Institute of Psychiatry, London, UK
Correspondence: Professor Anthony David, Institute of Psychiatry & GKT School of Medicine, Denmark Hill, London SE5 8AF, UK. Tel: 020 7848 0138; Fax: 020 7848 0572; e-mail: a.david{at}iop.kcl.ac.uk
Declaration of interest Funded by the NHS Health Technology Assessment programme. A.S.D. is participating in a trial funded by Janssen-Cilag and has acted as an advisor for them. He has received expenses to attend academic conferences from Astra-Zeneca and Lundbeck.
See pp. 290 299, this
issue.
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ABSTRACT |
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Aims To review the literature on patient and nurse satisfaction with, and attitudes towards, depots.
Method A systematic search of Medline, Embase, PsycINFO, CINAHL and The Cochrane Library was undertaken, along with citation searches. Studies were selected if satisfaction/attitude data were described in the title or abstract and original data were included. Study quality was rated.
Results The search produced 1374 articles; 22 articles met the inclusion criteria, 18 of which were cross-sectional surveys. Of the 12 studies with relevant data, 10 conveyed a positive opinion of depot medication. Five out of six studies comparing depot with oral medication showed patient preference for depot.
Conclusions High-quality data examining patient and nurse attitudes regarding depot antipsychotics are sparse. What data there are show a positive attitude to depots from patients. Future randomised controlled trials should include satisfaction as an outcome.
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INTRODUCTION |
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Objective
The objective of the review was to explore patient and nurse satisfaction
with depot antipsychotic medication. None of the studies included in the
effectiveness reviews reported data that directly assessed patient
satisfaction with the medication. Consequently, a wider review incorporating
studies of mixed design and not restricted to randomised controlled trials
(RCTs) was instituted. The specific aims were to investigate: patient
satisfaction with depot antipsychotic medication; the patient preferred
setting for the administration of depot antipsychotic medication; patient
preference for depot antipsychotic medication or oral antipsychotic
medication; and nurse satisfaction with depot antipsychotic medication.
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METHOD |
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Inclusion/exclusion criteria
Studies were included if they contained original data describing nurse or
patient satisfaction (i.e. any opinion or attitude) towards depot
antipsychotic medication according to the title or abstract. A second
independent reviewer selected studies from a random 10% of the references to
ensure that selection of studies was reliable. Where differences of opinion
occurred, these were resolved by discussion.
Analysis
The quality of the articles was assessed in two stages. The first stage
used a hierarchy of evidence. This is a method of categorising
studies via the attributes of their design. It is a hierarchy of bias, which
increases progressively downwards. We used an amalgamation of two hierarchies
(University of York NHS Centre for Reviews
and Dissemination, 1996; Greenhalgh, 1997)
essentially from RCTs, through non-randomised controlled trials, to cohort
studies, to case-control studies, to case series, etc. The categorisation for
each study was carried out by two of us (J.W., R.G.) independently and any
disagreements were resolved by discussion.
The second stage comprised the assessment of the studies using a 13-item checklist constructed specifically for the review. The items for this checklist were derived from a number of sources (University of York NHS Centre for Reviews and Dissemination, 1996; Greenhalgh, 1997) and finalised by discussion between us. The checklist focused upon those variables most often highlighted in critical appraisal, namely, justification of sample size, sampling, response/drop-out rates, validity of measures and the generalisability of the results (see Tables 1 and 2).
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RESULTS |
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The quality of the studies was mixed. Their performance on the checklist (Table 2) and marks scored was in the range 1-10 out of a maximum of 13 (mean score=44%). Ten (48%) studies failed to score on eight of the items. The studies performed best for: response rate specified (included by 90% of the studies) and demographic details (67%). However, only one study included a sample size calculation, and, although 19 studies stated their response or drop-out rate, only four of these justified or explained these rates. Similarly, 16 studies did not attempt to show that their sample was in any way representative of the population they were aiming to investigate.
