Why aren't depot antipsychotics prescribed more often and what can be done about it?

Inpatient antipsychotic medication switching and rehospitalization risk among patients with schizophrenia-spectrum disorders

OBJECTIVE

To describe patterns of antipsychotic switching among patients hospitalized for schizophrenia and to correlate antipsychotic switching with hospital readmission risk.

METHODS

We identified 3295 patients with index hospitalizations for schizophrenia or schizoaffective disorder from New York State Medicaid claims 2017-2018 who had filled at least one prescription for an antipsychotic in both the 44 days (one month +14 day grace period) prior to and after their admission. We identified patients who had kept or switched any of their antipsychotic medication between the pre- and post-periods surrounding their index hospitalization. We compared the kept and switched any groups, adjusting for patient characteristics.

RESULTS

Of patients who had filled antipsychotic prescriptions in both the 44 days prior to and after their hospitalization, 1599 (48.6 %) had switched at least one antipsychotic and 1215 (36.8 %) had switched their primary antipsychotic. Switching any antipsychotic was associated with increased hazards of readmission, HR = 1.21, 95%CI 1.09-1.35, which was slightly concentrated during the first 90 days after hospital discharge.

CONCLUSIONS

Switching antipsychotic medications during hospitalization occurs commonly and is associated with higher rehospitalization risk following hospital discharge.

Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers

OBJECTIVE

Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States.

METHODS

The authors conducted a secondary analysis of the 2020-2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing.

RESULTS

Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming.

CONCLUSIONS

Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.

Unraveling ethnic disparities in antipsychotic prescribing among patients with psychosis: A retrospective cohort study based on electronic clinical records

BACKGROUND

Previous studies have shown mixed evidence on ethnic disparities in antipsychotic prescribing among patients with psychosis in the UK, partly due to small sample sizes. This study aimed to examine the current state of antipsychotic prescription with respect to patient ethnicity among the entire population known to a large UK mental health trust with non-affective psychosis, adjusting for multiple potential risk factors.

METHODS

This retrospective cohort study included all patients (N = 19,291) who were aged 18 years or over at their first diagnoses of non-affective psychosis (identified with the ICD-10 codes of F20-F29) recorded in electronic health records (EHRs) at the South London and Maudsley NHS Trust until March 2021. The most recently recorded antipsychotic treatments and patient attributes were extracted from EHRs, including both structured fields and free-text fields processed using natural language processing applications. Multivariable logistic regression models were used to calculate the odds ratios (OR) for antipsychotic prescription according to patient ethnicity, adjusted for multiple potential contributing factors, including demographic (age and gender), clinical (diagnoses, duration of illness, service use and history of cannabis use), socioeconomic factors (level of deprivation and own-group ethnic density in the area of residence) and temporal changes in clinical guidelines (date of prescription).

RESULTS

The cohort consisted of 43.10 % White, 8.31 % Asian, 40.80 % Black, 2.64 % Mixed, and 5.14 % of patients from Other ethnicity. Among them, 92.62 % had recorded antipsychotic receipt, where 24.05 % for depot antipsychotics and 81.72 % for second-generation antipsychotic (SGA) medications. Most ethnic minority groups were not significantly different from White patients in receiving any antipsychotic. Among those receiving antipsychotic prescribing, Black patients were more likely to be prescribed depot (adjusted OR 1.29, 95 % confidence interval (CI) 1.14-1.47), but less likely to receive SGA (adjusted OR 0.85, 95 % CI 0.74-0.97), olanzapine (OR 0.82, 95 % CI 0.73-0.92) and clozapine (adjusted OR 0.71, 95 % CI 0.6-0.85) than White patients. All the ethnic minority groups were less likely to be prescribed olanzapine than the White group.

CONCLUSIONS

Black patients with psychosis had a distinct pattern in antipsychotic prescription, with less use of SGA, including olanzapine and clozapine, but more use of depot antipsychotics, even when adjusting for the effects of multiple demographic, clinical and socioeconomic factors. Further research is required to understand the sources of these ethnic disparities and eliminate care inequalities.

Long-acting antipsychotics in the treatment of schizophrenia: opportunities and challenges

INTRODUCTION

Maintenance antipsychotic treatment improves multiple outcomes in people with schizophrenia. These benefits are challenged by medication nonadherence, which is a common occurrence. Long-acting injectable antipsychotic (LAI) formulations were developed to reduce nonadherence and thereby improve outcomes. This narrative review is based on a PubMed search (January 2000 - August 2022) for studies on LAI antipsychotics.

AREAS COVERED

Opportunities and challenges associated with LAIs are reviewed. Advantages, compared to oral antipsychotics (OAs), include improved adherence, reduced relapse and hospitalization risk, delayed and lower relapse risk after stopping treatment, and the ability to differentiate true treatment resistance from 'pseudo'-resistance. Additionally, LAIs are associated with lower all-cause mortality than OAs. LAIs are under-used in many services, partly reflecting negative attitudes, misconceptions, and lack of knowledge among clinicians, patients, and carers. Practical barriers to LAI use include acquisition costs and inadequate service structures to administer/monitor LAI treatment.

EXPERT OPINION

The education and engagement of clinicians, patients and caregivers can assist more informed decision-making regarding LAIs. Future research regarding LAIs should encompass multiple complementary designs, focus on functionality and recovery outcomes, and include groups at high risk of relapse, including those with comorbid substance use disorders and early in the course of schizophrenia.

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.

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.

Efficacy of long-acting injectable versus oral antipsychotic drugs in early psychosis: A systematic review and meta-analysis

AIM

Long-acting injectable antipsychotic drugs (LAIs) are often used as an alternative to oral antipsychotics (OAPs) in individuals with psychosis who demonstrate poor medication adherence. Previous meta-analyses have found mixed results on the efficacy of LAIs, compared to OAPs, in patients with psychotic disorders. The objective of this meta-analysis was to compare the effectiveness of using LAIs versus OAPs in the early stages of psychosis.

METHODS

Major electronic databases were used to search for any studies examining the comparative effectiveness (i.e., relapse, adherence, hospitalization, and all-cause discontinuation) of any LAIs versus OAPs in early stages of psychosis. Studies published up to 6 June, 2019 were included and no language restriction was applied. Inclusion criteria were a diagnosis of schizophrenia or related disorder, where patients were in their first episode or had a duration of illness ≤5 years. Data were analysed using a random-effects model.

RESULTS

Fifteen studies (n = 10 584) were included, of which were 7 RCTs, 7 observational studies, and 1 post-hoc analysis. We found that LAIs provided advantages over OAPs in terms of relapse rates. No significant differences were found between LAI and OAP groups in terms of all-cause discontinuation, hospitalization, and adherence rates. However, considering only RCTs revealed advantages of LAIs over OAPs in terms of hospitalization rates.

