Tag Archives: depot medication

Depot medication – the discussion continues.

The latest guest post on the Mental Health Nursing Lecturers Tea party comes from Bob Tummey. Bob is a mental health nurse lecturer at Coventry University and is becoming quite well known as a writer on mental health issues – see for example . In this post, Bob is carrying on an earlier post from Jim Chapman.

 

I would like to continue the rather interesting debate raised by Jim Chapman in an earlier posting. Jim raised concern for the administering of depot neuroleptic medication through IMI into the subcutaneous wall of fat and not the intended dorsogluteal muscle, leading to poor uptake of medication. This raises the question as to whether people receiving the medication this way are actually gaining any effect. (For a couple of research studies see Nisbet, A.C (2006) Intramuscular gluteal injections in the increasingly obese population: retrospective study. BMJ. 332: 637-638 and also Chan et al (2006) Intramuscular injections into the buttocks: Are they truly intramuscular? European Journal of Radiology.)

I was very aware of this issue when working in New Zealand. The depot can be administered into the dorsogluteal muscle but the needle may not reach due the thickness of the subcutaneuous fat wall (which is becoming thicker as the population become larger/obese). However, the medication is still absorbed; it just takes a longer period of secretion into the system. The ventrogluteal is the muscle of choice across USA due to concerns for litigation (hitting the sciatic nerve and so on). Therefore it does seem to be the natural progression for all MH nurse education to consider the teaching of depot IMI into the venrogluteal. However, this does have implications for practice and will require all mentors (for instance) to be competent and taught first.

In UK, New Zealand and Australia, best practice dictates the use of the dorsogluteal (upper-outer quadrant) but mainly due to tradition and training offered (For the NZ and Australian focus please see, Wynaden, D et al. (2006) Best practice guidelines for the admin of IMI in mental health settings. Int. J MHN. 15: 195-200.) This muscle is also supported by the drug companies which I suspect is due to their dated research and the product information they share. I believe all drug trials for depot medication have used the dorsogluteal muscle, although these trials now need updating.

Another point for discussion I would like to raise is on the ethical issue of actual site. If the ventrogluteal is reportedly the best site then should we not be evidence-based and comply? However, coming from another angle, when I worked as a nurse specialist in NZ I came across a number of NZ MH nurses who administer the depot every week/two weeks into the deltoid (upper arm) muscle with the IMI needle. This ensures direct penetration of the muscle and absorption of the medication….. The UK nurses in NZ would not provide IMI this way, but maybe some research needs to be undertaken to consider any benefits to treatment. From a brief look at policy in the UK it seems that the deltoid is only to be used as a one-off/stat dose into the less-dominant arm and mainly for adolescents. However, ethically is this right? Or indeed, should we consider its use to ensure effective treatment? One thing seems quite certain, the use of the dorsogluteal IMI is now redundant.

In a recent MHN conference I attended in NZ the most subscribed plenary session by far was about administration of depot injections, facilitated by Dianne Wynaden. It is an interesting debate, but what are the answers….

Please share your thoughts and experiences.

 

Bob Tummey

 

 

The efficacy of neuroleptics. Why a change in injection technique might settle a score between biological and social psychiatry.

Mental health nurses have been involved in the administration of depot neuroleptics ever since the first depots were designed in the 1960s. They are given by a deep intramuscular injection into the gluteal muscle every fortnight or so and are particularly useful for people with schizophrenia who we believe are not to be trusted with remembering to take their medication by themselves.

 

There appears to be a shift at the moment in the UK in the way depots are administered, away from an injection in the gluteus maximus (the dorsogluteal method, using the upper outer quadrant method to correctly site the injection), to the injection being given in the gluteus medius (the ventrogluteal or hip site, midway between the top of the hip bone and the crest of the pelvis). The old method is relatively more dangerous (the sciatic nerve is nearby, there is a large blood supply to this muscle), and we now also know that the chances of actually injecting the muscle using this method are quite poor, because there is a large amount of subcutaneous tissue around this muscle. One study has shown that as many as 19 out of 20 people might be being injected into fat rather than muscle. On the other hand, the ventrogluteal method is safer because there are no major nerves are arteries nearby, and we can inject into the muscle with greater confidence as there is less subcutaneous tissue around the gluteus medius. In short, we’ve not actually being treating people with the correct dose of neuroleptic for years, but now we can because we’re going to use a site that is more effective.

 

So this change in technique might lend weight, one way or another to the debate about whether neuroleptics actually work. The commonly held belief about neuroleptics is that they help regulate dopamine and other neurotransmitters in the brain, an overexcitation of dopamine being responsible for the so called positive symptoms of schizophrenia, such as the hearing of voices or having unusual thoughts. Some people take the view though that there is poor evidence to support this theory. A purely biological explanation for schizophrenia is unsatisfactory. Schizophrenia is a complex ‘illness’ which can be explained just as well in psychological or sociological terms than by the medical model. In fact, some say, there is no such thing as schizophrenia, and it’s not very helpful to be labelled so. Some service users will say that neuroleptics have never helped their voices go away, and some do not actually want this to happen anyway!

 

If you believe that neuroleptics help reduce the symptoms of schizophrenia, but now know that people on depots have not been receiving anywhere near the correct dose, what has been keeping people well for so long? Have people been well? Have we been actually defining wellness based on how willing the recipients of depots have been to drop their trousers every fortnight?

 

If you don’t believe that neuroleptics work, knowing that they’ve not been given correctly anyway adds a little bit of weight to your argument. But now that people are going to receive the correctly prescribed dose, we should be able to tell once and for all whether they work.

 

Although this is clearly an oversimplified way of looking at just one element of a well documented debate, think about this – how would you feel if you found out that the injection you were receiving (often unwillingly) for many years, wasn’t actually being given properly?