Administration of Depot and Long-Acting Antipsychotic Injections

Administration of
depot and long-acting

antipsychotic
injections
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This guide was commissioned and funded by Janssen-Cilag Ltd. Janssen-Cilag Ltd has been
involved in the development of the content, but did not have editorial control.
MHP depot booklet THIS ONE 2 9/9/08 16:19 Page 1
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Cover photograph: Alamy
3 Working within a recovery approach
6 Informed choice
7 Pharmacology
13 Physical health
14 Follow up
15 Maintaining knowledge and skills
15 Conclusion
16 References
Contents
2 october :: vol 12 no 2 :: 2008 MENTAL HEALTH PRACTICE
MENTAL HEALTH PRACTICE ESSENTIAL GUIDE
Copyright RCN Publishing Company Ltd 2008. All rights reserved. No part of this
book may be reproduced, stored in a retrieval system, or transmitted in any form or by
any means, electronic, mechanical, photocopying, recording or otherwise, without prior
permission of the publisher.
This guide was written by John Crowley, Professor Matt Griffiths,
Sheila Hardy, Mark Vincent, Jacquie White and Andrew Voyce.
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october :: vol 12 no 2 :: 2008 3 MENTAL HEALTH PRACTICE
It is essential for healthcare professionals to
share good practice and information in
partnership with those who use health and social
care services (National Institute for Mental
Health in England 2008). The aim of this guide is
to inform all practitioners, managers, service
users and carers about the use of intramuscular
(IM) depot and long-acting injectable (LAI)
antipsychotic medication. The recognition of
service users need for privacy, safety and dignity
when receiving these injections will be
emphasised.
Fourteen years ago Good Practice in the
Administration of Depot Injections (Royal College
of Nursing (RCN) 1994) failed to mention the
humane aspects of the procedure of
administering injections in terms of privacy,
dignity and the environment. However, important
issues of dissatisfaction with the experience of
receiving injections were highlighted by service
users (RCN 1994):
The reason for having an injection had not
been explained.
They were receiving too much medication.
They received too little information on side
effects.
The group responsible for writing this guide in
2008, aware of the development of more
meaningful service user/patient and carer
involvement, reviewed a large number of
protocols, guides and procedures from across the
UK. Findings showed that the majority focused
on technical aspects and generally omitted the
importance of the relationship between the
healthcare professional and the service user. A
recent publication highlighted good practice in
the technical administration of all IM injections,
but did not address important differences in the
administration of depot or LAI antipsychotics
(Hunter 2008).
In support of the principle of incorporating the
recovery approach into every aspect of mental
health nursing practice (Department of Health
(DH) 2006a), this guide emphasises the
importance of a partnership between the
healthcare professional and service users, using
technical information to illustrate, educate and
encourage good practice. The working group has
considered the principles of working within a
recovery framework, the environment, working in
partnership, informed choice, pharmacology,
technique, monitoring and maintaining
competence and knowledge. In each section the
reader is signposted to a number of useful
publications and good practice points are
highlighted.
Please note: where possible the term service
user has been adopted; the term patient has been
used interchangeably where it seemed
appropriate or when it is citing a direct reference.
Cartoons The cartoons featured throughout this
guide (Andrew Voyce 2008) have been
created by a user of mental health services and
are a representation of the reported experiences
of people receiving depot injections in the 1980s.
The illustrations are presented without comment;
readers are encouraged to draw their own
conclusions of the nursing practice depicted.
Working within a recovery approach
Recovery is a deeply personal unique process of
changing ones attitudes, values, feelings, goals,
skill and or roles (Kelly and Gamble 2005).
Offering help, treatment and care in an
atmosphere of hope and optimism is the first and
overarching principle in the National Institute for
Health and Clinical Excellence (NICE) guidelines
on the treatment of people with schizophrenia
(NICE 2002).
Recovery means different things to different
people (Kelly and Gamble 2005). In mental health,
the notion of recovery is not about a cure of a
condition of biological origin; it is about the
recovery of the whole person. A way of living a
satisfying, hopeful and contributing life, even with
the limitations caused by illness. Recovery involves
the development of new meaning and purpose in
life as the individual grows beyond the catastrophic
effects of mental illness (Anthony 1993).
