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BOX 1
Antipsychotic medication
Dopaminergic pathways in schizophrenia
For patients who present with a first episode
of psychosis or require long-term maintenance Nigrostriatal pathway (projects from the substantia nigra to the basal
ganglia): dopamine blockade results in various movement disorders collectively
therapy, administration of antipsychotic
called extrapyramidal side effects. In tardive dyskinesia, for example, D2
medication alongside the delivery of receptors are upregulated (their numbers increase) to overcome chronic
psychological interventions is the recommended blockade of the receptors.
treatment option (NICE 2014). Depot
injections are widely used to treat the symptoms Mesolimbic pathway (projects from the midbrain ventral tegmental area
of schizophrenia. Non-adherence to medication to the nucleus accumbens): psychosis results from excessive dopamine
transmission in the mesolimbic pathway. Dopamine receptor blockade leads to
regimens is a major challenge in the treatment
control of positive symptoms.
of schizophrenia (Brissos et al 2014).
First generation antipsychotic drugs Tuberoinfundibular pathway (projects from the hypothalamus to the anterior
antagonise or block dopamine D2 receptors in pituitary gland): blockade of dopamine receptors in the tuberoinfundibular
the four main dopaminergic pathways in the pathway leads to hyperprolactinaemia caused by increased release of prolactin,
brain (Stahl 2013) (Box 1, Figure 1). Blocking resulting in milk production, breast tissue development and sexual dysfunction.
dopamine D2 receptors in the mesolimbic Mesocortical pathway (projects from the midbrain ventral tegmental area to
pathway produces the desired effect on the the prefrontal cortex): dopamine blockade exacerbates low concentrations of
positive symptoms of schizophrenia, but dopamine in the mesocortical pathway in patients with schizophrenia, leading
blockade of the other three dopaminergic to cognitive impairment and negative symptoms.
pathways (Box 1) has the potential to lead (Adapted from Gray et al 2009a, Stahl 2013)
to side effects. For example, blockade of
D2 receptors in the nigrostriatal pathway
can cause extrapyramidal side effects such FIGURE 1
as pseudoparkinsonism (Chadwick and Brain and spinal cord showing pathways involved in schizophrenia
Bressington 2009).
Second generation antipsychotic drugs, such Basal ganglia Corpus callosum
as risperidone, exert their effect by blocking
Mesocortical Thalamus
D2 receptors, but they also have effects on pathway
other receptors such as serotonin receptors Nigrostriatal
(5-HT2A) (British National Formulary (BNF) pathway
2015). Stahl (2013) provided an example of
how the serotonergic effect of a particular drug
is connected to the moderation of dopamine Frontal
release in the mesocortical pathway, where cortex
dopamine should be released thus improving the
Nucleus
cognitive symptoms of schizophrenia. Second accumbens
generation antipsychotic medication has an
effect on a range of receptors and offers a distinct Hypothalamus
clinical and side-effect profile (BNF 2015). Cerebellum
Tuberoinfundibular
Complete time out activity 1 Substantia nigra
pathway
Mesolimbic Ventral tegmental area
pathway
Oral medication versus depot injection
PETER LAMB
TABLE 1
Rating scales to identify and assess movement disorders in patients who received
antipsychotic medication
Scale Description Rating
Abnormal Involuntary 12-item scale using a five-point scoring High score = high severity
Movement Scale (Guy 1976) system to identify tardive dyskinesia
Extrapyramidal Symptom Rating scale that examines dyskinesia, High score = high severity
Rating Scale (Chouinard parkinsonism, dystonia and akathisia
and Margolese 2005)
Simpson-Angus Scale 10-item rating scale using a five-point Low score = low severity
(Simpson and Angus 1970) scale to detect parkinsonian symptoms
patients maintained outpatient status (Uchida intervals involved. Patients should also be
et al 2013). This finding questions the efficacy of given information about potential side effects
depot injection over a longer time period. and how these can be managed.
Patients place more importance on whether Patients may view depot injection as invasive,
they think medication is efficacious as opposed particularly since it can cause tissue damage
to other factors, such as side effects (Kikkert et at the injection site. Some patients experience
al 2006). It is therefore important to provide pain, with most pain felt five minutes after
patients with information about the efficacy administration (Phillips and Dillon 2009).
of a particular medication and to have an Brissos et al (2014) provided a critical
honest appraisal process in place to evaluate all appraisal of depot injections and the advantages
treatment options. Nurse prescribers should and disadvantages of their use compared with
support the patient to make choices about the oral medication. This information must be
2 Supporting patients treatment they would prefer (Table 2). articulated to patients to ensure that they are
to make decisions and It is important that nurses explore informed about their treatment options and can
choices is an important collaboratively what motivates the patient to exercise choice. Some of the advantages and
part of effective care take medication. To do this, nurse prescribers disadvantages of the use of depot injection listed
planning. In your clinical and mental health nurses require knowledge in Box 2, and referred to in this article, can be
practice, use the six about why a particular medication works, and used as a basis for discussion with the patient.
