Long-term medication in depot clinics and patients' rights: an issue for assertive outreach

This study investigated the knowledge and attitude of 100 patients about their depot neuroleptic medication. Patients were well informed about their medication, particularly those seen in depot clinics. Most patients were content with service delivery but 48% did not realise that they had a choice about receiving their treatment. This aspect of patients' rights should be addressed and demands sensitive management in the case of depot refusers, or when assertive outreach is planned. We suggest that such issues should be incorporated into an educational programme and discussed with patients when they are relatively well.

Depot neuroleptic medication is the main form of prophylactic treatment for schizophrenia and related psychotic illnesses. Although there is a great deal of research on the efficiency of these drugs, there has been less work on the way they are administered: but there is little value in having an effective treatment if it is not reliably taken. In the community, it both reduces relapse rates (Gilbert et ai 1995) and is cost-effective (Hale & Wood, 1996). 'Depots' may be adminis tered in a variety of settings including depot clinics. Research suggests that the majority of patients prefer depot clinics (Singh et al, 1995) although in Singh et ats study, 25% of attenders would have preferred alternative arrangements.
To our knowledge, there have been no studies which have specifically investigated the propor tion of patients that know that they may refuse their depot medication if they wish, although a recent review article by Brabbins et al (1996) covers the medico-legal framework of consent to neuroleptic medication. Guidance is given in the Code of Practice (Department of Health and the Welsh Office, 1993) about the issue of with drawing consent to treatment; however, there is no mention in the proposed Mental Health Services Patients' Charter (Department of Health, 1996).
This study set out to explore the following issues: (1) what knowledge do patients have about their depots, including their rights to refuse? (2) Are patients satisfied about the administration of their injection?

The study
Procedure One hundred patients who were prescribed depot neuroleptics were interviewed by N.E. and a semi-structured depot neuroleptic interview was completed in each case. Patients receiving depots were identified from various settings within the Norwich, Bury St Edmunds, and Cambridge catchment areas. Verbatim record ings of patients' replies were taken and a second psychiatric assessor made independent ratings of patients' responses.

Subjects
Patients were receiving treatment in the following catchment areas: Norwich (69%), Bury St Ed munds (20%) and Cambridge (11%). Most (86%) were out-patients, and all were informal at the time of interview. Patients were interviewed in a variety of settings including depot clinics, day centres, wards, hostels, out-patient clinics, and other forms of accommodation.
None were receiving compulsory treatment under the Men tal Health Act 1983.

Methods and measures
The interview comprised two main parts: (1) Information. This assessed the knowledge that patients had about their depots, including type, dose, frequency, when next due, and side-effects. They were also asked if they believed they could refuse treatment if they wished.
(2) Patient satisfaction. The following were established: who gives depot, administra tor's gender, and the setting in which the injection is given, compared with what the patient would prefer. Patients were asked whether they preferred intramuscular or oral medication, why they thought the depot was being given, and whether they believed that the depot was helping them.
Data were analysed using SPSS software.

Information about depots
The majority of patients (82%) correctly knew the name of their depot, 68% knew the correct dose, 95% knew the frequency of the injection, and 82% could say when their depot was next due. Table 1 shows that knowledge of type of depot and its dose was better in those receiving their depot in a depot clinic or day centre than in the other settings. Poor knowledge on the wards probably reflected a more unwell subgroup. Eighty-eight per cent of patients were able to supply an appropriate explanation for why they were being prescribed a depot. When patients were asked about what side-effects they experi enced, 41% admitted to no side-effects, 34% named one side-effect, 15% two, 6% three, 2% four, and 1% five and six respectively.
Patients were asked whether they thought they had a choice in receiving a depot: only 52% were clear that they did have a right to refuse. A larger proportion of those in the depot clinics knew they had a choice although this did not reach clinical significance. The distribution of replies by loca tion is shown in Table 2.

Attitudes towards depot
All depots were given either by CPNs or other nurses. Most patients (99%) were happy with who gave their depot, with 63% declaring no prefer ence. Of the nurses 61% were female; 73% of patients had no preference about the gender of the nurse, but 7% of patients (five male, two female) would have preferred a nurse of a different gender, usually a female instead of a male. Table 3 shows where depots were given. Over all, the majority (93%) of patients were happy with their arrangement with 38% not minding about the location. A third of patients would prefer to be receiving oral medication instead of an injection, with the remainder preferring the depot (53%) or citing no preference (14%). Of those wishing to change, half recognised that they have a choice.
When asked about the benefits of a depot, 54% considered that it helped, 26% thought it was of some use. 18% thought it provided no benefit, and 2% were uncertain.

General aspects of depot administration satis factory
Patients in this study were generally well informed about the nature of their depot treatment: this was particularly the case in depot clinics and day centres. Most patients were content with service delivery although a third of patients would have preferred to take only oral medication. Fewer side-effects than expected were re ported, 41% of patients considering that they had no symptoms.
Study revealed an unawareness about rights to refuse treatment Nearly half of those interviewed were unclear as to whether they had a choice about receiving the injection. Patients attending depot clinics were better informed about their rights whereas 10 out of the 14 in-patients, all informal, thought the depot was compulsory.

Assertive outreach is vital but patients also need to be aware of rights
The conceptual model of a comprehensive com munity-based programme for patients with chronic mental illnesses first developed by Stein & Test (1980), with its emphasis on assertive outreach, has been shown to have clear benefits for the patients and their carers (Burns & Santos, 1995). A component of the work of mental health staff in the community is to maximise patients' compliance with medication, although education plays an unclear role (Macpherson et al, 1996). In this study, both patients' information about their drugs and the adminis tration of depots appear to have been successful, but the lack of patients' knowledge about their rights is a serious cause of concern. All those receiving depots must be properly informed. This should be done at an early stage and the disadvantages of patients discontinuing their treatment discussed with them when they are relatively well. Information about 'rights' could also be incorporated into Patient Information Leaflets.