The values and principles of recovery should
underpin everything we do, every word we speak
to colleagues and service users, and every
intervention we offer. At the core of the recovery
approach is the absolute belief that there are no
limits to the potential for recovery after a
diagnosis of mental illness.
The basic principles and values of the recovery
approach will inform the nurse administering the
depot medication to work in partnership with the
patient and offer meaningful choice (DH 2006a).
What service users and carers should expect
from a service:
That their aims are valued.
Partnership working that offers meaningful
choice.
Optimism, hope and the possibility of positive
change.
The promotion of social inclusion.
Health and social care staff should provide
(Roberts and Wolfson 2004):
An understanding of recovery principles.
Recognition of, and support for, the individuals
personal resources.
An understanding of, and accommodation for,
the diverse views on mental illness, treatments,
services and recovery.
Awareness and skills to communicate
respectfully and develop good relationships.
An understanding and active protection of
service users rights.
An understanding of discrimination and social
exclusion; how these may affect lifestyle and
knowledge of how they can be reduced.
Acknowledgement of the importance of
cultural beliefs and values.
Comprehensive knowledge of community
services and resources.
Knowledge of patient groups and movements
and support in accessing them.
Knowledge of family, friends and carers views
and a willingness to support them.
The environment of administration Service
users have a right to care that actively promotes
(DH 2001a):
Privacy freedom from intrusion.
Dignity being worthy of respect.
The decision on which environment is chosen to
...but I have been by a Japanese one.
Paul! Its your injection today!
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administer the injection should be agreed
between service users and clinicians involved in
their care. Irrespective of the setting, and indeed
who administers the injection, the good practice
points in Box 1 should be followed.
Working in partnership It is important to note
that concordance is not a new, politically correct,
way of referring to compliance. Compliance
measures patient behaviour: the extent to which
patients take medicines according to the
prescribed instructions. However, concordance
measures a two-way consultation process:
shared decision-making about medicines
between a healthcare professional and a patient,
based on partnership, where the patients
expertise and beliefs are fully valued (National
Prescribing Centre (NPC) Plus 2007).
Creating a therapeutic alliance is dependent
on the attitudes, values and core
communication skills of the healthcare
professional. Patel et al (2005) specifically
highlight advocacy and treatment decision
making for enhanced nurse-patient interactions
as components of training and refresher
courses. Such training will help promote the
process of making shared decisions about
treatment with the patient.
The act of administering a depot or LAI
antipsychotic should not be seen as an isolated
behaviour; it should be viewed as an important
and integral part of the individual service users
whole matrix of care. While the administration of
the injection is most likely to be carried out by a
nurse, it would be wrong to assume that other
disciplines involved in the care should be divorced
from the process. Effective communication
between all professionals is essential in ensuring
consistent levels of care.
Gray and Robson (2005) have developed a
flexible and adaptable toolkit that can be used by
healthcare workers to structure conversations
with service users about medication. This toolkit
emphasises the service users rights, the need for
an exchange of information and two-way
BOX 1
Good practice points
Maintain a therapeutic environment by
valuing the nurse-patient relationship in the
context of the injection-giving process.
Create a safe and secure atmosphere
through provision of dependable and
consistent practitioners.
Where possible, the same person should
administer the injection on each occasion.
Exchange information about medication
and local resources.
Create space in clinics for service users to
meet and interact with each other.
(Adapted from Phillips and McCann (2007))
Shall we get it done now Paul?
Okay Marcia.
communication, and supports useful skills such as
problem solving and decision making. Box 2 lists
some useful communication skills.
Informed choice
Every adult must be presumed to have the
mental capacity to consent to, or refuse,
treatment unless they are unable to (Mental
Capacity Act 2005):
Understand the information relevant to the
decision.
Retain that information.
Use or weigh that information as part of the
process of making the decision.
Communicate their decision by talking, using
sign language or any other means.
Obtaining consent is a process rather than a
Useful skills for good communication
BOX 2
Using the service users own words.
Open-ended questions.
Reflective listening.
Summarising.
Eliciting and responding to feedback.
Working collaboratively.
Linking sessions together.
Setting an agenda.
Being flexible.
Building self-efficacy.
Taking an active therapeutic stance.
Emphasising personal choice and
responsibility.
