Administration of depot antipsychotic injections during COVID-19 in stable adult patients

General guidance on medicines management of mental health patients during COVID-19 is available from The Royal College of Psychiatrists.

This page gives advice on the administration of depot antipsychotic injections during COVID-19. The objective is to protect patients from unnecessary health care visits, to help preserve NHS capacity, and to provide options for the management of patients who are self-isolating or have symptoms of COVID-19.

Advice on other injectable medicines commonly used in primary care is available here.

Normal administration can be summarised as:

The dosing interval of depot antipsychotic injections varies from 1 week to 3 months.

During the COVID-19 pandemic, options include:

1) Short term single dose delay

  • For most formulations and most patients, a delay of 1-2 weeks is unlikely to cause harm or loss in efficacy
  • Where paliperidone monthly injection is delayed ensure the patient receives the correct number of injections over the course of a year.  To achieve this:
    • If there is a delay to the day of administration for a single month, try to revert to the original administration date the following month
    • For example, if an injection is given on 1st January, then delayed and given on 8th February, you should then attempt to regain the normal date and give again on 1st March

2) Long term amendments to depot prescribing

  • To reduce the number of depot administrations required, take specialist advice and consider increasing the dosing interval of the depot whilst retaining the same overall dose; for example:
    • flupentixol decanoate depot injection 100mg once weekly could be given as 400mg four weekly
    • further examples can be found here
  • A longer dosing interval does not diminish the effectiveness of the drug as long as the overall dose remains the same
  • There are some cases where an increase in the dosing interval may not be appropriate i.e.:
    • the dose of a single injection is above the licensed maximum
    • the patient deteriorates around the time the injection is due
    • the patient has tried higher doses before but experienced side effects

3) Long term amendments to risperidone and paliperidone prescribing 

  • Under specialist advice, risperidone 2 weekly injection can be switched to paliperidone monthly injection (Xeplion®) if GFR >50ml/min
  • Under specialist advice, paliperidone 1 monthly injection (Xeplion®) can be switched to paliperidone 3 monthly injection (Trevicta®) in stable patients who have had at least 4 months of paliperidone
  • Detailed advice on how to carry out the switch can be found here

4) Long term switch from depot to oral antipsychotics 

  • In some cases under specialist advice, it may be appropriate to switch a patient from a depot antipsychotic to an oral equivalent; however, this option carries an increased risk of relapse
  • Detailed advice on how to carry out the switch can be found here

If making any changes to a patient’s treatment, it is important to review the patient weekly after the change to ensure that they are physically and mentally well. This could be done over the phone.

For patients with COVID-19 symptoms, recommendations are: 

  • If the patient is due to have their dose administered, consider an alternative short term treatment plan. If currently psychologically well and risk of rapid relapse is considered low, consider delaying administration as per point 1 above
  • If the above is not possible, the depot should be given at home by someone wearing full personal protective equipment (PPE) in line with PHE guidance and the Trust’s infection control policy
  • Ensure a clear plan is agreed and documented with patient/carer, care coordinator and the responsible consultant regarding follow up after depot administration and monitoring of physical and mental health symptoms

Further advice from South London and Maudsley hospital: Depot medication – guidelines for use during coronavirus pandemic

This page was developed in conjunction with Professor David Taylor, Director of Pharmacy at the Maudsley Hospital and Peter Pratt, specialist mental health pharmacy advisor at NHSEI. We are hugely grateful for their input.