Reducing long acting antipsychotic injection dosage frequency: A pilot study in a community mental health team.

BACKGROUND: Antipsychotic long acting injections (LAI) allow a range of dosage intervals to be administered. Short intervals can be inconvenient for patients and staff. There are few clinical reasons for using them yet this is common practice. AIMS: This study aimed to examine the feasibility of reducing LAI frequency with service user consent. METHODS: The study took place in a community mental health team in the north of England. A specialist mental health pharmacist reviewed records of all service users on LAI and drew up an action plan. Each service user then met with the consultant psychiatrist for medication review. RESULT: Nineteen out of thirty service users on LAI had intervals less than the maximum licensed. The frequency was reduced in eight cases. After 6 months follow-up, there was no deterioration in symptoms. In nine cases, antipsychotic doses were also reduced as a result of the review. CONCLUSION: Where a service user is prescribed a LAI with a short dosage interval consideration should be given to increase the interval. This can free up service user and staff time. A medication focused review can also lead to other benefits such as dosage reduction.

Risperidone versus olanzapine for schizophrenia.

BACKGROUND: Antipsychotic medication is a mainstay of treatment for schizophrenia. Risperidone and olanzapine are popular choices among the new generation drugs. OBJECTIVES: To determine the clinical effects, safety and cost effectiveness of risperidone compared with olanzapine for treating schizophrenia. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (Sept 2005) which is based on regular searches of, amongst others, BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were inspected for further trials. We also contacted relevant pharmaceutical companies for additional information. SELECTION CRITERIA: We included all clinical randomised trials comparing risperidone with olanzapine for schizophrenia and schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS: We extracted data independently. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat/harm (NNT/H) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). MAIN RESULTS: We found no difference for the outcome of unchanged or worse in the short term (n=548, 2 RCTs, RR 1.00 CI 0.88 to 1.15). One study favoured olanzapine for the outcome of relapse/rehospitalisation by 12 months (n=279, 1 RCT, RR 2.16 CI 1.31 to 3.54, NNH 7 CI 3 to 25). Most mental state data showed the two drugs to be as effective as each other (n=552, 2 RCTs, RR 'no <20% decrease PANSS by eight weeks' 1.01 CI 0.87 to 1.16). Both drugs commonly cause adverse events: 75% given either drug experience an adverse event; 20% anticholinergic symptoms; both groups experienced insomnia although it was more frequent with risperidone (n=1588, 5 RCTs, RR 1.41 CI 1.15 to 1.72, NNH 15 CI 9 to 41); about 30% experienced sleepiness (n=1713, 6 RCTs, RR 0.92 CI 0.79 to 1.07). People given either drug often experienced some extrapyramidal symptoms (n=893, 3 RCTs, RR 1.18 CI 0.75 to 1.88); 25% of people using risperidone required medication to alleviate these symptoms (n=419, 2 RCTs, RR 1.76 CI 1.25 to 2.48, NNH 8 CI 4 to 25). People allocated to risperidone were less likely to gain weight compared with those given olanzapine and the weight gain was often considerable and of quick onset (n=984, 2 RCTs, RR gain more than 7% of their baseline weight in short term 0.47 CI 0.36 to 0.61, NNH 7 CI 6 to 10). Risperidone participants were less likely to leave the study due to metabolic side effects and weight gain compared with olanzapine (n=667, 1RCT, RR 0.19 CI 0.08 to 0.45). Patients on risperidone were more likely to experience abnormal ejaculation (n=370, 2 RCTs, RR 4.36 CI 1.38 to 13.76, NNH 20 CI 6 to 176). Both drugs are associated with high attrition rates; in the long term consistent findings show that 66% of those allocated risperidone left the study early compared with 56% given olanzapine (n=1440, 5 RCTs, RR 1.17 CI 1.08 to 1.27, NNH 11 CI 7 to 23). AUTHORS' CONCLUSIONS: We know very little of the effects of these drugs regarding service outcomes, general functioning and behaviours, engagement with services and treatment satisfaction from evaluative studies. There was generally a high rate of attrition in the trials and there appears to be little to differentiate between risperidone and olanzapine except on issues of adverse effects. Both drugs are associated with a reduction in psychotic symptoms but both commonly cause unpleasant adverse effects.

Risperidone versus olanzapine for schizophrenia.

