help them discover what they're actually capable of. And you know, perhaps that's true whether we're talking about insulin injections, or how about in the world of psychiatry, maybe we're talking about long-acting injectables. And here's where the science does come in handy. When people are frightened, data alone will rarely change their minds. I know it would not have changed mine all those years ago. But when people feel heard, supported, and ready to consider their options, information is empowering. For example, you know, there are studies examining long-acting injectables. This is what they did. They asked patients to rate injection site pain on a scale from zero to 100. You may be wondering the average ratings. What are they? Well, they were less than 10 out of 100. And over time, the ratings became even lower. In one study, no one discontinued treatment because of injection site pain. So sometimes what people need first is understanding, the need to feel heard. And then

Nonadherence Is Human, Not Defiance

SPEAKER_00 6:45

when the time is right, they do need the information that we have to share. Every time I give a talk about adherence, I ask the audience, how many of you have forgotten to take your own medication? I want you to know, I know you won't be surprised. Hands go up, heads nod. Because the truth is, many of us fill our pill organizers every Sunday with very good intentions. And then the following Sunday rolls around and we seem surprised because we discover a few mysterious pills still in the box. We look at them and we think, hmm, wonder whose pills those are. Of course, they're mine. This is a useful, helpful reminder for all of us. If educated, resourced healthcare professionals like all of us, we've got resources, routines, a clear understanding of why medicines matter. If we occasionally forget, come on, what does that tell us about the adherence conversation? Perhaps forgetting doesn't mean someone isn't participating in treatment. Doesn't mean they're resistant, just means they're human. We all forget. I recently came across a powerful quote from a colleague and friend, Dr. Les Sitrome. Many of you may know him. This is what he said: non-adherence is normal. It's human nature. The question is, what do we do to help you overcome that problem? Oh, when I heard that, I thought, yes, that's exactly the conversation we should be having. Not what's wrong with this patient, but how do we partner with them to create a treatment plan that they can actually live with? So think for a moment about what we're actually asking many of our patients to do. We're asking them, look, every morning, remember the medication, remember why you're taking it, remember that you have an illness. Take it even if you're feeling well, take it when you're traveling, take it when your routine changes, take it when you're busy, take it when you're discouraged, take it when you're experiencing side effects. Take it when part of you wonders whether you still need it. And when we frame it that way, adherence starts to look less like a character trait and more like an incredibly demanding task. I want you to know living with diabetes taught me that even when we understand and accept the importance of treatment, the daily vigilance, ah, my friends, it can be exhausting. I have a friend who's also a type one diabetic, and we saw something on Instagram, a funny reel, and it ended with this diabetes is dumb. And of course, tongue in cheek, but what it speaks to is how much energy it actually takes. So sometimes what looks like resistance, it's fatigue, disengagement. Well, it's simply the burden of thinking about an illness every single day. I remember one of my patients saying, it's not that I don't want to take the medicine. I just don't want to think about being sick every single morning. For her, the pill bottle wasn't just a pill bottle. It was a reminder of a vulnerability, a reminder that life, it just hadn't unfolded the way she imagined. Sometimes what patients are trying to avoid, it's not treatment, it's what the treatment represents. Another patient told me, I just want to wake up and feel like a normal person, not someone whose every day begins with a reminder that I have a problem. For her, stopping medication, it wasn't about denying that it helped. For her, it was an attempt to reclaim an identity that felt larger than her diagnosis. And that distinction truly matters. Because when we respond only by emphasizing the risks of stopping, we may end up missing the deeper conversation that our patient is trying to have with us. Things like, can I receive treatment without allowing this illness to define who I am? And for some patients, the right

Motivational Interviewing And Real Meaning

SPEAKER_00 11:30

treatment creates more room to be a person, not simply a patient. And this is where I find motivational interviewing to be so helpful. So, motivational interviewing, it doesn't start by trying to persuade someone to accept the treatment that we've already chosen for them. It's going to begin with curiosity. And it's going to sound like this. Would it be okay if we talked about the different ways this medication can be taken? What's worked well for you in the past? What's been difficult? What matters most to you in this moment? How would each of these options fit into your daily life? Remember, we ask permission before we dive into explaining and convincing. And we're going to explore ambivalence without trying to get rid of it. Imagine a patient saying to us, I don't want an injection. That feels like something you give people who are really sick. Okay, it'd be easy to respond with more education, to explain the pharmacology, review relapse data, go through all the practical advantages, but motivational interviewing, it's an invitation to slow down. So we might say something like, when you picture receiving an injection, it sounds as though it carries some sort of meaning for you beyond the medicine itself. Patient might tell us, it means I'm not normal. It means things are worse than I thought. Ah, now we're finally having a real conversation. Then we can ask, would it be okay if I shared how some other patients have thought about it? Maybe later down the road I might say, hey, what if anything sounds appealing about having to think about medication less often? Patient might say, you know, I travel for work, not packing pills every time would be easier. Or they might say, you know what, my mornings are chaotic. I often forget. Or they could tell us, I'm not ready, but I would like to know more. Ah, I think that's important to remember. The outcome isn't always an immediate yes. Sometimes the better outcome is just a more honest conversation, more trust, or a patient who's feeling safe enough with us to reconsider an option down the road. Motivational interviewing offers something valuable even when it doesn't produce immediate behavioral change. It protects our patient's autonomy, it reduces defensiveness, that push and pull. It helps us understand what is driving their decision. Because, you know, when we understand the meaning behind the behavior, our response changes. Once that happens, different

