An evaluation of the use of olanzapine pamoate depot injection in seriously violent men with schizophrenia in a UK high-security hospital

Mental health service utilisation and reoffending in offenders with a diagnosis of psychosis receiving non-custodial sentences: A 14-year follow-up study

OBJECTIVE

While psychosis is considered a risk factor for offending, little is reported about mental health service utilisation in offenders with psychosis and its relationship with reoffending. We examined the association between contact with mental health services and reoffending in those diagnosed with psychosis.

METHODS

We linked health and offending records in New South Wales (Australia) and identified all individuals with a diagnosis of psychosis and a subsequent offence resulting in a non-custodial sentence between 2001 and 2012. We examined the incidence and risk factors for reoffending, and time to reoffending between 2001 and 2015 using Cox regression and Kaplan-Meier survival methods. We specifically examined the association between clinical contact with community mental health services following the index offence and reoffending.

RESULTS

Of the 7393 offenders with psychosis, 70% had clinical contact and 49% reoffended. There was a linear relationship between an increased number of clinical contacts and reduced risk of reoffending: those with no clinical contact had more than a fivefold risk of reoffending compared to those with the highest number of contacts (adjusted hazard ratio = 5.78, 95% confidence interval = [5.04, 6.62]). Offenders with substance-related psychosis and those convicted of non-violent offences had fewer clinical contacts and higher rates of reoffending when compared with controls (adjusted hazard ratio = 1.29, 95% confidence interval = [1.13, 1.47] and adjusted hazard ratio = 1.26, 95% confidence interval = [1.18, 1.35], respectively).

CONCLUSION

This study supports an association between more frequent mental health service use and reduced risk of reoffending. Efforts to enhance mental health service utilisation in those with psychosis who are at a higher risk of reoffending should be promoted.

Olanzapine long-acting injection, discontinuation rates and reasons for discontinuation: 10 years' experience at a UK high-secure hospital

Background

Olanzapine pamoate has been shown to be an effective second-generation long-acting injection. Its popularity has possibly been adversely affected by the rare incidence of post-injection syndrome (PIS) and the associated requirement to monitor for 3 h after each injection.

Objective

This study aimed to collect and present data on the use of olanzapine long-acting injection (OLAI) over a 10-year period in a high-security forensic hospital in South East England.

Design

This was a non-interventional retrospective study collecting information from anonymised electronic patient and prescription records. As per hospital Trust guidelines, patient consent to access of hospital records was presumed unless explicitly withdrawn.

Method

All patients prescribed OLAI between the years 2009 and 2019 were identified. Data collected included date that OLAI was started, stopped, dose range, side effects and concomitant medication.

Results

Of 88 patients who were started OLAI, 45 (51%) continued at month 24. At 60 months, 22 of 70 (31%) patients for whom data were available continued with OLAI. Over 60% of continuers were on higher than recommended doses. Of almost 5000 injections administered, there was 1 episode of PIS.

Conclusion

OLAI is an effective treatment for schizophrenia and schizoaffective disorder, especially when used in patients have been able to tolerate the drug and were stabilised on it for 24 months. In over half the patients who continued OLAI, the doses were higher than that recommended by the manufacturer. The incidence of PIS in this study was very low in comparison with other studies.

Registration code

2049.

Clozapine resistant schizophrenia: Newer avenues of management

About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.

Olanzapine Pamoate Use for Schizophrenia: Retrospective Records Based Study from a Tertiary Care Hospital

BACKGROUND

Little is known from India about the experience of using olanzapine long-acting antipsychotic injectables (LAI). In this background, this study aimed to evaluate the clinical profile of patients suffering from schizophrenia who were prescribed olanzapine LAI and to evaluate the usefulness and acceptability of olanzapine LAI among these patients.

METHODS

In this retrospective study, data of all the patients with schizophrenia receiving olanzapine pamoate, was extracted.

