Long-acting Antipsychotic Medication Research Articles

An interventional pilot of customized adherence enhancement combined with long-acting injectable antipsychotic medication (CAE-L) for poorly adherent patients with chronic psychotic disorder in Tanzania

BackgroundChronic psychotic disorders (CPD) impose a particularly significant burden in resource-limited settings. Combining long-acting antipsychotic medication (LAI) with a customized adherence enhancement intervention (CAE-L) has potential to advance care.MethodsNineteen adults ≥ age 18 with CPD who self-reported missing ≥20% of antipsychotic medication within the last month were stabilized on oral haloperidol prior to transitioning to monthly haloperidol decanote for 25 weeks. Outcome evaluations were conducted at baseline and Week 25. Primary outcomes were oral medication adherence assessed via the Tablet Routines Questionnaire (TRQ) and LAI injection frequency. Secondary outcomes included CPD symptoms measured by the Brief Psychiatric Rating Scale and Clinical Global Impressions, functioning evaluated using the Social and Occupational Functioning Scale, and medication attitudes assessed with the Drug Attitudes Inventory.ResultsMean sample age was 38.79 (SD = 9.31) with 18 individuals completing the study. There was one serious adverse event, a relapse into substance use, not deemed study-related. Mean endpoint LAI dosage was 65.79 mg (SD = 22.38). TRQ mean scores were 21.84 (SD =13.83) and 12.94 (SD = 11.93) at screen and baseline respectively. For only two individuals who were on concomitant oral medication at 25 weeks, TRQ change was not calculated. LAI injection frequency was 100%. Medication attitudes scores significantly improved from 7.89 (SD = 2.72) to 9.83 (SD = 0.52) (p = .001.) Changes in CPD symptoms and functioning were non-significant.ConclusionsCAE-L appears to be preliminarily feasible and acceptable in Tanzanians with CPD.Trial registrationThe study was registered on ClinicalTrials.gov (NCT04327843) on March 31, 2020.

Psychosocial and Pharmacological Approaches for Improving Treatment Adherence and Outcomes in People With Severe Schizophrenia: A 10-Year Follow-up.

The objective of this study was to understand the psychosocial and pharmacological approaches linked to better treatment adherence and outcomes (psychiatric hospitalizations, clinical severity, and suicide attempts) among patients with schizophrenia receiving the standard treatment in mental health units (MHUs) compared with patients in a community-based, case-managed program (CMP). An observational, prospective (10 y) study was conducted involving patients with severe schizophrenia (N=688). The treatment adherence of patients in the CMP was higher than among those in the MHUs (12.2% vs. 84.3% abandoning treatment; P<0.0001). Hospital admissions and suicide attempts were significantly lower among those treated in the CMP than among those receiving standard care in the MHUs (P<0.001). Scores on the clinical severity scale decreased significantly more in the group in the CMP than in the group in the MHUs (P<0.005). Treatment with long-acting injectable antipsychotic medication was closely linked with higher treatment retention (P<0.001) and fewer hospital admissions and suicide attempts compared with treatment with oral antipsychotics in both patient groups, with the effect greater in the group in the CMP (P<0.001). We highlight how patients with severe schizophrenia treated in a CMP with integrated treatment showed a higher retention rate, fewer psychiatric hospital admissions and suicide attempts, and less clinical severity compared with those receiving standard treatment in MHUs. Treatment with long-acting antipsychotics was also clearly related to these outcomes. A combination of intensive case-managed integrated treatment and treatment with long-acting antipsychotic medication facilitated the achievement of clinical and rehabilitation goals in patients with schizophrenia with severe symptoms and impairment compared with standard care and treatment with oral antipsychotics.