CONCLUSIONS

LAIs may provide benefits over OAPs with respect to reducing relapse and hospitalization rates in early psychosis patients. There is a need for larger and better-designed studies comparing OAPs and LAIs specifically in early psychosis patients.

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.

Effect of long acting injectable antipsychotics on course and hospitalizations in bipolar disorder - a naturalistic mirror image study

PURPOSE

To determining whether the addition of a long-acting injectable antipsychotic (LAI-AP) has a positive effect on prognosis in bipolar disorder.

MATERIALS AND METHODS

Medical records of patients with bipolar disorder who were using LAI-AP at least for one year in the community mental health center (CMHC) until March 2020 were investigated. Comparisons were made between the period of one year before and after the initiation of LAI-AP. Hospital admission was the primary outcome. Residual symptom severity and functionality were evaluated with Personal and Social Performance Scale (PSP), Young Mania Rating Scale (YMRS), and Beck Depression Inventory (BDI).

RESULTS

There were 197 patients with bipolar disorder who were attending to the CMHC and 17 of them were under maintenance treatment with LAI-AP for at least one year. The LAI-APs used were aripiprazole (n = 8), paliperidone (n = 5) and risperidone (n = 4). Duration of illness was 13.5 ± 8.02 years and duration of LAI-AP treatment was 24.8 ± 22.74 months (median: 18). During the one-year period after the LAI-AP initiation, there were fewer days spent in hospital (2.5 ± 5.68 vs. 15.5 ± 20.59 days, p = .026) and the number of hospitalizations was lower than the year before the LAI-AP use (0.1 ± 0.39 vs. 0.9 ± 1.24 hospitalizations, p = .013). During the recovery period with LAI antipsychotics, there were mild residual symptoms presented with mean PSP (70.2), YMRS (1.7) and BDI (7.6) scores.

CONCLUSION

LAI-AP use may have positive effect on course for selected patients with a long history of bipolar disorder.

New approaches to antipsychotic medication adherence - safety, tolerability and acceptability

INTRODUCTION

Antipsychotic pharmacotherapy is considered a first-line treatment in schizophrenia-related disorders and is associated with favorable prognosis and lower mortality rates. However, low adherence rates present a major clinical challenge. In this paper, we will review contemporary approaches to improve adherence to antipsychotic treatment, considering their mechanism of action, safety, tolerability and acceptability.

AREAS COVERED

Novel pharmacological delivery methods included different routes of administration of registered medications (such as intramuscular clozapine preparation and transdermal asenapine), modifications of existing compounds (such as 3-monthly injectable formulation of paliperidone palmitate), and increased interest in oral long-acting medication formulations (such as with penfluridol). In addition, we reviewed innovative technology to monitor adherence, based on the use of electronic digital medicine systems and ingestible sensors.

EXPERT OPINION

All of these diverse approaches were clinically relevant in enhancing treatment adherence and found to be safe and tolerable. The place of each approach is predicated on a personalized approach in each patient, and future research could usefully use large comparative studies to establish robust treatment guidelines. The implementation of new and varied approaches to antipsychotic treatment adherence is welcomed and have the potential to make a significant impact on morbidity in this often difficult-to-treat population.

Patient subjective experience of treatment with long-acting injectable antipsychotics: a systematic review of qualitative studies

ABSTRACT Objective: To gain a better understanding of how long-acting injectable antipsychotic (LAI) therapy is perceived by patients. Methods: A search for qualitative studies has been carried out on PubMed, Google Scholar, PsycINFO and PsycArticles, yielding 11 studies suitable for a review of qualitative studies. The reporting approach chosen was meta-ethnography, following the ENTREQ statement recommendations. Key concepts common to the different studies were extrapolated and then analysed in a systematic and comparative way. Results: Some recurrent issues were associated with LAIs, such as fear of coercion, fear of needles and lack of knowledge about depot therapy. These topics are linked to each other and the patients most concerned about the disadvantages of LAIs are those who are less informed about them, or who have experienced coercion and trauma during hospitalisation. On the other hand, patients who had already received LAIs, and those who had a good therapeutic relationship with their healthcare providers expressed satisfaction with this form of treatment and its continuation. Conclusion: Long-acting injectable antipsychotics are a tool in the management of mental disorders, and a viable alternative to oral medication. Patients show curiosity towards this method of administration, but lack of knowledge is a common finding. Shared decision making about the use of LAIs antipsychotics requires that patients receive accurate information and support for their decision regarding medication.

Focused Ethnographic Examination of Barriers to Use of Long-Acting Injectable Antipsychotics

OBJECTIVE

The authors designed this project to identify barriers to using long-acting formulations of antipsychotics.

METHODS

The authors used a focused ethnographic approach. Patients, psychiatrists, nurses, therapists and administrators were interviewed about barriers to use of long-acting injectable (LAI) antipsychotics at six facilities in New York State, as were representatives from insurance firms, a pharmaceutical company, and a national professional organization. Interviews were conducted and analyzed by a central team not affiliated with the institutions.

RESULTS

Interviews were obtained with 23 patients, 16 psychiatrists, three nurses, 23 therapists, 14 administrators, four insurers, one representative from a pharmaceutical industry, and one representative from a national organization. Major barriers identified from the interviews included restricting discussions about LAI medication to only patients with nonadherence or repeated hospitalizations; inadequate education efforts with patients about LAI antipsychotics; inadequate support for patients making medication decisions; lack of communication within the treatment team about issues relevant to use of LAI formulations by patients; therapists' limited knowledge about LAI antipsychotics, which restricted their role in supporting patients making treatment decisions; psychiatrist concerns about the pharmacologic properties of LAI formulations; lack of clinic infrastructure to support LAI prescriptions; and payer concerns about whether the immediate costs of LAI administration would translate into later potential cost benefits.

CONCLUSIONS

Effective shared decision making about use of LAI antipsychotics requires that patients receive accurate information and support for their decision making. The training needs and administrative support requirements of all team members should be considered to provide patients with the information and support required.

Attitudes of European physicians towards the use of long-acting injectable antipsychotics

BACKGROUND

Prescription rates for long-acting injectable (LAI) antipsychotic formulations remain relatively low in Europe despite improved adherence over alternative oral antipsychotic treatments. This apparent under-prescription of LAI antipsychotics may have multiple contributing factors, including negative mental health practitioner attitudes towards the use of LAIs.

METHODS

The Antipsychotic Long acTing injection in schizOphrenia (ALTO) non-interventional study (NIS), conducted across several European countries, utilised a questionnaire that was specifically designed to address physicians' attitudes and beliefs towards the treatment of schizophrenia with LAI antipsychotics. Exploratory principal component analysis (PCA) of feedback from the questionnaire aimed to identify and characterize the factors that best explained the physicians' attitudes towards prescription of LAIs.

