Combining depot antipsychotic medications with novel antipsychotics in forensic patients: a practice in search of a principle

Current status and features of antipsychotic prescriptions in Japanese forensic psychiatric wards based on a forensic inpatient database

AIM

Psychopharmacotherapy plays an important role in the treatment of mentally disordered offenders (MDOs) with schizophrenia spectrum disorders. However, there have been few large-scale reports from multiple forensic psychiatric wards. This study aimed to clarify the current state of antipsychotic medications for MDOs with schizophrenia spectrum disorders in Japanese forensic psychiatric wards.

METHODS

Medical information, including age, sex, psychiatric diagnosis, index offense, seclusion or restraint experience during hospitalization, and medication for patients discharged from 32 forensic wards nationwide between September 1, 2019 and December 31, 2021 was provided by the Database Scientific Utilization Project of Japanese forensic psychiatric wards. We analyzed the data of MDOs with schizophrenia spectrum disorders who were prescribed psychotropic medications at the time of discharge, especially focusing on comparing differences between the three groups (clozapine, long-acting injection (LAI), and other medications).

RESULTS

A total of 362 MDOs with schizophrenia spectrum disorders were prescribed psychotropic medications at discharge. The prescription rates of clozapine and LAI were 23.2% and 24.9%, respectively. Additionally, the rate of antipsychotic polypharmacy was 37.8%. Among the three groups, the clozapine group had the highest rate of seclusion experience (46.4%), a long mean length of hospitalization (1758 days), and the lowest rate of antipsychotic polypharmacy (4.8%). Olanzapine was the most commonly prescribed antipsychotic medication.

CONCLUSION

This study revealed the current state of antipsychotic medications for MDOs admitted to forensic psychiatric wards in Japan. Future studies are needed to clarify the relevance of antipsychotic medications in the prognosis of MDOs.

Nationwide study on antipsychotic polypharmacy among forensic psychiatric patients

This nationwide retrospective cross-sectional study examines the prevalence of antipsychotic polypharmacy (APP) and demographic, forensic, and clinical factors associated with its practice among Greenlandic forensic psychiatric patients. We collected data from electronic patient files, court documents, and forensic psychiatric assessments. We defined APP as two or more concurrent prescriptions of antipsychotic medication. The study population of 74 patients had a mean age of 41.4 years, and 61 were men. All included patients had either schizophrenia or another ICD-10 F2-diagnosis. We used unpaired t-tests and Chi² or Fisher's exact test. The prevalence of APP was 35% (n = 26), and there was a significant association between APP and a prescription of clozapine (Chi², p = 0.010), olanzapine (Fisher's test, p = 0.003), and aripiprazole (Fisher's test, p = 0.013). Furthermore, we found a significant association between APP and prescription of a first-generation antipsychotic (FGA) (Chi², p = 0.011). Despite recommendations in guidelines, the use of APP is common practice. The majority of forensic psychiatric patients suffer from severe psychiatric disorders, often with other comorbidities, including substance use disorder. The severity and complexity in mental health render forensic psychiatric patients at high risk of APP treatment. Further knowledge on APP use is crucial to secure and further improve the psychopharmacological treatment for this group of patients.

The Prevalence and Factors Associated With Antipsychotic Polypharmacy in a Forensic Psychiatric Sample

Despite clinical guidelines limiting the use of multiple concomitant antipsychotics to the most exceptional and treatment resistant cases, the prevalence of antipsychotic polypharmacy has been increasing worldwide. There has been minimal research investigating the prevalence of antipsychotic polypharmacy in forensic psychiatric samples and the correlates associated with antipsychotic polypharmacy. This cross-sectional study aimed to establish the prevalence of antipsychotic polypharmacy in a forensic psychiatric inpatient sample and to investigate the demographical, clinical, and forensic factors associated with polypharmacy. All patients (N = 142) were prescribed at least one antipsychotic at the time of the study. Antipsychotic polypharmacy was prescribed to 54.93% of patients. Logistic regression results indicated increased length of hospitalization, high/medium security level, treatment with clozapine, and depot antipsychotic prescription were predictive of being placed on an antipsychotic polypharmacy regimen. The results suggest that those who are prescribed multiple antipsychotics are long stay patients who present with higher clinical complexity. The results from this study can be used to inform clinical practice leaders about the prevalence of antipsychotic polypharmacy in a forensic psychiatric institution. More research is needed to understand the clinical justifications for prescribing multiple antipsychotics in a forensic psychiatric sample and ways to safely reduce the prevalence of antipsychotic polypharmacy.