Transparency.
one-off event (DH 2001b). The need to maintain
this continual process is necessary as treatment
changes and the individuals understanding and
needs fluctuates. Responding to changing needs
for information exchange as the patient moves
along a spectrum from a place where decisions
may have been made for them towards
autonomy, shared decision making and informed
choice is important in supporting recovery.
Healthcare professionals, patients and their
carers should communicate progress along this
spectrum on transfer to other teams to ensure
that work can be continued and lessons learnt
from each episode of care.
A meaningful exchange of information,
discussion and choice depends on clear
communication of the rationale for treatment,
not just of the benefits and risks. This is most
useful when framed in the language of the
service user, rather than the language of
psychiatry, for example, what the medication is
expected to do for the problems experienced by
the service user. NPC Plus (2007), Usher and
Arthur (1997) and Rollnick et al (2000) suggest
frameworks to guide this process in practice.
Advanced decisions to refuse medical treatment
are legally binding if they are valid and applicable,
that is the person had consent at the time they
made the decision and that the decision made is
applicable to the current decision. Advanced
decisions do not have to be made in writing,
unless they are to refuse life-sustaining treatment
(Mental Capacity Act 2005).
The law and professional bodies recognise the
power of advance directives, advance statements
or living wills. These are documents made in
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advance of a particular condition arising and
show the patients treatment choices. While not
legally binding, they can provide useful
information about the wishes of a patient who is
subsequently unable to make a decision. There is
clearly an opportunity immediately following any
relapse or crisis to work with the patient and
carers to capture important information, which
can inform advanced statements .
The law in relation to capacity, consent and
mental health is fluid and complex. Dimond
(2008) provides a comprehensive overview and
includes example scenarios from mental health
practice. Further good practice points are shown
in Box 3.
Pharmacology
Although biological, social and psychological
factors are all important in the maintenance of
mental health, medication treatment focuses on
treating chemical imbalances in the brain to
minimise distressing symptoms and provide
protection from relapse. Positive symptoms of
psychosis are thought to be due to an excess of
the neurotransmitter chemical dopamine in the
synapses between brain cells in the limbic area
of the brain. Cognitive symptoms and negative
symptoms are thought to be related to too little
dopamine in the synapses of the cerebral cortex.
Mood symptoms are thought to be related to a
different neurotransmitter serotonin.
However, dopamine and serotonin levels are
finely balanced, too much of one can affect the
balance of the other.
Medication for psychosis is now classified into
three types. The first generation, or typical
BOX 3
Consent is an ongoing process.
Identify a rationale for the injection based
on the experience of the service user and in
his or her own language.
Frameworks to guide interventions in
process consent and reflect on ones own
competence are available (Usher and
Arthur 1997, NPC Plus 2007).
The Elicit-Provide-Elicit model can be used
to exchange information based on needs at
any one time (Rollnick et al 2000).
Work with the service user and carer to
capture information to inform future risk
and relapse plans and advanced statements.
Careful documentation and communication
can promote ongoing collaboration in an
informed choice process.
We can go in the empty side room Paul.
I was just saying to Alan how I saw this bloke at
a bus stop in Woolwich once and he reminded...
antipsychotics were the first to be licensed and
include most injections. Second- and third-
generation, or atypical antipsychotics, include
products that have been licensed since clozapine.
All antipsychotic medications target dopamine
receptors in the brain. In addition, antipsychotic
medication can affect a range of other types of
receptors including the receptors for serotonin,
acetylcholine, noradrenalin (norepinephrine) and
histamine as well as several other types of dopamine
receptors. This action is largely responsible for side
effects but can also be beneficial, for example, to aid
sleep. Evidence suggests that the different products
are largely equal in their ability to treat symptoms of
psychosis (efficacy) but their different side effect
profiles affect their acceptability, tolerability and
overall effectiveness in practice (Tandon and Jibson
2003, Lieberman et al 2005, Jones et al 2006).
Long-acting antipsychotic medications by
intramuscular injection Intramuscular injections
of antipsychotic medications were developed to
allow the medicines to be delivered in a modified
way, over time, following administration. This has
the advantage of promoting a steady therapeutic
concentration of the drug, while minimising some
of the side effects and variable effects on
symptoms that may result from the peaks and
troughs experienced when only tablets are taken.