RESULTS

Overall, 136/234 solicited physicians returned fully completed questionnaires. Physicians' mean age was 48.5 years, with mean psychiatric experience of 20.0 years; 69.9% were male, 84.6% held a consultant position, and 91.9% had a clinical specialty in general adult care. Most physicians considered themselves to have a high level of clinical experience with LAI antipsychotics (77.2%), with an increased rate of LAI antipsychotics prescription over the last 5 years (59.6%). Although the majority of physicians (69.9%) declared feeling no difference in stress levels when offering LAI compared to oral antipsychotics, feelings of 'no/more stress' versus 'less stress' was found to influence prescription patterns. PCA identified six factors which collectively explained 66.1% of the variance in physician feedback. Multivariate analysis identified a positive correlation between physicians willing to accept usage of LAI antipsychotics and the positive attitude of colleagues (co-efficient 3.67; p = 0.016).

CONCLUSIONS

The physician questionnaire in the ALTO study is the first to evaluate the attitudes around LAI antipsychotics across several European countries, on a larger scale. Findings from this study offer an important insight into how physician attitudes can influence the acceptance and usage of LAI antipsychotics to treat patients with schizophrenia.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Long-acting atypical antipsychotics in schizophrenia: A systematic review and meta-analyses of effects on functional outcome

OBJECTIVE

Impairment in psychosocial function is common in schizophrenia. Long-acting injectable atypical antipsychotics are thought to enhance psychosocial function by boosting adherence. However, no systematic review has examined the effects of long-acting injectable atypical antipsychotics on psychosocial function in clinical trials.

METHODS

We searched major databases including Medline/PubMed, PsychINFO, EMBASE, CINAHL, Scopus, Web of Science, Cochrane Central Register of Controlled Trials and Clinical Trial Registries for randomised controlled trials that compared long-acting injectable atypical antipsychotics to placebo, oral antipsychotic medications or long-acting injectable atypical antipsychotics for all years till 2018, with no language limits. We performed a systematic review of findings on change in psychosocial function and its predictors in the included reports. Data on change in psychosocial functioning were meta-analysed using a random-effects model.

RESULTS

A total of 26 studies were included in systematic review, and 19 studies with 8616 adults, 68.1% males were meta-analysed. Long-acting injectable atypical antipsychotics were superior to placebo (standardised mean difference = 0.39; 95% confidence interval = [0.32, 0.47]; p < 0.001; I² = 0%; 9 studies) and oral antipsychotic medications (standardised mean difference = 0.16; 95% confidence interval = [0.01, 0.31]; p = 0.04; I² = 77%; 10 studies) for improved psychosocial function and superiority was maintained in short- and long trials. Poor psychosocial function was predicted by longer treatment duration, severe symptoms, poor cognition and poor insight. Functioning was assessed by either a single or a combination of measures, but was not the primary outcome in most studies. Other sources of bias include poor blinding and reporting of randomisation.

CONCLUSION

Long-acting injectable atypical antipsychotics are beneficial for recovery of psychosocial function in comparison with placebo, but the magnitude of superiority over oral antipsychotic treatment was small. Severe psychopathology at baseline predicted poor psychosocial function. Future effectiveness trials in which post-randomisation involvement is kept to a minimum, and psychosocial function is included as primary outcome a priori, are needed to capture the real-world impact of long-acting injectable atypical antipsychotics and to address methodological biases.

Once-Monthly Subcutaneously Administered Risperidone in the Treatment of Schizophrenia: Patient Considerations

Adherence to antipsychotic medications is a major challenge in schizophrenia. Long-acting injectable antipsychotics have been shown to offer advantages over oral formulations. A new extended release formulation of risperidone for subcutaneous injection was developed to address issues of non-adherence. The aim of this manuscript was to compare the new subcutaneous formulation to currently available formulations of injectable risperidone and paliperidone to determine whether the novel delivery by subcutaneous injection may provide substantial benefits. A literature search was conducted using PubMed, OVID, and Cochrane Library electronic databases to assess the advantages and disadvantages of long-acting formulations of risperidone. Potential advantages of risperidone for subcutaneous injection include a simplified dosing and ease of administration. Potential disadvantages include injection site pain and medication cost.

Second-generation antipsychotic long-acting injections in bipolar disorder: Systematic review and meta-analysis

BACKGROUND

Non-adherence is a significant problem in bipolar disorder. Second-generation antipsychotics (SGA) long-acting injections (LAIs) may improve adherence in bipolar disorder and may prevent relapses. However, the evidence is limited and conflicting.

OBJECTIVE

The objective of this study was to evaluate efficacy and safety of SGA LAIs in bipolar disorder.

METHOD

Systematic review and meta-analysis of randomised controlled trials (RCTs) (≥6 months duration) investigating safety and efficacy of SGA LAIs for bipolar disorder. We searched Pubmed, Embase, CINAHL, Cochrane, PsycINFO, LiLACS, www.clinicaltrials.gov up to October 2016. We also contacted the manufacturers of SGA LAIs. Primary efficacy and safety outcomes were relapse rate and all-cause discontinuation respectively.

RESULTS

Total of seven RCTs (n = 1192) were included. SGA LAIs show superiority over placebo for study-defined relapse rate (RR = 0.58, 95% CI = 0.49-0.68, P < 0.00001) and all-cause discontinuation (RR = 0.72, 95% CI = 0.64-0.82, P < 0.00001). However, no significant difference was found between SGA LAIs and oral active control for relapse rate (RR = 0.92, P = 0.79) and all-cause discontinuation (RR = 1.2, P = 0.31). In terms of secondary outcomes, SGA LAIs performed better than placebo in relapse to mania/hypomania, young mania rating scales (YMRS), clinical global impression-severity (CGI-S), montgomery-asberg depression rating scale (MADRS). There was no significant difference between SGA LAIs and oral active control regarding relapse to mania/hypomania, YMRS, CGI-S, extra-pyramidal side effects (EPSEs), weight gain. However, the active control performed better than SGA LAIs in relapse to depression, MADRS, and prolactin-related AEs.

CONCLUSIONS

Current evidence is very limited to support the use of SGA LAIs (compared to oral medication) in bipolar disorder. Further high-quality studies, particularly comparing SGA LAIs with active control, are warranted.

Factors associated with first- versus second-generation long-acting antipsychotics prescribed under ordinary clinical practice in Italy

Background

For many years, long-acting intramuscular (LAI) antipsychotics have been prescribed predominantly to chronic and severe patients, as a last resort when other treatments failed. Recently, a broader and earlier use of LAIs, particularly second-generation LAIs, has been emphasized. To date, few studies attempted to frame how this change in prescribing took place in real-world practice. Therefore, this study aimed to describe the clinical features of patients prescribed with LAIs, and to explore possible prescribing differences between first- and second-generations LAIs under ordinary clinical practice in Italy.

