Long-acting injectable (LAI) antipsychotics are second-generation antipsychotic medications given as a shot every few weeks to every few months instead of a daily pill, so the medicine is delivered reliably without having to remember a daily dose. In our practice we believe LAIs are one of the most under-used tools in psychiatry, and the evidence strongly supports offering them to far more people than currently receive them.
The medications and how often they are given
Several second-generation antipsychotics come in long-acting injectable forms. How often you receive the shot, and the usual dose, depend on the specific product, as summarized below. Doses are individualized, and the ranges shown are typical.
| Generic name | Trade name | Typical starting dose | Common maintenance dose | How long each shot lasts | Notes |
|---|---|---|---|---|---|
| Risperidone | Risperdal Consta | 25 mg, with ~3 weeks of oral risperidone overlap | 25–50 mg | Every 2 weeks | Limited / variable availability |
| Risperidone | Rykindo | 25 mg, with one oral dose and ~1 week overlap | 25–50 mg | Every 2 weeks | — |
| Risperidone | Uzedy | 90–150 mg monthly (no oral loading needed) | 90–150 mg monthly, or 180–300 mg every 2 months | Monthly or every 2 months | — |
| Risperidone | Perseris | — | — | (was monthly) | No longer available (discontinued) |
| Paliperidone palmitate | Invega Sustenna | 234 mg on day 1, then 156 mg on day 8 (both in the deltoid) | 39–234 mg (commonly ~117 mg) | Monthly | — |
| Paliperidone palmitate | Invega Trinza | 3.5× the last monthly dose (273–819 mg) | 273–819 mg | Every 3 months | Only after ≥4 months on Sustenna |
| Paliperidone palmitate | Invega Hafyera | 1,092 mg or 1,560 mg | 1,092–1,560 mg | Every 6 months | Only after stabilizing on Sustenna or Trinza |
| Aripiprazole | Abilify Maintena | 400 mg, with 14 days of oral aripiprazole 10–20 mg | 400 mg (300 mg if needed) | Monthly | — |
| Aripiprazole lauroxil | Aristada | Aristada Initio 675 mg plus one 30 mg oral aripiprazole dose | 441, 662, or 882 mg | Monthly (882 mg every 6 weeks; 1,064 mg every 2 months) | — |
| Olanzapine | Zyprexa Relprevv | 210–300 mg every 2 weeks, or 405 mg every 4 weeks | 150–300 mg every 2 weeks, or 300–405 mg every 4 weeks | Every 2–4 weeks | Certified site + 3-hour monitoring; not offered at OhanaPsych |
A note on availability: Availability of some injectables changes over time. Perseris, a monthly risperidone injection, has been discontinued and is no longer available. The two-week risperidone injection (Risperdal Consta) currently has limited and variable availability. Zyprexa Relprevv (olanzapine) must be given at a specially certified facility with a 3-hour observation period after each injection, and OhanaPsych is not a certified Relprevv site, so we do not offer that particular product. We will always help you choose an option that is available and right for you.
Why we recommend them
The single biggest reason people with schizophrenia, schizoaffective disorder, and bipolar I disorder relapse and end up hospitalized is missed doses of medication, and missing even part of a daily oral regimen is extremely common and often goes unrecognized. Long-acting injectables solve this directly: the medicine is given and we know it was received. The evidence is consistent and strong. Large real-world studies of tens of thousands of patients show that LAIs lower the risk of rehospitalization and treatment failure compared with the same medication taken by mouth (Tiihonen et al., 2017; Kishimoto et al., 2021). Mirror-image studies, which compare the same patients before and after starting an LAI, show sharp drops in hospitalization (Kishimoto et al., 2013). And in early-phase and first-episode illness — exactly when protecting the brain from relapse matters most — randomized trials show LAIs reduce hospitalization and better control symptoms than usual oral care (Kane et al., 2020; Subotnik et al., 2015; Schreiner et al., 2015).
An under-used option that deserves wider consideration
Despite this evidence, LAIs remain under-prescribed, often held back as a “last resort” for people who have already relapsed many times. Expert consensus argues the opposite: long-acting injectables should be offered far earlier and to many more people with appropriate psychiatric diagnoses, as a first-line choice, not a punishment (Sajatovic et al., 2018; Schneider-Thoma et al., 2022). In our practice we discuss LAIs with most people for whom they are clinically appropriate, because preventing even one relapse can protect someone’s job, relationships, housing, and long-term recovery.
Especially helpful in real life
Long-acting injectables can be a particularly good fit for people whose daily lives make a pill bottle hard to manage. For someone experiencing homelessness or housing instability, an injection means there is no daily medication to store, lose, or have taken by someone else, and treatment continues even when life is unsettled. In a randomized study of people with schizophrenia and a history of incarceration, a monthly injection delayed treatment failure far longer than daily oral pills (Alphs et al., 2015). The same is true for busy schedules, frequent travel, or simply the ordinary difficulty of remembering a pill every single day. Many people also find it freeing not to be reminded of their illness each morning.
Side effects
Because these are the same medicines as their oral forms, the side effects are the same as second-generation antipsychotics in general — most importantly the metabolic effects (weight, blood sugar, and cholesterol), along with possible drowsiness, restlessness, or movement effects — and we monitor for them the same way. The main differences are mild injection-site soreness and, for one specific olanzapine product, a brief post-injection observation period. Stopping is simply a matter of not scheduling the next injection, and the medicine then wears off gradually.