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

Long-acting depot antipsychotics were developed specifically to promote treatment adherence (compliance) and they are a valuable option for patients requiring maintenance medication for schizophrenia. Depot use has fallen in recent years, perhaps owing to the introduction of oral atypical antipsychotics. Psychiatrist and patient acceptance of depot medication is variable. The depot formulation and the traditional ‘depot clinic’ seem to have an image problem, although many patients already receiving depot medication like it. Some psychiatrists may not adequately consider the risks and benefits when contemplating prescribing depot medication. Further, public opinion and planning forces in psychiatric health services may have a negative influence on the use of long-acting treatments. This review considers possible reasons for underutilisation of depot antipsychotics in maintenance treatment of schizophrenia and highlights the potential benefits and future role of depot drugs.

Prevalence of multiple antipsychotic use and associated adverse effects in Australians with mental illness

AIM

This article analyzes the prevalence of use of concurrent multiple antipsychotics and high dosage treatment in people with mental illness, to assess the burden of antipsychotic drug-related side-effects associated with multiple use, and to identify strategies shown to reduce antipsychotic polypharmacy.

METHODS

Literature reviewed was sourced from MEDLINE, Embase, CINAHL, InformIT, PsycINFO, International Pharmaceutical Abstracts, Cochrane Library database and Joanna Briggs Institute databases to identify Australian studies published between January 2000 and February 2015. Studies that reported prevalence of multiple antipsychotic use or addressed the issue of antipsychotic drug-related side-effects were included. Systematic reviews, randomized controlled trials, and observational pre-post studies of Australian and international interventions aiming to reduce multiple antipsychotic use in mental health settings were also identified.

RESULTS

Nineteen studies reporting prevalence of multiple antipsychotic use were identified. The proportion of patients taking more than one antipsychotic ranged from 5 to 61%. Of the studies assessing dosages used, between one-third and one-half of all patients taking multiple antipsychotics received doses higher than recommended. Data from one national study reported that people taking multiple antipsychotics were more likely to experience at least one side-effect in comparison to consumers taking a single antipsychotic (90 verses 80%).International evidence of direct trials of conversion from treatment regimens involving multiple antipsychotics to those based on monotherapy show that between 50 and 75% of people with serious mental illness could be successfully converted to single-agent treatment, with up to 25% obtaining an improvement in health and the remaining 50% staying well managed.

CONCLUSION

Use of multiple antipsychotics is common among Australian people with mental illness, despite guidelines recommending that only one antipsychotic should be used in most cases. People taking more than one antipsychotic at a time are more likely to experience side-effects, and to receive higher than recommended antipsychotic doses. Direct trials that aimed to reduce multiple antipsychotic use suggest it is possible to effectively reduce therapy in the majority of people without worsening outcomes. Simple educational programmes targeting health professionals have not been found to be effective; however, complex multifaceted programmes and quality improvement programmes have demonstrated effect.

A systematic review of psychotropic drug prescribing for prisoners

OBJECTIVE

To conduct a review of the literature on prescribing psychotropic drugs for prisoners.

METHODS

Articles were retrieved from nine databases, reference lists, citations, governmental prison websites, and contact with authors. The articles included were written in English, focused on adults' time as prisoners, included at least one drug of interest, and discussed prescribing. Thirty-two articles met these inclusion criteria.

RESULTS

Five main themes were identified from the reviewed studies: polypharmacy, high-dose therapy, duration of treatment, documentation and monitoring, and issues associated with the prisoners' environment.

CONCLUSIONS

Consideration of these themes within the included studies identified areas for future research, particularly models of good practice, as numerous descriptions of poor practice exist. Policy-makers and prescribers should review current systems and practices, to ensure the care being offered to prisoners is optimal.

Prescribing patterns and the use of therapeutic drug monitoring of psychotropic medication in a psychiatric high-security unit

The aim of this study was to investigate the use of psychotropic medication and therapeutic drug monitoring in a high-security psychiatric unit and to compare the doses and serum concentrations both with the recommended intervals and with the doses and serum concentrations in a control group. One hundred thirty-two patients were admitted in the period from January 2000 to December 2005. All available samples were used when comparing serum concentrations and doses with the recommended ranges. For the comparison of doses and serum concentration-to-dose (C:D) ratios with the control group only 1 sample from each patient was used. A total of 459 analyses of 27 different drugs in samples from 8 women and 73 men were included. The median number of therapeutic drug monitoring analyses per patient was 4 (range 1-29). Thirty-seven of the 81 patients (46%) used 2 or more antipsychotics at the same time. Clozapine, lamotrigine, olanzapine, quetiapine, ziprasidone, and zuclopenthixol were often given in doses above the recommended. The serum levels were frequently above those recommended for clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and zuclopenthixol. The serum levels were significantly higher in the study group than in the control group for clozapine, lamotrigine, quetiapine, and zuclopenthixol. The given dose was significantly higher in the study group than in the control group for clozapine, lamotrigine and zuclopenthixol. The C:D ratio was significantly lower in the study group than in the control group for olanzapine but higher for quetiapine. The non-evidence based practice of high-dose polypharmacy with several antipsychotics is widely used in this unit. The use of higher doses in the study group than in the control group was not due to differences in metabolism or adherence to treatment between the 2 groups. The frequent use of therapeutic drug monitoring did not seem to have a great impact on the prescribed doses.