The achievement of a steady therapeutic level
from regular injections also affords protection
from relapse beyond the time the last injection
was received. Specific information about each
product can be found in the individual summary
of product characteristics.
If lifestyle factors make regular taking of oral
medication difficult, or the service user has a
preference for injections rather than tablets, this
can provide an important protection from stress,
prevent relapse and maintain mental health in
the future.
First-generation long-acting depot
antipsychotic injections First-generation
antipsychotic LAIs are commonly called depot
injections. Depot refers to the way the drug is
deposited and stored in the muscle before being
absorbed. Manufacturers formulated these
products in an oil base, which takes time to move
out of the muscle into the bloodstream. The oils
used include sesame and coconut and differ
between products. The injections are made deep
into the gluteus muscle.
Time to steady state, when optimal therapeutic
dose is achieved, can take between eight and 12
weeks after first administration of the full dose.
Peak concentration occurs from seven to ten days
after the injection and this is when side effects
are also likely to peak (Bazire 2007).
These medications take a long time to be
eliminated from the body, so various benefits, and
indeed side effects, can persist for some time
following the last injection. This is why
administration of a small test dose is
recommended. A test dose also allows an
assessment of any allergic response (for example
to a nut oil diluent). The elimination effect should
also be taken into consideration when switching
from an oral product to an injection or between
different types of injections, because side effects
related to the original drug can emerge in this
period.
Second-generation long-acting antipsychotic
injections Risperidone was the first second-
generation LAI to be licensed in the UK. The
risperidone LAI antipsychotic works in a different
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way to the first-generation depot injections. Tiny
polymer beads impregnated with the active
compound are mixed with a diluent. After injection
the diluent is quickly dissipated and the polymer
beads break down over a period of a few weeks,
slowly releasing the drug as they do so (Ramstack
et al 2003). The drug will not reach a therapeutic
level for a few weeks after injection, therefore it is
essential that the patient receive alternative
antipsychotic medication during the initial period
of treatment following the first injection.
Test doses are not required as long as the
service user has previously demonstrated
tolerance to oral risperidone. Time to elimination
from the body can be quicker and fall off more
rapidly after the last injection, than in comparison
with the oil-based depot injections. The
importance of accepting the injection at regular
intervals to prevent relapse must be considered
when planning treatment. It is licensed for
administration into the gluteus muscle. Other
second- and third-generation LAIs are in
development.
Off-label and unlicensed medications Most
medicines that healthcare professionals use are
licensed for a specific use and user group. This is a
strict process, aimed at improving safety and
ensuring that medicines in use are proven in how
they work. However, some medicines are not
licensed for certain user groups and, therefore,
their use is known as off-label. An example of off-
label use is often seen in medicines for children or
people with a learning disability, because it is not
ethical to undertake clinical trials on these groups.
However, where these medicines are known to be
effective, have a good safety record, and it is
considered best practice to use them, practitioners
will commonly prescribe and administer these
medicines in the best interests of the patients to
treat their condition.
Anyone who is to have a medicine that is
off-label or unlicensed, for example, medicine
that has not been granted a product licence for
use in the UK, should be informed that the
medicine is of a specific class, and made aware
of the risks and benefits of such medicines so
that they can make an informed decision about
whether they wish to receive that particular
medicine (Nursing and Midwifery Council (NMC)
2008a). Good practice points are listed in Box 4.
Details of an individual drugs specific licensed
indications are contained in its summary of
product characteristics (SPC). Please refer to the
British National Formulary, published twice a
year and available online at www.bnf.org. SPCs
and patient information leaflets are also available
online via the electronic Medicines Compendium
... me of these two blokes I knew in the
hospital, one of them used to look down in
case there were any dog ends to pick up, and
the other ones claim to fame...
You can put your jacket on the bed and get
ready Paul.
www.medicines.org.uk. Healy (2005), Bazire
(2007) and Taylor et al (2007) each provide
accessible texts on pharmacology and more
detailed prescribing information.
Injection technique Administering
intramuscular injections should not be an isolated
behaviour, but rather an important part of a
process of medication management requiring
thought and professional judgement (NMC
2008a). Knowledge and skills in anatomy,
physiology, patient assessment, patient
preparation and nursing intervention are all
essential to fulfilling the role (Shepherd 2002).