A Program to Increase the Appropriate Use of Long-Acting Injectable Antipsychotic Medications in Community Settings

The Multilevel Facilitation of Long-Acting Antipsychotic Medication Program (MAP) is a novel intervention to increase the appropriate use of long-acting injectable (LAI) antipsychotics in community mental health clinics. The authors investigated the feasibility of MAP, facilitators and barriers to use, and preliminary impact on LAI medication use. Two clinics in Texas and two in Ohio serving 750 and 617 individuals with schizophrenia receiving oral antipsychotics, respectively, were asked to change clinical procedures for 1 year by using either the not receiving optimum benefit (NOB) checklist or the checklist plus MAP. Providers used the NOB checklist to identify individuals who could benefit from switching to LAI antipsychotics. MAP clinics used the NOB checklist plus nonbranded academic detailing for providers and a shared-decision-making video and tool for consumers. Use of MAP components was tracked, and barriers and facilitators were collected quarterly. Antipsychotic prescription counts were provided by participating clinics. Barriers to use of MAP included loss of local champions and administrators, difficulty with provider buy-in, limited availability of peer specialists, and a lack of infrastructural support to integrate MAP into clinic flow. Higher scores on the NOB checklist were associated with more provider LAI medication offers and greater patient acceptance of LAI antipsychotics. LAI medication use increased in clinics over time, but it is unclear whether this increase was due to MAP. Changing MAP components to fit local procedures and to circumvent unique barriers could aid implementation. Further research should investigate the potential impact of MAP components on LAI medication use.

M122. DEPRESSION IN SCHIZOPHRENIA SPECTRUM DISORDERS: LONGITUDINAL COURSE AND THE RELATIONSHIP WITH OTHER CLINICAL PARAMETERS AND QUALITY OF LIFE

BackgroundThe relationship between schizophrenia and depression is complex. Longitudinal studies on the course of depression in first episode schizophrenia populations are scarce and there are conflicting results on the predictive value of some baseline measures.MethodsWe conducted an open label longitudinal cohort study which included 126 patients with first-episode schizophrenia spectrum disorders treated with long-acting antipsychotic medication over 24 months. Depression was assessed at three monthly intervals using the Calgary Depression Scale for Schizophrenia. Changes in depression over time were assessed using the linear mixed-effect models for continuous repeated measures. The relationship between depression and other clinical parameters was assessed with regression models.ResultsDepressive symptoms were most prominent at baseline and showed highly significant reductions in the first three months (p<0.0001). Majority of the patients with depression improved with antipsychotic medication alone and we found associations between depressive symptoms with insight and poorer quality of life, however only illness awareness (p=0.0035) was the only significant predictor on depression in our regression analysis. There were a few differences between patients who experienced depression during the acute phase of treatment and those in the post-acute phase.DiscussionOur findings suggest that depression in schizophrenia is common and generally responds well to treatment. The relationship between depression and insight has implications for further treatment considerations

