Depot Antipsychotic Medication Research Articles

Quality Improvement Project - Initial survey of a new Mental Health of Intellectual Disabilities Service established in Ireland in January 2022

Introduction A new mental health service specialising in intellectual disabilities in Ireland was set up in January 2022. Its current compliment of staff includes is a Consultant Psychiatrist, Trainee Psychiatrist, Social Worker and Administrator. The current National Directive in Ireland is to prioritize Mental Health of Intellectual Disabilities services. Objectives The aim of the project is to establish the current baseline level of diagnostics and interventions within the new service. Our aim is to develop this service by implementing and following the gold standard guidelines and determine what extra resources does the service need. Methods The first fifty case notes of patients assessed by the new service were inspected. The reviewer looked for evidence of the following clinical descriptions:Diagnosis of Intellectual Disabilities and its severity; Mental Capacity; Psychiatric Diagnoses; Physical health diagnoses; Medications and evidence of a Positive Behavioural Support Plan to manage complex challenging behaviours. Results The fifty patient audit contained 38 (76%) men and 12 (24% women) . One patient had Mild Intellectual Disabilities (ID), 39 (78%) had Moderate ID and 10 (20%) had Severe ID. All patents were very vulnerable and had limited or lacking Mental Capacity. Common diagnoses of the following were recorded in the following numbers and percentages; - Autism diagnosis 30 ( 60% ); Epilepsy 19 (38%); & Down Syndrome 9 (18%). A Formal Psychiatric diagnosis was identified in 26 (52%) of patients. Challenging Behaviour (severe and complex) was identified for 41 ( 82%) of the patients. The full breakdown of psychiatric diagnoses was ‘Psychotic illness’ – 9 (18%); Anxiety – 7(14%); Bipolar Affective Disorder 5 (10%): Depression – 4(8%); Attention Deficit Hyperactivity Disorder (ADHD) 3 (6%); Obsessive Compulsive Disorder (OCD) – 2(4%); Dementia – 2(4%): Post Traumatic Stress Disorder (PTSD) – 1 (2%); & Schizoaffective Disorder 1(2%). A Positive Behavioural Support plan (PBS) was available to support 33 (66%) of patients. 42 (84%) of patients were prescribed antipsychotic medication. 12 (24%) were prescribed more than one antipsychotic. 20 (40%) were prescribed an antipsychotic without a formally documented diagnosis of a psychotic disorder. 12 (24%). Conclusions The results of this first survey highlight areas in which the service can be improved. The service has requested funding for a Community Nurse and a Psychologist. Psychological evaluations and Positive Behavioural Support plans are essential for people with complex challenging behaviours. A Community Nurse should assist with Health Promotion and help supervise patients requiring Depot Antipsychotic medication or Clozapine. We also plan to set up a joint clinic with the Consultant Neurologist on a regular basis. Disclosure of Interest None Declared

Impact of diagnosis on outcomes for compulsory treatment orders in New Zealand.

Compulsory community treatment orders (CTOs) are controversial because they enforce psychiatric treatment of patients in the community. It is important to know which patients benefit from compulsory treatment to better inform CTO use. To examine the effect of a range of diagnoses on outcomes associated with CTOs to determine whether there are specific outcome signatures for CTOs according to diagnosis. New Zealand's Ministry of Health databases provided demographic, service use and medication-dispensing data for all individuals placed on a CTO between 2009 and 2018. We used a hierarchical approach to categorise individuals according to diagnosis. Admission rates, admission days per year, community care and medication dispensing were analysed according to diagnosis and CTO status. In total, 14 726 patients were placed on a CTO over the 10-year period between 1 January 2009 and 31 December 2018. For psychotic disorders, CTOs were associated with reduced admission frequency and duration. However, the opposite occurred for dementia disorders, bipolar disorders, major depressive disorder and personality disorders. Higher rates of medications, including depot antipsychotic medications, were dispensed on CTOs for all diagnostic groups. CTOs were associated with reduced admission frequency and admission days per year for patients with psychotic disorders, whereas the opposite occurred for other diagnostic groups. Rather than seeking to establish whether CTOs are effective, we suggest that there are specific outcome signatures associated with CTOs for different disorders and knowledge of these can improve understanding and clinical practice in this area.