Nurses need to be fully aware of the
consequences and, by default of their registration,
be accountable for their clinical interventions.
Practice must be evidence based and
demonstrate cogent understanding of the
intervention and its context. Local protocols and
procedures should be followed. Core principles of
safe practice and an exemplar standard operating
procedure for prescribing, preparing and
administering injectable medicines are available
from the National Patient Safety Agency (2007).
In addition the good practice points in Box 5
should be noted.
Monitoring All clinicians who prescribe or
administer medicines are accountable for the care
that they give, and are responsible for undertaking
a comprehensive assessment of the patient under
their care. It is also their responsibility to ensure
there is a valid prescription for the medicine they
are administering. As part of their assessment a
clinician looking after any patient will need to be
aware of other current medications to ensure that
medications are not contraindicated (NMC 2008a).
All antipsychotic medication can give rise to
BOX 4
Be clear about the licensed indication for
the injection, including any contraindications,
interactions, the maximum dose, frequency
and muscle for administration.
Check allergy status of patients and staff,
remembering that nut oil diluents are used
in depot antipsychotic injections (not
risperidone LAI).
Use a test dose (not necessary with
risperidone LAI where tolerance to oral
risperidone is already demonstrated).
Use the correct type of needle to make sure
the active ingredient can travel down the
needle bore. With risperidone LAI, always
use the needle supplied in the pack.
Consider absorption and elimination effects
when starting, switching or stopping
products.
unwanted effects. The purpose of this guide is not
to list these verbatim, but nurses involved in the
care of service users receiving depot or LAI
antipsychotic treatment need to be aware of what
unwanted symptoms might emerge. (See the
pharmacology section for suggested resources.)
Subjective experience of medication Data on
side effects and efficacy of medicines come from
large clinical trial data sets and it should always
be remembered that the experience of taking
medication is subjective. Although some effects
and side effects can be predicted from the
pharmacology and can be measured
systematically, the experience of the person taking
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The choice of injection site should be
determined in conjunction with the service
user, however reference to the individual
products SPC should be made to determine
which sites are licensed because any
deviation from these means the drug is being
used off-label.
Injection sites should be rotated at each visit
and the previous site examined.
Before administration, hands should be
washed thoroughly and protective gloves
worn. A non-touch technique should be used
to prepare the injection according to the
manufacturers information.
The area in which medication is to be
prepared should be as clean and uncluttered
as possible and distractions and
interruptions should be avoided.
Filter needles should not be used for drawing up
depots, and only the needle supplied with the
dose pack should be used for risperidone LAI.
Needles should be long enough to reach
muscle and leave 5mm of the needle length
clear of the skin. If the chosen needle is not
long enough to reach muscle, the injection may
be given into adipose tissue and this may
affect the rate of absorption and potentially
reduce the efficacy of the drug.. The choice of
needle for administration is, therefore,
important. Nisbet (2006) suggests that the
traditionally used green 21 gauge 35mm
needle may not be long enough to reach
muscle at the dorsogluteal site in many
patients. Females are likely to have a deeper
fat layer at this dorsogluteal site. Individual
clinical judgement should be used depending
on the size of the patient. A variety of lengths
of green 21 gauge needles are available.
The site may be cleaned thoroughly for 30
seconds with a 70 per cent isopropyl alcohol
swab and allowed to dry for at least 30
seconds before administering the injection
(Lister and Sarpal 2004).
The use of the Z-track method is
recommended as it reduces discomfort and
prevents seepage back through the needle
track (Rodger and King 2000). See Box 6,
page 12.
the medicine and the observations of carers are
equally important and should form a central part
of any assessment or review. Lifestyle factors and
personal preference should also be considered
when making shared decisions about which drug
is best to prescribe. Thus a patient with existing
risk factors for cardiovascular disease should
consider injections with a low propensity to cause
weight gain. A patient in employment may wish to
consider an injection that is less likely to cause
sedation.
Side effects Regular systematic monitoring of
side effects is essential using a validated tool,
such as the Side Effect Scale/Checklist for
BOX 5
Antipsychotic Medication (SESCAM) (Bennett et
al 1995) or the Liverpool University Neuroleptic
Side Effect Rating Scale (LUNSERS) (Day et al
1995). Monitoring of physical health parameters
is discussed in the next section.
