Back in the 1970s, the depot injectable antipsychotics were around and much discussed as a solution to non-compliance in patients who had frequent relapses because as soon as they left the hospital, they stopped taking medications. 
There were Prolixin Clinics, and visiting nurses who took the medication to the patients. It seemed to me that it sounded like a better idea than it was, at least in the inner-city environment where I worked. Besides the Big Brother [1984] feel to the scheme, many of the patients were as unlikely to show up for their monthly injection as they were to take their oral medication. In recent history, the Long Acting Injectable [LAI] Atypical Antipsychotics tend to be released late as the drugs go off-patent, presumably as a patent extension ploy [above].
The PRELAPSE study that I introduced in prelapse: prequel1… is unique in my experience. I was alerted to it by Johanna Ryan of RxISK and Mad-in-America in her well researched post [The Once and Future Abilify: Depot Injections for Everyone?]. They are proposing to start off with a depot antipsychotic in first episode of Schizophrenia. I suppose the logic is to get off "on the right foot" by using a depot medication from the get-go to pre-empt any noncompliance problems. Their proposal is to divvy up clinical sites, half of which will use treatment-as-usual with oral antipsychotics of the clinician’s choice, and the other will use the injectable Abilify Maintena®. They plan to compare the groups at two years.
Well, out of the gate, that study doesn’t make much sense. First, do I want to commit a patient to maintenance antipsychotics the day I meet him/her? What about the patients whose psychosis is short-lived and may never return? Brief Reactive Psychosis it’s called? What about at least giving the patient the chance to recover and remain medication-free if possible. The depot medications have traditionally only been used for patients who have a recurrent relapsing pattern and are medication non-compliant. And there are plenty of people who would see this scheme as "forced drugging." But my complaint is something else, and why I started with the Dan Markingson story in prelapse: prequel1…. When you treat a case of a first episode of Schizophrenia, you pick a drug and a dose, and monitor the response – adjusting the dose or changing drugs based on the patient’s clinical response. Some patients are very sensitive to the EPS symptoms or other side effects of one drug, and you don’t know that until you try. The goal is the minimum effective dose and that’s determined by usage. Some patients don’t respond to one medication, but another works just fine. With a depot medication, you’re committed from the start.
That’s what I think happened to Dan Markingson. He was started on a fixed dose of a drug in a blinded study. I don’t think he ever fully responded. He needed a clinician who was on top of things and tried upping the dose, or changing drugs – the kind of medication tweaking that’s necessary with many of the drugs we use in medicine. With depot medication, that’s always going to be impossible. I’d never do what’s suggested in this study in the real world of clinical psychiatry. Since these depot medications have been around for at least forty years, why didn’t we think of doing this a long time ago? There must be some other factor in deciding to try this scheme in first episode cases.
Just a side marketing note: we saw that when the original PPI’s for acid reflux was about to go off patent the introduction of a similar drug, basically the same with a small chemical change.
The result was one Purple Pill being sold OTC, the other pill being sold by prescription. The people being given the prescriptions were often low income and with their prescription cards the medication was low or no cost. People with slightly higher incomes were forced to pay the OTC price.
This is a win win for the drug company since they will sell the medication in both cases and maintain a hold on a person’s treatment through their insurance. We, the public, then subsidize the drug company through our entitlement programs.
There is more to this issue including subsidizing poor food choices and promoting other negative behaviors, but the winner is the drug company.
Steve Lucas
Another good reason to be conservative in the use of LAI antipsychotic drugs for patients with first episode schizophrenia is that the diagnosis is not always stable. Over 10 years of follow-up the diagnosis changes for one patient in nine (11%), most often to a mood disorder. There were also frequent diagnostic shifts in the opposite direction. Course of illness is a key element of diagnosis, so the necessarily cross-sectional diagnoses made in first-episode cases are inherently provisional.
Thanks Doc Carroll! You’re right: in addition to the young people who may be having a one-time psychotic episode under the influence of anything from family abuse to funny drugs to being “saved” by that strange church down the road, there are others who may have a long-term problem. And it may not be “schizophrenia” at all.
I recently heard a lecture about a very good “Open Dialogue” pilot project, based on active listening and minimum possible medication, up in Mass. One of the young men who came their way was having intrusive thoughts about stabbing people, committing mayhem of various sorts. The thoughts seemed both crazy and immoral to him but he couldn’t force them out of his mind. He didn’t believe that an outside being was commanding him to do these things, and he didn’t hear voices. What he really had was a fairly well-known variation of OCD. Yet he’d arrived with a fresh diagnosis of “schizophrenia” from a local psych practice and a fat script for Seroquel.
I used to think it was only in the bad old days, fifty or sixty years ago, that American shrinks called everything “schizophrenia” (especially in poor people and dark-skinned folks). I’m afraid we may be “at risk” of going back there. What I fear is that many of the folks enrolled in this PRELAPSE Study may not fit the description of a “schizophrenic” at first … but after two solid years on continuous, fairly high dose antipsychotics, they will look and act so much like one that they’ll be stuck in the system for life.
As someone who’s had awful reactions to medications, I find the idea of starting out with a monthly injection quite frightening. It seems very callous and controlling from my perspective. I find it hard to believe anyone would be in favor of this when the tweaking you mention is so necessary.
Laurie,
Well said!