- Email: [email protected]
Advantages of depot antipsychotics
CORRESPONDENCE 3
Fragmin and fast revascularisation during instability in coronary artery disease (FRISC II) investigators. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Lancet 1999; 354: 708–15.
Advantages of depot antipsychotics Sir—In their letter, Rok Tacvar and Majca Dernovsek (June 10, p 2073)1 raise the potential but untested benefits of depot atypical antipsychotics. We are concerned with the general benefits of depot antipsychotics as a mode of treatment delivery. There is good evidence that depot delivery of classic neuroleptics decreases the relapse rate in schizophrenia when compared with orally administered classic antipsychotics, due to better treatment adherence. None of the three patients we presented2 would have met standard criteria for treatment resistance as they had not had sufficient trials of different therapeutic agents before the homicides. They had, however, shown poor treatment adherence. In each of these three cases, the failure of treatment with oral atypical antipsychotics was a result of a failure by the patient to take the medication, probably the most common cause for treatment failure. There is some evidence that clozapine may have a specific effect to reduce violence,3 but little evidence to support this for other atypical antipsychotics. The naturalistic study cited by Tacvar and Dernovsek4 included a relatively small number of patients treated with atypical drugs and combined clozapine and risperidone. There were significantly fewer readmissions to hospital for patients on oral atypical drugs and depot classic antipsychotics than those discharged on oral classic antipsychotics, but those selected for depot treatment had significantly worse histories of noncompliance. We take this as support for the point we wish to make. Many patients refuse to have the blood tests necessary for clozapine therapy, only some of those treated with clozapine respond to it, and in our experience, patients on clozapine or other atypical drugs quite often fail to adhere to treatment. Attempts to improve treatment adherence through education of patients are important but are often unfunded. Atypical antipsychotic drugs given orally do not necessarily improve treatment adherence where there is a history of non-compliance. While depot atypical antipsychotic drugs given in a depot
594
preparation might have many benefits, until they are easily available, the use of classic antipsychotic drugs given in depot cannot be abandoned where there is a history of non-compliance. *H G Kennedy, S W Mikhail *Central Mental Hospital, Dundrum, Dublin 14, Ireland; and North London Forensic Service, Camlet Lodge Secure Unit, Chase Farm Hospital, Enfield EN2 8JL, UK (e-mail: [email protected]) 1
2
3
4
Tacvar R, Dernovsek MZ. Antipsychotic drugs and risk of homicide. Lancet 2000; 355: 2073. Mikhail SW, Kennedy HG. Homicide, novel antipsychotics, and non-compliance. Lancet 2000; 355: 1189. Volavka J. The effects of clozapine on aggression and substance abuse in schizophrenic patients. J Clin Psychiatry 1999; 60 (suppl): 43–46. Tacvar R, Dernovsek MZ, Zvan V. Choosing antipsychotic maintenance therapy—a naturalistic study. Pharmacopsychiatry 2000; 33: 66–71.
Safe feeding after stroke Sir—In his May 13 commentary1 Hillel Finestone highlighted the importance of swallowing difficulty and malnutrition after stroke, but was distinctly uncritical in his description of the various approaches to management. Poststroke dysphagia often improves spontaneously in the weeks after onset. However, in the first week or two, the outcome with respect to swallowing, nutrition, functional state, or even survival is very uncertain and not easily predicted. Where outcomes are unpredictable and treatment effects modest, randomised controlled trials are needed to identify the best approaches to management. Finestone did not refer to any of the randomised trials or systematic reviews relevant to feeding of stroke patients, nor to the paucity of evidence available to direct our management. The lack of reliable evidence has been highlighted by a Cochrane Review.2 Although both dysphagia and malnutrition are associated with poor outcomes after stroke, it is unclear to what extent they actually cause poor outcomes and, if they do, whether efforts to improve swallowing and nutrition would improve outcomes. Important questions confront the clinician in the acute stage of stroke: will therapy enhance recovery of swallowing? how long is it reasonable to leave a patient “nil by mouth” on parenteral fluids only? How soon should one start tube feeding in patients with dysphagia? Is feeding via a percutaneous endoscopic gastrostomy (PEG) tube more effective, or as safe, as via a nasogastric tube, and how
