The knowledge and attitudes of psychiatrists towards antipsychotic long-acting injections in Nigeria

Pre-emptive ice pack cryotherapy for reducing pain caused by long-acting deltoid injectable antipsychotic treatment: A single-center open-label study

PURPOSE

This empirical study aims to investigate the efficacy of pre-emptive cryotherapy in reducing pain that is caused by the deltoid intramuscular (IM) injection of long-acting injectable (LAI) antipsychotics in clinical settings.

PATIENTS AND METHODS

This study included 29 outpatients receiving LAI antipsychotic treatment. The evaluations of pain during (1) the usual procedure (control), (2) pre-emptive use of ice pack cryotherapy (pre-cooling), and (3) pre-emptive use of a room-temperature ice pack (pre-touching) were conducted using a numerical rating scale (NRS) for comparison. All patients were administered with LAI antipsychotics via deltoid IM. Furthermore, the results of the Positive and Negative Symptom Scale (PANSS), clinical global impressions (CGI) scale, and Global Assessment of Functioning (GAF) scale that were administered during the control procedure were evaluated.

RESULTS

The median NRS pain scores during the IM injection of LAI antipsychotics were 4.0 (3.0-5.0), 2.0 (1.0-3.0), and 3.0 (2.5-6.0) for the control, pre-cooling, and pre-touching conditions, indicating a significant difference (p = 6.0 × 10-6). The NRS pain scores for the pre-cooling condition were significantly lower than those for the control and pre-touching conditions (p = 2.5 × 10-5 and 6.7 × 10-5, respectively). No significant correlation was observed between the NRS pain scores for the control condition and the PANSS, CGI scale, or GAF scale scores. Furthermore, no adverse events were recorded during the study period.

CONCLUSION

Pain during the deltoid IM injection of LAI antipsychotics was found to be reduced by pre-emptive skin cooling. To date, this is the first study to confirm the effectiveness of pre-emptive cryotherapy for relieving such pain in clinical situations.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Prescribing patterns of long-acting injectable antipsychotics in a community setting in South Africa

Background

Long-acting injectable antipsychotics (LAI - APs) improve adherence to antipsychotics and decrease functional decline in schizophrenia. Yet they are prescribed late, in patients with established functional decline. Although LAI - APs are widely prescribed in South Africa, there is a paucity of research regarding the prescription profile for LAI - APs.

Aim

This study aimed to describe prescribing practices for LAI - APs at psychiatric clinics.

Setting

Community psychiatric clinics in South Africa.

Methods

A retrospective review of the psychiatric files of all patients on LAI - APs attending the clinics over the study period was conducted. Sociodemographic, clinical and pharmacological information regarding the LAI - AP prescribed was extracted from the files.

Results

A total of 206 charts were examined. The mean age of the study population was 46 (SD ± 12) years. Significantly more patients were male (n = 154; 74.8%), single (n = 184, 89.3%) and unemployed (n = 115; 55.8%) (p < 0.001). Approximately half had a comorbid substance use disorder (47.6%). The most common indication for the prescription of a LAI - AP was non-adherence (66%). Only 9.7% of the patients were prescribed a LAI - AP alone. No significant socio-demographic or clinical characteristic was associated with this prescribing habit. A LAI - AP was prescribed in combination with an oral antipsychotic, mood stabiliser or antidepressant in 53.9%, 44.7% and 7.8% of patients, respectively.

Conclusion

Long-acting injectable antipsychotics were prescribed mainly following noncompliance with oral antipsychotics and may represent a missed opportunity to prevent functional decline. The high prevalence of LAI - AP polypharmacy has been highlighted.

Development and Evaluation of a Web-Based Educational Toolkit on the Knowledge, Attitudes, and Practices of Psychiatric Prescribers Regarding Long-Acting Injectable Antipsychotics

BACKGROUND

Long-acting injectable antipsychotics (LAIs) are unique and effective pharmacological treatment options for schizophrenia that are underutilized in clinical practice. Research surrounding prescriber barriers to the underuse of LAIs are limited to a few seminal studies which identified psychiatric prescriber barriers to the use of LAIs as knowledge deficits, uninformed attitudes, and poor prescribing practices. There is a gap in the literature regarding effective educational interventions to target the identified psychiatric prescriber barriers to the use of LAIs.

AIMS

The study aimed to develop a web-based educational toolkit that would positively affect the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs.