RESULTS

40 patients (males-55%; mean [SD] age- 36.2 (12) years; mean duration of illness (SD) prior to depot-143.3 (115.9) months) were included in the study. Olanzapine LAI was invariably prescribed in patients with a past history of non-compliance. Data was available for a mean (SD) follow-up duration of 17 (10.8) months. The most frequently used dose of olanzapine LAI used was 300 mg every two weeks (55%). This was followed by 405 mg every four weeks in (32.5%). Mean Clinical Global Impression (CGI) Severity score prior to starting of olanzapine LAI was 5.8 (0.7), which reduced to 2.7 (1.1) at the time of last follow-up or the last use of olanzapine LAI, and this was a statistically significant improvement (paired t-test value = 16.41; P < 0.001). Only one (2.5%) patient experienced Post injection Delirium/Sedation Syndrome during the study period. Only one patient was hospitalized after starting depot olanzapine.

CONCLUSION

Olanzapine LAI is mostly used in patients with a history of non-compliance. Olanzapine LAI is associated with a significant reduction in the severity of illness.

Conference proceedings of the 4th Masterclass Psychiatry: Transcultural Psychiatry - Diagnostics and Treatment, Luleå, Sweden, 22-23 February 2018 (Region Norrbotten in collaboration with the Maudsley Hospital and Tavistock Clinic London)

BACKGROUND

According to estimates from the European Commission, Europe has experienced the greatest mass movement of people since the Second World War. More than one million refugees and migrants have arrived in the European Union in the past few years. Mental health and primary care professionals are more likely than ever to meet patients from different cultures and backgrounds.

AIMS

To equip mental health and primary care professionals with transcultural skills to deal with patients from unfamiliar backgrounds.

METHOD

Lectures and case discussions to explore the latest advances in the diagnosis and treatment of serious mental health problems in a transcultural context.

RESULTS

Lectures covered transcultural aspects of mental health problems, treatment in different cultural and ethnic contexts, and assessment of risk factors for self-harm and harm in migrant populations.

CONCLUSIONS

Clinicians require a sound grounding in transcultural skills to confidently and empathically deal with patients from unfamiliar backgrounds.

Reducing the stigma of long acting injectable antipsychotics - current concepts and future developments

BACKGROUND

Long acting injectable antipsychotics (LAI-APs) are considered a major advance in psychiatric treatment concerning treatment adherence and outcomes. Yet, both, doctors and patients remain sceptical.

AIM

To explain the rationale for using LAI-APs, review their effectiveness and explore barriers to use.

METHOD

Clinical overview of LAI-APs from the patient and doctor's perspective.

RESULTS

LAI-APs were developed to increase adherence to treatment, thereby improving treatment outcomes. LAI-APs may reduce the risk of relapse and hospitalisation. Yet, the evidence from the few meta-analyses available remains weak. Both patients and doctors may associate LAI-APs with stigma and coercion. Current means of improving adherence include more focus on the therapeutic relationship, better information, adverse effects minimisation and half-life extension of LAI-APs. Future means of improving adherence include novel administration techniques that abolish the need for injection.

CONCLUSIONS

For both, clinicians and drug developers, drug adherence remains a major target for improving treatment outcomes.

THE USE OF LONG-ACTING ANTIPSYCHOTICS FOR THE MANAGEMENT OF AGGRESSIVENESS IN SCHIZOPHRENIA: A CLINICAL OVERVIEW

Aggressive behaviour represents a challenge in the treatment of patients with schizophrenia, being often associated with clinical predictors of severity of illness such as poor insight, psychotic re-exacerbation, concomitant substance misuse or comorbidity with personality disorders. As psychotic relapses and consequent risk of aggressive behaviour are often associated with a poor compliance, purpose of the present manuscript is to give an overview of the available data about the use of depot antipsychotics for the management of violence in patients with schizophrenia. A research in the main database sources has been conducted to identify relevant papers about the topic. Few studies (most of them retrospective and with small sample sizes) have investigated the effectiveness of depot antipsychotic for the treatment of aggressive behaviour in schizophrenia. Aripiprazole depot appears to be promising for the management of aggressive behaviour of subjects with schizophrenia, however data about its efficacy in the long-term are absent and lack of evidence prevents the recommendation of this compound for the treatment of aggressiveness in subjects affected by schizophrenia. In addition, there is not sufficient evidence to conclude that a specific depot antipsychotic may have a better efficacy on aggressive behaviour of patients affected by schizophrenia. Prospective comparative studies (e.g. with oral clozapine and aripiprazole depot) are needed to assess the real clinical advantage of the use of depot antipsychotic versus oral alternatives for the prevention of violent behaviour in schizophrenia.