Ten of the twelve studies that included specific attitudinal or preferential data found that their patients held some positive views towards depot antipsychotic medication. One reported a neutral view and one a negative attitude (Table 3).
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Four of the five studies investigating patient preference regarding treatment setting reported that the majority preferred to receive their medication at the depot clinic (a regular forum attached to a hospital or community centre where depots are administered), whereas Poole & Grimes (1998) found the preferred setting to be at home (Table 4). None of the studies found a majority of patients in favour of GP-based treatment. Indeed, this was the third least preferable option for all of the studies.
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There were six studies that reported on a direct comparison of oral v. depot from the point of view of patient preference (Table 5). Five studies found that the majority of participants preferred to receive their medication via depot administration rather than in tablet form. Desai (1999), in an open non-randomised study comparing patients switched from depot to risperidone, found that 80% of their sample preferred oral medication.
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Two studies investigated the importance given to particular side-effects. Buis (1992) asked patients to complete an amended version of the UKU side-effect rating scale (Lingjaerde et al, 1987), where objective criteria had been replaced by subjective criteria. They then formed a hierarchy of the side-effects that were most important or troublesome. The top five were: sleepiness, increased fatigability, weight gain, tension or inner unrest and concentration difficulties. Side-effects associated with movement were among the least important. Larsen & Gerlach (1996) reported that extrapyramidal symptoms (EPS) (apart from akathisia) were least reported by patients. However, 88% of patients who reported no side-effects had at least one EPS. Larsen & Gerlach (1996) also found that non-physical or psychic side-effects (dullness/tiredness) were the most frequently reported. This is in contrast to the perception of the patients' physician, who focused mainly on EPS.
Nurse satisfaction
There were minimal data for nurse satisfaction with depot antipsychotics.
No one paper focused specifically on the issue of nurse satisfaction with
depot antipsychotics and all data included were embedded within articles
looking at other topics. There were differences between the attitude of
community psychiatric nurses (CPNs) and practice nurses. Bennett et
al (1995) reported that,
overall, the CPNs' attitude was favourable towards administering and
monitoring medication, although 29% felt that it did not utilise their skills.
However, Burns et al
(1998) reported that two-thirds
of practice nurses administered depots but most lacked confidence and
training. Kendrick et al
(1998) surveyed practice
nurses by post and held a focus group to find that they felt unsupervised and
that CPNs should be administering depots. Cantle
(1997) surveyed 26 delegates
(GPs and primary care nurses) at a training day for depot neuroleptics: 88% of
the group stated that they would like more training. Warren
(1998) carried out an audit of
depot administration and reported that nurses wanted more training in
medication and treating psychoses in general. Finally, only one of the five
studies looking at patient preference for treatment setting investigated nurse
opinion. Brooker et al
(1996) asked clinic nurse
managers of 135 depot clinics to rate their overall satisfaction (0=totally
unsatisfactory, 8=excellent) with their clinic arrangements. The mean rating
was 4.8, with 40% scoring below this figure.
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DISCUSSION |
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Data quality
The favourable findings regarding depots in the majority of studies are in
contrast to the negative popular perception of depot antipsychotic medication
and the view put forward in the introduction
(Anderson et al, 1989;
Pereira & Pinto, 1997). However, the scarcity and mixed quality of the studies make generalisations
problematic. First, no studies asked the same question to guage overall
satisfaction, so amalgamating the responses may be inappropriate. Similarly,
comparison between studies was difficult. Second, the higher quality studies
tended to show less positive results, indicating a possible relationship
between study quality and outcome, but because there are only two dissenters
this cannot be concluded with confidence. Another more persuasive explanation
for the findings is sample selection bias. The patients involved in the
studies were, by definition, attenders and
compliers. People who attend depot clinics would be expected to
be reasonably positive about depots, otherwise they would not attend. Data on
non-attenders and non-compliance are, ipso facto, hard to obtain. The
key factor is that the studies did not formally seek a sample that was
representative of all those who were prescribed depot antipsychotic medication
but took a convenience sample with all its associated pitfalls. Similarly, a
non-selected group of patients on maintenance oral medication would include
many who had been either on depots in the past or at least offered them and
declined. The views of such patients on depots (presumably rather negative)
would complete the picture, as well as perhaps offering insights into why such
patients dislike depots (see Hoencamp
et al, 1995). The most informative study would compare a
population-based survey of all patients on maintenance treatment depot
and oral. Depot recipients are bound to have been given oral medication
previously and many patients on oral medication also will have experience of
depots. Hence, each could express a preference. Reasons for
accepting/declining depots could be gathered systematically.