Physical Health Monitoring of Patients Prescribed Depot Antipsychotic Medication in North West Edinburgh Community Mental Health Team (CMHT)

AimsTo assess the effect of interventions in the physical health monitoring of patients prescribed depot antipsychotic medications. We hypothesised that compliance with monitoring would improve post-intervention. It is well recognised that patients with severe mental illness have a significantly reduced life expectancy. Depot antipsychotic medication increases the risk of cardiovascular disease, metabolic syndrome, stroke and type 2 diabetes. The SIGN guidelines recommend that all patients on antipsychotic medications should have annual physical health monitoring. Baseline data of patients on depot antipsychotic medication in North West (NW) Edinburgh CMHT in 2019 demonstrated that this was not being achieved. We sought to create interventions to improve compliance with physical health monitoring for patients on depot antipsychotic medication.MethodsBaseline data were collected in 2019 for all patients under NW Edinburgh CMHT receiving depot antipsychotic medication (60 patients). The data addressed 9 domains including smoking status, blood monitoring, BMI and physical monitoring.Following the baseline data collection interventions were put in place to increase compliance with monitoring. These interventions included a physical health questionnaire and training of staff in the CMHT to perform phlebotomy and ECGs.Following these interventions the data (74 patients) were re-audited in 2020 following the same domains.After this initial re-audit a physical health monitoring clinic was implemented in order to specifically target this patient population. The data (66 patients) were then re-audited in 2021.ResultsBaseline data identified that domains were reached between 8% (Lipid monitoring) and 51% (glucose monitoring). Following the initial interventions 77% of domains improved in compliance. Between the two periods, notable improvements were observed in the monitoring of Blood Pressure (9% to 37%), ECG (20% to 43%) and lipids (29% to 46%). There was however a decline in all domains between the 2020 and 2021 data, with 66% of domains still having improved compared to 2019 data.ConclusionOverall, interventions have improved compliance with monitoring of physical health for patients on depot antipsychotic medications. It is likely that continuing effects of the COVID-19 pandemic contributed to the decline between the 2020 and 2021 data. As a result of this audit a weekly physical health monitoring clinic has been set up and once formally established it is hoped that compliance with physical health monitoring will continue to improve. Limitations include effects of COVID-19 pandemic, inconsistency in documentation and patient non-attendance to the monitoring clinic. We recommend further audit cycles, with additional interventions being implemented as identified.

Examining long-acting injectable antipsychotic (depot) medication in the elderly: a five-year retrospective cross-sectional study evaluating depot use in an Australian psychogeriatric service.

The primary aim was to examine the use of long-acting injectable (LAI) antipsychotic (depot) medication in a cohort of older patients in a community psychogeriatric service. From 2014 to 2018, all patients who were on LAIs each year were analysed for various characteristics including their profile, type of LAI used, dose and relapse rates related to switching, ceasing and community treatment order (CTO) use. A total of 880 patients were managed by the service with 142 recorded cases of LAI use in total over the 5 years (16.1%). Second-generation antipsychotics (SGAs) outnumbered first-generation antipsychotics (FGAs) by 2:1, with a trend of increasing use of SGA LAIs. The most commonly used LAI was Paliperidone monthly injection (PP1M) (50.7%). Lower than usual adult chlorpromazine equivalent daily doses of LAIs were used. The relapse rate while on a LAI was 13.4%. Moreover, 54.9% of the patients on LAIs were on a CTO. Relapse rates were lower on LAIs in combination with a CTO (7.7%). LAIs, especially the SGAs, are increasingly used in our service. In combination with a CTO, LAIs are an effective treatment in reducing relapse rates in the elderly.

Physical health monitoring of patients prescribed depot antipsychotic medication in north west Edinburgh community mental health team

