In Reply: On behalf of my coauthors, I would like to thank Dr. Amdur for raising a number of salient points. That obtaining long-acting risperidone is complicated is a mental health systems issue that needs to be addressed. When new—and presumably expensive—medications are introduced, there is almost always a "push back" from our reimbursement systems that is designed to slow the use of the medication and thereby reduce the cost to the system. Cost and value are thus put into conflict.
Progress often comes with a price in both effort and dollars. We shouldn't expect progress to necessarily "fit" into the existing system, which most of us would agree is broken in many places. Clozapine didn't fit well initially because of its expense and the requirement for blood testing, but we managed to make it work. Our colleagues in rheumatology and oncology have mastered the "buy and bill" process. A new long-acting atypical injectable medication—a medication we have all asked to have—may not fit well initially into our current system, but as in all evolutionary progression, we need to adapt or our relevance and even our existence become less valuable to society.
Dr. Amdur's point that use of long-acting risperidone is perceived to be cumbersome and time-consuming probably refers to the required refrigeration and the actual administration of the injection. This may be the first medication in psychiatry that requires refrigeration. However, it is only one of many in other areas of medicine, and solutions must therefore be available. The actual injection is easily given. It is an isotonic water-based suspension and thus is a much easier and less painful injection than the oil-based solutions of conventional depot medications—it goes in more rapidly and doesn't need "Z-tracking." While a gluteal injection may be somewhat less convenient than a deltoid injection, it does not require major disrobing. The procedure does require appropriate safeguards and "chaperones," but as physicians we should be able to find ways to address these issues as well.
In addition, Dr. Amdur's observation that the use of conventional depot medications has declined because of physicians' resistance and the advent of second-generation antipsychotics is true in the United States but not in Europe, where long-acting injectable medications are the mechanism of choice for delivery of antipsychotics for 10 to 50 percent of patients, depending on the country. Because of this level of variability between the United States and other places, I believe it is an issue of choice, not a real issue. With the availability of a long-acting injectable second-generation medication, we have a different choice.
We have faced many challenges and misunderstandings in psychiatry. We thank Dr. Amdur for identifying several with long-acting injectable risperidone. We can overcome most with the combination of an ever-expanding database of science and a persistent desire to provide our patients with the best care available. Our patients with schizophrenia deserve no less from us.