areas summarised its range of side effects (Gray et al 2009b). Nurses can practice a shared decision-making
in Table 2 as an aide It is important for nurse prescribers and framework. Topics for patient choice (Table 2)
memoire to structure other healthcare professionals to engage have been shaped around the role of depot
a meaningful exchange collaboratively with the patient and to discuss injection in the treatment of schizophrenia,
of information with the evidence base that supports the use of each and can facilitate a culture of shared decision
a patient. Write a medication. Simple questions could be used making. Important factors for shared decision
reflective account during the first patient consultation (Doran making are knowledge exchange and the
about what it felt 2013); for example, ‘I believe that some use of advanced treatment directives (Gray
like to use this style. medication could be helpful to you in feeling et al 2009b). In an examination of how
Pay attention to how better. How do you feel about that?’ followed patients exercised their choice with regards
the patient responded by ‘what are the main two problems that you to medication, patients who are supported to
to being asked about would like medication to help with?’ access information from different sources to
their choices and The patient can be given the opportunity make their decisions – ‘informed service users’ –
the advantages and to discuss how they want to take their were favoured (Gale et al 2012).
disadvantages of this medication, in particular the choice between Complete time out activity 2
approach. a daily routine of taking oral medication
versus an injection formulation and the dosing
Depot injection
BOX 2 Patients and nurse prescribers have various
Advantages and disadvantages of depot injection drug options to choose from. Eight drugs are
licensed for the treatment of schizophrenia in
Advantages the UK via depot injection. The BNF (2015)
Improved bioavailability of the drug. provides clear indications and dosing schedules
Less potential for misuse or overdose.
for each of the medications discussed in this
Administration of the drug facilitates regular contact with the nursing team.
Prescriber knows the exact amount of the drug prescribed and administered.
article and should be referred to when one of
Assists patients who have difficulty remembering to take a daily dose of these medications is prescribed. Fluphenazine
oral medication. decanoate, haloperidol, zuclopenthixol
decanoate and flupentixol decanoate are classed
Disadvantages
Potential effect on the therapeutic relationship between the patient and
as first generation antipsychotics. Risperidone,
healthcare professional. olanzapine embonate, paliperidone and
Potential needle injection site problems such as pain, irritation and abscess aripiprazole are classed as second generation
formation. antipsychotics (BNF 2015).
Potential for delayed or prolonged side effects.
Slow dose titration required. Fluphenazine decanoate
Patients may experience lack of control over their treatment plan. Fluphenazine enanthate was the first depot
Association of stigma. injection to be manufactured in 1966, followed
Requirement to travel to the clinic to receive the medication or to receive 18 months later by fluphenazine decanoate
home visits.
(Johnson 2009). Fluphenazine decanoate
(Adapted from Burton 2010, Stevens and Rodin 2011, Brissos et al 2014)
belongs in the phenothiazine group (BNF
TABLE 2
Topics to assist patient choice in the treatment for schizophrenia
Issue Description Rationale
Drug formulation There are several drug formulations available, such Some patients prefer a particular formulation to
as tablets, liquids, and depot or orodispersible help them remember to take their medication.
formulations, for the range of medication prescribed Patients who live on their own might not have
for the treatment of schizophrenia. family members to prompt them with adherence
and might therefore prefer a depot injection.
Frequency of Administration of depot injection could be weekly, Nurses can assist patients to consider
administration two to four weekly, or at set or flexible intervals frequency of administration by identifying that
(British National Formulary (BNF) 2015). some depot injections have fixed administration
periods whereas others are flexible. The nurse
should always refer to the latest edition of the
BNF to provide accurate information.
Location of medication Patients can choose to receive a depot injection at Patients may prefer to attend a medication
administration home, at a GP clinic or a community mental health clinic to receive the depot injection so that they
clinic. can discuss their physical health needs with a
community nurse.
Site of administration Some depot injections are licensed for different If a patient is considering a depot injection,
muscle sites (BNF 2015). discussing the administration site with them
could assist them to choose which medication
they would prefer.
Advance treatment Patients can make treatment decisions when they Advance treatment directives can be offered
directives are well for implementation if they become ill. and enable the patient to exercise choice when
making their treatment decisions.
Societal views Stigma associated with being mentally ill. The patient may choose to receive medication
in a GP clinic on a monthly basis to avoid
perceptions of stigma associated with attending
a mental health clinic.
Side effects and All medication is associated with side effects and Patients should be given information about how
monitoring requirements these should be explained to patients. Patients should side effects can be monitored and the range
be offered information about side effects that they of interventions that can be offered. This can
can access when they are at home, such as leaflets assist patients to make informed choices about
and websites. the type of medication they wish to take.
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• hypertension
• managing infected wounds
• tissue viability
• care of patients with tuberculosis
• severe psoriasis
• anticoagulant therapy
• hand hygiene
• post-operative nutrition and hydration