AimsTo monitor the quality of physical health monitoring of patients prescribed depot antipsychotic medication in the North West Edinburgh Community Mental Health Team (CMHT). We also evaluated the completeness of prescriptions and Mental Health Act (Scotland) (Act) 2003 paperwork where relevant.BackgroundAntipsychotic medications are medicines for treating conditions such as Schizophrenia, but some may be associated with an increased risk of Metabolic Syndrome. Moreover, evidence indicates that patients with major mental disorder have a reduced life expectancy in comparison to those without such diagnoses. These two factors illustrate the importance of the physical health of this patient cohort being monitored on a regular basis. This project will evaluate how a local CMHT is performing, with the possibility of enacting service improvements if required.MethodThe records of the 60 patients prescribed depot antipsychotic medication administered by this CMHT were reviewed. A check-list was created consisting of 14 categories analysing the quality of physical health monitoring, as well as compliance with prescription standards and, where relevant, Mental Health Act (Scotland) (Act) 2003 paperwork. We compared patient records against our checklist for the calendar year of 2019. The Scottish Intercollegiate Guidelines Network (SIGN) 131 (Management of Schizophrenia) section 5.2 was used as the gold standard for physical health monitoring against which the data we collected was compared.ResultWe identified a wide range of flaws with the current system and implementation of monitoring, and difficulty in locating the required information. There was no consistent monitoring of physical observations on electronic record, nor an accepted alternative way in which this was documented. Furthermore, blood tests were not consistently obtained either by the service or GP practices in a reproducible manner. This led to discussions within the CMHT regarding creation of a new pathway for the monitoring of this patient cohort using a Quality Improvement model, with the ultimate goal to establish a regular physical health clinic.ConclusionThere is significant evidence that patients with major mental disorder do not access healthcare as consistently as those without, leading to a disparity in life expectancy. In light of the fact that antipsychotic medications can be associated with Metabolic Syndrome, we have an even greater responsibility to tackle this marked health inequality by appropriately monitoring our patients. This was not done well in this particular CMHT, but this project will lead to improvements in the service and ultimately patient care.

Attitudes Concerning Antipsychotic Depot Medication in the German General Population: A Representative Telephone Survey.

Treatment of schizophrenia with depot medication has advantages compared with oral medication, and among these include an improved compliance. Despite such advantages, prescription rates in many European countries are lower than 20%. The aim of this survey was to study the attitudes toward depot medication among the German general population. To the best of our knowledge, only selective samples have been investigated up until now. A representative sample of 754 people were interviewed via telephone by a professional market research and polling organization. The questionnaire queried demographic characteristics, experience with medication, and the treatment of mental disorders. Subjects' attitudes toward medication in general, long-term medication, and depot medication were surveyed. Most (66.7%) of the subjects stated that they would be willing to receive depot medication. Subjects who experienced the treatment of mental disorders were more likely to be willing to receive depot medication. Among the reasons for not using depot medication, "fear of injection" (66.3%) and "more self-control when taking medication as tablets" (48.9%) were stated as the most frequent reasons. This study found a good acceptance of antipsychotic depot medication among the German general population in terms of willingness to receive such treatment. We argue that the clinical practitioners' assumptions that depot formulations would be refused by many patients are unsubstantiated.

30.2 Pharmacokinetics of Antipsychotics

In this presentation, we will do the following: 1) review the foundation of pharmacokinetics, including absorption, distribution, metabolism, and elimination; 2) describe the difference in pharmacokinetics between oral and depot antipsychotic medications; and 3) compare and contrast the pharmacokinetics of available depot antipsychotic medications.

The effect of financial incentives on patients\u2019 motivation for treatment: results of \u201cMoney for Medication,\u201d a randomised controlled trial

BackgroundOffering financial incentives is an effective intervention for improving adherence in patients taking antipsychotic depot medication. We assessed whether patients’ motivation for treatment might be reduced after receiving financial rewards.MethodsThis study was part of Money for Medication, a multicentre, open-label, randomised controlled trial, which demonstrated the positive effects of financial incentives on antipsychotic depot compliance. Three mental healthcare institutions in Dutch secondary psychiatric care services participated. Eligible patients were aged 18–65 years, had been diagnosed with schizophrenia or another psychotic disorder, had been prescribed antipsychotic depot medication or had an indication to start using depot medication, and were participating in outpatient treatment. For 12 months, patients were randomly assigned either to treatment as usual (control group) or to treatment as usual plus a financial reward for each depot of medication received (€30 per month if fully compliant; intervention group). They were followed up for 6 months, during which time no monetary rewards were offered for taking antipsychotic medication. To assess treatment motivation after 0, 12 and 18 months, interviews were conducted using a supplement to the Health of the Nation Outcome Scales (HoNOS) and the Treatment Entry Questionnaire (TEQ).ResultsPatients were randomly assigned to the intervention (n = 84) or the control group (n = 85). After 12 months, HoNOS motivation scores were available for 131 patients (78%). Ninety-one percent of the patients had no or mild motivational problems for overall treatment; over time, there were no significant differences between the intervention and control groups. TEQ data was available for a subgroup of patients (n = 61), and showed no significant differences over time between the intervention and control groups for external motivation (β = 0.37 95% CI: -2.49 – 3.23, p = 0.799); introjected motivation (β = − 2.39 95% CI: -6.22 – 1.44, p = 0.222); and identified motivation (β = − 0.91 95% CI: -4.42 – 2.61, p = 0.613). After the 6-month follow-up period, results for the HoNOS and TEQ scores remained comparable.ConclusionsOffering financial incentives for taking antipsychotic depot medication does not reduce patients’ motivation for treatment.Trial registrationNetherlands Trial registration, number NTR2350.

