539859 research-article2014
APY0010.1177/1039856214539859Australasian PsychiatrySuetani et al.
Australasian
Psychiatry
Community treatment orders
We need to talk about depot: effect of Community Treatment Order on depot antipsychotic medication compliance
Australasian Psychiatry 2014, Vol 22(4) 357–359 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214539859 apy.sagepub.com
Shuichi Suetani Registrar, West Adelaide Community Mental Health Team, Woodville, SA, and; Clinical Lecturer, Discipline of Psychiatry, University of Adelaide, Adelaide, SA, Australia Edward Foo Consultant Psychiatrist, West Adelaide Community Mental Health Team, Woodville SA, Australia Douglas Wilson Consultant Psychiatrist, West Adelaide Community Mental Health Team, Clinical Lead, Woodville SA, Australia
Abstract Objective: The current study compares the compliance rates of patients on depot who were on Community Treatment Orders with those who were not on such Order with a view to objectively quantify the effect of Community Treatment Orders on depot antipsychotics medication compliance. Methods: “Day difference” measurements between the scheduled depot data and the administered date were collected for both voluntary and involuntary patients receiving depot medication at the same community clinic over a 6-month period. Results: The results demonstrated a trend for greater compliance to depot medications by those not on a Community Treatment Order compared with those who were, but there was no statistically significant difference between the two groups. Conclusions: The current study highlighted that while Community Treatment Order may be a reasonable shortterm tool to encourage patients’ compliance at an early treatment stage, ongoing effort should be put into improving patients’ attitude towards depot medications to ensure a better long-term outcome for individuals with schizophrenia. Keywords: depot medication, community treatment order, community psychiatry
T
he most recent Australian national survey results1 showed over 90% of individuals with psychotic illness have been prescribed psychotropic medication, with over 88% of participants reporting compliance. Over the years, other reported compliance rates range from 25–96% in different studies with different methodologies and definitions,2–4 but on average, it is estimated at around 50%.5,6 In addition to being an important predicting factor in achieving remission,7 poor or partial medication compliance is associated with an increased risk of symptom relapse and associated hospital admissions as well as increased risk of suicide attempts and developing a more resistant illness.3,8,9
Attitudes towards depot medication may be an important factor in the underutilisation of this treatment. In the past, doctors tended to underestimate patient willingness for depot medication thus hindering initiation of such treatment.11,12 However, a trial involving longacting risperidone depot13 has shown that even in a group of initially reluctant patients with first-episode schizophrenia, almost three-quarters of them accepted depot medication with structured psychoeducation. A small study from Canada14 demonstrated encouraging results in the use of motivational interview for increasing the depot medication acceptance rate among patients.
Despite the great potential benefit associated with transparency of compliance and clinical recommendations,10 the use of depot medication remains relatively low with only 12.1% and 11.2% of patients in Australia receiving atypical and typical antipsychotic depot mediations, respectively.1
Corresponding author: Shuichi Suetani, West Adelaide Community Mental Health Team, Registrar, 57 Woodville Road, Woodville SA 5011, Australia. Email: [email protected] 357
Downloaded from apy.sagepub.com at UNIV OF CONNECTICUT on May 14, 2015
Australasian Psychiatry 22(4)
Table 1. Comparison between average mean day difference of those on CTOs* and those who not on a CTO Depot medication
On CTO (n=31)
Not on CTO (n=59)
Significance
Flupenthixol Flupenazine Haloperidol Paliperidone Risperidone Zuclopenthixol Total
+ 0.08 (n=3) + 2.88 (n=1) N/A (n=0) + 2.59 (n=18) + 0.10 (n=6) + 0.16 (n=3) + 1.64 (n=31)
N/A (n=0) N/A (n=0) −0.15 (n=2) + 0.67 (n=20) + 0.65 (n=10) + 0.38 (n=21) + 0.50 (n=59)
p=0.0931 (NS)
* Community Treatment Order.
