A brief introduction to depot medication used in mental health

1. A brief introduction to depot medication used in mental health The aims of the session are to provide information about: Who might be prescribed depot medication and why? What are the main types of depot injection used? How does the medication work? What are the main side effects? What are typical and atypical medicines? How is Risperdal Consta different to other depots? What happens if people miss an appointment? Where can I find more information?

2. Who might be prescribed depot medication? People who have at some point experienced symptoms of a psychotic illness. This could be schizophrenia, a bi-polar disorder or a schizoaffective disorder. Some of these symptoms might include hearing voices talking about them, to them or telling them to do things. They may believe that people are following them, watching them or trying to harm them or others around them. They may experience very strong false beliefs about the world, called delusions .These can be paranoid ideas, that people are spying on them or trying to harm them, or grandiose delusions, where they believe they are very famous or important. They may believe that the TV or articles in the news paper refer specifically to them, and tell the public all about them.They may think that people can read their thoughts, or that they can read other peoples. They might think that some other force is implanting thoughts into their own mind, or that they are able to do this. Imagine how vulnerable this must make you feel. Imagine how frightening these symptoms must be.

3. How should the depot be given? Antipsychotic depot medications are all deep intra muscular injections, that should be given in the upper outer buttock. Some are also licensed to be given into a lateral thigh. It is recommended that Z tracking technique should be used to administer the injection. It is best practice that no more than 2 mls in volume should be given in any one site, at one time. This is to reduce patient discomfort and reduce localised reactions such as pain, irritation and the forming of nodules. Most depot preparations are stable in the vegetable oil they are suspended in. This means that you can mix different concentrations of the same drug if produced by the same manufacturer.

4. What are the main types of depot medication used? Like other depot preparations, neuroleptic depots are generally made up of a drug suspended in vegetable oil, and are given intra-muscularly, for slow release over a given period of time. Depot medication has been used for many years, and was traditionally associated with people who could not manage to take their own medication regularly and effectively on a day to day basis. This is an outmoded way of thinking about depot medication, as some people simply find it more convenient. In recent years people are given much smaller doses of depot medication, which can help control their symptoms without giving them too many of the side effects. Some of the most common drug names are: Flupentixol Decanoate(Psytixol®/Depixol®) Zuclopentixol Decanoate(Clopixol®) Fluphenazine (Modecate®), Pipothiazine (Piportil®), Haliperidol Decanoate (Haldol®) Risperidone Long Acting Injection (Risperdal Consta®)

5. How does the medication work? All depot antipsychotics work by effecting the amount of a particular neuro transmitter called dopamine, which used in the brain to pass messages between the nerves. They act by blocking the dopamine receptors in the brain. There is also some evidence that another neurotransmitter called serotonin interacts with the dopamine system, and can influence the way it functions. In people with mental illness, the chemical messaging systems do not always work in the way that they should.

6. What are the side effects? Any drug carries the risk of anaphylaxic shock. People who will be coming to the Surgery will be well established on their medication, so this risk is very low. As with any drug, the severity of the side effects depends on the persons individual response to it and sometimes the dose given. The main side effects experienced by people taking depot medication can be quite unpleasant, and include symptoms categorised into three main groups: Extra Pyramidal Side Effects (EPSE), anticholinergic reaction and prolactin elevation. EPSE include : unusual body movements such as tremors similar to those in Parkinson’s disease, a feeling of restlessness (this is sometimes called akathisia,) muscle stiffness (sometimes called dystonia), excessive production of saliva causing drooling, and repetitive movements of the head, face and neck (and occasionally limbs) which may occur gradually over time and can sometimes be irreversible (this is called tardive dyskinesia.) Anticholinergic reactions include: blurred vision, confusion, increased or rapid heart rate, a dry mouth, difficulty passing urine and getting constipated. Generally a drying up of membranous tissues.

7. What are the side effects? Continued Raised prolactin symptoms include: erectile problems and decreased libido, difficulty reaching orgasm, general dissatisfaction with sex, enlargement and tenderness of breasts, lactation, irregular periods or periods that stop, infertility, reduced bone mineral density that could potentially lead to osteoporosis. Weight gain is a frequently experienced side effect of antipsychotic medication There is strong evidence linking people with schizophrenia with Type II diabetes but there is not enough conclusive evidence to say that this is caused by the medication. In a survey conducted by Rethink, called Just one percent, most people said that their priority in the development of new drugs was to find one with fewer side effects. Its hardly surprising that experiencing side effects, can be enough to discourage people from remaining concordant with the medication they are prescribed to help manage their symptoms. Some clients report discomfort at the injections site, and odeoma, pruritus and the forming of nodules under the skin are other localised reactions

8. What are the similarities and differences in typical and atypical depot injections? ‘Typical’ or traditional antipsychotic drugs are usually associated with giving people more EPSE side effects. ‘Atypical’ antipsychotic drugs are the newer, drugs which offer a different profile in terms of side effects, with a reduced likelihood of EPSE, but may still cause weight gain and other side effets. There are quite few oral atypical antipsychotic drugs, but currently only one long acting injection that is an atypical antipsychotic drug. This is called Risperdal Consta and is a long acting injection of an oral drug called Risperidone. Risperdal Consta can only be giving fortnightly, as one of three pre specified doses. Other ‘typical’ depot medications can be given at intervals negotiated by the doctor and the patient

9. How is Risperdal Consta different to other depots? Other depot preparations consist of a drug suspended in vegetable oil, and the amount of drug is stable throughout the total volume of the ampoule. Risperdal Consta is made up of a encapsulated micro-spheres (which looks like a powder), which are then carried in a special solution that you mix with it, to allow injection. The amount of drug is not stable in the solution. This is why there are only pre-set doses (25mg, 37.5mg and 50mg) and a special pack is provided to give the drug It is a refrigerated item. The company provide a teflon coated needle to administer the injection with. Its important not to use a normal IM needle, as the micro-spheres would stick to the inside, and so the patient would not get the total dose of medication. The needle provided is rather long, this simply is because the trials were carried out in the USA where there is a greater population of obese people. It should ideally be prepared 20 minutes before being given to the patient. If the medication is left out of the fridge for 20 min, its shelf life is then reduced to 7 days, this is important to remember when considering the cold chain of transportation of the drug, from the point of ordering to point of receipt.

10. What happens if people miss an appointment? It’s best to book people in for their next appointment when you see them for their injection. Some people are very organised and will remember this appointment, others may write it in their diary, whilst for some people, offering to write the appointment down for them is helpful. Some people have ‘injection’ cards. If some one does not attend for their depot appointment, it may be for one of several reasons. The primary reason might not be that they do not wish to have their treatment. Please try to remember this! It’s a good idea to ring the person to check whether they had remembered, and to establish another time that they can come to the surgery to receive their injection. The impact of missing their appointment is likely to vary depending on the stability of their current health, and the interval at which they have their medication, so missing it by a week is more significant for someone who had their depot every fortnight, than for some one who has it every four weeks. Most people who are having their depot at their GP surgery will have had fairly stable mental health for a number of years and have found having their depot a useful way of staying well. These people will be motivated by this to attend the surgery. If some did not come for their injection after two appointments the GP would need to liaise with the consultant psychiatrist who discharged the person to their care. Most people would take a number of months to relapse after stopping depot medication. This is because it remains in the system for a long time.

11. Where can I find more information? www.sussexpartnership.nhs.uk/services-and-information/medication/ www.bnf.org www.rcpsych.ac.uk/mentalhealthinformation.aspx www.mentalhealthshop.org/products/rethink_publications/only_the_best.html