soon after stroke should a PEG be inserted? Finestone comments that “complications of tube feeding occasionally occur”, then lists some of the minor ones. This is potentially misleading. We have systematically reviewed reports of complication rates of PEG insertion, specifically amongst stroke patients. The five reports identified (references available from MD and CW) include a total of 310 patients, of whom about 8% died within a week or two of the procedure (although it is impossible to know what proportion were due to the procedure itself), and 25% died during the hospital admission. The complication rates among these 310 patients, during variable follow-up periods, were: aspiration pneumonia 19%; tube blockage, breakage, or removal 11%; wound infection 8%; gastrointestinal haemorrhage 0·6% (one fatal); and fatal bowel perforation 0·3%. Complications occur more than occasionally and may be serious and sometimes fatal. The balance of risks and benefits of PEG compared with nasogastric tubes is unclear, particularly in the first few weeks after stroke.1 Not surprisingly, therefore, a survey of preferences of almost 3000 physicians who manage stroke in the UK showed wide variation in the use of oral supplements and in the timing and method of tube feeding in dysphagic stroke patients.3 If feeding policies after stroke influence outcome, this variation is unacceptable since it means that many patients are not receiving optimum care. In response to these uncertainties, the FOOD trial, an international (18 countries), multicentre (123 centres) randomised trial, has been established and has already controlled over 2200 patients (but aims to recruit many more; www.den. ed.ac.uk/food accessed July 7, 2000). We need reliable evidence from randomised trials and systematic reviews on which to base our management decision, not just opinions or observations on current practice. *Martin Dennis, Charles Warlow Department of Clinical Neurosciences, University of Edinburgh, Edinburgh EH4 2XU, UK (e-mail: [email protected]) 1 2
3
Finestone HM. Safe feeding methods in stroke patients. Lancet 2000; 355: 1662–63. Bath PMW, Bath FJ, Smithard DG. Inteventions for dysphagia in acute stroke (Cochrane Review). In: The Cochrane Library, Issue 1, 2000 Oxford: Update software. Ebrahim S, Redfern J. Stroke care—a matter of chance. A national survey of stroke services. London: The Stroke Association, 1999.
THE LANCET • Vol 356 • August 12, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
Fragmin and fast revascularisation during instability in coronary artery disease (FRISC II) investigators. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Lancet 1999; 354: 708–15.
Advantages of depot antipsychotics Sir—In their letter, Rok Tacvar and Majca Dernovsek (June 10, p 2073)1 raise the potential but untested benefits of depot atypical antipsychotics. We are concerned with the general benefits of depot antipsychotics as a mode of treatment delivery. There is good evidence that depot delivery of classic neuroleptics decreases the relapse rate in schizophrenia when compared with orally administered classic antipsychotics, due to better treatment adherence. None of the three patients we presented2 would have met standard criteria for treatment resistance as they had not had sufficient trials of different therapeutic agents before the homicides. They had, however, shown poor treatment adherence. In each of these three cases, the failure of treatment with oral atypical antipsychotics was a result of a failure by the patient to take the medication, probably the most common cause for treatment failure. There is some evidence that clozapine may have a specific effect to reduce violence,3 but little evidence to support this for other atypical antipsychotics. The naturalistic study cited by Tacvar and Dernovsek4 included a relatively small number of patients treated with atypical drugs and combined clozapine and risperidone. There were significantly fewer readmissions to hospital for patients on oral atypical drugs and depot classic antipsychotics than those discharged on oral classic antipsychotics, but those selected for depot treatment had significantly worse histories of noncompliance. We take this as support for the point we wish to make. Many patients refuse to have the blood tests necessary for clozapine therapy, only some of those treated with clozapine respond to it, and in our experience, patients on clozapine or other atypical drugs quite often fail to adhere to treatment. Attempts to improve treatment adherence through education of patients are important but are often unfunded. Atypical antipsychotic drugs given orally do not necessarily improve treatment adherence where there is a history of non-compliance. While depot atypical antipsychotic drugs given in a depot
594
preparation might have many benefits, until they are easily available, the use of classic antipsychotic drugs given in depot cannot be abandoned where there is a history of non-compliance. *H G Kennedy, S W Mikhail *Central Mental Hospital, Dundrum, Dublin 14, Ireland; and North London Forensic Service, Camlet Lodge Secure Unit, Chase Farm Hospital, Enfield EN2 8JL, UK (e-mail: [email protected]) 1
2
3
4
Tacvar R, Dernovsek MZ. Antipsychotic drugs and risk of homicide. Lancet 2000; 355: 2073. Mikhail SW, Kennedy HG. Homicide, novel antipsychotics, and non-compliance. Lancet 2000; 355: 1189. Volavka J. The effects of clozapine on aggression and substance abuse in schizophrenic patients. J Clin Psychiatry 1999; 60 (suppl): 43–46. Tacvar R, Dernovsek MZ, Zvan V. Choosing antipsychotic maintenance therapy—a naturalistic study. Pharmacopsychiatry 2000; 33: 66–71.