Good practice dictates that monitoring should
be carried out on a three-monthly basis and at
least at every medication review. Both SESCAM
and LUNSERS are broad scales and provide an
indication of the presence of side effects. More
focused outcome measures may be used to assess
specific adverse events, for example the Abnormal
Involuntary Movement Scale (for tardive
dyskinesia) (National Institute of Mental Health
(NIMH) 1976), Barnes Akathisia Scale (Barnes
1989). Cunningham-Owens (1999) describes in
detail the assessment of extra pyramidal status.
In a recent study, ability to manage side effects
was rated higher than the experience of side
effects by patients although the highest rated
item was efficacy (Kikkert et al 2006).
Assessment of positive effects is, therefore, as
important as assessment of side effects. Data
from assessments should be used to inform a
collaborative dialogue with patients about their
experiences. Importantly, information should be
exchanged about current coping strategies and
how these may be enhanced. Using a problem-
BOX 6
The Z-track technique
Immediately before injection, apply a
shearing force with the non-dominant hand
to the skin, approximately 25mm from the
chosen injection site, thus sliding the dermal
layer over the muscle.
Holding the needle at 90 to the skin,
quickly insert the needle (leaving 5mm on
the outside). Pull back on the plunger; if no
blood is aspirated continue. If blood is
aspirated, discard the syringe and needle
and start again using an alternative site.
Slowly inject the contents of the syringe at a
rate of 1ml per 10 seconds.
Withdraw the needle quickly and
immediately release the pressure on the skin.
The natural elasticity of the skin returns the
dermal layer to its former position, thus
sealing the needle track.
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solving approach to help patients identify and
enhance their ways of coping with medication
problems is important because these skills can
often be generalised to other areas of their lives.
Physical health
Severe mental illness is associated with a higher
incidence of physical illness and chronic disease
(Brown 1997).
The most common physical conditions are:
Cardiovascular disease People with
schizophrenia are twice as likely to have some
form of cardiovascular disease in comparison
with people who do not have schizophrenia
(Brown 1997).
Diabetes The risk of diabetes in a person with
schizophrenia is 14.9 per cent, compared with the
1.2 per cent to 6.3 per cent risk observed in the
general population (Dixon et al 2000).
Obesity Evidence suggests excess weight gain can
be two to three times more prevalent in people
with schizophrenia than in the general population
(Allison and Casey 2001). This may be due to high
levels of smoking, unhealthy diets and lack of
exercise common lifestyle choices of people with
schizophrenia (McCreadie 2003). However,
antipsychotic medication can also exacerbate
weight gain (Allison and Casey 2001). This
antipsychotic treatment-induced weight gain
increases both the risk for hyperglycaemia and type
2 diabetes, as well as the risk for hypertension and
cardiovascular disease (Fontaine et al 2001).
These increased risks of physical disease may
be more prevalent because of the difficulty
accessing or receiving appropriate health care
from primary and secondary services. Buntwal et
al (1999) noted that 30 per cent of people with
mental health problems using one mental health
unit had been struck off a GPs list at some point.
Despite evidence to suggest that people with
schizophrenia have relatively high levels of
contact with their GPs (Jablensky et al 2000),
there appear to be inconsistencies in the way
their problems are identified or managed. For
example, studies have shown that patients with
schizophrenia and heart disease have fewer blood
pressure or recent cholesterol tests (Hippisley-
Cox and Pringle 2005).
The English government has produced
guidelines (NICE 2002, 2006) recommending
that physical health checks for people with
severe mental illness should normally be provided
annually in primary care. To promote equality of
access and quality of services, there needs to be
systematic disease prevention and health
promotion programmes in place to challenge
...was that hed been crossing a field in
Hailsham in 1942 and got machine-gunned by
a German fighter. Escaped by jumpin in a
ditch. So this bloke in Woolwich was looking
down at the gutter and I said to him...
Can you just hold your shirt up for me?
discrimination. This can be achieved by all
organisations working collaboratively to provide
services, which are fair, personal and responsive
to patients needs and wishes (DH 2006b).
The General Medical Services contract stipulates
that these regular, physical health checks are part
of the mental health review alongside regular
review of medication (British Medical Association
2006). However, if the service user is not in
contact with primary care then secondary
services should monitor his or her physical health.