Methods

The STAR Network “Depot” Study is an observational, longitudinal, multicenter study involving 35 centers in Italy. In the cross-sectional phase, patients prescribed with LAIs were consecutively recruited and assessed over a period of 12 months. Descriptive statistics and multivariable logistic regression analyses were employed.

Results

Of the 451 recruited patients, 61% were males. The level of social and working functioning was heterogeneous, as was the severity of disease. Seventy-two per cent of the patients had a diagnosis of the schizophrenia spectrum. Seventy per cent were prescribed with second-generation antipsychotic (SGA) LAIs (mostly paliperidone, aripiprazole and risperidone). Compared to first-generation antipsychotic (FGA) LAIs, patients prescribed with SGA LAIs were more often younger; employed; with a diagnosis of the schizophrenia spectrum or bipolar disorder; with higher levels of affective symptoms; with fewer LAI prescriptions in the past.

Discussion

LAIs’ prescribing practices appear to be more flexible as compared to the past, although this change is mostly restricted to SGA LAIs.

Long-acting injectable antipsychotics for the treatment of schizophrenia in Spain

Antipsychotics are an essential component in the treatment of schizophrenia. Long-acting injectable formulations (LAI) arose to improve adherence with the associated potential of reducing the risk of relapse. The objective of this article is to analyze the use of LAI antipsychotics in Spain, which is similar to other European countries but with a predominance of the use of second generation LAI, to discuss the possible causes of prescribing differences with respect to other countries (including organizational aspects, attitudes of psychiatrists, patients and family members, and clinical practice guidelines), and to discuss their use in acute psychiatric units, first episode, and in children and adolescents. In our view, while it is necessary to increase existing evidence regarding the advantages of LAI antipsychotics and the differentiation between LAI antipsychotics currently available, their use will likely continue to grow driven by clinical experience.

To trust or not to trust? Faith issues in psychopharmacological prescribing

Aims and Method

To ascertain attitudes, awareness, knowledge and variations in prescribing habits of psychiatrists when addressing issues of faith, culture and dietary requirements (in keeping with the General Medical Council's and the Royal College of Psychiatrists' guidelines), and how these may affect the trust in doctor–patient relations. We undertook a cross-sectional postal survey aimed at clinicians in South West Yorkshire Mental Health Trust.

Results

We obtained 38 responses (40% of the total number of questionnaires sent out) from two mailshots. Although the majority of respondents indicated that they were aware of the presence of potentially forbidden animal-derived ingredients in medication, only half expressed the view that a discussion regarding the above should take place prior to prescribing such medication.

Clinical Implications

Diversity training combined with taking a genuine interest in patients' wishes will not only minimise ‘mistrust’ but also facilitate prescribing in a therapeutic relationship.

When taking medication may be a sin: dietary requirements and food laws in psychotropic prescribing

Religious laws do not usually forbid the use of psychotropic medication, but many do forbid the consumption of animal-based derivatives of bovine and/or porcine origin (e.g. gelatin and stearic acid) such as are found in many medications. Demonstrating awareness of this, combined with a genuine concern about how it affects the patient, may strengthen the doctor—patient relationship and avoid non-adherence. In this article, we outline dietary requirements of key religions and belief systems that may have a bearing when prescribing medication containing animal-based ingredients. We identify common psychotropics that contain animal-based derivatives and suggest alternative prescribing options and approaches to dealing with sensitive ethical issues.

Insight and treatment attitude in schizophrenia: comparison of patients on depot and atypical antipsychotics

Aims and Method

To establish if participants with schizophrenia receiving depot antipsychotics had less insight than similar participants receiving oral atypical antipsychotics. We assessed the difference between these two groups.

Results

Participants on oral antipsychotics had greater insight than those on depot antipsychotics (ITAQ, P=0.01). In the multiple regression analysis, only receiving depot antipsychotics contributed significantly to explaining variance in insight (adjusted R2=0.135, F=8.99, P=0.004).

Clinical Implications

Depot antipsychotics seem to be prescribed to a subgroup of people with schizophrenia who are likely to be less adherent because of lower levels of insight. These individuals are on significantly higher doses of antipsychotic medication. Clinicians should review their patients on depot antipsychotics at regular intervals.

Why indeed? Invited commentary on… Why aren't depot antipsychotics prescribed more often and what can be done about it?

A recent review concluded that replicated, evidence-based studies have demonstrated several areas of advantage for long-acting antipsychotics over oral antipsychotics. These include improved global outcome and reduced risk of rehospitalisation, psychopharmacological benefits such as more consistent bioavailabilty and more predictable dose–blood level correlations, an improved pharmacokinetic profile allowing lower dosages to be used with a consequent reduced likelihood of side-effects, and a reduced burden of care when injections are required only every 2–6 weeks (Robert & Geppert, 2004). Further, if a patient relapses despite receiving uninterrupted depot treatment, this indicates the need to consider reasons for deterioration other than poor adherence. However, perhaps the critical advantage over oral preparations is the avoidance of covert non-adherence (Barnes & Curson, 1994). With depot treatment, any decision by the patient not to continue medication will be signalled by failure to attend for, or refusal of, injection. The clinical team can therefore act to intervene appropriately, bearing in mind that non-adherence may be both a cause and consequence of worsening of illness. Lastly, with depot preparations the risk of self-poisoning is reduced.

Why are long-acting injectable antipsychotics still underused?

‘Depot antipsychotics' (‘long-acting injectable antipsychotic medications' or LAIs) are underused in the treatment of schizophrenia (including first episodes) and, possibly, of schizophrenia with comorbid substance use disorders. Patients' and clinicians' beliefs and attitudes, and service barriers, affect best practice and evidence-based care in LAI prescription. Poor medication adherence is a key reason for LAI prescription, but patients receiving LAIs may still relapse or experience significant side-effects. Patients' and clinicians' attitudes towards antipsychotic medication, as well as the quality of their recovery-focused relationship, are key factors in adherence. Clinicians should avoid a dichotomous ‘oralv. LAI’ choice: LAIs may have a place at various stages in the continuum of care and they should be one of the options discussed with any patient requiring long-term treatment, even early in the illness course. Many clinicians need better education about LAIs and greater familiarity with schizophrenia treatment guidelines.