While there are some Australian data that suggest community treatment orders (CTOs) are effective in reducing hospital admission rates by coercing compliance with depot medication,15,16 this notion has been questioned by a recent randomised controlled trial in the United Kingdom.17 Furthermore, the long-lasting effect of such potentially improved compliance remains unclear.18,19 In the current study, we performed a retrospective analysis of available data at our community clinic to compare the compliance rates of patients on depot who were on a CTO with those who were not. Our aim was to objectively quantify the effect of CTOs on patients’ compliance with depot medication.
Methods A list of patients on depot medication was obtained from the depot service at the Beaufort clinic, a metropolitan community mental health service with a patient load of 470 at the time of the study. There were 105 patients who were receiving depot medications. The lead author reviewed depot medication charts to determine the day difference between the scheduled depot date and the administered date. For example, if a patient had depot scheduled for the 10th of January but received it on 12th of January, the day difference was calculated as +2. If the same patient actually presented earlier than the scheduled date, say on the 9th of January, then the day difference was calculated as -1. A mean value for the sum of day difference was calculated for each patient as a mean day difference. This measurement was used as a direct, objective indicator of medication compliance. All available data from the 6 months between 1 November 2012 and 30 April 2013 were collected, as was the CTO status of the patients as of 30th of April. An unpaired t-test was conducted to determine the statistical significance of the difference between the mean day difference of the two groups.
Results Out of 470 patients under the care of our clinic, 105 patients (22.3%) were receiving depot medication. There were 44 patients at the clinic who were under CTOs, of which 39 patients (88.6%) were receiving depot medication. Of the 105 patients on the depot list, 15 were excluded from the analysis due to unclear data availability (incomplete data entries in eight cases, missing data in six and one patient had not had their depot yet). Out of the 90 patients included in the study, 31 (34.4%) were on CTOs and 59 (65.6%) were not. The average mean day difference for those on CTOs was +1.64 days and the average mean day difference for those not on a CTO was +0.50 days. Further analysis of the data showed that paliperidone was the most utilised depot at our service, with 38 out of 90 patients receiving the monthly depot (42.2%) with a similar distribution among those who were on CTOs (n=18) and those who were not on a CTO (n=20). Interestingly, zuclopenthixol decanoate, the second most popular depot at our clinic, was given far more commonly to those who were not on a CTO (n=21) compared with those who were on CTOs (n=2). Table 1 shows the average mean day difference according to CTO status and different depot medications.
Discussion Almost all (88.6%) of the patients who were on CTOs at the Beaufort clinic over the duration of this study were receiving depot medication. Patients on CTOs were more often late for their depot compared with those who were not. However, there was no statistically significant difference between the two groups and the clinical significance of a 1.14 day delay in getting the depot medication is likely to be minimal. It needs to be kept in mind that due to legal obligations placed upon our service, patients who are on CTOs
358 Downloaded from apy.sagepub.com at UNIV OF CONNECTICUT on May 14, 2015
Suetani et al.
receive more intensive follow-up such as phone call reminders and home visits to facilitate them getting their depot medications on time. Nevertheless, our results suggest an increased reluctance in patients to have depot medication while they are on CTOs and an increased willingness to have depot medication if they are not on a CTO. We feel that CTOs have become a clinical double-edged sword. On one hand, this “forced cooperation” may sway some patients to have long-term depot medication after the expiration of their CTOs, but on the other hand, patients may associate depot medication with the involuntary treatment that took away their autonomy, hence feeling negative about the depot medication itself. We believe that there is an accumulating evidence base to suggest that by increasing awareness of the benefits of depot medication among patients, we may be able to reduce our reliance on CTO to administer such treatment and increase the utilisation of depot medications at the same time, hopefully at an early illness stage, thus optimising the potential benefit associated with medication compliance in patients with schizophrenia. Our study had several limitations. First, the study was of a retrospective analysis over a relatively short period. Subsequently, it was not clear what proportion of the patients not on a CTO at the time of the analysis had been on a CTO prior to that. Neither was it explored whether or not the patient was commenced on depot medication prior to receiving, or while already on a CTO. The small sample size of 105 also limits the power of the study. Another limitation was the fact that not all patients had been on depot mediation or on a CTO for the entire 6-month period for which we examined data. A few of the patients had only had a handful of depot medications during this period. Finally, our patient cohort, while naturalistic, was biased towards patients with a longer duration of illness due to our service provision, and this could have resulted in a sampling error. Furthermore, given the nature of CTO application process, it is possible that those who are on CTOs have more treatment-resistant illness than those who are not on CTO.