METHODS

A one-group, before and after design with a convenience, purposive sample of 17 psychiatric prescribers to assess the knowledge, attitudes, and practices (KAP) using a 20-item KAP questionnaire before and after a presentation of a web-based educational toolkit about LAIs was chosen.

RESULTS

The web-based educational toolkit slightly improved the total and three subscales KAP scores of psychiatric prescribers. However, only the difference in total KAP scores was found to be statistically significant.

CONCLUSIONS

The developed and evaluated web-based educational toolkit could provide a foundation for positive change to psychiatric prescribers' KAP regarding LAIs.

Antipsychotic-Related Stigma and the Impact on Treatment Choices: A Systematic Review and Framework Synthesis

BACKGROUND

Antipsychotics are a class of medications primarily used to treat individuals with psychotic disorders. They have also been indicated for patients with other psychiatric conditions, such as post-traumatic stress disorder and major depressive disorder. Non-adherence is prominent amongst individuals prescribed antipsychotics, with medication-related self-stigma and social stigma identified as major factors. No previous reviews have focused on stigma associated specifically with antipsychotic medication. This systematic literature review aimed to synthesise evidence on the prevalence of stigmatising attitudes and behaviours related to antipsychotic treatment and understand their impact on antipsychotic treatment initiation and continuation.

METHODS

Two independent reviewers screened studies from databases, congress proceedings, ClinicalTrials.gov, and PsychU.org; relevant studies reported quantitative or qualitative data on antipsychotic-related stigma in adults with psychotic disorders, mood disorders, borderline personality disorder or anxiety disorders, or healthcare providers or caregivers of these patients, and any impact on treatment. Framework synthesis facilitated extraction and synthesis of relevant information; quantitative and qualitative data were coded and indexed against a pre-specified thematic framework by two independent reviewers.

RESULTS

Forty-five articles reporting on 40 unique studies were included; 22 reported quantitative data, 16 reported qualitative data, and two reported quantitative and qualitative data relating to antipsychotic-related stigma. Framework synthesis identified four themes: 1) impact of antipsychotic treatment on a) social stigma or b) self-stigma; 2) impact of side effects of antipsychotic treatment on a) social stigma or b) self-stigma; 3) impact of route of administration of antipsychotic treatment on stigma; 4) impact of stigma on the use of antipsychotics.

CONCLUSION

This systematic literature review found that antipsychotic-related social and self-stigma is a factor in non-adherence to antipsychotics. Further research should examine stigma in a wider range of patients and the extent to which clinicians' treatment decisions are impacted by the potential stigma associated with antipsychotic medications.

Attitude and preferences towards oral and long-acting injectable antipsychotics in patients with psychosis in KwaZulu-Natal, South Africa

Background

Patient attitudes to and satisfaction with their treatment are associated with improved adherence. There is a paucity of data on patient drug attitudes and preference to oral compared to long-acting injectable (LAI) antipsychotic treatment.

Aim

To describe patients attitudes and preferences towards oral versus LAI antipsychotic formulations and explore factors associated with their drug attitudes.

Setting

Two psychiatric hospitals in KwaZulu-Natal, South Africa.

Method

A cross–sectional survey of 140 adult outpatients with schizophrenia spectrum disorders receiving LAI with or without oral antipsychotics (a total of 70) were compared to patients receiving oral antipsychotics only (N = 70). A sociodemographic-clinical questionnaire, chart review and the Drug Attitude Inventory scale (DAI–30) were used.

Results

Of the 140 participants, 98 (70%) preferred the medication formulation currently prescribed, and 132 (94.3%) reported a positive drug attitude towards their antipsychotic medication. The adjusted regression analysis indicated that study participants who were currently on a formulation that matched their preference scored better on the DAI-30 than individuals with a mismatch in use and preference (p < 0.04). In terms of covariates, we found, on one hand, that study participants who are divorced (compared to single) with schizophrenia diagnosis (compared to other psychotic or schizoaffective disorder) are more likely to have lower score on DAI-30. On the other hand, we found that study participants with a higher household income and longer duration of the psychotic illness were associated with greater DAI-30 score.

Conclusion

The majority of participants preferred their current oral and LAI formulation. Drug attitude was influenced by several factors, including matched medication use. Focused psychoeducation should be considered for newly diagnosed, lower socio-economic groups and patients with non-affective psychosis to improve drug attitude.