Long-acting injectable antipsychotics for prevention and management of violent behaviour in psychotic patients

BACKGROUND AND AIMS

It has been well established that long-term antipsychotic treatment prevents relapse, lowers number of rehospitalisations, and also effectively reduces violent behaviour. Although violent behaviour is not a typical manifestation of schizophrenia or other psychotic disorders, the diagnosis of psychosis increases the overall risk of violence. One of the few modifiable factors of violence risk is adherence with medication. In contrast, non-adherence with drug treatment and subsequent relapse increases risk of violent acts. Non-adherence can be addressed partially by long-acting injectable antipsychotics (LAI). The aim of our review was to examine the role of antipsychotic drugs, especially LAI, in prevention and management of violent behaviour in psychosis.

METHODS

This is a non-systematic, narrative review of the data from open, naturalistic, retrospective, and population studies, case series, and post hoc analyses of randomised controlled trials. Search of electronic databases (PubMed, Embase) was performed to identify relevant papers.

RESULTS

Nine published papers (3 cross-sectional chart reviews, 4 retrospective studies, 2 prospective, randomised trials) were found. The results indicated positive clinical and antiaggressive effects of LAI in psychotic patients with high risk of violent behaviour.

DISCUSSION

Reviewed evidence suggests that secured drug treatment with LAI may have clinical benefit in schizophrenia patients with high risk of violent behaviour. LAI significantly reduced the severity of hostility, aggressivity, number of violent incidents, and criminal offences. These findings are supported further by the empirical evidence from clinical practice, high rates of prescribed LAI to schizophrenia patients in high-security and forensic psychiatric facilities.

CONCLUSIONS

Available data encourage the use of LAI in forensic psychiatry, especially during court-ordered commitment treatment.

Effectiveness of paliperidone depot injection in seriously violent men with comorbid schizophrenia and dissocial personality disorder in a UK high-security hospital

BACKGROUND

High-security hospital patients are often complex in presentation and are characterized by treatment resistance, medication nonadherence and history of violence. Paliperidone is licensed both as an oral and depot antipsychotic medication in the treatment of schizophrenia. Clinical trials have shown that paliperidone depot is well tolerated with similar efficacy to risperidone depot but with additional practical advantages. Whilst data exist for the effectiveness of paliperidone palmitate (PP), there are no studies involving patients in forensic settings or those with comorbid personality disorder. Our aim was to evaluate the effectiveness of PP on violence, aggression and personality disorder symptoms.

METHODS

This project was a retrospective service evaluation involving 11 patients, carried out in a high-security hospital. A combination of patient records and interviews with the treating consultant psychiatrist were used to ascertain a Clinical Global Impression (CGI) score, the effect of PP on specific personality disorder symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol and affective dysregulation) and incidents of violence and aggression. Engagement with occupational and psychological therapies was also evaluated. Metabolic parameters were reviewed.

RESULTS

A total of 6 out of 11 patients continued on PP, most of whom had schizophrenia and dissocial personality disorder with histories of violence. All showed improvement in the CGI score with associated benefits in the three personality symptom domains. Overall, two patients demonstrated a reduction in the risk of violence. There was improvement in engagement with occupational therapy and psychological work. No significant effects on metabolic parameters were noted although hyperprolactinaemia, albeit asymptomatic, was consistently recorded.

CONCLUSIONS

This pragmatic service evaluation of a small but complex patient group demonstrated, for the first time, that PP was effective in reducing violence as well as improving personality pathology across all dimensions: a finding which could have significant implications for management of such high-security patients.

The successful concurrent use of two long-acting depot antipsychotics in a patient with treatment-resistant schizophrenia and history of serious violence: a case report

OBJECTIVE

This case report describes a forensic psychiatric patient presenting with treatment-resistant schizophrenia and serious interpersonal violence complicated by poor adherence to oral medication who was treated successfully with two concurrent long-acting depot antipsychotics.