S100. EFFECTS OF CANNABIS USE ON BODY MASS, FASTING GLUCOSE AND LIPIDS DURING THE FIRST 12 MONTHS OF TREATMENT IN SCHIZOPHRENIA SPECTRUM DISORDERS

BackgroundAcute cannabis use stimulates appetite, while general population studies suggest that chronic use is associated with reduced risk of obesity and other cardiometabolic risk factors.MethodsIn this study, we investigated changes in body mass index (BMI), fasting blood glucose and lipids, and rates of metabolic syndrome risk factors in cannabis users vs. non-users in 109 minimally treated patients with first-episode schizophrenia, schizophreniform or schizo-affective disorder who were treated according to a standardized treatment regime with depot antipsychotic medication over 12 months. Participants underwent repeated urine toxicology tests for cannabis and those testing positive at any time during the study (n=40), were compared with those who tested negative at all time points (n=69).ResultsThere was a significant group*time interaction effect (p=0.002) with the cannabis negative group showing a greater increase in BMI than the cannabis positive group, after adjusting for age, sex, methamphetamine use and modal dose of antipsychotic. There were no group*time interaction effects for fasting blood glucose or lipids. Post hoc tests indicated significant increases in fasting blood glucose and triglycerides and a decrease in high-density lipoprotein cholesterol for the cannabis negative group, with no significant changes in the cannabis positive group. Rates of metabolic syndrome did not differ significantly between groups. However, more cannabis negative patients had elevated waist-circumference at endpoint (p=0.003).DiscussionAlthough other indirect effects such as dietary neglect and smoking may be contributory and could explain our findings, it may be that chronic cannabis use directly suppresses appetite, thereby preventing weight gain in users.

Effects of cannabis use on body mass, fasting glucose and lipids during the first 12 months of treatment in schizophrenia spectrum disorders

While acute cannabis use stimulates appetite, general population studies suggest that chronic use is associated with reduced risk of obesity and other cardiometabolic risk factors. In this study we investigated changes in body mass index (BMI), fasting blood glucose and lipids, and rates of metabolic syndrome risk factors in cannabis users vs. non-users in 109 minimally treated patients with first-episode schizophrenia, schizophreniform or schizo-affective disorder who were treated according to a standardized treatment regime with depot antipsychotic medication over 12 months. Participants underwent repeated urine toxicology tests for cannabis and those testing positive at any time during the study (n = 40), were compared with those who tested negative at all time points (n = 69). There was a significant group*time interaction effect (p = 0.002) with the cannabis negative group showing a greater increase in BMI than the cannabis positive group, after adjusting for age, sex, methamphetamine use and modal dose of antipsychotic. There were no group*time interaction effects for fasting blood glucose or lipids. Post hoc tests indicated significant increases in fasting blood glucose and triglycerides and a decrease in high-density lipoprotein cholesterol for the cannabis negative group, with no significant changes in the cannabis positive group. Rates of metabolic syndrome did not differ significantly between groups, although more cannabis negative patients had elevated waist-circumference at endpoint (p = 0.003). It may be that chronic cannabis use directly suppresses appetite, thereby preventing weight gain in users. However, other indirect effects such as dietary neglect and smoking may be contributory and could explain our findings.

Going the distance: reviewing antipsychotic depot or long-acting injectable treatments in Australasia.

The aim of this study is to provide an opinion paper reviewing the role of depot or long-acting injectable (LAI) antipsychotic medications, with comments on individual newer LAIs such aripiprazole maintena and paliperidone palmitate. In particular, we share our recent experience of using paliperidone three-monthly LAI. We also reflect on the associated benefits and potential harms of LAIs, and when they may be used. LAI antipsychotics are an important and arguably under-utilised therapeutic option, particularly where medication adherence is a priority, and where an informed patient opts for this formulation. Paliperidone is the first three-monthly LAI antipsychotic, and as such represents a significant advance in the range of treatment choices.

