Intended for healthcare professionals

Rapid response to:

Papers

Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7423.1075 (Published 06 November 2003) Cite this as: BMJ 2003;327:1075

Rapid Response:

Clinical indication is critical: Injection use in mental health

Hutin et al1 highlight the frequency of injection use per person per
annum and claim that injections are overused in developing and
transitional countries. They further note the frequency distribution tends
to be skewed to the right as some patients have a high number of
injections due to chronic disease such as diabetes. Thus the mean average
will be higher than the median and could lead to false conclusions about
injection overuse within the population at large. The critical point here
is that injection use frequency without clinical indication data is
problematic. Thus it is essential that the global message be to reduce
clinically inappropriate injections rather than to simply reduce injection
use frequency per se.

Further the authors state that “prescribers overestimate patients’
preference for injections” and thereby contribute to overuse of
injections. Whilst this may be true in some situations, we found the
opposite in our survey of psychiatrists working in the South East of
England where 69% believed that depot antipsychotic long-acting injections
for schizophrenia were less acceptable to patients than oral
antipsychotics2. Although not directly comparable, this should be set
against the clear preference for long acting injections over oral
medication in patients with long-term mental illness currently on depots
that emerged from a systematic review of the subject3. Long-acting
injections have advantages in the treatment of many chronic conditions
and, many have argued, are under-utilised in psychiatry4.

The prescribing practice of an individual clinician is subject to a
multitude of influences, including: patients’ acceptance of injections or
tablets, stigma, cost, availability of medication, prescribing knowledge
and experience. Eliminating re-use of injection equipment without
sterilisation is an important challenge but we would caution against over-
generalising from this problem to other equally pressing global challenges
such as ensuring the delivery of antipsychotic treatment to people with
chronic mental health problems.

References:

1. Hutin YJF, Hauri AM and Armstrong GL Use of injections in
heathcare settings worldwide, 2000: literature review and regional
estimates. BMJ 2003; 327: 1075

2. Patel MX, Nikolaou V, and David AS. Psychiatrists’ attitudes to
maintenance medication for patients with schizophrenia. Psychol. Med.
2003; 33: 83-89.

3. Walburn J, Gray R, Gournay K, Quraishi S and David AS. A
systematic review of patient and nurse attitudes to depot antipsychotic
medication. BJPsych 2001; 179: 300-307.

4. Glazer WM and Kane JM. Depot neuroleptic therapy: an underutilized
treatment option. J Clin. Psychiatry 1992; 53: 426-33.

Competing interests:
MXP and ASD have received consultation fees from the pharmaceutical industry and have previously worked on two clinical drug trials for Janssen-Cilag.

Competing interests: No competing interests

12 November 2003
Maxine X. Patel
MRC Special Training Fellow (Health Services Research)
Anthony S. David, Professor of Cognitive Neuropsychiatry
Psychological Medicine, PO Box 68, Institute of Psychiatry, DeCrespigny Park, London, SE5 8AF, UK