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

Therapeutic Outcomes of Treatment With Long-Acting Injectable Antipsychotics in Forensic Populations With Schizophrenia-Spectrum Diagnoses

The advantages of long-acting injectable antipsychotics (LAIs) in schizophrenia are well studied. However, forensic involvement is common in schizophrenia, and incarcerated individuals are often excluded from clinical trials. Nonadherence and oral medication diversion in forensic populations with schizophrenia, and the relationship between antipsychotic nonadherence and crime support LAI utilization in this subset of patients. Yet, federal regulations limit data generation in forensic populations. This review characterizes data on therapeutic outcomes of LAIs in correctional populations with schizophrenia-spectrum diagnoses. A search for primary literature was conducted in PubMed. Favorable effects of LAIs were observed on adherence, psychiatric symptomatology, patient satisfaction, health care costs, and frequency of criminal charges. Data were primarily retrospective and included small samples and individuals with historical versus current forensic involvement. Although limited, available literature and insights into the correctional system suggest advantages to LAI use in forensic populations. Barriers to conducting research in correctional settings must be addressed to facilitate further data generation.

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.

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.

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.