Ethical acceptability of offering financial incentives for taking antipsychotic depot medication: patients\u2019 and clinicians\u2019 perspectives after a 12-month randomized controlled trial

BackgroundA randomized controlled trial ‘Money for Medication’(M4M) was conducted in which patients were offered financial incentives for taking antipsychotic depot medication. This study assessed the attitudes and ethical considerations of patients and clinicians who participated in this trial.MethodsThree mental healthcare institutions in secondary psychiatric care in the Netherlands participated in this study. Patients (n = 169), 18–65 years, diagnosed with schizophrenia, schizoaffective disorder or another psychotic disorder who had been prescribed antipsychotic depot medication, were randomly assigned to receive 12 months of either treatment as usual plus a financial reward for each depot of medication received (intervention group) or treatment as usual alone (control group). Structured questionnaires were administered after the 12-month intervention period. Data were available for 133 patients (69 control and 64 intervention) and for 97 clinicians.ResultsPatients (88%) and clinicians (81%) indicated that financial incentives were a good approach to improve medication adherence. Ethical concerns were categorized according to the four-principles approach (autonomy, beneficence, non-maleficence, and justice). Patients and clinicians alike mentioned various advantages of M4M in clinical practice, such as increased medication adherence and improved illness insight; but also disadvantages such as reduced intrinsic motivation, loss of autonomy and feelings of dependence.ConclusionsOverall, patients evaluated financial incentives as an effective method of improving medication adherence and were willing to accept this reward during clinical treatment. Clinicians were also positive about the use of this intervention in daily practice. Ethical concerns are discussed in terms of patient autonomy, beneficence, non-maleficence and justice. We conclude that this intervention is ethically acceptable under certain conditions, and that further research is necessary to clarify issues of benefit, motivation and the preferred size and duration of the incentive.Trial registrationNederlands Trial Register, number NTR2350.

Pregnenolone as an adjunct to risperidone for treatment of women with schizophrenia: A randomized double-blind placebo-controlled clinical trial

There have been few studies of pregnenolone therapy in schizophrenia and those that exist have been subject to several critical limitations, thus yielding inconsistent results. We attempted to assess the therapeutic effect of pregnenolone in a patient sample as homogeneous as possible. In this randomized double-blind clinical trial, 82 female inpatients with chronic schizophrenia, who had discontinued their antipsychotic medications for at least one week in case of any oral antipsychotic medication or a month for any depot antipsychotic medication, received risperidone plus either pregnenolone (50 mg/day) or placebo for 8 weeks. Inclusion criteria were acute illness with a baseline Positive and Negative Syndrome Scale (PANSS) negative subscale score of ≥20. Exclusion criteria were the presence of severe depression or other concomitant psychiatric disorders. Primary outcome was defined as the difference in the PANSS total score change from baseline to week 8 in the pregnenolone group compared to the placebo group. No significant difference was found in the PANSS total score changes between the two arms (mean difference (CI 95%) = −9.41 (−20.24 to 1.41); p = 0.087). Significant differences were initially found for PANSS negative change scores (mean difference (CI 95%) = −2.61 (−5.03 to −0.19); p = 0.035) and general psychopathology change scores (mean difference (CI 95%) = −5.93 (−11.37 to −0.48); p = 0.033). However, these findings did not survive Bonferroni correction for multiple testing. While this trial may suggest a potential effect of pregnenolone on schizophrenia symptoms, further studies are warranted.

Switching From the Oral to the Depot Formulation of a Medication: Clinically Relevant Pharmacokinetic Concepts and Considerations.

This column presents principles that will aid the prescriber in transitioning patients from an oral to a depot antipsychotic medication. The column covers the differences in the pharmacokinetics of oral versus depot formulations that are critical in making a smooth transition. Also discussed are some of the reasons to use these medications, which, in the author's opinion, are currently underutilized. This column focuses on the big picture and the fundamentals of oral versus depot formulations rather than comparing the relative merits or potential advantages of the various marketed depot formulations.