METHOD

Treatment response was measured for a 6-month period at 6-weekly intervals, post-initiation using the Positive and Negative Symptoms of Schizophrenia with Excited Component score (PANSS-EC), Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression Scale (CGI).

RESULTS

At 6 months, the presentation was found to have markedly improved. The overall PANSS-EC score was reduced by 43.9%, with reductions in Positive Symptom and Excited Component subscales most evident. BPRS Score was reduced from 81 at baseline to 47 at 18 weeks. There was improvement in the patient's level of cooperativeness, aggression and engagement in ward therapeutic activities.

CONCLUSION

Although concurrent use of two depot antipsychotics requires further exploration, there is potential benefit for patient groups presenting with treatment-resistant schizophrenia and poor compliance. Due to risk of serious adverse effects which are difficult to reverse with long-acting formulations, we recommend this option be reserved for this complex patient population and exclusively in care settings allowing close physical health monitoring.

Evaluation of olanzapine pamoate depot in seriously violent males with schizophrenia in the community

OBJECTIVES

Olanzapine is a well established treatment for schizophrenia. The olanzapine pamoate depot (long-acting injectable) formulation improves compliance and clinical trials have shown it to be effective. However, there are no previously published reports evaluating olanzapine depot in violent patients with schizophrenia in the community. We evaluated the clinical efficacy of olanzapine depot, its effect on violence, hospitalization and incarceration in community patients with schizophrenia and prior history of serious violence.

METHODS

This was a retrospective service evaluation in a community forensic psychiatry service where patients had schizophrenia spectrum disorder and a significant history of violence. Treatment resistance, substance use disorders and antisocial personality disorder were common. Nine deidentified patient records were audited for 12 months pre and 12 months post olanzapine depot initiation to identify any clinical changes, breaches of (legislated) psychiatric treatment orders, hospital admission days, days incarcerated and emergency presentations.

RESULTS

Community forensic psychiatric patients treated with olanzapine depot showed an improvement in psychotic symptoms (p = 0.008) with overall decreases in violence, supported by reductions in hospitalization days (p = 0.018) and days incarcerated (p = 0.043). Several patients had reduced psychiatric treatment order breaches and emergency presentations.

CONCLUSIONS

Community forensic psychiatric patients with schizophrenia responded to olanzapine depot with decreased violence and reduced hostility. A depot antipsychotic medication that reduces violence and improves engagement has significant implications for greater effective community management of forensic patients with schizophrenia.

Psychotropic prescribing in seriously violent men with schizophrenia or personality disorder in a UK high security hospital

OBJECTIVES

To analyze antipsychotic prescribing patterns in a UK high security hospital (HSH) that treats seriously violent men with either schizophrenia or personality disorder and examine how different groups consented to treatment and prescribing for metabolic conditions. We hypothesized that there would be high prevalence of antipsychotic polypharmacy, and high-dose antipsychotic and clozapine prescribing.

BACKGROUND

HSHs treat seriously violent, mentally disordered offenders, and the extant literature on prescribing patterns in forensic settings is sparse.

METHODS

Prescribing and clinical data on all 189 patients in a UK HSH were collected from the hospital's databases. Data were analyzed using SPSS.

RESULTS

The population was split into the following groups: schizophrenia spectrum disorder (SSD-only), personality disorder (PD-only), and comorbid schizophrenia spectrum disorder and PD. The majority (93.7%) of all patients were prescribed at least one antipsychotic, and (27.5%) were on clozapine. Polypharmacy was prevalent in 22.2% and high-dose antipsychotic in 27.5%. Patients on clozapine were more likely to be prescribed antidiabetic, statins, or antihypertensive medication. Patients in the PD-only group were more likely to be deemed to have the capacity to consent to treatment and be prescribed clozapine in contrast to the SSD-only group.

CONCLUSIONS

Rates of clozapine and high-dose antipsychotic prescribing were higher than in other psychiatric settings, while polypharmacy prescribing rates were lower. Higher clozapine prescribing rates may be a function of a treatment-resistant and aggressive population. A higher proportion of PD-only patients consented to treatment and received clozapine compared with in-house SSD-only as well as other psychiatric settings. Implications of the findings are discussed.