Current guidelines for the treatment of patients with schizophrenia advocate that patients receive treatment with a long-acting injectable (LAI) antipsychotic medication if they prefer such treatment or if they have a history of poor or uncertain adherence. Available LAI formulations in the United States include first-generation antipsychotics (fluphenazine decanoate and haloperidol decanoate), risperidone/paliperidone containing products (risperidone microspheres, paliperidone palmitate, and risperidone subcutaneous), aripiprazole containing products (aripiprazole monohydrate and aripiprazole lauroxil), and olanzapine pamoate. LAI antipsychotics can address the guesswork about adherence status and patients may prefer them if they are offered this as a choice, including individuals early in their disease course. Additional approved indications in the United States for LAI antipsychotics include bipolar I disorder maintenance treatment for risperidone microspheres and aripiprazole monohydrate, and schizoaffective disorder for paliperidone palmitate once monthly. Differences and similarities among the different products are discussed, including guidance regarding optimal treatment selection. Tips are provided to enhance effective patient communication to maximize the likelihood of acceptance of this treatment modality.

Little information exists on the medium- to long-term outcome of switching patients with schizophrenia from traditional depot to atypical oral antipsychotic agents. By detailed clinical audit, we identified a representative group of 102 patients of an Irish psychiatric service with DSM-IV chronic schizophrenia and on depot neuroleptics for a mean of 15 years. Of 69 eligible to participate, 33 entered a 6-month switch study of risperidone, with limited follow-up of consenters and non-consenters at 1 and 2 years. At 6 months, 23 of 33 were still on risperidone and had small significant improvements in clinical and extrapyramidal side effects, QOL and adjunct medication measures over baseline. At 12 months, 19 of 33 were still on risperidone, reducing to 13 of 33 at 2 years. At 2 years, of 32 surviving consenters to switch, 19 had suffered clinically detrimental events and were no longer on risperidone, compared to none of the 33 surviving non-consenters, who were all still on depot. These findings suggest that switching from depot to risperidone may encounter high rates of refusal and attrition subsequent to switch. While a majority of switched patients may improve after to least 6 months, audit plus switch may have clinically unfavourable effects on others over a 2-year follow-up period.

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

Physicians' attitudes to depot medication are often focused on improved compliance (adherence), and thus, short- and long-term treatment outcomes. By contrast, patients receiving such formulations tend to have a quite different viewpoint of medication. Factors such as convenience, side-effects and their beliefs about their illness play an important role in determining whether patients will adhere to their prescribed treatment regimen. The relationship between the patient and physician is of crucial importance in determining a patient's attitude to their medication; it is becoming increasingly clear that managing the illness in the long-term and avoiding relapse, while ensuring compliance, should be reframed as a collaborative process between the patient and physician.

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

Guidelines for treating various conditions can be helpful in setting practice standards, but the presence of several sets of guidelines from different countries, experts, and settings, written at different times, can also create confusion. Here we provide a “guideline of guidelines” for the treatment of schizophrenia, or “meta-guidelines,” which not only reconcile the various existing standards but also update them to include the use of several newer agents, most of which were marketed following the publication of existing standards.

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.

Existe poca información sobre la evolución a medio y a largo plazo de cambiar a los pacientes con esquizofrenia del depot tradicional a agentes antipsicóticos orales atípicos. Por una verificación clínica detallada, identificamos un grupo representativo de 102 pacientes de un servicio psiquiátrico irlandés con esquizofrenia crónica segiin DSM-IV y neurolépticos depot durante una media de 15 años. De los 69 elegibles para participar, 33 entraron en un estudio de cambio de 6 meses de risperidona, con seguimiento limitado de los pacientes que consintieron y los que no consintieron al año y a los dos años. A los 6 meses, 23 de los 33 estaban todavía con risperidona y tenían pequefias mejorías significativas en los efectos secundarios clínicos y extrapiramidales, la calidad de vida y la medicación auxiliar medi-dos con respecto a la línea de base. Al año, 19 de los 33 estaban todavía con risperidona, reduciéndo-se a 13 de los 33 a los 2 años. A los 2 años, de los 32 supervivientes que consintieron el cambio, 19 habían sufrido acontecimientos perjudiciales clínicamente y no estaban ya con risperidona, comparado con ninguno de los 33 supervivientes que no consintieron, que estaban todavía con el depot. Estos hallazgos indican que cambiar del depot a risperidona puede encontrar tasas altas de rechazo y reducción posteriores al cambio. Mientras que una mayoría de los pacientes cambiados pueden mejorar des-pués de 6 meses al menos, la verificación más el cambio pueden tener efectos clínicamente desfavora-bles en otros durante un período de seguimiento de 2 años.

Objective: Depot antipsychotic medication is often prescribed as maintenance treatment for patients with bipolar affective disorder. In this study we examined the case notes of 14 patients with bipolar disorder who had been prescribed depot antipsychotics. Our aim was to establish the effectiveness of depot medication in this group.

Method: We calculated the total number of hospital admissions, length of hospital stay, and total number of affective episodes for each patient from the onset of their illness to the time of the study. The frequency of affective episodes and hospital admission were compared during periods on or off depot medication.

Results: Treatment with depot antipsychotics was associated with a significant decrease in the number of hospital admissions, overall affective episodes and manic episodes in particular.

Conclusions: Prophylactic treatment with depot antipsychotics may be useful for certain patients with bipolar disorder, in particular those patients who experience frequent manic episodes. Further proof of the efficacy of depot antipsychotics in the prophylaxis of bipolar affective disorder requires the completion of a double-blind prospective trial.