Clozapine use in patients with severe mental illness was associated with a significantly increased risk of death compared with that for the general population. Causation could not be established. Adverse effects and death are common causes of clozapine discontinuation.

Many medicines available over the counter from pharmacies are known to have abuse potential, including diphenhydramine (DPH), an antihistamine with antimuscarinic properties used for the treatment of insomnia. We present a brief review of the literature describing DPH abuse, and report the case of GF, a 56 year old woman who was admitted to an inpatient addictions unit for detoxification from DPH. A literature search revealed five case reports of DPH abuse including a total of six patients, published between 1986 and 2001. All reported cases exhibited features of DSM-IV criteria for substance dependence, and there was an apparent link with antipsychotic usage. GF was treated with antipsychotics, and was using up to thirty 50 mg DPH tablets each day. She described feeling 'good and calm' and 'it stopped the tremors'. GF tolerated a gradual dose reduction schedule, and completed the detoxification programme relatively comfortably. She was discharged from the inpatient detoxification unit as planned, and had not relapsed at six months. The described case report highlights the importance of enquiring about non prescribed medication when taking a drug history. Similarly community pharmacists and GPs should be vigilant to excessive requests for DPH, particularly in patients with a psychotic illness.

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Objective. The aim of this retrospective study was to assess the clinical effectiveness of risperidone long acting injection (RLAI) at 2 years within an acute mental health setting. Method. All patients who received RLAI between July 2002 and December 2004 were identified from pharmacy records, and data collected by retrospective case note review. In order to give an indication that their condition was unresponsive to treatment, patients' drug histories were reviewed to determine whether or not they had previously been treated with clozapine or received two or more failed trials of other antipsychotic medication. Results. Eighty-four patients were included in the study and 56 discontinued at 2 years. The most common reason for treatment discontinuation was lack of effectiveness, accounting for 32 patients, whilst eight patients discontinued due to adverse effects. Patients remaining on treatment spent 67% of the time in an outpatient setting. Conclusion. The proportion of patients remaining on RLAI at 2 years was 33%. Limitations of the naturalistic methodology used in this study hindered any precise determination of which patients were likely to continue RLAI. However, it was apparent that a history of previous treatment failure with at least two antipsychotics was associated with RLAI treatment discontinuation.

Typical antipsychotics are effective in the management of schizophrenia, but are associated with troublesome adverse effects which may lead to treatment discontinuation and relapse. Long-acting depot formulations of these drugs improve patient compliance, but do not reduce the incidence of adverse effects. There is evidence to suggest that newer atypical antipsychotic drugs have a reduced propensity to induce movement disorders and are associated with a modest reduction in relapse rates. The introduction of risperidone long-acting injection (RLAI) provided clinicians with the first long-acting formulation of an atypical antipsychotic. Objective. The aim of this study was to investigate the outcomes of patients from an acute mental health trust who received RLAI during the 18-month period following its licensing in the UK in order to examine measures of clinical effectiveness, and reasons for treatment discontinuation. Methods. Data were collected retrospectively from medical notes. Results. Fifty-nine patients were included in the study, and at the time of data collection 32 (54%) had discontinued treatment. The most common reason for discontinuation was lack of effectiveness, although all of the patients who discontinued due to lack of response were treatment resistant. RLAI appeared to be well tolerated, with only 12% of patients discontinuing due to adverse effects. Thirty-eight percent of the patients treated with RLAI showed a good response as measured by discharge from inpatient setting, and of the 22 outpatients at time of data collection, five had one re-hospitalisation during the study period. Conclusion. This study concludes that RLAI appears to be well tolerated, and shows some effectiveness in the treatment of schizophrenia, but may not be effective for patients who are treatment resistant.