Antipsychotic long-acting injections: prescribing practice in the UK

BACKGROUND

Data from the USA, Australia and Europe suggest that the proportion of patients with schizophrenia prescribed an antipsychotic long-acting injection (LAI) varies from around a quarter to a third. Use of LAIs has been associated with male gender and younger age.

AIMS

To characterise the use of LAIs in people with schizophrenia in three clinical settings in the UK.

METHOD

The study used audit data from quality improvement programmes conducted by the Prescribing Observatory for Mental Health.

RESULTS

Long-acting injections were found to be prescribed for between a quarter and a third of patients, depending on the clinical setting. Flupentixol, risperidone and zuclopenthixol were most commonly prescribed and were combined with an oral antipsychotic in half of cases, frequently constituting high-dose prescribing. The use of LAIs was not consistently associated with age, gender or ethnicity.

CONCLUSIONS

Antipsychotic LAIs are commonly prescribed. We did not replicate previous findings with respect to demographic variables associated with their use.

Antipsychotic medication and length of stay at a psychiatric maximum-security unit in Norway (1987-2000)

The aim of this study was to evaluate psychopharmacological treatment and the length of stay (LOS) of patients with schizophrenia in a maximum-security psychiatric unit. Data were collected from the hospital files of 82 consecutively admitted patients with schizophrenia who were both admitted and discharged between the years 1987 and 2000. Psychotropic medication and LOS at the time of discharge were registered. Ninety-five per cent of the patients received antipsychotic medication. Zuclopenthixol was the most frequent medication, given to 43% of the patients. Antipsychotic polypharmacy was found in 20% of the cases. Twenty-seven per cent of the patients were medicated with doses above the recommended therapeutic dose range. During the study period, there was no change in the administration and number of psychotropics, but there was an increase in the dosage of antipsychotics. However, LOS was unchanged during the same time. This supports other findings, which suggest that there is no clinical benefit of higher antipsychotic dosage. It is suggested that an optimized medication practice could yield beneficiary effects, not only for schizophrenic symptoms, but also for violence in schizophrenic patients.

Comparative efficacy and safety of long-acting risperidone and risperidone oral tablets

A double-blind study of long-acting injectable risperidone and oral risperidone tablets was conducted in 640 patients with schizophrenia. All patients received flexible doses of 1-6 mg of oral risperidone for 8 weeks. Doses were stable during weeks 5-8. At the end of week 8, symptomatically stable patients were randomly assigned to receive long-acting risperidone (active injections, dummy oral) or continued oral risperidone (dummy injections, active oral) for 12 weeks. Significant improvements were demonstrated from baseline to endpoint in Positive and Negative Syndrome Scale (PANSS) total (P<0.001) and factor scores (P<0.05) in both groups. According to a noninferiority analysis, the two treatments showed comparable efficacy in total PANSS scores over the short-term. No unexpected adverse events were recorded. The findings indicate that symptomatically stable patients can be safely switched from oral risperidone to long-acting injectable risperidone without compromising efficacy.

Evidence for use of depot neuroleptic medication

OBJECTIVE

To review the evidence guiding conventional and atypical depot neuroleptic usage.

METHOD

A search of biomedical electronic databases including Medline, Embase, PsychInfo and Cochrane was performed. Hand searching of journals was also carried out.

RESULTS

Depot neuroleptics are safe and effective in the maintenance treatment of patients with schizophrenia. There is some evidence to support the use of depot neuroleptics in illnesses other than schizophrenia. The evidence base guiding depot usage is sparse.

CONCLUSIONS

Although guidelines are emerging there is a pressing need for rigorous well designed trials of depot antipsychotic usage. The advent of atypical depot antipsychotic preparations should stimulate research in this important area of clinical practice.

Atypical and conventional depot medications

The introduction of atypical antipsychotics created a therapeutic dilemma between choosing the oral novel antipsychotic or the conventional depot form. Clinicians want the advantages of both, resulting in higher levels of polypharmacy. Modern psychiatry is probably in a transitional stage from the depot culture to safer oral medications or even to a safer depot culture.