Elevated sera levels of galectin-3 in stable schizophrenia

IntroductionGalectin-3 (Gal-3) is a unique member of the lectin family involved in cell proliferation, adhesion, apoptosis and immune responses. Deletion of the Gal-3 gene reduces experimental autoimmune encephalomyelitis and variation of gene encoding for Gal-3 already showed to be related with cognitive function. Also, elevated Gal-3 sera levels were measured in patients with Alzheimer's disease.Aims and objectives We measured the serum concentrations of Gal-3 in patients with schizophrenia in remission and try to determine possible correlation of Gal-3 sera levels with clinical parameters, especially cognitive aspects.MethodsIn this pilot study were included patients with schizophrenia in remission on three months stable depot antipsychotic medication (risperidone and paliperidone) (n = 27) and healthy controls (n = 18). Serum levels of Gal-3 were measured using sensitive enzyme-linked immunosorbent assay (ELISA) kits, specific for humans (R&D Systems, Minneapolis). Cognition was evaluated using the Positive and Negative Syndrome Scale (PANSS) cognitive factors.ResultsHigher mean values of Gal-3 were measured in patients with schizophrenia in remission compared with healthy volunteers (1389.69 vs. 994.23 pg/mL; P = 0.011), but correlation with PANSS cognitive factor was not established (P = 0.748).ConclusionsThese findings suggest that the role of Gal-3 should be explored further, in different stages of disorder and depending on applied therapy, but also considering specific cytokine milieu.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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

High-security hospital patients are often complex in presentation and are characterized by treatment resistance, medication nonadherence and history of violence. Paliperidone is licensed both as an oral and depot antipsychotic medication in the treatment of schizophrenia. Clinical trials have shown that paliperidone depot is well tolerated with similar efficacy to risperidone depot but with additional practical advantages. Whilst data exist for the effectiveness of paliperidone palmitate (PP), there are no studies involving patients in forensic settings or those with comorbid personality disorder. Our aim was to evaluate the effectiveness of PP on violence, aggression and personality disorder symptoms. This project was a retrospective service evaluation involving 11 patients, carried out in a high-security hospital. A combination of patient records and interviews with the treating consultant psychiatrist were used to ascertain a Clinical Global Impression (CGI) score, the effect of PP on specific personality disorder symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol and affective dysregulation) and incidents of violence and aggression. Engagement with occupational and psychological therapies was also evaluated. Metabolic parameters were reviewed. A total of 6 out of 11 patients continued on PP, most of whom had schizophrenia and dissocial personality disorder with histories of violence. All showed improvement in the CGI score with associated benefits in the three personality symptom domains. Overall, two patients demonstrated a reduction in the risk of violence. There was improvement in engagement with occupational therapy and psychological work. No significant effects on metabolic parameters were noted although hyperprolactinaemia, albeit asymptomatic, was consistently recorded. This pragmatic service evaluation of a small but complex patient group demonstrated, for the first time, that PP was effective in reducing violence as well as improving personality pathology across all dimensions: a finding which could have significant implications for management of such high-security patients.

Financial incentives for improving adherence to maintenance treatment in patients with psychotic disorders (Money for Medication): a multicentre, open-label, randomised controlled trial

Provision of financial incentives is a promising intervention for improving adherence in patients taking antipsychotic medication. We aimed to assess the effectiveness of this intervention for improving adherence to antipsychotic depot medication in patients with psychotic disorders, irrespective of their previous compliance. We did this multicentre, open-label, randomised controlled trial at three mental health-care institutions in secondary psychiatric care services in the Netherlands. Eligible patients were aged 18-65 years, had been diagnosed with schizophrenia or another psychotic disorder, had been prescribed antipsychotic depot medication or had an indication to start using depot medication, and were participating in outpatient treatment. Patients were randomly assigned (1:1), via computer-generated randomisation with a block size of four, to receive 12 months of either treatment as usual plus a financial reward for each depot of medication received (€30 per month if fully compliant; intervention group) or treatment as usual alone (control group). Randomisation was stratified by treatment site and suspected prognostic factors: sex, comorbid substance-use disorder (absent vs present), and compliance with antipsychotic medication in the 4 months before baseline (<50% vs ≥50%). Patients, clinicians, interviewers, and research assistants were masked to group allocation before, but not after, group assignment. The primary outcome was the Medication Possession Ratio (MPR), defined as the number of depots of antipsychotic medication received divided by the total number of depots of antipsychotic medication prescribed during the 12 month intervention period. Patients were followed up for 6 months, during which time no monetary rewards were offered for taking antipsychotic medication. We did analysis by intention to treat. This trial is registered with the Nederlands Trial Register, number NTR2350. Between May 21, 2010, and Oct 15, 2014, we randomly assigned 169 patients to the intervention group (n=84) or the control group (n=85). Primary outcome data were available for 155 (92%) patients. At baseline, the mean MPR was 76·0% (SD 28·2%) in the intervention group versus 77·9% (28·5%) in the control group. At 12 months, the mean MPR was higher in the intervention group (94·3% [SD 11·3%]) than in the control group (80·3% [19·1%]), with an adjusted difference of 14·9% (95% CI 8·9-20·9%; p<0·0001). This difference was maintained throughout the 6 month follow-up period: mean MPR of 86·6% (SD 22·2%) in the intervention group versus 76·0% (22·7%) in the control group (adjusted difference 6·5%, 95% CI 2·0-10·9; p=0·047). Financial incentives are an effective way of improving adherence to antipsychotic depot medication among patients with psychotic disorders. Further research is needed to study the long-term effects of this intervention. Dual Diagnosis Center.