Converting oral to long-acting injectable antipsychotics: a guide for the perplexed

There has been increasing recognition that antipsychotic nonadherence is common across all stages of schizophrenia, starting from the first episode. Moreover, numerous meta-analyses of the existing literature indicate superiority of long-acting injectable (LAI) over oral antipsychotics when one adjusts for the greater illness severity and duration among patients in LAI antipsychotic trials. The increasing availability of LAI antipsychotic options has raised interest in converting patients from oral medication; however, the successful transition from oral to the comparable LAI antipsychotic requires an understanding of the current extent of antipsychotic exposure, the kinetics of the LAI preparation, and the expected plasma levels achieved by the LAI formulation. The purpose of this article is to provide, in a concise format, the essential information for converting patients to the LAI forms of haloperidol, fluphenazine, risperidone, paliperidone, olanzapine, and aripiprazole from the comparable oral medication, and how the use of plasma antipsychotic levels can be invaluable for this process.

Does formulation matter? A systematic review and meta-analysis of oral versus long-acting antipsychotic studies

Recently, many authors highlighted the potential advantages of a broader prescription of long-acting injectable antipsychotics (LAIs) based on various assumptions, including favorable pharmacokinetic features. In this systematic review, data from randomized controlled trials comparing LAIs versus the oral formulation of the same antipsychotic were meta-analyzed in order to ascertain whether the route of administration may be associated with a different efficacy and tolerability profile. Of 21 included studies, 18 contributed to the meta-analysis, providing data for risperidone, olanzapine, aripiprazole, zuclopenthixol, fluphenazine and haloperidol. For all drugs, the number of dropouts for any reason (primary outcome) did not differ between the two formulations, except for a small effect in favor of LAI aripiprazole (2 comparisons; 986 patients; relative risk (RR) 0.78; 95% confidence interval (CI) 0.64 to 0.95). Similarly, no differences emerged in terms of dropouts for adverse events, extrapyramidal symptoms, prolactin increase (except for a small advantage for LAI risperidone), weight gain, non-response rate, relapse rate, and dropouts for inefficacy (except for a small advantage for oral olanzapine). Data on aripiprazole proved to be of high quality according to the GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation), therefore we are confident that the effect estimate is close to the true effect. Data on risperidone were of moderate quality, while data on olanzapine, fluphenazine, zuclopenthixol and haloperidol were of low quality. In conclusion, there is no robust evidence to support doctors in choosing LAI instead of oral formulations in order to obtain better tolerability and efficacy.

Indications for and use of long-acting injectable antipsychotics: consideration from an inpatient setting

Studies have examined the differences in sociodemographic/clinical characteristics between patients on long-acting injectable (LAI) versus oral medications. However, most studies did not focus specifically on patients for whom LAIs would clearly be indicated. We performed a chart review of patients with schizophrenia or schizoaffective disorder. Patients were categorized as having an 'indication for an LAI' or not on the basis of their adherence history. Patients for whom an LAI was indicated and prescribed on discharge were then compared with similar patients for whom an LAI was not prescribed. Of 305 charts reviewed, consisting of 279 unique patients, 27.2% were judged to have an indication for an LAI (n=76), but only 32.9% of these (n=25) were discharged on an LAI. In the multiregression model, being African American, residing in a psychiatric residence, having a previous history of an LAI trial, and being treated with a higher antipsychotic dose were predictive of LAI prescription. It is important to focus on the population who are not likely to receive an LAI, but who have such indications for treatment.

Establishing a physical health monitoring service for patients on depot antipsychotic medication

INTRODUCTION

Patients with major mental illness are recognised to be at risk of premature death for a multitude of reasons. This initiative aimed to improve the physical health monitoring of patients prescribed depot antipsychotic medication in a catchment area of ~36 000 in Ireland.

OBJECTIVES

International best practice recommends monitoring of blood tests, physical parameters such as weight, BMI, waist circumference and blood pressure, and side effects of patients prescribed antipsychotic medication. A clinic was established to target these interventions.

METHODS

A cohort of patients receiving antipsychotics in long-acting injectable form was chosen. A twice-yearly, multidisciplinary health monitoring clinic was established. Evaluation involved an audit of medical records which measured the proportion of those attending the clinic who had blood test monitoring and physical parameters recorded.

RESULTS

Before the clinic's implementation, 30% of patients had evidence of some blood test monitoring, 9% had evidence of complete blood testing and one patient had evidence of physical health parameters having been recorded. One year after the implementation 78% of patients had evidence of some blood test monitoring, 61% had evidence of full blood test monitoring and 100% had evidence of physical parameters recorded.

CONCLUSIONS

The clinic was positively received by patients, and led to improved teamwork. Recommendations include organising concurrent psychiatric and phlebotomy clinics so that patients may avail of psychiatric review and blood testing at a single appointment. As a result of the increased focus on physical health monitoring, a similar project is planned to target all patients prescribed antipsychotics.

Antipsychotic prescribing and its correlates in New Zealand

OBJECTIVES

Antipsychotics are the cornerstone of schizophrenia management. There is substantial literature on their efficacy and optimal use. Doubts remain, however, regarding the translation of this knowledge into day-to-day practice. This study aimed to investigate antipsychotic prescribing in three New Zealand regions and its relationship to clinical guidelines and patient characteristics.

METHODS

We studied 451 patients discharged from inpatient units with a diagnosis of schizophrenia or a related disorder (International Classification of Disease, version 10) between July 2009 and December 2011. Available information included patient demography, legal status, prescribed medications, duration of index admission and prescriber's country of postgraduate training and years of postgraduate experience.

RESULTS

There was a high rate (33.7%) of multiple antipsychotic prescription, and lower than expected clozapine use (20%); Maori were prescribed clozapine more frequently than non-Maori (24% vs. 13%, respectively). Compulsory treatment was associated with more use of injectable medication and increased length of stay in hospital. Clinician characteristics did not significantly influence prescribing.

CONCLUSIONS

Observed prescribing practice aligned with existing guidelines except for antipsychotic polypharmacy and clozapine under-utilisation.

A systematic review and meta-analysis of the effect of depot antipsychotic frequency on compliance and outcome

BACKGROUND

Depot antipsychotics are commonly used to improve adherence and clinical outcomes such as relapse and readmission. Dosing regimens vary but are commonly two- and four-weekly. To date, the effect of administration at two-weekly or four-weekly intervals on outcome has not been examined in a meta-analysis.

AIMS

A systematic review and meta-analysis on whether the frequency of depot antipsychotic administration (e.g., two- vs four-weekly) makes any difference to compliance and outcome.

METHODS

A systematic search of Medline, EMBASE and PsycInfo for RCTs that compared the frequency of depot administration (e.g., two- vs four-weekly) for an equivalent dose. Outcomes were compliance, psychiatric symptomatology, quality of life, adverse drug reactions (ADRs), patient preference, admission rates, bed-days and costs.

