Objective

The objective of the review was to explore patient and nurse satisfaction with depot antipsychotic medication. None of the studies included in the effectiveness reviews reported data that directly assessed patient satisfaction with the medication. Consequently, a wider review incorporating studies of mixed design and not restricted to randomised controlled trials (RCTs) was instituted. The specific aims were to investigate: patient satisfaction with depot antipsychotic medication; the patient preferred setting for the administration of depot antipsychotic medication; patient preference for depot antipsychotic medication or oral antipsychotic medication; and nurse satisfaction with depot antipsychotic medication.

Inclusion/exclusion criteria

Studies were included if they contained original data describing nurse or patient satisfaction (i.e. any opinion or attitude) towards depot antipsychotic medication according to the title or abstract. A second independent reviewer selected studies from a random 10% of the references to ensure that selection of studies was reliable. Where differences of opinion occurred, these were resolved by discussion.

Analysis

The quality of the articles was assessed in two stages. The first stage used a ‘hierarchy of evidence’. This is a method of categorising studies via the attributes of their design. It is a hierarchy of bias, which increases progressively downwards. We used an amalgamation of two hierarchies (University of York NHS Centre for Reviews and Dissemination, 1996; Reference GreenhalghGreenhalgh, 1997) — essentially from RCTs, through non-randomised controlled trials, to cohort studies, to case-control studies, to case series, etc. The categorisation for each study was carried out by two of us (J. W., R. G.) independently and any disagreements were resolved by discussion.

The second stage comprised the assessment of the studies using a 13-item checklist constructed specifically for the review. The items for this checklist were derived from a number of sources (University of York NHS Centre for Reviews and Dissemination, 1996; Reference GreenhalghGreenhalgh, 1997) and finalised by discussion between us. The checklist focused upon those variables most often highlighted in critical appraisal, namely, justification of sample size, sampling, response/drop-out rates, validity of measures and the generalisability of the results (see Tables 1 and 2).

Table 1 Characteristics of included studies (study denoted by first author and year of publication)

Study	Design	Participants	n	Satisfaction outcome measures
Anderson 1989	Cross-sectional survey	Diagnosis: not specified; patients attending 2 depot clinics over a 1-month period.	168	16-item questionnaire investigating general attitudes towards the depot clinic
		Setting: hospital-based depot clinics
Bennett 1995	Cross-sectional survey	Diagnosis: not specified	55	20-item questionnaire investigating CPNs' practice in administration of depot medication and their attitudes towards it
		Profession: CPN
		Setting: CPNs in 3 health districts
Brooker 1996	Cross-sectional survey	Diagnosis: not specified; attendees of depot clinics in north-west catchment area	270	34-item questionnaire investigating clients' views about their depot medication and the arrangements of their depot clinic
		Setting: depot clinics
Reference BuisBuis 1992	Cross-sectional survey	Diagnosis: not specified; “most had a diagnosis of schizophrenia”	44	Adapted UKU side-effect scale. Objective criteria replaced with subjective
		Setting: out-patient clinic
Burns 1998	RCT	Diagnosis: schizophrenia	149	Exit interviews describing nurses' attitudes towards their ability to perform the structured assessments
		Profession: practice nurses
		Setting: 140 general practices, south London
Reference CantleCantle 1997	Cross-sectional survey	Diagnosis: not applicable	26	10-item questionnaire regarding management of schizophrenia in general practice
		Profession: GPs and practice nurses
		Setting: study day
Reference DesaiDesai 1999	Quaisi-case—control	Diagnosis: DSM—IV schizophrenia	143	Patient acceptance of medication on 7-point scale
		Setting: out-patients referred to the study		Comparison of depot/oral on 7-point scale
Eastwood 1997	Cross-sectional survey	Diagnosis: not specified; patients receiving depot medication in a number of settings	100	Semi-structured depot neuroleptic interview investigating patients' knowledge about their medication and their attitudes towards it
Garavan 1998	Cross-sectional survey	Diagnosis: DSM—III—R schizophrenia	70	Drug attitude inventory
		Setting: out-patient clinic
Goldbeck 1999	Cross-sectional survey	Diagnosis: not specified; patients receiving depot medication at a community health centre in Clydebank	59	Semi-structured interview looking at depot medication issues
		Setting: community health centre
Hoencamp 1995	Cross-sectional survey	Diagnosis: DSM—III schizophrenia	174	17-item Modified Patient Request Scale (Dutch Version); 8-item Neuroleptic Evaluation and Attitude List (interview)
		Setting: out-patient clinic, depot=81, oral=93
Jacobsson 1980	Cross-sectional survey	Diagnosis: schizophrenia	43	Interview
		Setting: hospital depot clinic		Questionnaire
Kendrick 1998	Cross-sectional survey	Diagnosis: not applicable	192	Postal survey
		Profession: practice nurse		Focus group
		Setting: GP surgery
Larsen 1996	Cross-sectional survey	Diagnosis: ICD-10 schizophrenia	53	14-item questionnaire specially designed to evaluate the patients' attitude to treatment; Psychological General Well-being Schedule
		Setting: out-patient clinic
Pan 1989	Quasi-case—control	Diagnosis: schizophrenia; attenders and irregular attenders at depot clinic	80	4-part Health Belief Questionnaire specifically designed for the study
		Setting: hospital depot clinic
Pereira 1997	Cross-sectional survey	Diagnosis: chronic schizophrenia/paranoid psychosis	173	Semi-structured interview/questionnaire investigating patients' attitudes towards their medication
		Setting: out-patient clinic
Poole 1998	Cross-sectional survey	Diagnosis: not specified; patients receiving depots in a number of settings within the locality	47	Questionnaire asking patients to choose where they would prefer to received their medication
Reference Sandford, Sandford and GournaySandford 1996	Cross-sectional survey	Diagnosis: not specified; patients receiving depots in 5 clinics	58	Structured interview investigating patients' views of the care and service they received at the clinic
		Setting: 5 depot clinics
Singh 1995	Cross-sectional survey	Diagnosis: schizophrenia (188), manic—depressive psychosis (15) and schizoaffective disorder (15)	218	17-item interview questionnaire investigating
		Setting: hospital-based depot clinic		patients' views of the care and service they received at the clinic
Smith 1999	Quasi-case—control	Diagnosis: schizophrenia DSM—III—R	40	4-item interview schedule derived from motivational interviewing, investigating attitudes towards medication and compliance
		Setting: depot clinic and day hospital
Reference WarrenWarren 1998	Cross-sectional survey	Diagnosis: not specified; patients receiving depot antipsychotics	76	Structured interview schedules investigating the quality of care during the administration of depot medication
		Profession: 68 nurses
		Setting: various
Reference WistedtWistedt 1995	Cross-sectional survey	Diagnosis: schizophrenia (68); other diagnoses (5)	73	Six questions investigating patient attitudes towards their depot medication, asked by mental health nurse
		Setting: depot clinic