Are Depot Anti-psychotics Associated with Longer Persistence in Treatment Compared with Oral Antipsychotics among Patients with Schizophrenia?

Aim: Non-adherence with antipsychotics is associated with poor outcomes in patients with schizophrenia. It was anticipated that drop-out from treatment due to non-compliance with oral anti-psychotics could be abated with the use of depot antipsychotics. However previous studies are divergent regarding the association between persistence in treatment and the use of depot antipsychotics. This study aimed to compare treatment persistence among out-patients with schizophrenia receiving depot versus oral antipsychotics in Lagos, Nigeria. Methodology: Relevant clinical data of out-patients with schizophrenia (n=160) were retrieved one year post-hospitalisation at a public psychiatric facility in Nigeria. Treatment persistence (time to all cause treatment discontinuation) among the cohort of patients was determined using the Kaplan-Meier Survival analyses. Persistence in treatment between patients receiving depot versus oral antipsychotic medications alone was compared using the log rank test. Results: Nearly half (49.1%) of the cohort dropped out of treatment within one month of discharge, while 18.2% persisted for one year. There was no significant difference (p=0.727) in the mean duration of treatment persistence between patients receiving depot antipsychotics (17.4(±2.4) weeks), and those receiving oral medications alone (19.4 (±2.2) weeks). Conclusion: There is a high rate of drop-out from treatment among patients with schizophrenia, after discharge from in-patient care. Prescription of depot medications was not associated with longer persistence treatment in the studied cohort. This finding highlights the need to develop interventions to facilitate treatment persistence among patients with schizophrenia.

Cost-effectiveness of therapeutic interventions in schizophrenia

BackgroundVarious studies have reported that a decision-tree analysis is useful to evaluate different treatment strategies in real clinical practice. ObjectiveThe main aim of this study was to research the clinical decisions regarding the treatment of patients who were diagnosed with schizophrenia. MethodCost-effectiveness study of three different interventions to treat patients with schizophrenia were studied. Interventions were divided into the following categories: a) day hospital (psycho-educational treatment+psychiatric consultation+psychopharmacological treatment); b) therapy adherence clinic (psychopharmacological treatment with depot antipsychotic medication+psychiatric consultation); c) outpatient psychiatric care (psychopharmacological treatment+psychiatric consultation). For this purpose decision tree model was designed and three outcomes were measured (therapeutic compliance, non-compliance and rehospitalization). TreeAge software was used in order to estimate outcome probabilities and sensitivity analysis, distribution Beta for probabilities and Gamma for cost of interventions. ResultsThe probability of therapeutic compliance and average semestral cost of therapy adherence clinic, outpatient psychiatric care and day hospital are 0.594, 0.284, 2.393, and mean cost intervention US$ 2145.6, US$ 700.2 and US$ 1412.1 respectively (IC95%), according to Montecarlo analysis. ConclusionsAccording to the results, the clinical decision to treat patients in therapy adherence clinic improved therapeutic compliance, but the cost of treatment was higher. There were extra costs and risks to society and patient that are associated with therapeutic non-compliance. It is less expensive for the health care system to provide the patients outpatient psychiatric care, but perhaps in the long-term outpatient psychiatric care is more costly for the patient, their family, and society. According to the many important limitations of this study, further studies are needed to reject/confirm these strategies to be included in real clinical practice.

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

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. 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. 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. 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. 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.