RESULTS

Seven studies from eight papers (n=3994) were found covering olanzapine, paliperidone, risperidone, haloperidol and fluphenazine enanthate/decanoate with follow-up of up to one year. Meta-analyses were possible for psychotic symptoms and ADRs. There were no differences in psychotic symptoms or quality of life between two- and four-weekly doses. Health service use was not reported. For ADRs, the only significant difference detected was that two-weekly injections were less likely to lead to site pain (RR 0.16, 95% CI 0.07-0.38; 2 studies n=1667). There were no differences in other ADRs.

CONCLUSIONS

There were surprisingly little data on the effect of dosing frequency for an equivalent dose on clinical outcomes. There is a need for long-term studies of a wide range of outcomes including cost-effectiveness. Claims for advantages of new preparations over others require careful evaluation.

The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal

Despite their widespread use, long-acting injectable (LAI) antipsychotics (APs) are often regarded with some negativity because of the assumption of punishment, control and insufficient evolution towards psychosocial development of patients. However, LAI APs have proved effective in schizophrenia and other severe psychotic disorders because they assure stable blood levels, leading to a reduction of the risk of relapse. Therapeutic opportunities have also arisen after introduction of newer, second-generation LAI APs in recent years. Newer LAI APs are more readily dosed optimally, may be better tolerated and are better suited to integrated rehabilitation programmes. This review outlines the older and newer LAI APs available for the treatment of schizophrenia, with considerations of past and present pharmacological and therapeutic issues. Traditional, evidence-based approaches to systematic reviews and randomized clinical trials are of limited utility in this area so this paper's blending of experimental trials with observational research is particularly appropriate and effective.

[French Society for Biological Psychiatry and Neuropsychopharmacology task force: Formal Consensus for the prescription of depot antipsychotics]

BACKGROUND

Compliance is often partial with oral antipsychotics and underestimated for patients with serious mental illness. Despite their demonstrated advantages in terms of relapse prevention, depot formulations are still poorly used in routine. As part of a process to improve the quality of care, French Association for Biological Psychiatry and Neuropsychopharmacology (AFPBN) Task Force elaborated a Formal Consensus for the prescription of depot antipsychotics in clinical practice.

METHODS

The Task Force recommends as first-line choice, the use of long-acting injectable (LAI) second-generation antipsychotics in patients with schizophrenia, schizoaffective disorder and delusional disorder. They can be considered as a second-line option as a monotherapy to prevent manic recurrence or in combination with mood stabilizer to prevent depressive recurrence in the maintenance treatment of bipolar disorder. LAI second-generation antipsychotics can also be used after a first episode of schizophrenia. Depot neuroleptics are not recommended during the early course of schizophrenia and are not appropriate in bipolar disorder. They are considered as a second-line option for maintenance treatment in schizophrenia.

RESULTS

LAI formulations should be systematically proposed to any patients for whom maintenance antipsychotic treatment is indicated. LAI antipsychotics can be used preferentially for non-compliant patients with frequent relapses or aggressive behaviors.

CONCLUSION

A specific information concerning the advantages and inconveniences of the LAI formulations, in the framework of shared-decision making must be delivered to each patient. Recommendations for switching from one oral/LAI form to another LAI and for using LAI antipsychotics in specific populations (pregnant women, elderly patients, subjects in a precarious situation, and subjects having to be treated in a prison establishment) are also proposed.

Guidelines for the use and management of long-acting injectable antipsychotics in serious mental illness

BACKGROUND

Long-acting injectable (LAI) formulations are not widely used in routine practice even though they offer advantages in terms of relapse prevention. As part of a process to improve the quality of care, the French Association for Biological Psychiatry and Neuropsychopharmacology (AFPBN) elaborated guidelines for the use and management of antipsychotic depots in clinical practice.

METHODS

Based on a literature review, a written survey was prepared that asked about 539 options in 32 specific clinical situations concerning 3 fields: target-population, prescription and use, and specific populations. We contacted 53 national experts, 42 of whom (79%) completed the survey. The options were scored using a 9-point scale derived from the Rand Corporation and the University of California in the USA. According to the answers, a categorical rank (first-line/preferred choice, second-line/alternate choice, third-line/usually inappropriate) was assigned to each option. The first-line option was defined as a strategy rated as 7-9 (extremely appropriate) by at least 50% of the experts. The following results summarize the key recommendations from the guidelines after data analysis and interpretation of the results of the survey by the scientific committee.

RESULTS

LAI antipsychotics are indicated in patients with schizophrenia, schizoaffective disorder, delusional disorder and bipolar disorder. LAI second-generation antipsychotics are recommended as maintenance treatment after the first episode of schizophrenia. LAI first-generation antipsychotics are not recommended in the early course of schizophrenia and are not usually appropriate in bipolar disorder. LAI antipsychotics have long been viewed as a treatment that should only be used for a small subgroup of patients with non-compliance, frequent relapses or who pose a risk to others. The panel considers that LAI antipsychotics should be considered and systematically proposed to any patients for whom maintenance antipsychotic treatment is indicated. Recommendations for medication management when switching oral antipsychotics to LAI antipsychotics are proposed. Recommendations are also given for the use of LAI in specific populations.

CONCLUSION

In an evidence-based clinical approach, psychiatrists, through shared decision-making, should be systematically offering to most patients that require long-term antipsychotic treatment an LAI antipsychotic as a first-line treatment.

Understanding depot antipsychotics: an illustrated guide to kinetics

Long-acting injectable (LAI) antipsychotics can have considerable advantages over oral medications for the management of patients with schizophrenia. Despite the high prevalence of treatment nonadherence with oral pharmacotherapy, LAI antipsychotics are significantly underutilized in this patient population. The availability of newer LAI antipsychotic preparations combined with a resurgent interest in the use of typical antipsychotics has rekindled awareness of the value of LAI medications. This article is intended to provide a visual understanding of the various kinetic profiles of LAI antipsychotics to facilitate initiation and greater use of these agents.

Effect of prior treatment with antipsychotic long-acting injection on randomised clinical trial treatment outcomes

BACKGROUND

It is uncertain whether antipsychotic long-acting injection (LAI) medication in schizophrenia is associated with better clinical outcomes than oral preparations.

AIMS

To examine the impact of prior treatment delivery route on treatment outcomes and whether any differences are moderated by adherence.

METHOD

Analysis of data from two pragmatic 1-year clinical trials in which patients with schizophrenia were randomised to either an oral first-generation antipsychotic (FGA), or a non-clozapine second-generation antipsychotic (SGA, CUtLASS 1 study), or a non-clozapine SGA or clozapine (CUtLASS 2 study).