Preference for depots
Hoencamp et al
(1995) did compare patients on
oral and depot medication but could not obtain data regarding preference from
those currently on oral medication. It was reported that 26 of the 93 patients
on oral medication had been on depot medication previously but only two
preferred depot medication. Nevertheless, the conclusion that can be drawn
from this and similar studies is that the majority of patients on depot
antipsychotic medication accept their medication, with approximately a quarter
of patients in three of the studies not satisfied. Desai
(1999) was the only study
reporting that patients preferred oral medication to their current depot
medication. However, this can be attributed to bias because the sample was
composed of patients whose psychiatrists had considered that they would
benefit from a switch from depot antipsychotic medication to risperidone, an
oral atypical antipsychotic drug.
The results show that the majority of patients prefer to have their medication administered at a clinic organised for this purpose. This may be because of the social contact afforded by attending the clinic and ready access to health care professionals. These benefits would not follow from attendance at the GP surgery, where there would be few other relevant facilities on site. However, the bias described previously may also explain the preference for treatment setting. All five studies took their sample from patients receiving their medication at a depot clinic. None of the studies took a representative sample from patients of clinics, at home and at their GP surgery.
Reasons for preference
The evidence reviewed showed clear patient preference for depot
antipsychotic medication over oral antipsychotic medication. Therefore,
although evidence of clinical superiority may be elusive, we have found
support for a subjective superiority for depots. One possible
explanation is convenience. Wistedt
(1995) found that 67% of their
sample thought it easier to have an injection than taking tablets once or
twice daily. Hoencamp et al
(1995) also found convenience
to be an important factor, because 42% of those who preferred depots cited
this as a reason why. In contradiction to the concerns regarding the loss of
personal freedom, Jacobsson & Odling
(1980) reported that 67% of
their sample receiving antipsychotics via a depot did so because of the
control they had over the timing and dosage of treatment.
The emphasis of patients on the psychological side-effects described by Buis (1992) and Larsen & Gerlach (1996) and its discordance with the emphasis of health professionals (Larsen & Gerlach, 1996) highlights the need for a patient focus. Although the physical side-effects must be addressed for the patient's safety and satisfaction, the psychological aspects also need to be addressed to improve quality of life. The neglect of this dimension may lead to non-compliance.
Nurse satisfaction
There are few studies looking at the perception of nurses administering
depot antipsychotic medication. We may conclude, nevertheless, that there is
ambiguity as to the type of nurse who should administer depot antipsychotic
medication and that more and better training should be given (see
Burns et al, 1998;
Kendrick et al,
1998).
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APPENDIX: SEARCH STRATEGY |
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The above databases were also searched using specific depot drug names in order to make the search as comprehensive as possible (see text). These were combined with satisfaction and related terms, as follows:
Reference searching
The references of the included studies were inspected for further studies.
Each of the included studies was sought as a citation on the SCISEARCH
database. Reports of articles that had cited these studies were inspected in
order to identify further trials.
Library source searching
The catalogues at the Institute of Psychiatry and the Royal College of
Nursing were searched to obtain secondary sources:
Hand-searching
The following journals were hand-searched for June, July and August 1999 to
identify publications that may not have been entered on the databases yet:
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication September 6, 2000. Revision received February 5, 2001. Accepted for publication February 8, 2001.
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