T236. A PROGRAM TO INCREASE THE APPROPRIATE USE OF LONG-ACTING ANTIPSYCHOTIC MEDICATIONS IN COMMUNITY SETTINGS

BackgroundAntipsychotic medications are evidence-based treatments for schizophrenia that improve health outcomes and reduce costs. However, rates of non-adherence to oral antipsychotic medications can exceed 60%. We examined whether a simple checklist to identify individuals not receiving optimum benefit from current oral antipsychotic treatment (NOB Checklist) and The Multi-level Facilitation of Long-acting Antipsychotic Medication Program (MAP) could increase the appropriate use of long-acting injectable antipsychotic medication (LAI) in community clinics.MethodsTwo clinics in Texas and two in Ohio changed clinical procedures in one of two ways 1) NOB only clinics--providers used a five-item checklist to identify individuals with schizophrenia on oral antipsychotics who were Not receiving Optimum Benefit from current treatment and may therefore benefit from a switch to LAI. 2) MAP- providers used the NOB checklist AND received MAP; MAP is a novel behavior change intervention designed to improve the identification of individuals who could benefit from LAI, improve their outcomes and reduce inappropriate use of resources associated with poor adherence. MAP targets 3 stakeholder groups 1) the consumer for whom peer specialists showed a video describing shared decision making and how to make a choice between tablets and injections, and provided a balanced shared-decision making tool to assist them in choosing medication route,2) the provider who received academic detailing describing various LAI options, how to make good offers as part of a shared decision making dialogue, and important benefits of LAI including the ability to disentangle efficacy versus poor adherence and to help individuals with cognitive and practical problems that lead to poor adherence, and 3) the administrators who received information on how LAI could improve outcomes for individuals and clinic processes, how to encourage the use of LAI among providers and how to provide regular feedback to providers about prescribing practices. The primary outcome was the percentage of LAI versus oral antipsychotic medication prescribed to individuals with schizophrenia.ResultsHigher NOB checklist scores were associated with an increased provider likelihood of LAI offers and increased consumer acceptance of LAI. All clinics increased use of LAI over time. In Texas, where MAP was fully implemented, the MAP clinic had greater use of LAI over time (eventually reaching about 50% of all antipsychotic use) vs. the NOB only clinic. In Cleveland, the patient stakeholder curriculum was not delivered and there was no significant difference in LAI use between MAP and NOB clinics.DiscussionThe NOB checklist appears to be a useful tool to help identify patients who might be appropriate candidates for LAI and the full MAP program may help clinicians and consumers to work together to optimize the appropriate use of LAI in outpatient settings. Implementation must be customized for clinics and workflows to determine which parts of the MAP program are practical and appropriate. Participation of consumer stakeholders may be essential to delivery of the MAP Program.

Early recovery in the first 24 months of treatment in first-episode schizophrenia-spectrum disorders

Studies assessing the treatment outcomes in first-episode schizophrenia have reported mixed results. While symptom improvement is frequently robust, when other domains are considered outcomes are generally poorer. We explored response trajectories, rates and predictors of recovery in the domains of core psychopathology, clinician-rated social and occupational functioning and patient-rated quality of life over 24 months of treatment in 98 patients with first-episode schizophrenia spectrum disorders who were treated with a long-acting antipsychotic medication. There was robust improvement in core psychopathology (effect size d = 3.36) and functionality (d = 1.78), with most improvement occurring within the first six months of treatment. In contrast, improvement in subjective quality of life was less marked (d = 0.37) and slower, only reaching significance after 12 months of treatment. Symptom remission was achieved by 70% of patients and over half met our criteria for functional remission and good quality of life. However, only 29% met the full criteria for recovery. Patients who met the recovery criteria had better premorbid adjustment, were less likely to be of mixed ethnicity and substance use emerged as the only modifiable predictor of recovery. Only 9% of our sample achieved both functional remission and good quality of life despite not being in symptom remission. We found high rates of symptom remission, functional remission and good quality of life in patients, although relatively few achieved recovery by meeting all three of the outcome criteria. Symptom remission is not a necessary prerequisite for functional remission and good quality of life, although few non-remitters achieve other recovery criteria.

A retrospective study of the role of long-acting injectable antipsychotics in preventing rehospitalization in early psychosis with cannabis use

BackgroundDespite compelling evidence that cannabis use is associated with neurocognitive deficits, loss of cerebral gray matter, relapse and rehospitalization, a substantial number of individuals with early psychosis continue to use recreational or medicinal marijuana. One identified pathway to relapse is non-adherence. Recurrent relapses modify the trajectory of illness and culminate in long-term disability. Long-acting antipsychotic medications are superior to oral equivalents in preventing relapse. PurposeThe current paper sought to examine the role of long-acting antipsychotics in preventing relapse in cannabis using early psychosis patients. MethodsThe present retrospective study, which was based in an early psychosis program in mid-Michigan, examined the association between patient perceptions of antipsychotic medication and subsequent rehospitalization, among cannabis users (n = 24) and non-users (n = 27). Patient perceptions of antipsychotic medications were assessed using a single question from the NAVIGATE Patient Self-Rating Form: “Between now and your next visit, do you think we should keep your medication the same, or consider changing the medication?”. ResultsCannabis users were substantially more likely to report dissatisfaction with antipsychotic medication (Pearson Chi-square 9.67, df = 1.0, p < 0.002), and more likely to experience rehospitalization (Pearson Chi-square 4.40, df = 1.0, p = 0.036). Those maintained on long-acting injectable antipsychotic medications were rehospitalized less frequently when compared to others maintained on oral formulations (Pearson Chi-square 4.61, df = 1.0, p = 0.032). ConclusionsDissatisfaction with antipsychotics may predict non-adherence and subsequent rehospitalization in early psychosis patients who use cannabis. Long-acting antipsychotics may prevent rehospitalization.