RESULTS

Across both trials, 43% (n = 155) of participants were prescribed an FGA-LAI before randomisation. At 1-year follow-up they showed less improvement in quality of life, symptoms and global functioning than those randomised from oral medication. This difference was confined to patients rated as less than consistently adherent pre-randomisation. The relatively poor improvement in the patients prescribed an LAI pre-randomisation was ameliorated if they had been randomised to clozapine rather than another SGA. There was no advantage to being randomly assigned from an LAI at baseline to a non-clozapine oral SGA rather than an oral FGA.

CONCLUSIONS

A switch at randomisation from an LAI to an oral antipsychotic was associated with poorer clinical and functional outcomes at 1-year follow-up compared with switching from one oral antipsychotic to another. This effect appears to be moderated by adherence, and may not extend to switching to clozapine. This has implications for clinical trial design: the drug from which a participant is randomised may have a greater effect than the drug to which they are randomised.

Naturalistic outcomes of community treatment orders: antipsychotic long-acting injections versus oral medication

BACKGROUND

Community treatment orders (CTOs) are initiated to compel the patient in the community to take part in a management plan, of which medication is often a part. CTOs were introduced in 2008, in England and Wales. We evaluated naturalistic outcomes of CTOs, according to the antipsychotic formulation prescribed at CTO initiation.

METHODS

A cohort study with prospective consecutive sampling and 1-year follow-up was conducted in a large mental health trust in South London. Measures included: demographics, psychotropics and CTO outcomes. Comparison groups were long-acting injection (LAI) versus oral formulations only, for the primary outcomes of time to CTO cessation in days and time to first hospital admission in days, whilst the CTO remained active.

RESULTS

For the 188 included patients, the CTO ceased within 1 year, either due to revocation (22.3%), discharge (28.1%) or lapse (19.7%). The CTO was renewed at 6 months for 92 (48.9%) patients, and then 56 (29.8%) were renewed again at 12 months. The antipsychotic formulation at CTO initiation was more likely to be LAI (60.6%) than oral (39.4%). Time to CTO cessation was longer for LAI than oral (median 251 versus 182 days, p = 0.030). A total of 54 patients experienced at least one admission; there was no difference between groups by drug formulation (oral 28.4% versus LAI 28.9%, p = 0.933). The mean time to first admission was 147.1 days and did not differ by formulation.

CONCLUSIONS

CTO duration was longer for those prescribed an antipsychotic LAI at CTO initiation, although the time to first admission and number of admissions did not differ between groups. CTOs not only compel treatment, but bind services to the patient, resulting in more intensive follow up. Whether enhanced treatment, via oral or LAI and enabled by the CTO, translates into improved clinical outcomes is yet to be determined.

A qualitative study of experiences with and perceptions regarding long-acting injectable antipsychotics: Part I-patient perspectives

OBJECTIVE

Despite the well-acknowledged problem of poor adherence to antipsychotic (AP) medication, long-acting injectables (LAIs) that could improve adherence are underused in Canada. Attitudes concerning LAIs among patients and psychiatrists may contribute to this underuse. Our objective was to investigate perceptions of and attitudes toward LAIs among patients in Canada.

METHOD

Focus groups were conducted with 34 patients with a diagnosis of schizophrenia spectrum psychoses in 4 Canadian provinces. The focus groups inquired about experiences with and attitudes toward LAI APs. The sessions were audiotaped and transcribed verbatim, and transcripts were coded using a combination of deductive and inductive methods.

RESULTS

Four themes emerged: awareness of and knowledge about LAIs; perceptions about LAIs; cost and convenience considerations; and issues arising from the coercive context under which LAIs were often prescribed. Nine patients had never heard about LAIs, and some others reported not having understood what was discussed with them regarding LAIs. Patients had typically heard about LAIs in either a context of coercion or of medication nonadherence. Patients had positive and negative perceptions concerning LAIs. The positive perceptions centred on relapse prevention and reduced effort in ensuring adherence, and the negative perceptions centred on financial costs and the inconvenience of appointments to receive injections.

CONCLUSION

To enhance LAI usage, some of the issues that need to be addressed are the inadequacy of information given to patients, the element of coercion involved in LAI introduction, the pragmatic barriers to LAI uptake by patients, and negative subjective perceptions about LAIs.

Working alliance and its relationship to outcomes in a randomized controlled trial (RCT) of antipsychotic medication

BACKGROUND

Long acting injections (LAI) have been associated with perceptions of coercion in cross sectional studies but there have been no longitudinal studies of the effects on clinical relationships with newer depot medications.

METHOD

Randomized controlled trial with (50) participants with a diagnosis of schizophrenia randomized to risperidone LAI or oral atypical antipsychotic medication. The main outcome was the Working Alliance Inventory (WAI) with background variables (symptoms, side effect, social functioning, quality of life) measured before randomization and at two years.

RESULTS

At follow-up (14 risperidone LAI and 16 oral medication) analyses including predictors of missing data and baseline score showed a trend for those on risperidone LAI to reduce WAI score and those on oral medication showing no change. Sensitivity analyses showed (i) a significant detrimental effect of LAI on WAI and (ii) the pattern of results was not affected by change in symptoms over the study.

CONCLUSION

This is the first study to show that the prescription of depot atypical depot medication is associated with detrimental effects on clinical relationships after 2 years of continual treatment.

Clinician hesitation prior to clozapine initiation: is it justifiable?

Clozapine has been endorsed by national clinical guidelines for 10 years and yet underutilisation and delay to initiation remain rife. Although there will be good clinical reasons for clozapine not being initiated for some patients, it is hypothesised here that for others, clinicians' attitudes and preferences are the most likely predictive factors.

Patients' acceptance of the deltoid application of risperidone long-acting injection

OBJECTIVE

Recently risperidone long-acting injection (RLAI) was approved for alternative injection into the deltoid muscle in addition to the already established injection into the gluteal muscle. For the first time two different injection locations of a long-acting antipsychotic injection can be offered to patients. Their actual acceptance is of key interest.

EXPERIMENTAL PROCEDURES

We surveyed 60 patients stabilized on gluteal RLAI therapy in our depot outpatient clinic. Participants were offered the possibility of switching to the alternative deltoid injection in a standardized manner. Prior to switching patients scored the extent of perceived pain and experienced level of shame through the present gluteal injection therapy on a 7-point-scale. Patients choosing to switch were followed up after three months and asked to report on their individual experience.

RESULTS

Switching to the deltoid application was chosen by 34 out of 60 patients. Three months later 15 patients were still receiving deltoid injections. The main reason for their staying with the deltoid injection was improved practicability as reported by these patients and 13 out of 15 patients clearly preferred the new location over the gluteal application. The main reason for returning to the gluteal injection was the pain experienced through the injection in the deltoid. Patients' initial decision whether to switch was not correlated with either perceived pain or the experienced level of shame through the preceding gluteal injections.