improving patients’ attitude towards depot medications to ensure a better long-term outcome for individuals with schizophrenia. Disclosure In the last year DW has given talks for Pfizer, Astra Zeneca and Eli-Lilly. Previously he has given talks for Janssen-Cilag, Bristol-Myer-Squib, Sanofi, Novartis, Lunbeck, Wyeth and Boehringer. SS and EF report no conflict of interest.
References 1. Waterrus A, Morga V, Castle D, et al. Medication for psychosis – consumption and consequences: The second Australian national survey of psychosis. Aust NZ J Psychiatry 2012; 46: 762–773. 2. Lacro J, Dunn L, Dolder C, et al. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. J Clin Psychiatry 2002; 63: 892–909. 3. Leucht S and Heres S. Epidemiology, clinical consequences, and psychosocial treatment of nonadherence in schizophrenia. J Clin Psychiatry 2006; 67: 3–8. 4. Lieberman J, Stroup T, McEvoy J, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005; 353: 1209–1223. 5. Osterberg L and Blaschke T. Adherence to medication. N Engl J Med 2005; 353: 487–497. 6. Tiihonen J, Haukka J, Taylor M, et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry 2011; 168: 603–609. 7. Lambert M, Karow A, Leucht S, et al. Remission in schizophrenia: validity, frequency, predictors, and patients’ perspective 5 years later. Dialogues Clin Neurosci 2010; 12: 393–407. 8. Robinson D, Woerner M, Alvir J, et al. Predictor of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 1999; 56: 241–247. 9. Law M, Soumerai S, Ross-Degnan D, et al. A longitudinal study of medication nonadherence and hospitalization risk in schizophrenia. J Clin Psychiatry 2008; 69: 47–53. 10. Kane J and Garcia-Ribera C. Clinical guideline recommendations for antipsychotic longacting injections. Br J Psychiatry 2009; 195: 63–67. 11. West J, Marcus S, Wilk J, et al. Use of depot antipsychotic medications for medication nonadherence in schizophrenia. Schizophr Bull 2008; 34: 955–1001. 12. Heres S, Schimitz F, Leucht S, et al. The attitude of patients towards antipsychotic depot treatment. Int Clin Psychopharmacol 2007; 22: 275–282. 13. Weiden P, Schooler N, Weedon J, et al. A randomized controlled trial of long-acting injectable risperidone vs continuation on oral atypical antipsychotics for first-episode schizophrenia patients: Initial adherence outcome. J Clin Psychiatry 2009; 70: 1397–1406. 14. Kisely S, Ligate L, Roy M, et al. Applying motivational interviewing to the initiation of long-acting injectable atypical antipsychotics. Australas Psychiatry 2012; 20: 138–142. 15. Vaughan K, McConaghy N, Wolf C, et al. Community treatment orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission. Aust NZ J Psychiatry 2000; 34: 801–808. 16. Muirhead D, Harvey C and Ingram G. Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: Clinical outcome. Aust NZ J Psychiatry 2006; 40: 596–605.
Conclusion The current study demonstrated a negative association between the use of CTOs and improved compliance with depot medications. The clinical implication of this result is that while CTO may be a reasonable short-term tool to encourage patient compliance at an early treatment stage, additional ongoing effort should be put into
17. Burns T, Rugkasa J, Molodynski A, et al. Community treatment orders for patients with psychosis (OCTET): A randomised controlled trial. Lancet 2013; 381: 1627–1633. 18. Lambert T, Singh B and Patel M. Community treatment orders and antipsychotic longacting injections. Br J Psychiatry 2009; 195: 57–62. 19. Taylor M and Ng K. Should long-acting (depot) antipsychotics be used in early schizophrenia? A systematic review. Aust NZ J Psychiatry 2013; 47: 624–630.
359 Downloaded from apy.sagepub.com at UNIV OF CONNECTICUT on May 14, 2015
APY0010.1177/1039856214539859Australasian PsychiatrySuetani et al.
