Injectable psychotropic medications may decrease relapse and rehospitalization rates compared to oral medications for patients aged 18-65 with schizophrenia. Dorothy Johnson's behavioral systems nursing model supports using long-acting injectables to prevent relapse by maintaining effective behavioral functioning. Several studies found decreased rehospitalization and improved outcomes with long-acting injectable antipsychotics compared to oral medications. However, increased use of injectables also decreases patient choice and agency over their own treatment. Nurses need to consider patients' and ethical implications regarding preferred treatment methods.

1. Does injectable psychotropic medication result in decreased relapse and rehospitalization when compared with oral
medications in patients with schizophrenia between the ages of 18-65?
Heather Fast, Nancy Feist, Jenna Henricks and Sario Omar
Research and Evidence Based Nursing Practice
Research
Applications to Practice
Nursing Theorist: Dorothy Johnson
Ethical Implications
• Known for nursing model of behavioral system.
• Theory fosters the efficient and effective behavioral functioning of
the patient to prevent illness.
• Aims to encourage efficient and effective behavioral system to
prevent illness in patients. This would support the use of
injectables to prevent relapse in patients with schizophrenia
• Seven subsystems of human behavior help determine either
effective or ineffective functioning of an individual.
• Human being as “a behavioral system.”
• While in hospital and in community, nurses can work to respond to
each patient’s behavioral system when evaluating medication
effectiveness.
• Strengths of model: behavioral assessment is key to any medication
success, focuses on the strength of the patient rather than
pathology. Johnson also viewed nursing as a science AND an art,
which fits with mental health care.
• A weakness of this model is that the subsystems are poorly defined
and it cannot be generalized to large populations, but is concerned
with the individual.
• Aripiprazole (Abilify) has been shown to be effective in preventing
rehospitalization rates in first break psychosis (Kane et al, 2014).
• According to Zhornitsky and Stip (2012), long acting injectables (LAIs)
decreased the risk of relapse when compared to oral treatments in a
randomized study of patients with a variety of mental health diagnoses.
• Kaplan, Casoy, and Zummo concluded that LAIs reduced noncompliance and
decreased rehospitalization, and have also been found to promote better
quality of life (2013).
• Atypical long-acting injectable antipsychotics were associated with
significantly lower mean number of re-hospitalizations and ER visits compared
with oral antipsychotics, as well as fewer days in the hospital (Lafeuille et.
al., 2013).
• Along with the clinical benefits, atypical LATs offer promise for cost savings
because of reduced inpatient hospital utilization (Lafeuille et. al., 2013).
• Lambert et. al. (2011) found that risperidone long-acting therapy in patients
with schizophrenia was associated with improvements in clinical and
functional outcomes and decreased hospitalization rates in the US, Spain,
Australia, and Belgium, despite differences in health care delivery systems.
• Whose interests are being protected? The patient’s, the community’s or the healthcare
system?
• Rehospitalization is costly, and the mental health system is overloaded. When relapse
happens, there are often long waits for a bed.
• Patient may not prefer IM route. Or, patient may prefer IM route and not know IM is
available. IM should not be reserved for “noncompliant” mental health patients only.
• Patients who relapse after first break psychosis may lose choices if treatment is not
available through the court system through commitments, Jarvis orders, and Price-
Sheppard Orders.
• Failed treatment can cause many negative life outcomes (negative family consequences,
job loss, loss of housing).
• Regardless of research best practices, patients who are not under court order still have a
right to refuse treatments.
• Use of injectables decreases patient choice and patient agency and control over treatment;
it requires the intervention of a health care professional.
• Nurses should know IM sites appropriate for injectable psychotropic
medications. Quiroz et. al. found that both the deltoid and gluteal
sites are equivalent when used as a route to administer risperidone
(2011). However, some drugs vary.
• The ventrogluteal site avoids major blood vessels and nerves in the
dorsalgluteal site, and avoids risk of delivering medication to adipose
tissue in the gluteal site which decreases medication effectiveness
(Miller, 2014).
• Z-Track administration reduces pain and prevents diversion of
medication into subcutaneous tissue.
• Nurses should know the amount of drug that can be safely
administered in each site.
• Nurses should expect that patients will be using an oral agent while IM
medications begin to work.
• Nurses should advocate for the right of patients to attempt oral
medications when the alternative is refusal of all medication.
• Nurses need to understand the right of patients to refuse treatment
except when prohibited by court order or when a behavioral
emergency is declared.
References
A Gonzales. (2011). Theoretical Foundations of Nursing: Dorothy Johnson, the behavioral systems model. [Web log comment]. Retrieved from http://nursingtheories.weebly.com/dorothy-johnson.html
Kane, J.M., Peters-Strickland, T., Baker, R.A., Hertel, P., Eramo, A., Jin, N., . . . Sanchez, R. (2014). Aripiprazole once-monthly in the acute treatment of schizophrenia: findings from a 12-week, randomized, double-blind, placebo-controlled study. Journal of Clinical Psychiatry 75(11), 1254-1260
Kane, J.M., Sanchez, R., Zhao, J., Duca, A.R., Johnson, B.R., McQuade, R.D., … Peters-Strickland, T., (2013). Hopsitalisation rates in patients switched from oral anti-psychotics to aripiprazole once-monthly for the management of schizophrenia. Journal of Medical Economics 16(7), 917-925. doi:
10.3111/13696998.2013.804411
Kaplan, G., Casoy, J., & Zummo, J. (2013). Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia. Patient Preference and Adherence, 7, 1171-1178. doi: 10.2147/PPA.S53795
Lafeuille, M-H., Laliberte, F., Lefebvre, P., Frois, C., Fastenau, J., & Duh, M.S. (2013). Impact of atypical long-acting injectable versus oral antipsychotics on re-hospitalization rates and emergency room visits among relapsed schizophrenia patients: a retrospective database analysis. BMC
Central Psychiatry. 13.221. doi: 10.1186/1471-244X-13-221.
Lambert, T., Oliveres, J.M., Peuskens, J., DeSouza, C., Kozma, C., Otten, P.,...Akhras, K.S. (2011). Effectiveness of injectable risperidone long-acting therapy for schizophrenia: data from the US, Spain, Australia, and Belgium. Annals of General Psychiatry. doi: 10.1186/1744-859X-10-10
Miller, I. (2014, April 23). The ventrogluteal injection site. TheNursePath. Retrieved from http://thenursepath.com/2014/04/23/the-ventrogluteal-im-injection-site/
Potkin, S., Bera, R., Zubek, D., & Lau, G. (2013). Patient and Prescriber Perspectives on Long-acting Injectable (LAI) Antipsychotics and Analysis of In-office Discussion Regarding LAI Treatment for Schizophrenia. Retrieved fromhttp://www.medscape.com/viewarticle/814033_4
Quiroz, J. A., Rusch, S., Thyssen, A., Palumbo, J. M., & Kushner, S. (2011). Deltoid Injections Of Risperidone Long-acting Injectable in Patients with Schizophrenia. Innovations in Clinical Neuroscience, 8(6), 20–28.
Zhornitsky, S., & Stip, E. (2012). Oral versus long-acting injectable antipsychotics in the treatment of schizophrenia and special populations at risk for treatment nonadherence: A systematic review. Schizophrenia Research and Treatment, vol.2012, Article ID 407171, 12 pages, doi:10.1155/2012/407171
Potkin et. al., 2013
A. Gonzalez, 2011
Kane et. al, 2014
Z-Track Method
Miller, 2014
Miller, 2014