CONCLUSIONS

The application of RLAI in the deltoid muscle is viewed as an alternative to the injection in the gluteal muscle by a considerable number of patients. Nevertheless, some patients experience increased injection pain through this application location while others perceive the switch as beneficial in terms of practicability. Therefore offering both injection locations with their respective pros and cons should become standard in the RLAI treatment offered.

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

BACKGROUND

Antipsychotic long-acting injections (LAIs) reduce covert nonadherence with medication in the clinical management of psychotic disorders. However, they are variably utilised by clinicians, especially in the long term. Factors including poor knowledge, stigma and perceived coercion can all adversely influence LAI utilisation. Previous research has emanated almost exclusively from developed countries. This study explores the knowledge and attitudes of psychiatrists and trainees in Nigeria towards LAIs.

METHODS

A cross-sectional study was undertaken among mental health professionals in Nigeria using a pre-existing questionnaire.

RESULTS

Participant psychiatrists (n = 128) expressed positive attitudes towards LAIs. Their knowledge concerning LAIs and its side effects was fair. The participants reported that nearly half (41.7%) of their patients with a psychotic illness were on LAIs. Those who reported a high prescribing rate for LAIs (>40%) were more likely to endorse more positive 'patient-centred attitudes' (p < 0.04). In contrast to previous reports, psychiatrists reported that patients were less likely to feel ashamed when on LAIs, though most endorsed the statement that force was required during LAI administration.

CONCLUSION

The desirability of treatment by injections differs in Africa in comparison to Western cultures, possibly due to the increased potency that injections are perceived to have. This is perhaps evidenced by high rates reported for use of LAIs. Nigerian psychiatrists had positive attitudes to LAIs but their knowledge, particularly regarding side effects, was fair and needs to be improved. Providing information to patients prior to antipsychotic treatment may enhance informed consent in a country where medical paternalism is still relatively strong.

Monitoring and documentation of side effects from depot antipsychotic medication: an interdisciplinary audit of practice in a regional mental health service

This audit reviewed current practice within a rural mental health service area on the monitoring and documentation of side effects of antipsychotic depot medication. A sample of 60 case files, care plans and prescriptions were audited, which is 31% of the total number of service users receiving depot injections in the mental health service region (n= 181). The sample audited had a range of diagnoses, including: schizophrenia, schizoaffective disorder, bipolar affective disorder, depression, alcoholic hallucinosis and autism. The audit results revealed that most service users had an annual documented medical review and a documented prescription. However, only five (8%) case notes examined had documentation recorded describing the condition of the injection site, and alternation of the injection site was recorded in only 28 (47%) case notes. No case notes examined had written consent to commence treatment recorded. In 57 (95%) of case notes, no documentation of recorded information on the depot and on side effects was given. The failure to monitor and record some blood tests was partly attributed to a lack of clarity regarding whose responsibility it was. A standardized checklist has been developed as a result of the audit and this will be introduced by all teams across the service.

Applying Motivational Interviewing to the initiation of long-acting injectable atypical antipsychotics

OBJECTIVE

Non-concordance with pharmacotherapy is common in psychiatric patients. Long-acting injectable atypical antipsychotic (LAI AA) medication may improve adherence but patients and clinicians may be reluctant to consider this alternative. This paper describes the application of Motivational Interviewing (MI) to the commencement of LAI AA.

METHOD

We developed a workshop applying the principles of MI to address medication adherence through the use of LAIs. This includes a training video to illustrate the following motivational techniques, as summarised by the acronym OARS: (a) Open questions; (b) Affirmation of patients' self-efficacy and support; (c) Reflections of patients' thoughts, desires, abilities, reasons, needs, and commitments; (d) Summaries of the patient's history to promote consideration of change.

RESULTS

We delivered four workshops across Canada. Results of feedback (n=25) were encouraging.

CONCLUSIONS

Motivational Interviewing has many applications in psychiatric care for engagement in treatment, reduction in alcohol or substance misuse, and improving medication acceptance and adherence. Further research is required to assess whether changes in physicians' views are reflected in improved adherence.

Treatment adherence with early prescription of long-acting injectable antipsychotics in recent-onset schizophrenia

Although response to treatment for the first episode of schizophrenia is generally favourable, nonadherence with the treatment is the first cause of relapse and rehospitalisation within the next few years. Long-acting injectable antipsychotics (LAIAs) combine the advantages of the newer antipsychotics and the long-acting formulation. The evaluation concerns 25 schizophrenic patients hospitalised for the first time, treated with risperidone long-acting injectable (RLAI) associated with reintegration methods, and followed up for at least 18 months. Clinical observation was completed using Clinical Global Impression (CGI) scale and Global Assessment of Functioning (GAF). Clinical improvement was coupled with a good reintegration rate, very few relapse, or rehospitalisation. Bimonthly injection combined with psychosocial methods improved interactive followup, and therefore patients' compliance with the treatment. Treating with LAIA as early as possible, from the first episode if possible, can reduce relapse, number and duration of rehospitalisation, and cognitive symptoms and improve the quality of life and prognosis.

Role of long-acting injectable second-generation antipsychotics in the treatment of first-episode schizophrenia: a clinical perspective

Approximately 80% of patients with the first-episode schizophrenia reach symptomatic remission after antipsychotic therapy. However, within two years most of them relapse, mainly due to low levels of insight into the illness and nonadherence to their oral medication. Therefore, although the formal data available is limited, many experts recommend prescribing long-acting injectable second-generation antipsychotics (mostly risperidone or alternatively paliperidone) in the early stages of schizophrenia, particularly in patients who have benefited from the original oral molecule in the past and agree to receive long-term injectable treatment. Early application of long-acting injectable second-generation antipsychotics can significantly reduce the risk of relapse in the future and thus improve not only the social and working potential of patients with schizophrenia but also their quality of life.

Patient and Health Care Provider Perspectives on Long Acting Injectable Antipsychotics in Schizophrenia and the Introduction of Olanzapine Long-Acting Injection

Olanzapine long acting injection has joined risperidone and paliperidone as the second generation long acting antipsychotic injection options for treatment of patients with schizophrenia. Long acting injections are important alternatives to oral medications for patients who have difficulty adhering to daily or multiple daily medication administrations, yet may be underutilized or not well understood. Patient perceptions, adherence, and preferences are important issues for health care providers to address when discussing treatment options with their patients. Reviewed here are overall patient and health care provider attitudes and perceptions regarding long acting injections and the details of olanzapine long acting injectable, the newest agent, and how it will fit in the marketplace. In addition, efficacy, safety, dosing and use data regarding this newest long acting agent are reviewed and compared to other available long acting agents.