Perceptions of Psychiatrists Toward the Use of Long-Acting Injectable Antipsychotics: An Online Survey Study From India

PURPOSE/BACKGROUND

Despite proven benefits of long-acting injectables (LAIs), these are frequently underused by the psychiatrists. Accordingly, this study aimed to explore the perceptions of psychiatrists toward the use of LAI antipsychotics in their routine clinical practice.

METHODS/PROCEDURE

An online e-mail survey was conducted by using Survey Monkey platform.

RESULTS

A total of 622 psychiatrists with a mean age of 41 years who were in psychiatric practice for approximately 14 years participated in the survey. Participants reported using LAI, mainly for patients with schizophrenia, with LAI prescribed to approximately one-tenth (9.30%) of their patients in acute phase of illness and in one-fifth (18.42%) of patients in stabilization/stable phase. Fluphenazine decanoate (32.7%) was the most commonly used LAI followed by flupenthixol decanoate (19.5%), haloperidol decanoate (17.8%), and olanzapine pamoate (11.1%). The most common reasons for starting LAI were history of medication (100%) and treatment (80.5%) nonadherence, followed by having frequent relapses/exacerbations of symptoms (54.8%). Overall, more than half of the participants felt the level of acceptance of LAI among patients offered to be quite reasonable (54.3%), and mostly, LAIs were used as combination therapy with oral antipsychotics (73.6%). Despite all these, approximately three-fifths (59%) of the participants reported that they underuse LAI to a certain extent, with most common reasons that deter them from using LAI being the cost (55.45%), lack of interest of patients in receiving LAI (42.9%), lack of regular availability (41.3%), and patients being scared of receiving injectables (41.2%).

CONCLUSIONS/IMPLICATIONS

The LAI antipsychotics despite having several benefits are still underused by a substantial proportion of practicing psychiatrists.

Attitude and perceptions of patients towards long acting depot injections (LAIs)

BACKGROUND

Despite the well-established efficacy of the long acting depot injectable (LAIs) antipsychotics, these are significantly underused and underutilized by the mental health professionals, with a belief that patients will not accept the same.

AIMS & OBJECTIVES

To explore the acceptability and perception of patients towards various psychiatric treatments, with specific focus on LAIs. Additionally the study aimed to compare the acceptability of various types of treatments including LAIs between patients with severe mental disorders (Psychotic disorders and Bipolar disorder) and those with Common mental disorders (Anxiety, neurotic and depressive disorders).

METHODOLOGY

A self-designed semi-structured questionnaire was used to evaluate the preferred treatment options of all the new patients attending the psychiatry outpatient clinic of a tertiary care hospital. Depending on the response, they were further probed for the reasons for accepting or rejecting the LAIs.

RESULTS

2659 patients were interviewed who were divided into two groups (Group I - 321 subjects with psychotic disorders and 120 subjects with bipolar affective disorder (BPAD) and Group II - 2218 subjects with neurotic, stress-related and unipolar depressive disorders). More than three-fourth (78.8%) of the participants in the whole study sample opted for tablets only as their first preferred choice and injectables were opted by about 5% of the participants only, with no significant difference between the 2 groups. After being explained about LAIs, one fourth of the participants (24.9%) reported that they may consider LAIs, without any significant difference between the 2 groups. Among those who refused to take LAIs even after explanation, the commonly reported reasons were difficulty in visiting hospital frequently for the injectables (41.69%), injectables being painful (19.41%), fear of injections (13.96%), no need to take LAIs (12.45%) and preference to take some other types of medicines (8.52%).

CONCLUSIONS

Considering the fact that LAIs are highly underused in patients with severe mental disorders and there is lack of awareness about LAIs among patients with severe mental disorders, the present study findings suggest that there is reasonable level of acceptance of LAIs among patients with severe mental disorders when explained about the same.

Positive views on antipsychotic long-acting injections: results of a survey of community patients prescribed antipsychotics

BACKGROUND

We aimed to assess patients' views about antipsychotic long-acting injections (LAIs).

METHODS

We interviewed patients prescribed an antipsychotic (oral or LAI) in our community teams. In a subanalysis, responses were analysed for differences between patients currently receiving an LAI and those prescribed only oral medication.

