The successful concurrent use of two long-acting depot antipsychotics in a patient with treatment-resistant schizophrenia and history of serious violence: a case report.

OBJECTIVE: This case report describes a forensic psychiatric patient presenting with treatment-resistant schizophrenia and serious interpersonal violence complicated by poor adherence to oral medication who was treated successfully with two concurrent long-acting depot antipsychotics. METHOD: Treatment response was measured for a 6-month period at 6-weekly intervals, post-initiation using the Positive and Negative Symptoms of Schizophrenia with Excited Component score (PANSS-EC), Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression Scale (CGI). RESULTS: At 6 months, the presentation was found to have markedly improved. The overall PANSS-EC score was reduced by 43.9%, with reductions in Positive Symptom and Excited Component subscales most evident. BPRS Score was reduced from 81 at baseline to 47 at 18 weeks. There was improvement in the patient's level of cooperativeness, aggression and engagement in ward therapeutic activities. CONCLUSION: Although concurrent use of two depot antipsychotics requires further exploration, there is potential benefit for patient groups presenting with treatment-resistant schizophrenia and poor compliance. Due to risk of serious adverse effects which are difficult to reverse with long-acting formulations, we recommend this option be reserved for this complex patient population and exclusively in care settings allowing close physical health monitoring.

Innovation and pragmatism required to reduce seclusion practices.

Seclusion may be harmful and traumatic to patients, detrimental to therapeutic relationships, and can result in physical injury to staff. Further, strategies to reduce seclusion have been identified as a potential method of improving cost-effectiveness of psychiatric services. However, developing alternative strategies to seclusion can be difficult. Interventions to reduce seclusion do not lend themselves to evaluation using randomized controlled trials (RCTs), though comprehensive literature reviews have demonstrated considerable non-RCT evidence for interventions to reduce seclusion in psychiatric facilities. In the UK, a recent 5-year evaluation of seclusion practice in a high secure UK hospital revealed reduced rates of seclusion without an increase in adverse incidents. To assess the effect of a novel intervention strategy for reduction of long-term segregation on a high secure, high dependency forensic psychiatry ward in the UK, we introduced a pilot program involving stratified levels of seclusion ("long-term segregation"), multidisciplinary feedback and information sharing, and a bespoke occupational therapy program. Reduced seclusion was demonstrated and staff feedback was mainly positive, indicating increased dynamism and empowerment on the ward. A more structured, stratified approach to seclusion, incorporating multidisciplinary team-working, senior administrative involvement, dynamic risk assessment, and bespoke occupational therapy may lead to a more effective model of reducing seclusion in high secure hospitals and other psychiatric settings. While lacking an evidence base at the level of RCTs, innovative, pragmatic strategies are likely to have an impact at a clinical level and should guide future practice and research.