Table 2 Checklist results: quality of studies

Study (first author and year)	Explicit a priori aims	Definition/size of population under investigation	Sample size calculation	Justification that sample is representative of population	Inclusion/exclusion criteria stated	Demographic details	Research independent of routine care/practice	Justification of validity/reliability of measures	Original questionnaire available	Response/drop-out rate specified	Justification of response/drop-out rate	Discussion of generalisability	Statement of source of funding	Marks lost	Percentage of maximum quality score
Brooker 1996	+	+	-	+	-	+	+	N/A	+	+	+	+	+	2	77
Pan 1989	+	-	-	-	+	+	+	+	+	+	N/A	+	+	3	69
Larsen 1996	+	+	-	-	+	+	+	+	+	+	-	+	+	3	69
Reference Sandford, Sandford and GournaySandford 1996	+	+	-	+	+	+	+	+	-	+	+	+	-	3	69
Burns 1998	+	+	-	-	+	+	+	-	N/A	+	-	+	+	4	62
Reference DesaiDesai 1999	-	-	+	-	+	+	-	N/A	+	+	+	+	+	4	62
Garavan 1998	-	-	-	-	+	+	+	+	N/A	+	-	+	+	5	54
Hoencamp 1995	-	-	-	+	-	+	+	+	+	+	-	+	-	6	54
Smith 1999	+	-	-	-	+	+	+	N/A	+	+	-	-	-	6	46
Pereira 1997	+	+	-	-	+	+	-	-	-	+	-	-	+	7	46
Jacobsson 1980	-	-	-	-	+	+	-	-	+	+	+	+	-	7	46
Kendrick 1998	+	+	-	-	-	-	+	-	+	+	-	+	-	7	46
Reference CantleCantle 1997	-	-	-	-	+	-	+	+	-	+	-	+	-	8	38
Reference WistedtWistedt 1995	-	-	-	-	+	+	-	N/A	+	+	-	-	-	8	31
Bennett 1995	-	+	-	+	-	-	-	+	-	+	-	+	-	8	38
Singh 1995	+	-	-	-	+	+	+	-	-	+	-	-	-	8	38
Goldbeck 1999	-	+	-	-	-	+	-	-	-	+	-	-	-	10	23
Reference WarrenWarren 1998	-	+	-	+	-	-	-	-	-	+	-	-	-	10	23
Eastwood 1997	+	-	-	-	-	+	+	-	-	-	-	-	-	10	23
Poole 1998	-	+	-	-	-	-	-	-	-	+	+	-	-	10	23
Anderson 1989	-	-	-	-	+	-	-	-	-	-	-	+	-	11	15
Reference BuisBuis 1992	-	-	-	-	-	-	-	-	-	+	-	-	-	12	8
Total	10/22	10/22	1/22	5/22	12/22	14/22	12/22	7/18	8/20	19/22	4/21	12/21	7/22	Mean	Mean
														6.9	44