BACKGROUND: Antipsychotic medication is a mainstay of treatment for schizophrenia and risperidone and olanzapine are the most popular treatment choice of the new generation drugs. OBJECTIVES: To determine the clinical effects, safety and cost effectiveness of risperidone compared with olanzapine for treating schizophrenia. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (June 2004) which is based on regular searches of, amongst others, BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were inspected for further trials. We also contacted relevant pharmaceutical companies for additional information. SELECTION CRITERIA: We included all clinical randomised trials comparing risperidone with olanzapine for schizophrenia and schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS: We extracted data independently. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat/harm (NNT/H) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). MAIN RESULTS: We found no difference for the outcome of unchanged or worse in the short term (n=548, 2 RCTs, RR 1.00 CI 0.88 to 1.15). One study, sponsored by the manufactures of olanzapine, favoured this drug for the outcome of relapse/rehospitalisation by 12 months (n=279, RR 2.16 CI 1.31 to 3.54, NNT 7 CI 4 to 25). Most mental state data showed the two drugs to as effective as each other (n=552, 2 RCTs, RR 'no <20% decrease PANSS by eight weeks' 1.01 CI 0.87 to 1.16). At least two thirds of people given risperidone or olanzapine experienced an adverse event (n=300, 2 RCTs, RR 1.16 CI 0.70 to 1.94). About 20% had anticholinergic symptoms (n=719, 3 RCTs, RR 1.12 CI 0.77 to 1.63) and 20% of both groups experienced insomnia (n=594, 3 RCTs, RR 1.33 CI 0.95 to 1.85) and approximately 33% sleepiness (n=719, 4 RCTs, 0.99 CI 0.79 to 1.23). One third of people given either drug experienced some extrapyramidal symptoms (n=893, 3 RCTs, RR 1.18 CI 0.75 to 1.88) but 25% of people using risperidone require medication to alleviate extrapyramidal adverse effects (n=419, 2 RCTs, RR 1.76 CI 1.25 to 2.48, NNH 8 CI 4 to 25). People allocated to risperidone were less likely to gain weight compared with those given olanzapine and the weight gain resulting from olanzapine can be considerable and of rapid onset (n=377, 1 RCT, RR gain more than 7% of their baseline weight 0.40 CI 0.23 to 0.70, NNT 8 CI 6 to 17). Risperidone may cause more sexual dysfunction than olanzapine (n=370, 2 RCTs, RR abnormal ejaculation 4.36 CI 1.38 to 13.76, NNH 20 CI 6 to 176; n=31, 1 RCT, RR impotence 2.43 CI 0.24 to 24.07). Within trials both drugs are associated with equal attrition (n=1217, 7 RCTs, RR leaving the study early 1.17 CI 0.92 to 1.49). AUTHORS' CONCLUSIONS: Data regarding quality of life and economic outcomes are difficult to interpret, and for both these highly marketed new drugs we know very little from evaluative studies regarding service outcomes, general functioning and behaviour, engagement with services and treatment satisfaction. There is little to differentiate between risperidone and olanzapine except on the issue of adverse effects and both these drugs have unpleasant adverse effects. Risperidone is particularly associated with movement disorders and sexual dysfunction. Olanzapine can cause considerable rapid weight gain.This review highlights the need for large, independent, well designed, conducted and reported pragmatic randomised studies.

Depot risperidone for schizophrenia.

BACKGROUND: Risperidone is the first new generation antipsychotic drug made available in a long acting injection. OBJECTIVES: To examine the clinical effects of depot risperidone for people with schizophrenia and schizophrenia-like psychoses. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's Register (December 2002), references of all included studies, and contacted industry and authors of included studies. SELECTION CRITERIA: Randomised clinical trials comparing depot risperidone with other treatments for people with schizophrenia and/or schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS: Two reviewers independently inspected citations and/or abstracts, ordered papers, re-inspected and quality assessed the results, and extracted data. For dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT), on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). MAIN RESULTS: One study (n=400) compared depot risperidone with placebo but 56% of people did not complete the three-month study rendering most global and mental state data unusable. Risperidone depot compared with placebo did not affect levels of anxiety (n=400, RR 0.58 CI 0.32 to 1.05) but may decrease agitation (n=400, RR 0.60 CI 0.39 to 0.92). Risperidone depot did not substantially influence hallucinations (n=400, RR 1.23 CI 0.47 to 3.22) but 'psychosis' was reduced (n=400, RR 0.52 CI 0.33 to 0.83, NNT 9 CI 7 to 26). Attrition was higher for the placebo group compared with people allocated risperidone depot (n=400, RR 0.74 CI 0.63 to 0.88, NNT 6 CI 4 to 12). Severe adverse events were common (13% to 23%) but significantly more so in the placebo group (n=400, RR 0.59 CI 0.38 to 0.93, NNT 11 CI 7 to 70). Poor reporting, however, makes these difficult to interpret. Movement disorders were equally common in both groups (n=400, RR 2.38 CI 0.73 to 7.78) although it looks as if there is a trend for the higher depot doses to encourage movement disorders. One study (n=640) compared depot risperidone against oral risperidone for stable people with relatively mild illness. For global outcomes there was no clear difference between the depot group and oral group (n=640, RR 'no global improvement' 1.06 CI 0.92 to 1.22). Mental state measures were also similar across groups. Overall, in this study compliance was good (n=640, RR <4 injections or "major protocol violation" 1.16 CI 0.81 to 1.67). Adverse effects were poorly reported but over half of both groups reported some adverse effect (n=640, RR 1.04 CI 0.91 to 1.18). REVIEWER'S CONCLUSIONS: There is no reliable data to support the claim that depot risperidone is beneficial for people with schizophrenia. For reasonably well, stable people it may mean that the need for regular oral doses can be avoided, but adverse affects are not well reported. For more severely ill people, few benefits are evident although it may increase compliance with injections in comparison with placebo. Use of depot risperidone, especially at the higher doses, is weakly associated with movement disorders. Well designed and reported, randomised studies, firmly grounded in real world clinical practice are needed to fully assess the effects of this new preparation.