Long Acting Injectables As Relief

SPEAKER_00 14:20

possibilities start to emerge. So let's do this. Let's take a moment and talk about long-acting injectables. You know, the decision to switch from an oral medication to an injectable is rarely just about how the medication is delivered. It may bring up concerns about stigma, identity, control, and what accepting an injection might suggest about the illness itself. And I have to tell you, for some of my patients, it creates a very different experience. I've heard these patients who have been who are receiving long-acting injectables tell me things like, you know, I don't have to think about it every day anymore. I have room in my life for other things. Or I can focus on being a parent, an employee, a spouse, or a student. Look, thinking about medication less often can create more space for the people, the roles, and the parts of life that matter most. I'm reminded of a patient who'd spent years organizing her life around periods of illness and recovery. You know, there were missed days at work, history of disrupted relationships, plans really that she was afraid to make because she never knew when things might begin to unravel again. Once she found a treatment approach that fit her life, something began to shift. She returned to work consistently. She started making plans again. She became more present with her children. Not because medication suddenly solved every problem, but because managing treatment, it no longer consumes so much of her attention. And at one point she told me, you know, I finally feel like I'm building a life instead of constantly recovering from one. And that's what recovery-oriented care, that's what it's asking us to notice, not just symptom improvement,

When Reminders Strain Relationships

SPEAKER_00 16:25

but what's become possible in our patients' lives. And we all know families notice these shifts too. Many family members quietly carry the burden of reminding. This is what they ask. Did you take your medication? Did you refill your prescription? Did you remember your medicine this morning? With enough family therapy, and I know you've heard this too, those reminders, even though they come from love, over time they begin to strain relationships. I remember once a spouse told me, you know, I hated asking every morning. I know it sounded like I didn't trust him, but I was honestly terrified of what might happen if he forgot. Eventually, this is what she said. Their mournings had begun to revolve around medication. She no longer felt like simply his wife. She had become the person who monitored, reminded, checked, and worried. But after his medication delivery changed, she noticed something she just hadn't expected. This is what she told me. I could be his wife again. I didn't have to be the medicine police. Of course, that change did not remove every concern, but it gave something important back to their relationship. And sometimes changing the way medication is delivered changes more than just adherence. It changes the emotional roles that people have been forced to assume within a system. One practical advantage of long-acting injectables is that they remove some of the daily uncertainty. Look, we no longer have to worry whether the medication made it from the bottle to the patient. For some clinicians, that is reassuring. Also for

Offer Options Earlier With Respect

SPEAKER_00 18:20

families, it's reassuring. And for some patients, it's also reassuring. And increasingly, experts are encouraging us to move beyond the idea that these medications should be reserved only for the latest stages of illness, or they're offered only after repeated difficulties with oral medications. This may be especially important in first episode psychosis. The early course of illness, we all know it can shape so much of what follows. A relapse can disrupt education, employment, relationships, a person's confidence, their sense of who they are. This doesn't mean that every person experiencing a first episode should receive long-acting injectables. It means they deserve to know that it's an option. Why wait until someone's experienced multiple relapses or hospitalizations or significant disruption before discussing the full range of evidence-based treatments? Perhaps the earlier conversations open doors to better outcomes. And at the center of those conversations is something that matters deeply, and that's choice. Some patients prefer long-acting injectables when they are offered as an option, including earlier in the course of the illness, not as a consequence, not as evidence that the oral medicine failed, not as treatment reserved for later, but just as one evidence-based option among several. That's exactly how my endocrinologist approached insulin pump therapy. It wasn't presented as punishment, not evidence that I somehow failed. It wasn't a last resort. It was just an option. For me personally, and what I think is true for our patients. Choice communicates respect. This is what we're telling our patients. Look, you have options. Your preference matters. We're making this decision together. You're more than a diagnosis. You know, I've often wondered why we don't approach long-acting injectables in psychiatry in much the same way. Daily oral medication works beautifully for many people. Long-acting injectables work beautifully for others. The goal isn't to identify who has earned access to a particular intervention. The goal is to expand the conversation, help our patients choose the approach that best supports the life they want to live. Perhaps it's time we begin thinking about long-acting injectables in much the same way. And that may require us to examine some of our own assumptions. Do we unconsciously think of long-acting injectables as treatments for difficult patients? Do we reserve them for people who have already relapsed several times? Do we describe them in ways that communicate freedom and choice or in ways that communicate control? I want you to know I've had these conversations with many patients over the years, and they really do notice how we frame an option. They hear the difference between. This is what we do when people won't take their medication. Hey, and here's another evidence-based way of receiving treatment. Let's talk about whether it might fit your life. How we introduce an option can shape whether patients can imagine choosing it. Collaborative care means more than offering treatment. It really does mean offering choices. And trusting that patients can partner with us in deciding what best supports their life that they want

Two Questions To Revisit

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to live may be the place to start. So thank you for joining me for this episode of the human side of psychopharmacology with Dr. Sondra Jan. Before we close, I'll leave you with two questions. One, what treatment option might you be saving for later that deserves a place in today's conversation? And two, what assumptions about adherence, readiness, or even ourselves might be worth revisiting? Okay, my friends, until next time, remember, the medication matters, the diagnosis matters, the evidence matters, but every encounter is therapeutic, and how we show up matters.