B Ladds, R Cosme, F Rivera
B Ladds, R Cosme, F Rivera. Concurrent Use of Two Depot Antipsychotic Medications in Schizophrenia. The Internet Journal of Psychiatry. 2009 Volume 1 Number 1.
Schizophrenia is often associated with impaired insight and consequent non-adherence to treatment. To promote adherence the psychiatric practice has for decades included the administration of long-acting antipsychotic medication through an injectable intra-muscular route. In addition to this parenteral medication, persistent symptoms have sometimes necessitated the prescription of additional medication. A common scenario has included the provision of an oral atypical antipsychotic added to depot haloperidol or fluphenazine injections. However, non-adherence to the oral medicine remains a potential problem. To address this problem, one could administer two long-lasting intra-muscular medications concurrently, one a typical and the other an atypical antipsychotic. This is a clinical practice for which a rationale exists but for which there is scarce empirical data to support it. We report the case of a patient who responded to treatment only after receiving a combination of both typical and atypical oral antipsychotics who was then transitioned to the depot formulation of both medications.
A 49 year old woman with schizophrenia was hospitalized for aggressive and bizarre behavior. She had been institutionalized for 20 years, after which she stopped taking medication. She began taking eight-hour showers with bleach, talking incoherently and believing that someone wanted to poison her. She showed a poor response to risperidone, but she did begin to respond when it was combined with fluphenazine and benztropine. By two months, her symptoms had substantially improved. She was spending less time in the shower, began participating in activities and was no longer manifesting psychosis. However her insight into her need for medication was impaired. Given this poor insight and her history of non-adherence, she was placed on a depot formulation of fluphenazine decanoate and intra-muscular risperidone prior to discharge. No significant side effects were noted.
It is common practice to combine two antipsychotic medications for treatment resistant schizophrenia. When there is also a history of non-adherence, the use of two concurrent anti-psychotic depot medications may serve an important therapeutic role. This is especially the case where one of the depot medications is of the typical type and the other is atypical. However, this “Dual-Depot” regimen has received little formal scientific study as it relates to efficacy and safety. Traditional advantages of depot medications may also apply with the dual regimen including guaranteed delivery, reliable monitoring, and increased opportunity for timely intervention when a dose is missed [1,2].
Several analyses have been performed on the use of depot antipsychotic medication and have found a clear benefit over oral therapy; The case is also true for the use of depot medication added to an oral regimen , but to our knowledge the use of two depot antipsychotic medications have not been prevalent either in a trial bases or in case report literature.
The case reported here provides anecdotal support for a pharmaco-therapeutic practice of a “Dual-Depot” regimen that deserves further study. This could be of significant benefit to provide a better care to patients with treatment resistant schizophrenia, poor compliance to oral medication, and those receiving long-term outpatient and inpatient care where depot antipsychotics have been chronically underused .