Australasian
Psychiatry
Community treatment orders
We need to talk about depot: effect of Community Treatment Order on depot antipsychotic medication compliance
Australasian Psychiatry 2014, Vol 22(4) 357–359 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214539859 apy.sagepub.com
Shuichi Suetani Registrar, West Adelaide Community Mental Health Team, Woodville, SA, and; Clinical Lecturer, Discipline of Psychiatry, University of Adelaide, Adelaide, SA, Australia Edward Foo Consultant Psychiatrist, West Adelaide Community Mental Health Team, Woodville SA, Australia Douglas Wilson Consultant Psychiatrist, West Adelaide Community Mental Health Team, Clinical Lead, Woodville SA, Australia
Abstract Objective: The current study compares the compliance rates of patients on depot who were on Community Treatment Orders with those who were not on such Order with a view to objectively quantify the effect of Community Treatment Orders on depot antipsychotics medication compliance. Methods: “Day difference” measurements between the scheduled depot data and the administered date were collected for both voluntary and involuntary patients receiving depot medication at the same community clinic over a 6-month period. Results: The results demonstrated a trend for greater compliance to depot medications by those not on a Community Treatment Order compared with those who were, but there was no statistically significant difference between the two groups. Conclusions: The current study highlighted that while Community Treatment Order may be a reasonable shortterm tool to encourage patients’ compliance at an early treatment stage, ongoing effort should be put into improving patients’ attitude towards depot medications to ensure a better long-term outcome for individuals with schizophrenia. Keywords: depot medication, community treatment order, community psychiatry
T
he most recent Australian national survey results1 showed over 90% of individuals with psychotic illness have been prescribed psychotropic medication, with over 88% of participants reporting compliance. Over the years, other reported compliance rates range from 25–96% in different studies with different methodologies and definitions,2–4 but on average, it is estimated at around 50%.5,6 In addition to being an important predicting factor in achieving remission,7 poor or partial medication compliance is associated with an increased risk of symptom relapse and associated hospital admissions as well as increased risk of suicide attempts and developing a more resistant illness.3,8,9
Attitudes towards depot medication may be an important factor in the underutilisation of this treatment. In the past, doctors tended to underestimate patient willingness for depot medication thus hindering initiation of such treatment.11,12 However, a trial involving longacting risperidone depot13 has shown that even in a group of initially reluctant patients with first-episode schizophrenia, almost three-quarters of them accepted depot medication with structured psychoeducation. A small study from Canada14 demonstrated encouraging results in the use of motivational interview for increasing the depot medication acceptance rate among patients.
Despite the great potential benefit associated with transparency of compliance and clinical recommendations,10 the use of depot medication remains relatively low with only 12.1% and 11.2% of patients in Australia receiving atypical and typical antipsychotic depot mediations, respectively.1
Corresponding author: Shuichi Suetani, West Adelaide Community Mental Health Team, Registrar, 57 Woodville Road, Woodville SA 5011, Australia. Email: [email protected] 357
Downloaded from apy.sagepub.com at UNIV OF CONNECTICUT on May 14, 2015
Australasian Psychiatry 22(4)
Table 1. Comparison between average mean day difference of those on CTOs* and those who not on a CTO Depot medication
On CTO (n=31)
Not on CTO (n=59)
Significance
Flupenthixol Flupenazine Haloperidol Paliperidone Risperidone Zuclopenthixol Total
+ 0.08 (n=3) + 2.88 (n=1) N/A (n=0) + 2.59 (n=18) + 0.10 (n=6) + 0.16 (n=3) + 1.64 (n=31)
N/A (n=0) N/A (n=0) −0.15 (n=2) + 0.67 (n=20) + 0.65 (n=10) + 0.38 (n=21) + 0.50 (n=59)
p=0.0931 (NS)
* Community Treatment Order.
