Proposed legislative amendments, medication shortages and the absence of national treatment guidelines for psychosis, bipolar disorders and depression can impact on the use of psychotropic medications.
Antipsychotics are mainly used for severe mental disorders such as psychosis and bipolar disorders, alongside non-pharmacological interventions. Seljeflot et al.'s report in this edition of the Journal of the Norwegian Medical Association (1) serves as a potential basis for generating hypotheses about factors that impact on psychotropic medication use.
Use of long-acting injectable antipsychotics increased considerably
The authors highlight major changes in the use of psychotropic medications during the period 2012–2023. Use of anxiolytics more than doubled, while use of antidepressants fell by a quarter. Use of long-acting injectable antipsychotics increased considerably, whereas mood stabilisers saw a downward trend. Several factors may have played a role in these observed changes, including legislative amendments and the framework for mental health care.
The development of antipsychotics marked a major medical breakthrough, and the reduction of positive psychotic symptoms can facilitate more effective collaboration between the patient and therapist on non-pharmacological interventions. The risk of aggressive behaviour is reduced when patients with schizophrenia are treated with antipsychotics (2). Long-acting injectable antipsychotics eliminate the need for daily tablets and help maintain a stable serum concentration. Meta-analyses show that long-acting injections reduce mortality (3) and the risk of readmission to hospital (4) compared to oral treatment. One drawback of long-acting injections is that it takes longer for the medication to be metabolised in the event of an adverse reaction or interaction. Some patients report negative experiences with antipsychotics (5), and long-acting injections in particular can be associated with coercive use (6). Beyond individual assessments of indication, efficacy and side effects, the use of antipsychotics is, in my experience, also influenced by legal considerations and political priorities.
It is worth considering whether patients are now being hospitalised at a more advanced stage of illness, with more severe symptoms, thereby contributing to the increased use of antipsychotics
In 2017, the conditions for involuntary examination and treatment of patients were modified to require a lack of capacity to consent. Despite the stricter legal requirements, the number of patients subjected to involuntary mental health care has risen (7). There has also been a significant increase in decisions to administer involuntary medication (7). For example, long-acting injectable antipsychotics can be administered if the patient refuses medication. The number of patients receiving court-ordered treatment has doubled since 2017 (8), while the number of psychiatric inpatient beds has decreased (7). Although it is difficult to pinpoint definitive causative factors, it is worth considering whether patients are now being hospitalised at a more advanced stage of illness, with more severe symptoms, thereby contributing to the increased use of antipsychotics.
Other factors may, however, also have adverse implications. We are currently experiencing a critical shortage of ZypAdhera (9), the most commonly used long-acting injectable antipsychotic. Patients who have been stabilised and are benefiting from ZypAdhera are being forced to switch to an antipsychotic with potentially unknown effects. If the shortage continues, use of ZypAdhera will decrease, and future shortages of this nature will also impact on use.
As Seljeflot et al. point out, lithium plays a key role in the treatment of bipolar disorders. Based on my experience, it is concerning that the use of lithium and mood stabilisers has decreased. One hypothesis is that patients with mania who are hospitalised involuntarily are now being discharged earlier due to the capacity to consent requirement, so there is no opportunity to initiate maintenance treatment prior to discharge.
The Storting (Norwegian parliament) is currently reviewing a proposed amendment to the Mental Health Care Act, where the term 'decision-making capacity' would replace 'capacity to consent', and the standard of proof would be lowered to 'highly probable' (10). If the amendment is approved, it will have implications for the treatment of psychotic disorders and severe affective disorders, but its impact on the use of psychotropic medications remains unclear.