Safe feeding after stroke Sir—In his May 13 commentary1 Hillel Finestone highlighted the importance of swallowing difficulty and malnutrition after stroke, but was distinctly uncritical in his description of the various approaches to management. Poststroke dysphagia often improves spontaneously in the weeks after onset. However, in the first week or two, the outcome with respect to swallowing, nutrition, functional state, or even survival is very uncertain and not easily predicted. Where outcomes are unpredictable and treatment effects modest, randomised controlled trials are needed to identify the best approaches to management. Finestone did not refer to any of the randomised trials or systematic reviews relevant to feeding of stroke patients, nor to the paucity of evidence available to direct our management. The lack of reliable evidence has been highlighted by a Cochrane Review.2 Although both dysphagia and malnutrition are associated with poor outcomes after stroke, it is unclear to what extent they actually cause poor outcomes and, if they do, whether efforts to improve swallowing and nutrition would improve outcomes. Important questions confront the clinician in the acute stage of stroke: will therapy enhance recovery of swallowing? how long is it reasonable to leave a patient “nil by mouth” on parenteral fluids only? How soon should one start tube feeding in patients with dysphagia? Is feeding via a percutaneous endoscopic gastrostomy (PEG) tube more effective, or as safe, as via a nasogastric tube, and how
soon after stroke should a PEG be inserted? Finestone comments that “complications of tube feeding occasionally occur”, then lists some of the minor ones. This is potentially misleading. We have systematically reviewed reports of complication rates of PEG insertion, specifically amongst stroke patients. The five reports identified (references available from MD and CW) include a total of 310 patients, of whom about 8% died within a week or two of the procedure (although it is impossible to know what proportion were due to the procedure itself), and 25% died during the hospital admission. The complication rates among these 310 patients, during variable follow-up periods, were: aspiration pneumonia 19%; tube blockage, breakage, or removal 11%; wound infection 8%; gastrointestinal haemorrhage 0·6% (one fatal); and fatal bowel perforation 0·3%. Complications occur more than occasionally and may be serious and sometimes fatal. The balance of risks and benefits of PEG compared with nasogastric tubes is unclear, particularly in the first few weeks after stroke.1 Not surprisingly, therefore, a survey of preferences of almost 3000 physicians who manage stroke in the UK showed wide variation in the use of oral supplements and in the timing and method of tube feeding in dysphagic stroke patients.3 If feeding policies after stroke influence outcome, this variation is unacceptable since it means that many patients are not receiving optimum care. In response to these uncertainties, the FOOD trial, an international (18 countries), multicentre (123 centres) randomised trial, has been established and has already controlled over 2200 patients (but aims to recruit many more; www.den. ed.ac.uk/food accessed July 7, 2000). We need reliable evidence from randomised trials and systematic reviews on which to base our management decision, not just opinions or observations on current practice. *Martin Dennis, Charles Warlow Department of Clinical Neurosciences, University of Edinburgh, Edinburgh EH4 2XU, UK (e-mail: [email protected]) 1 2
3
Finestone HM. Safe feeding methods in stroke patients. Lancet 2000; 355: 1662–63. Bath PMW, Bath FJ, Smithard DG. Inteventions for dysphagia in acute stroke (Cochrane Review). In: The Cochrane Library, Issue 1, 2000 Oxford: Update software. Ebrahim S, Redfern J. Stroke care—a matter of chance. A national survey of stroke services. London: The Stroke Association, 1999.
THE LANCET • Vol 356 • August 12, 2000
For personal use only. Not to be reproduced without permission of The Lancet.