While there are some Australian data that suggest community treatment orders (CTOs) are effective in reducing hospital admission rates by coercing compliance with depot medication,15,16 this notion has been questioned by a recent randomised controlled trial in the United Kingdom.17 Furthermore, the long-lasting effect of such potentially improved compliance remains unclear.18,19 In the current study, we performed a retrospective analysis of available data at our community clinic to compare the compliance rates of patients on depot who were on a CTO with those who were not. Our aim was to objectively quantify the effect of CTOs on patients’ compliance with depot medication.
Methods A list of patients on depot medication was obtained from the depot service at the Beaufort clinic, a metropolitan community mental health service with a patient load of 470 at the time of the study. There were 105 patients who were receiving depot medications. The lead author reviewed depot medication charts to determine the day difference between the scheduled depot date and the administered date. For example, if a patient had depot scheduled for the 10th of January but received it on 12th of January, the day difference was calculated as +2. If the same patient actually presented earlier than the scheduled date, say on the 9th of January, then the day difference was calculated as -1. A mean value for the sum of day difference was calculated for each patient as a mean day difference. This measurement was used as a direct, objective indicator of medication compliance. All available data from the 6 months between 1 November 2012 and 30 April 2013 were collected, as was the CTO status of the patients as of 30th of April. An unpaired t-test was conducted to determine the statistical significance of the difference between the mean day difference of the two groups.
Results Out of 470 patients under the care of our clinic, 105 patients (22.3%) were receiving depot medication. There were 44 patients at the clinic who were under CTOs, of which 39 patients (88.6%) were receiving depot medication. Of the 105 patients on the depot list, 15 were excluded from the analysis due to unclear data availability (incomplete data entries in eight cases, missing data in six and one patient had not had their depot yet). Out of the 90 patients included in the study, 31 (34.4%) were on CTOs and 59 (65.6%) were not. The average mean day difference for those on CTOs was +1.64 days and the average mean day difference for those not on a CTO was +0.50 days. Further analysis of the data showed that paliperidone was the most utilised depot at our service, with 38 out of 90 patients receiving the monthly depot (42.2%) with a similar distribution among those who were on CTOs (n=18) and those who were not on a CTO (n=20). Interestingly, zuclopenthixol decanoate, the second most popular depot at our clinic, was given far more commonly to those who were not on a CTO (n=21) compared with those who were on CTOs (n=2). Table 1 shows the average mean day difference according to CTO status and different depot medications.
Discussion Almost all (88.6%) of the patients who were on CTOs at the Beaufort clinic over the duration of this study were receiving depot medication. Patients on CTOs were more often late for their depot compared with those who were not. However, there was no statistically significant difference between the two groups and the clinical significance of a 1.14 day delay in getting the depot medication is likely to be minimal. It needs to be kept in mind that due to legal obligations placed upon our service, patients who are on CTOs
358 Downloaded from apy.sagepub.com at UNIV OF CONNECTICUT on May 14, 2015
Suetani et al.
receive more intensive follow-up such as phone call reminders and home visits to facilitate them getting their depot medications on time. Nevertheless, our results suggest an increased reluctance in patients to have depot medication while they are on CTOs and an increased willingness to have depot medication if they are not on a CTO. We feel that CTOs have become a clinical double-edged sword. On one hand, this “forced cooperation” may sway some patients to have long-term depot medication after the expiration of their CTOs, but on the other hand, patients may associate depot medication with the involuntary treatment that took away their autonomy, hence feeling negative about the depot medication itself. We believe that there is an accumulating evidence base to suggest that by increasing awareness of the benefits of depot medication among patients, we may be able to reduce our reliance on CTO to administer such treatment and increase the utilisation of depot medications at the same time, hopefully at an early illness stage, thus optimising the potential benefit associated with medication compliance in patients with schizophrenia. Our study had several limitations. First, the study was of a retrospective analysis over a relatively short period. Subsequently, it was not clear what proportion of the patients not on a CTO at the time of the analysis had been on a CTO prior to that. Neither was it explored whether or not the patient was commenced on depot medication prior to receiving, or while already on a CTO. The small sample size of 105 also limits the power of the study. Another limitation was the fact that not all patients had been on depot mediation or on a CTO for the entire 6-month period for which we examined data. A few of the patients had only had a handful of depot medications during this period. Finally, our patient cohort, while naturalistic, was biased towards patients with a longer duration of illness due to our service provision, and this could have resulted in a sampling error. Furthermore, given the nature of CTO application process, it is possible that those who are on CTOs have more treatment-resistant illness than those who are not on CTO.