Effective communication between healthcare
professionals in primary and secondary care will
help the service user benefit from physical
assessment.
The Sainsbury Centre for Mental Health (2003)
advocates that a physical health review for a
person receiving treatment with an antipsychotic
injection should include:
Advice about diet, exercise, smoking, and
substance and alcohol abuse.
Protection against influenza by offering annual
immunisation in view of increased occurrence
of cardiac and respiratory disorders, and
diabetes.
Regular preventative care, for example cervical
cytology.
Routine monitoring of weight and blood
pressure.
Blood tests to measure glucose, cholesterol,
and a full blood count.
An electrocardiogram.
The healthcare professional may also consider
blood tests to monitor liver function, thyroid
function, kidney function and creatine
phosphokinase (Taylor et al 2007). More recently,
measuring the waist-to-hip ratio has been
suggested as a method of measuring risk of
cardiovascular disease (Yusuf et al 2005). A new
tool has been developed to help nurses assess 28
physical health parameters and know what to do
next if results are out of range (in print).
Follow up
Any healthcare professional with the
responsibility of administering depot injections
also has a responsibility to ensure there is a
robust system that identifies and follows up
service users who are not able to receive their
injection on the due date.
Because of the pharmacokinetic profile of
risperidone LAI, it is essential to follow up those
service users who have missed a dose. As there is
at least a three-week lag between the
administration of the drug to effective dose level,
the emergence of symptoms following a missed
dose is not likely to be evident for at least three
weeks. However, as the drug is eliminated more
... I bet youve been machine-gunned by a
German fighter. He turned round and said:
No...
Just going in now...
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quickly from the system than the older drugs, it
is important to follow up the service user
ideally within a day of his or her missed dose.
With the slower time to elimination of the first
generation depot antipsychotics, there is a greater
window of opportunity for following up of those
service users who have missed a dose. Assertive
follow up is important, ideally within a few days
of the missed dose.
Maintaining knowledge and skills
It is essential that all practitioners are aware of their
responsibilities within the regulations and conduct
governing their profession (NMC 2008b). With the
development of Agenda for Change and the
Knowledge and Skills Framework (DH 2004a,
2004b) implemented in most countries of the UK, it
is incumbent on the practitioner to maintain
professional knowledge and development. While the
employer has an obligation to support employees
during the course of their work, it is the responsibility
of practitioners to maintain their contemporary
practice by formal and informal methods, using the
expertise of colleagues, patients, carers and others
involved in their day-to-day work.
Conclusion
Antipsychotic medication remains a mainstay of
treatment for people experiencing serious mental
ill health. It is the professional, legal and ethical
responsibility of those administering the
medication to be suitably skilled in contemporary
evidence-based techniques and to be
academically equipped to support the medication
management of those under their care.
This guide is not intended to be either definitive
or exhaustive; it has been created to promote
thinking and to stimulate further discussion.
Local protocols and governance arrangements
should still be followed, as long as they reflect
current evidence; if they do not then it is the
registered nurses responsibility to challenge
them. Where required, this guide might inform
the review of such local arrangements, thereby
encouraging a person-centred approach to LAI
and depot management
...but I have been by a Japanese one three
times. I laughed. Turns out hed been in
Malaya, and it happened then.
There! Thats it. All over for now. You can go back to the lounge now, Paul.
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This guide was prepared by:
John Crowley, lecturer, University of Greenwich/Researcher Oxleas NHS Foundation
Trust; Professor Matt Griffiths, independent nurse consultant prescribing and medicines
management, visiting professor of prescribing medicines management, The University of
Northampton, senior nurse, medicines management University Hospitals of Leicester NHS
Trust; Sheila Hardy, nurse practitioner, Park Avenue Medical Centre, Northampton; Mark
Vincent, principal lecturer, The University of Northampton; Jacquie White, lecturer,
University Teaching Fellow, University of Hull; Andrew Voyce, service user
Address for correspondence: Sheila Hardy sheila.hardy@gp-k83042.nhs.uk
The views expressed in this guide are those of the authors and not those of Janssen-Cilag Ltd.
Footnote:
Many of the policy references in this guide
apply to England. Despite this, it is intended
that the spirit of this guide should be equally
relevant to readers in Scotland, Wales and
Northern Ireland.
Notes:
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