Abstract
Antipsychotic depots, or long-acting injections (LAIs), seem to go in and out of fashion. In the 1970s, LAIs were perhaps an essential part of the move from asylums to the community because institutionalized patients could not be expected to take responsibility for their medication having never done so before. However, the high doses of conventional LAIs used caused an epidemic of acute and chronic movement disorders. When oral atypical antipsychotics arrived in the 1990s, LAIs came to be seen as harmful anachronisms imposed on miscreant patients against their will. Only now, after the introduction of a range of atypical LAIs, has the reputation of LAIs recovered somewhat.
In this issue, Mrigendra Das and colleagues describe the outcome of using paliperidone LAI in seriously violent inpatients in a high-security hospital. LAIs are almost always used to assure adherence in outpatients so this is an unusual application. The authors comment that apparent treatment resistance and poor compliance are fairly common in forensic settings so the use of LAIs might be beneficial. Indeed, LAI treatment was beneficial: personality disorder symptoms such as impulse control were widely improved and episodes of violence decreased somewhat. However, 3 of 11 patients stopped the LAI because of poor efficacy. Overall, nonetheless, there was a strong signal that the use of LAIs should be considered in violent detained patients.
In the second paper in this issue, Hector Loscertales and co-workers describe efforts made to withdraw a single patient from high dose lorazepam (20–25 mg/day). Such attempts are usually prolonged and fruitless but this one was prolonged and successful. The patient was originally switched to a (perhaps record-breaking) dose of 16 mg of clonazepam daily with 5 mg lorazepam allowed as a night-time dose. On discharge, the patient was supplied with medication in an electronically monitored punch-card format into which a gradually reducing dose of medication was dispensed. At the time of writing, the patient was taking just 1.5 mg clonazepam with 5 mg lorazepam, a partial success when considered out of context but a rare victory in the field of benzodiazepine dependence.