improving patients’ attitude towards depot medications to ensure a better long-term outcome for individuals with schizophrenia. Disclosure In the last year DW has given talks for Pfizer, Astra Zeneca and Eli-Lilly. Previously he has given talks for Janssen-Cilag, Bristol-Myer-Squib, Sanofi, Novartis, Lunbeck, Wyeth and Boehringer. SS and EF report no conflict of interest.
References 1. Waterrus A, Morga V, Castle D, et al. Medication for psychosis – consumption and consequences: The second Australian national survey of psychosis. Aust NZ J Psychiatry 2012; 46: 762–773. 2. Lacro J, Dunn L, Dolder C, et al. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. J Clin Psychiatry 2002; 63: 892–909. 3. Leucht S and Heres S. Epidemiology, clinical consequences, and psychosocial treatment of nonadherence in schizophrenia. J Clin Psychiatry 2006; 67: 3–8. 4. Lieberman J, Stroup T, McEvoy J, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005; 353: 1209–1223. 5. Osterberg L and Blaschke T. Adherence to medication. N Engl J Med 2005; 353: 487–497. 6. Tiihonen J, Haukka J, Taylor M, et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am J Psychiatry 2011; 168: 603–609. 7. Lambert M, Karow A, Leucht S, et al. Remission in schizophrenia: validity, frequency, predictors, and patients’ perspective 5 years later. Dialogues Clin Neurosci 2010; 12: 393–407. 8. Robinson D, Woerner M, Alvir J, et al. Predictor of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry 1999; 56: 241–247. 9. Law M, Soumerai S, Ross-Degnan D, et al. A longitudinal study of medication nonadherence and hospitalization risk in schizophrenia. J Clin Psychiatry 2008; 69: 47–53. 10. Kane J and Garcia-Ribera C. Clinical guideline recommendations for antipsychotic longacting injections. Br J Psychiatry 2009; 195: 63–67. 11. West J, Marcus S, Wilk J, et al. Use of depot antipsychotic medications for medication nonadherence in schizophrenia. Schizophr Bull 2008; 34: 955–1001. 12. Heres S, Schimitz F, Leucht S, et al. The attitude of patients towards antipsychotic depot treatment. Int Clin Psychopharmacol 2007; 22: 275–282. 13. Weiden P, Schooler N, Weedon J, et al. A randomized controlled trial of long-acting injectable risperidone vs continuation on oral atypical antipsychotics for first-episode schizophrenia patients: Initial adherence outcome. J Clin Psychiatry 2009; 70: 1397–1406. 14. Kisely S, Ligate L, Roy M, et al. Applying motivational interviewing to the initiation of long-acting injectable atypical antipsychotics. Australas Psychiatry 2012; 20: 138–142. 15. Vaughan K, McConaghy N, Wolf C, et al. Community treatment orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission. Aust NZ J Psychiatry 2000; 34: 801–808. 16. Muirhead D, Harvey C and Ingram G. Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: Clinical outcome. Aust NZ J Psychiatry 2006; 40: 596–605.
Conclusion The current study demonstrated a negative association between the use of CTOs and improved compliance with depot medications. The clinical implication of this result is that while CTO may be a reasonable short-term tool to encourage patient compliance at an early treatment stage, additional ongoing effort should be put into
17. Burns T, Rugkasa J, Molodynski A, et al. Community treatment orders for patients with psychosis (OCTET): A randomised controlled trial. Lancet 2013; 381: 1627–1633. 18. Lambert T, Singh B and Patel M. Community treatment orders and antipsychotic longacting injections. Br J Psychiatry 2009; 195: 57–62. 19. Taylor M and Ng K. Should long-acting (depot) antipsychotics be used in early schizophrenia? A systematic review. Aust NZ J Psychiatry 2013; 47: 624–630.
359 Downloaded from apy.sagepub.com at UNIV OF CONNECTICUT on May 14, 2015