RESULTS

In total, 226 patients (57%) completed the study questionnaire. The majority agreed that LAIs ensured delivery of the right amount of medication and protection against hospital admissions (57% and 60%, respectively). A minority of participants were more concerned than not about the use of a needle (46%), pain from injection (48%) and the need to travel to receive the injection (34%). A majority expressed a preference for injection site (deltoid or gluteal) (65%) and clinic location (69%). A higher proportion of patients currently receiving an LAI compared with those prescribed oral medication thought an LAI was beneficial because this formulation obviated the need to: swallow tablets (63% versus 41%; p = 0.0013), remember to take tablets daily (75% versus 51%; p = 0.0004), remember tablets when away from home (72% versus 49%; p = 0008). Current LAI users were more likely than those on oral treatment to agree that LAIs keep patients out of hospital (76% versus 44%; p = 0.0001) and that the injection ensured delivery of the right amount of medication (71% versus 44%; p = 0.0002). Women were more likely than men to prefer administration by a clinician of the same gender (34% versus 12%; p = 0.0001).

CONCLUSIONS

In our study, a greater proportion of patients prescribed an LAI regarded LAIs as beneficial compared with those on oral medication.

Healthcare professionals' level of medication knowledge in Africa: a systematic review

AIMS

Understanding how much healthcare professionals (HCPs) know about medication can help in devising strategies to improve rational medication use. This study aimed to synthesize information on the level of medication knowledge of HCPs in Africa.

METHOD

We performed a systematic literature study in Embase and PubMed. We included original studies quantifying HCPs' medication knowledge, published between 2012 and 2016. We extracted disease focus, country, number and type of HCPs included and all medication-related knowledge questions and scored the quality of papers. The outcome measure was the percentage of HCPs who correctly answered medication knowledge questions.

RESULTS

We identified 64 studies from 12 African countries, comprising 13 911 HCPs, mostly nurses/midwifes and physicians. We extracted 306 medication-related knowledge questions, and only 52% (SD 28) of HCPs correctly answered them. Knowledge questions were mainly about medication prescribed for communicable diseases (70%), followed by non-communicable diseases (11%), and family planning/gynaecology (10%). Most papers concluded that there was a considerable medication knowledge gap among HCPs.

CONCLUSION

We found a low level of medication knowledge across different disease areas, countries and HCPs. This underlines the continuous need to strengthen the undergraduate and postgraduate education in (clinical) pharmacology and therapeutics in Africa.

Reliability and validity of the Medication Adherence Rating Scale in a cohort of patients with schizophrenia from Nigeria

INTRODUCTION

Assessing adherence in schizophrenia facilitates interventions that optimize outcomes. Adherence rating questionnaires are feasible and non-intrusive; however, no validated measure exists in sub-Saharan Africa. We aimed to assess the psychometric properties of the 10-item Medication Adherence Rating Scale (MARS).

METHODS

This was a cross-sectional study of a cohort of patients with schizophrenia (n=230). A sociodemographic questionnaire, the Mini International Neuropsychiatric Interview (MINI), Positive and Negative Syndrome Scale (PANSS), Scale for the Unawareness of Mental Disorder (SUMD) and the MARS were all administered by an interviewer.

RESULTS

The MARS demonstrated good reliability (Cronbach's alpha: 0.76). The scale was reducible to a 3-factor construct (1 - medication adherence behavior, 2 - attitude to taking medications, and 3 - negative side effects and attitude to psychotropics), with significant though weak external validity in relation to psychopathology (p<0.001) and insight (p<0.001). The first factor showed good internal consistency (α=0.80), comprising six items that could serve as a reliable proxy measure of adherence in place of the MARS.

CONCLUSION

The MARS demonstrated fair psychometric characteristics in assessing adherence in patients with schizophrenia in this cohort. The scale may be useful in the dimensional assessment of medication adherence for schizophrenia in sub-Saharan African settings.

Perceptions and knowledge of antipsychotics among mental health professionals and patients

Aims and method To assess the patients' most influential concerns regarding long-acting injectable antipsychotics (LAIs) and mental health professionals' preconceptions about these concerns. For both groups, to assess the level of knowledge about LAIs. This cross-sectional study used semi-structured interviews of patients with schizophrenia or schizoaffective disorder (n = 164), nurses (n = 43) and physicians (n = 20). Results The mental health professionals overestimated many of the patients' fears of LAIs, and the expressed fears exceeded the actual experiences of patients already on LAIs. Acceptance to switch to LAIs was associated with shorter time from diagnosis. Nurses and patients disclosed limited knowledge of antipsychotics. Clinical implications Physicians and nurses should aim to identify the individual patient's concerns about LAIs in the discussion about choice of antipsychotic treatment early in the course of illness.