A shared decision
Whether to use a long-acting injectable is always a decision we make together, with your goals and preferences at the center. Our role is to make sure you know it is an option and to be honest that, for many people, it is one of the most effective ways to stay well.
Culturally grounded care
We care for the whole person, in the spirit of lōkahi — balance and harmony among the body, mind and emotions, spirit, ʻohana (family), and our connection to the ʻāina (land) and community. To mālama (care for and protect) you and to support living pono (in balance), we explain your options clearly, decide together, welcome your ʻohana, and honor the values that ground you. Offering kōkua (help given freely, with aloha) is at the heart of how we practice.
Common questions about long-acting injectable antipsychotics
How often do I need the injection?
It depends on the medication and dose, ranging from every two weeks to every six months. For example, paliperidone palmitate can be given monthly, every three months, or every six months, while risperidone and aripiprazole options range from every two weeks to every two months.
Why would I choose a shot over a daily pill?
Missed doses are the most common cause of relapse and hospitalization. An injection delivers the medicine reliably, and strong evidence shows long-acting injectables lower the risk of relapse and rehospitalization compared with the same oral medication.
Are long-acting injectables only for severe or treatment-resistant illness?
No. They are often under-used and held back too long. Expert consensus supports offering them earlier and more widely, including in first-episode illness, for people with appropriate diagnoses.
Do they have different side effects than the pills?
The medication side effects are the same as the oral form, so we monitor metabolic and other effects the same way. The main added considerations are mild injection-site soreness and, for one olanzapine product, a short post-injection observation period.
This page is general health education from OhanaPsych. It is not a substitute for a personal evaluation by a qualified clinician who knows your situation, and reading it does not create a provider–patient relationship. Do not start, stop, or change any medication without talking with your clinician. In an emergency, call 911.
George Mackel, MSN, APRN, NP-C, PMHNP-BC, CARN-AP — President & Owner
References
Alphs, L., Benson, C., Cheshire-Kinney, K., Lindenmayer, J.-P., Mao, L., Rodriguez, S. C., & Starr, H. L. (2015). Real-world outcomes of paliperidone palmitate compared to daily oral antipsychotic therapy in schizophrenia: A randomized, open-label, review board-blinded 15-month study. Journal of Clinical Psychiatry, 76(5), 554–561. https://pubmed.ncbi.nlm.nih.gov/25938474/
Kane, J. M., Schooler, N. R., Marcy, P., Achtyes, E. D., Correll, C. U., Robinson, D. G., et al. (2020). Effect of long-acting injectable antipsychotics vs usual care on time to first hospitalization in early-phase schizophrenia: A randomized clinical trial. JAMA Psychiatry, 77(12), 1217–1224. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2768027
Kishimoto, T., Nitta, M., Borenstein, M., Kane, J. M., & Correll, C. U. (2013). Long-acting injectable versus oral antipsychotics in schizophrenia: A systematic review and meta-analysis of mirror-image studies. Journal of Clinical Psychiatry, 74(10), 957–965. https://pubmed.ncbi.nlm.nih.gov/24229745/
Kishimoto, T., Hagi, K., Kurokawa, S., Kane, J. M., & Correll, C. U. (2021). Long-acting injectable versus oral antipsychotics for the maintenance treatment of schizophrenia: A systematic review and comparative meta-analysis of randomised, cohort, and pre-post studies. The Lancet Psychiatry, 8(5), 387–404. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00039-0/abstract
Sajatovic, M., Ross, R., Legacy, S. N., Correll, C. U., Kane, J. M., DiBiasi, F., et al. (2018). Identifying patients and clinical scenarios for use of long-acting injectable antipsychotics — Expert consensus survey part 1. Neuropsychiatric Disease and Treatment, 14, 1463–1474. https://pubmed.ncbi.nlm.nih.gov/29922062/
Schreiner, A., Aadamsoo, K., Altamura, A. C., Franco, M., Gorwood, P., Neznanov, N. G., et al. (2015). Paliperidone palmitate versus oral antipsychotics in recently diagnosed schizophrenia. Schizophrenia Research, 169(1–3), 393–399. https://www.sciencedirect.com/science/article/pii/S0920996415004442
Schneider-Thoma, J., Chalkou, K., Dörries, C., Bighelli, I., Ceraso, A., Huhn, M., et al. (2022). Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: A systematic review and network meta-analysis. The Lancet, 399(10327), 824–836. https://www.thelancet.com/article/S0140-6736(21)01997-8/fulltext
Subotnik, K. L., Casaus, L. R., Ventura, J., Luo, J. S., Hellemann, G. S., Gretchen-Doorly, D., et al. (2015). Long-acting injectable risperidone for relapse prevention and control of breakthrough symptoms after a recent first episode of schizophrenia: A randomized clinical trial. JAMA Psychiatry, 72(8), 822–829. https://pmc.ncbi.nlm.nih.gov/articles/PMC5065351/
Tiihonen, J., Mittendorfer-Rutz, E., Majak, M., Mehtälä, J., Hoti, F., Jedenius, E., et al. (2017). Real-world effectiveness of antipsychotic treatments in a nationwide cohort of 29,823 patients with schizophrenia. JAMA Psychiatry, 74(7), 686–693. https://www.semanticscholar.org/paper/9cfca764dc05d09f99c5c465ba83ea35ddd2f47f