Prediction of disability in schizophrenia: Symptoms, cognition, and self-assessment

Schizophrenia is associated with wide-ranging disability across multiple functional domains. There are several determinants of disability that have been identified to date, including cognitive and social cognitive impairments, impairments in everyday functional skills and social skills, difficulties in self-assessment of abilities, and negative symptoms. These impairments are related to different elements of disability, and disability and its predictors are not a single global dimension. Further, although psychotic symptoms have limited cross-sectional correlations with everyday functioning, emerging evidence suggests that long-term clinical stability, often induced through treatment with long-acting antipsychotic medications, is also associated with improvements in everyday functioning. This review addresses the characteristics and origins of disability, with treatment implications noted in each disability domains.

A customized adherence enhancement program combined with long-acting injectable antipsychotic medication (CAE-L) for poorly adherent patients with chronic psychotic disorder in Tanzania: A pilot study methodological report

Chronic psychotic disorders (CPDs) occur worldwide and cause significant burden including reduced quality of life and functional impairment. Care for CPD includes psychosocial and pharmacologic interventions (i.e. antipsychotic drugs) and ongoing health monitoring. This is challenging in resource-limited settings where staff are sparse and/or undertrained. Importantly, mental health human resource needs predict continued deficits compounded by increasing disease burden. A U.S. team recently developed and tested a CPD treatment approach that combines the use of long-acting antipsychotic medication (LAI) with a brief and practical customized adherence enhancement behavioral intervention (CAE-L). This report describes the methodological details of an ongoing, first-ever refinement and preliminary testing of CAE-L in poorly adherent patients with CPD in Tanzania. Additional innovative elements include: 1) a manualized curriculum that targets specific barriers and facilitators to medication adherence in Tanzanians with CPD, and 2) targeting known, high-risk individuals with CPD (those who miss ≥20% of prescribed antipsychotic medication). The study procedures are intended to pave the way for implementing a large-scale intervention trial for CPD in the Tanzanian setting. An important component of this project is capacity building to help form the next generation of care providers. Visit exchanges modeled on a successful NIH-funded Medical Education Partnership Initiative (MEPI) template will also use the U.S. and Tanzanian teams to share expertise, problem-solve, and plan iterative refinements of project deliverables. Taken together, this project has potential to advance the care of people with CPD in Tanzania and has high generalizability to Sub-Saharan Africa and other lower-resource settings.

Comparing Pain of the First-generation Long-Acting Antipsychotic Injections among Three Different IM Techniques