Nurse satisfaction

There were minimal data for nurse satisfaction with depot antipsychotics. No one paper focused specifically on the issue of nurse satisfaction with depot antipsychotics and all data included were embedded within articles looking at other topics. There were differences between the attitude of community psychiatric nurses (CPNs) and practice nurses. Bennett et al (Reference Bennett, Done and Hunt1995) reported that, overall, the CPNs' attitude was favourable towards administering and monitoring medication, although 29% felt that it did not utilise their skills. However, Burns et al (Reference Burns, Millar and Garland1998) reported that two-thirds of practice nurses administered depots but most lacked confidence and training. Kendrick et al (Reference Kendrick, Millar and Burns1998) surveyed practice nurses by post and held a focus group to find that they felt unsupervised and that CPNs should be administering depots. Cantle (Reference Cantle1997) surveyed 26 delegates (GPs and primary care nurses) at a training day for depot neuroleptics: 88% of the group stated that they would like more training. Warren (Reference Warren1998) carried out an audit of depot administration and reported that nurses wanted more training in medication and treating psychoses in general. Finally, only one of the five studies looking at patient preference for treatment setting investigated nurse opinion. Brooker et al (Reference Brooker, Faugier and Gray1996) asked clinic nurse managers of 135 depot clinics to rate their overall satisfaction (0=totally unsatisfactory, 8=excellent) with their clinic arrangements. The mean rating was 4.8, with 40% scoring below this figure.

Data quality

The favourable findings regarding depots in the majority of studies are in contrast to the negative popular perception of depot antipsychotic medication and the view put forward in the introduction (Reference Anderson, Leadbetter and WilliamsAnderson et al, 1989; Reference Pereira and PintoPereira & Pinto, 1997). However, the scarcity and mixed quality of the studies make generalisations problematic. First, no studies asked the same question to guage overall satisfaction, so amalgamating the responses may be inappropriate. Similarly, comparison between studies was difficult. Second, the higher quality studies tended to show less positive results, indicating a possible relationship between study quality and outcome, but because there are only two dissenters this cannot be concluded with confidence. Another more persuasive explanation for the findings is sample selection bias. The patients involved in the studies were, by definition, ‘attenders’ and ‘compliers’. People who attend depot clinics would be expected to be reasonably positive about depots, otherwise they would not attend. Data on non-attenders and non-compliance are, ipso facto, hard to obtain. The key factor is that the studies did not formally seek a sample that was representative of all those who were prescribed depot antipsychotic medication but took a convenience sample with all its associated pitfalls. Similarly, a non-selected group of patients on maintenance oral medication would include many who had been either on depots in the past or at least offered them and declined. The views of such patients on depots (presumably rather negative) would complete the picture, as well as perhaps offering insights into why such patients dislike depots (see Reference Hoencamp, Knegtering and KooyHoencamp et al, 1995). The most informative study would compare a population-based survey of all patients on maintenance treatment — depot and oral. Depot recipients are bound to have been given oral medication previously and many patients on oral medication also will have experience of depots. Hence, each could express a preference. Reasons for accepting/declining depots could be gathered systematically.

Preference for depots

Hoencamp et al (Reference Hoencamp, Knegtering and Kooy1995) did compare patients on oral and depot medication but could not obtain data regarding preference from those currently on oral medication. It was reported that 26 of the 93 patients on oral medication had been on depot medication previously but only two preferred depot medication. Nevertheless, the conclusion that can be drawn from this and similar studies is that the majority of patients on depot antipsychotic medication accept their medication, with approximately a quarter of patients in three of the studies not satisfied. Desai (Reference Desai1999) was the only study reporting that patients preferred oral medication to their current depot medication. However, this can be attributed to bias because the sample was composed of patients whose psychiatrists had considered that they would benefit from a switch from depot antipsychotic medication to risperidone, an oral atypical antipsychotic drug.

The results show that the majority of patients prefer to have their medication administered at a clinic organised for this purpose. This may be because of the social contact afforded by attending the clinic and ready access to health care professionals. These benefits would not follow from attendance at the GP surgery, where there would be few other relevant facilities on site. However, the bias described previously may also explain the preference for treatment setting. All five studies took their sample from patients receiving their medication at a depot clinic. None of the studies took a representative sample from patients of clinics, at home and at their GP surgery.

