Depot fluphenazine decanoate and enanthate for schizophrenia

BACKGROUND: In the years after the discovery of oral antipsychotic medications, it became clear that there was a link between stopping medication and relapse of psychotic symptoms. A series of long-acting preparations was developed. These depot preparations, are frequently used for those who find taking oral medication on a regular basis difficult or unacceptable. However, it has been a consistent concern that any reduction in relapse rate afforded by the depot preparations may be offset by an increase in undesirable side effects. There is one oral preparation and two depot forms (enanthate (Moditen) and decanoate (Modecate)). The decanoate form is more frequently used but both versions were reviewed in this work. OBJECTIVES: To compare depot fluphenazine medication to oral fluphenazine for treatment of schizophrenia. SEARCH STRATEGY: Electronic searches of Biological Abstracts, CSG's Register, EMBASE, LILACS, MEDLINE, PsycLIT, SCISEARCH, hand searching the references of all identified studies and contacting the manufacturers of the compounds. SELECTION CRITERIA: All randomised clinical trials that compared fluphenazine enanthate or fluphenazine decanoate to oral fluphenazine for people with schizophrenia or other psychoses were included. DATA COLLECTION AND ANALYSIS: One reviewer (CEA) inspected study citations and then the second reviewer (ME) independently inspected 20% of citations to ensure reliability. Full reports of the studies of agreed relevance were obtained and data extracted in the same manner by the authors. Trials were allocated to three quality categories, as described in the Cochrane Collaboration Handbook. Data were analysed on an intention-to-treat basis, and, where possible, parametric continuous data were presented. Tests for heterogeneity were undertaken. MAIN RESULTS: Data were very limited. There was no difference between fluphenazine hydrochloride and its depot form for outcomes such as global impression of functioning, relapse/re-hospitalisation, poor initial response to treatment, leaving the study early, depressed mood / suicide and side effects such as movement disorders, uncomfortable dry mouth, sleep problems and weight gain were equally common in both groups. Direct measures of mental state, social functioning and satisfaction with care were either not measured or presented in such as way as to make any analysis impossible. REVIEWER'S CONCLUSIONS: All six included studies relate to people with schizophrenia who are already stable on oral fluphenazine or seem contented to stay in the studies. How the data from this review relate to everyday psychiatric practices, where compliance with medication is more problematic, is debatable. The use of depot fluphenazine continues to be based on clinical judgement rather than evidence from methodical evaluation within trials. A large pragmatic randomized controlled trial is long overdue.