Aim and objectives: To determine the optimal technique to prevent leakage and pain from LAIs, the study compared three types of intramuscular injection techniques: (a) Airbubble technique, (b) Z-track method, and (c) a combination of the air-bubble technique and Z-track method. Background: Long-acting antipsychotic injections (LAIs) are often injected through the muscle, allowing the medication to be slowly absorbed through it. Past literature yields inconclusive results in how to minimize the leakage and pain experienced at the injection site. Design: This experimental study had a within-subjects design. Methods: A total of 144 patients who received the firstgeneration LAIs were purposively sampled from a psychiatry hospital. All participants experienced the three types of injection methods over a 3-month period. They were all asked to rate their level of pain using the numerical rating scale, and after each injection, medical personnel rated the level of medication leakage at the injection site. Results: No significant differences were found in the leakage level between the air-bubble technique, Z-track method, and the combination of the two (F=0.53, p>0.05). Pain level also showed no significant difference between the three types of injection methods during pre-injection (F=0.68 p>.05), 5 minutes post-injection (F=0.87, p>0.05), and 30 minutes post-injection (F=0.97, p>0.05). Conclusion: During the injection of long-acting antipsychotic medication, we suggest consulting the guidance of a clinical injection expert. Choosing an injection method that is most familiar to the nursing staff would allow the minimization of medication leakage and pain at the injection site. Relevance to clinical practice: Nurses should make sure the guidance of a clinical injection expert and verify knowledge of the IM injection skill. Choosing correct injection site and process that can effectively experience of pain and leakage at the injection site.

P.3.d.062 - Protocol proposal for switching long-acting antipsychotic medication in psychotic patients: from fluphenazine decanoate to paliperidone palmitate

P.3.d.062 - Protocol proposal for switching long-acting antipsychotic medication in psychotic patients: from fluphenazine decanoate to paliperidone palmitate

Efficacy and Effectiveness of Depot Versus Oral Antipsychotics in Schizophrenia

Nonadherence is a major challenge in schizophrenia treatment. While long-acting (depot) antipsychotic medications are often recommended to address adherence problems, evidence on the comparative effectiveness of depot versus oral antipsychotics is inconsistent. We hypothesize that this inconsistency could be due to systematic differences in study design. This review evaluates the effect of study design on the comparative effectiveness of antipsychotic formulations. The optimal use of different antipsychotic formulations in a general clinical setting depends on better understanding of the underlying reasons for differences in effectiveness across research designs. A PubMed literature review targeted English-language studies (2000-2011) with information on relapse, hospitalization, or all-cause discontinuation for depot and oral antipsychotic treatment arms in schizophrenia. The time frame was chosen to reflect research focused on the newer generation of antipsychotic agents. The search required at least 1 term from each of the following categories: (1) schizophrenia; (2) inject, injection, injectable, injectables, injected, depot, long-acting; and (3) iloperidone, fluphenazine, haloperidol, paliperidone, risperidone, olanzapine, asenapine, flupentixol, flupenthixol, lurasidone, clopenthixol, fluspirilene, zuclopentixol, zuclopenthixol. Thirteen relevant studies were identified by 2 independent reviewers; these studies included information on 19 depot-oral comparisons. Age- and gender-adjusted risk ratios (RRs) (depot/oral) were calculated for the identified endpoints and pooled by study design (randomized controlled trial [RCT], prospective observational, and retrospective observational). Meta-analysis with random effects was used to estimate the pooled RRs, by study design. Average conversion factors between study designs were calculated as the ratios of pooled RRs. Meta-analysis of adjusted endpoints showed no apparent benefit of depot over oral formulations in RCTs, with an RR of 0.89 (P = .416). In contrast, there was a significant advantage for depot formulations in other study designs (prospective RR = 0.62 [P < .001]; retrospective RR = 0.56 [P < .001]). These imply conversion factors of 1.43 and 1.59 between RCTs and prospective and retrospective designs, respectively. The comparative effectiveness of antipsychotic formulations is sensitive to research design. Depot formulations displayed significant advantages in nonrandomized observational studies, whereas in RCTs no difference was observed. The estimated conversion factors may facilitate comparison across studies.