Reasons for preference

The evidence reviewed showed clear patient preference for depot antipsychotic medication over oral antipsychotic medication. Therefore, although evidence of clinical superiority may be elusive, we have found support for a ‘subjective superiority’ for depots. One possible explanation is convenience. Wistedt (Reference Wistedt1995) found that 67% of their sample thought it easier to have an injection than taking tablets once or twice daily. Hoencamp et al (Reference Hoencamp, Knegtering and Kooy1995) also found convenience to be an important factor, because 42% of those who preferred depots cited this as a reason why. In contradiction to the concerns regarding the loss of personal freedom, Jacobsson & Odling (Reference Jacobsson and Odling1980) reported that 67% of their sample receiving antipsychotics via a depot did so because of the control they had over the timing and dosage of treatment.

The emphasis of patients on the ‘psychological’ side-effects described by Buis (Reference Buis1992) and Larsen & Gerlach (Reference Larsen and Gerlach1996) and its discordance with the emphasis of health professionals (Reference Larsen and GerlachLarsen & Gerlach, 1996) highlights the need for a patient focus. Although the physical side-effects must be addressed for the patient's safety and satisfaction, the psychological aspects also need to be addressed to improve quality of life. The neglect of this dimension may lead to non-compliance.

Nurse satisfaction

There are few studies looking at the perception of nurses administering depot antipsychotic medication. We may conclude, nevertheless, that there is ambiguity as to the type of nurse who should administer depot antipsychotic medication and that more and better training should be given (see Reference Burns, Millar and GarlandBurns et al, 1998; Reference Kendrick, Millar and BurnsKendrick et al, 1998).

Database searching

1. (a) Medline, 1966—May 1999 (updated weekly): [(DEPOT$.mp/or exp Delayed-action preparations)/and (ANTIPSYCHOTIC$.mp/or exp antipsychotic agents or “NEUROLEPTIc$. MP)]

2. (b) PsycINFO, 1887—May 1999 (updated monthly): [(DEPOT$.mp/and (ANTIPSYCHOTIC$.mp/or “NEUROLEPTIC$.mp/or exp neuroleptic drugs)]

3. (c) CINAHL, 1993—April 1999 (updated monthly): [DEPOT$.mp/or exp injections, intramuscular)/and (ANTIPSYCHOTIC$.mp/or exp antipsychotic agents or “NEUROLEPTIC$.mp)]

4. (d) Embase, 1980—May 1999 (updated weekly): [DEPOT$.mp/and (ANTIPSYCHOTIC$.mp/or exp atypical antipsychotic agent/or NEUROLEPTIC$.mp/or exp neuroleptic agent)]

5. (e) The Cochrane Library (issue 4, 1999)

The above databases were also searched using specific depot drug names in order to make the search as comprehensive as possible (see text). These were combined with ‘satisfaction’ and related terms, as follows:

1. (a) Medline [(exp consumer satisfaction/or exp job satisfaction/or exp patient satisfaction/or exp personal satisfaction/or satisfaction.mp) or (exp attitude/or exp attitude of health personnel/or exp attitude to health/or attitude.mp)]

2. (b) PsycINFO [(exp satisfaction/or satisfaction.tw) or (exp adult attitudes/or exp attitudes/or exp drug use attitudes/or exp attitudes towards mental illness/or attitude$.tw)]

3. (c) CINAHL [(exp consumer satisfaction/or exp job satisfaction/or exp patient satisfaction/or exp personal satisfaction/or satisfaction.mp) or (exp attitude/or exp attitude of health personnel/or attitude to mental illness/or attitude$.mp)]

4. (d) Embase [(exp job satisfaction/or exp life satisfaction/or exp patient satisfaction/or exp satisfaction/or satisfaction.mp) or (exp patient attitude/exp nurse attitude/exp physician attitude/or attitude$.mp)]

Reference searching

The references of the included studies were inspected for further studies. Each of the included studies was sought as a citation on the SCISEARCH database. Reports of articles that had cited these studies were inspected in order to identify further trials.

Library source searching

The catalogues at the Institute of Psychiatry and the Royal College of Nursing were searched to obtain secondary sources:

1. (a) Depot and [antipsychotic or neuroleptic]

2. (b) Psychiatric Nursing and Depot

Hand-searching

The following journals were hand-searched for June, July and August 1999 to identify publications that may not have been entered on the databases yet:

1. (a) Acta Psychiatrica Scandinavica

2. (b) Journal of Mental Health

3. (c) British Journal of Psychiatry

4. (d) Schizophrenia Bulletin

5. (e) Psychiatric Bulletin

CLINICAL IMPLICATIONS

1. • Patients currently on depot medication are generally happy with that mode of delivery.

2. • Most patients on depots prefer them to oral drugs.

3. • Convenience seems to be the main reason for patient preference of depot.

LIMITATIONS

1. • There are no data from randomised controlled trials on the issue of patient satisfaction.

2. • The quality of data is not high.

3. • Surveys from representative samples of patients on maintenance antipsychotic medication have not been carried out.