Systematic Review and Meta-analysis of Anticholinergic Side Effects of Long-acting Antipsychotics

Background: There are few studies on the anticholinergic side effects of long-acting antipsychotics. They tend to be used with stigmatized, severely ill and non-concordant patients rather than first episode psychosis. Aim: To investigate prevalence/incidence rate of anticholinergic side effects of long-acting antipsychotics. Methods: We included all participants with schizophrenia, schizoaffective disorder or schizotypal disorder on depot antip- sychotics in the trials within all Cochrane reviews published by the Cochrane schizophrenia group. A search was under- taken in the Cochrane Database and data extracted into Microsoft Excel to analyze frequencies, prevalence and confidence intervals of the anticholinergic side effects of all identified long-acting antipsychotic medications. Result: We found seven reviews for seven depot antipsychotics. For example for fluphenazine decanoate at least a quarter of the participants experienced blurred vision 24.5% (CI 11 to 47) in the short-term, 16 % (CI 10-27) in the medium-term, and 21.4 % (CI 16-28) in the long-term. Conclusion: The anticholinergic side effects of long-acting depot antipsychotics are not any more frequent than the anti- cholinergic side effects of oral antipsychotics. There is no evidence to suggest that oral medications are better tolerated than long-acting depot preparations.

Challenges in the design and conduct of controlled clinical effectiveness trials in schizophrenia

The introduction of antipsychotic medication has been a major advance in the treatment of schizophrenia and allows millions of people to live outside of institutions. It is generally believed that long-acting intramuscular antipsychotic medication is the most effective approach to increasing medication adherence and thereby reduce relapse in high-risk patients with schizophrenia, but the data are scant. To report the design of a study to assess the effect of long-acting injectable risperidone in unstable patients and under more realistic conditions than previously studied and to evaluate the effect of this medication on psychiatric inpatient hospitalization, schizophrenia symptoms, quality of life, medication adherence, side effects, and health care costs. The trial was an open randomized clinical comparative effectiveness trial in patients with schizophrenia or schizo-affective disorders in which parenteral risperidone was compared to an oral antipsychotic regimen selected by each control patient's psychiatrist. Participants had unstable psychiatric disease defined by recent hospitalization or exhibition of unusual need for psychiatric services. The primary endpoint was hospitalization for psychiatric indications; the secondary endpoint was psychiatric symptoms. Overall, 382 patients were randomized. Determination of a persons' competency to understand the elements of informed consent was addressed. The use of a closed-circuit TV interview for psychosocial measures provided an economical, high quality, reliable means of collecting data. A unique method for insuring that usual care was optimal was incorporated in the follow-up of all subjects. Patients with schizophrenia or schizo-affective disorders and with the common co-morbid illnesses seen in the VA are a challenging group of subjects to study in long-term trials. Some techniques unique in the VA and found useful may not be generalizable or applicable in other research or treatment settings. The trial tested a new antipsychotic medication early in its adoption in the Veterans Health Administration. The VA has a unique electronic medical record and database which can be used to identify the endpoint, that is, first hospitalization due to a psychiatric problem, with complete ascertainment. Several methodologic solutions addressed competency to understand elements of consent, the costs and reliability of collecting interview data gathering, and insuring usual care.

Risperidone long-acting injection: safety and efficacy in elderly patients with schizophrenia.

Antipsychotic medication is considered the cornerstone of the treatment in elderly patients with schizophrenia. Long acting risperidone injection was the first antipsychotic available for use in this group of patients. Current scientific literature revealed that long-acting risperidone is effective in treating the positive and negative symptoms of schizophrenia and some improvements in cognition and functioning have also been found. In terms of efficacy, there is a paucity of randomized trials but the studies suggest that long-acting risperidone is efficient in the long-term management of schizophrenia, with a safety profile similar to that of oral risperidone. It seems that patient acceptance of treatment is greater when patients are switched from a traditional oral medication to depot risperidone and some improvements in cognition and functioning might be related. Further long-term comparisons with other oral and long-acting antipsychotic medications are needed. These studies should include cost-effectiveness data. Research into metabolic side effects is also needed.

Concurrent Use of Two Depot Antipsychotic Medications in Schizophrenia

Schizophrenia is often associated with impaired insight and consequent non-adherence to treatment. To promote adherence the psychiatric practice has for decades included the administration of long-acting antipsychotic medication through an injectable intra-muscular route. In addition to this parenteral medication, persistent symptoms have sometimes necessitated the prescription of additional medication. A common scenario has included the provision of an oral atypical antipsychotic added to depot haloperidol or fluphenazine injections. However, non-adherence to the oral medicine remains a potential problem. To address this problem, one could administer two long-lasting intramuscular medications concurrently, one a typical and the other an atypical antipsychotic. This is a clinical practice for which a rationale exists but for which there is scarce empirical data to support it. We report the case of a patient who responded to treatment only after receiving a combination of both typical and atypical oral antipsychotics who was then transitioned to the depot formulation of both medications.

Medication Adherence and Hospitalization Among Patients With Schizophrenia Treated With Antipsychotics

This analysis assessed rates of medication adherence and predictors of nonadherence and hospitalization among patients treated with long-acting injectable and oral antipsychotic therapies. Data were from a retrospective analysis of Florida Medicaid recipients with schizophrenic disorder (ICD-9-CM code 295.XX) who received a prescription for an antipsychotic between July 1, 2004, and June 30, 2005. Patients were required to have filled one additional antipsychotic prescription during follow-up. Adherence measures included medication possession ratio (MPR), medication persistence, medication consistency, and maximum gap in treatment. Multivariate logistic regression models identified predictors of nonadherence and hospitalization. Patients were considered adherent if they had an MPR ≥ .8. A total of 12,032 patients met selection criteria. The mean ± SD MPR was .79 ± .23, medication persistence was 94.1% ± 16.4%, medication consistency was 83.3% ± 16.4%, and the maximum gap in treatment was 29.7 ± 41.4 days. Thirty-seven percent of patients were hospitalized for any cause, and 32% had a psychiatric hospitalization. Predictors of nonadherence included newly starting treatment; younger age; a substance abuse diagnosis; use of a mood stabilizer, antidepressant, anxiolytic, or anticholinergic; and receipt of long-acting first-generation antipsychotics. Receipt of long-acting second-generation therapy or receipt of both first- and second-generation medications was associated with lower likelihood of nonadherence. Predictors of hospitalization risk included a diagnosis of other psychoses or substance abuse, anticholinergic use, and nonadherence to therapy. Results document rates of antipsychotic adherence and predictors of nonadherence and hospitalization. Findings may be useful to health plan administrators, formulary decision makers, and physicians.

Most Psychiatrists Unlikely To Use Depot Antipsychotics

Most Psychiatrists Unlikely To Use Depot Antipsychotics

Who Receives Long-Acting Antipsychotic Medications?

Back to table of contents Next article Taking IssueFull AccessWho Receives Long-Acting Antipsychotic Medications?William M. Glazer M.D.,William M. Glazer M.D.Search for more papers by this author,Published Online:1 Apr 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In my psychiatric rotation in medical school in 1972, I quickly learned that depot fluphenazine was used for "noncompliant" patients. In 1978, I found, to my consternation, that my mental health center prescribed this medication significantly more often to African-American patients than to Caucasians. Similar prescribing practices were found in other settings. In 2006 psychiatrists have two other long-acting injectable medications to choose from, and we consider the term "noncompliant" to be pejorative and prefer "nonadherent." But we still believe that these agents are for nonadherent patients. We have not made much progress over the past 30 years.In this issue Shi and colleagues report on a large three-year, prospective observational study of patients treated for schizophrenia. Although the study, funded by Eli Lilly and Company (for which I am a consultant and speaker), was not designed to identify why clinicians choose depot antipsychotics, it is the most comprehensive one to characterize the patients receiving these medications. The authors report that patients treated with a first-generation depot medication were more likely than those receiving oral medications to be younger, male, African American, less educated, and more clinically and socially dysfunctional. Over the one-year follow-up period adherence improved while these patients received depot medications.The study would suggest that nonadherence is not the only indication for depot antipsychotics. However, if nonadherence is a reasonable indication for these medications, then we are not coming close to meeting that need. The low point prevalence of use of these agents in the United States (10%–15%) hardly matches the estimated rate of nonadherence (<50%) in the population treated. So what, exactly, is the indication for depot antipsychotics?Little evidence supports the characteristics noted in the study as predictors of nonadherent behavior. And common sense tells us that this small subgroup of patients is not the only one to benefit from long-acting antipsychotics. So what has happened? For reasons that are too complex to discuss here, we seem to relegate the use of depot medications to uninsured, substance-abusing patients who belong to racial and ethnic minority groups or have criminal histories.Shi and colleagues' findings indicate a need for a deeper understanding of our prescribing behavior with depot antipsychotics. We seem to prescribe these medications with erroneous assumptions that reveal some prejudices—such as prescribing them on the basis of race or predicted dangerousness rather than problematic adherence. We must explore why U.S. clinicians, compared with many non-U.S. clinicians, resist using long-acting antipsychotics. We need to look at cultural forces that may drive what, I fear, is a punitive attitude in our prescription of depot medications.President, Glazer Medical Solutions FiguresReferencesCited byDetailsCited ByAchieving better outcomes for schizophrenia patients in Hong Kong: Strategies for improving treatment adherence8 February 2021 | CNS Neuroscience & Therapeutics, Vol. 27, No. S1Impact on length of stay and readmission rates when converting oral to long-acting injectable antipsychotics in schizophrenia or schizoaffective disorderMental Health Clinician, Vol. 6, No. 5SSRN Electronic JournalThe role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal2 July 2014 | Therapeutic Advances in Psychopharmacology, Vol. 4, No. 5The Effect of Race-Ethnicity and Geography on Adoption of Innovations in the Treatment of SchizophreniaMarcela Horvitz-Lennon, M.D., M.P.H., Margarita Alegría, Ph.D., and Sharon-Lise T. Normand, Ph.D.1 December 2012 | Psychiatric Services, Vol. 63, No. 12Journal of Medical Economics, Vol. 15, No. 4BMC Psychiatry, Vol. 9, No. 1Current Psychiatry Reports, Vol. 10, No. 4 Volume 58Issue 4 April, 2007Pages 437-437PSYCHIATRIC SERVICES April 2007 Volume 58 Number 4 Metrics PDF download History Published online 1 April 2007 Published in print 1 April 2007

Treatment of schizophrenia with long-acting fluphenazine, haloperidol, or risperidone.

Objective: This study compares 3 cohorts of patients with schizophrenia before, during, and after initiating treatment with fluphenazine decanoate (FD), haloperidol decanoate (HD), or long-acting injectable risperidone (LAR). Methods: Administrative data are analyzed from California Medicaid (Medi-Cal) beneficiaries with schizophrenia who initiated FD, HD, or LAR treatment. Patients were required to have been continuously enrolled in Medi-Cal for 180 days before and 180 days after the start of the new episode of long-acting antipsychotic therapy. Results: There were few demographic and clinical differences among patients initiating FD, HD, and LAR. During the 180 days before starting long-acting injections, most patients initiating FD (53.5%), HD (58.5%), and LAR (61.2%) received oral antipsychotic medications for <80% of the days in this period (medication possession ratio: <0.80). The mean duration of depot treatment episodes was 58.3 days (SD = 53.6) for FD, 71.7 days (SD = 56.4) for HD, and 60.6 days (SD = 48.8) for LAR (F = 18.3, df = 2, 2694, P < .0001, HD > FD). Few patients who started on FD (5.4%), HD (9.7%), or LAR (2.6%) continued for at least 180 days. Most patients in each group (FD [77.4%], HD [78.9%], and LAR [75.5%]) received oral antipsychotic medications during the 45 days after discontinuing long-acting injections. Coprescription with antidepressants, mood stabilizers, and benzodiazepines was common. Conclusions: Patients treated with long-acting antipsychotic injections tend to have complex pharmacological regimens and recent medication nonadherence. A great majority of patients initiating long-acting antipsychotic medications discontinue use within the first few months of treatment.