Patients’ perspectives on three-monthly administration of antipsychotic treatment with paliperidone palmitate – a qualitative interview study

Abstract

Introduction

Three-monthly dosage of paliperidone palmitate entails longer time to relapse after discontinuation, is similarly tolerable and safe compared to monthly injections of paliperidone palmitate and is beneficial for the caregivers. However, few studies have so far explored in depth the patients’ experiences with paliperidone palmitate medication every three months, or with switching from monthly to three-monthly injections of paliperidone palmitate.

Material and methods

A qualitative study based on individual interviews with persons with schizophrenia who receive three-monthly paliperidone palmitate in Norway, Sweden and Denmark. Data was analysed according to qualitative content analysis.

Results

Twenty-four patients, 16 men and 8 women, took part in individual interviews. The patients’ mental health care professionals mainly recommended the switch to three-monthly paliperidone palmitate, and few or no disadvantages were described. According to the patients, three-monthly paliperidone palmitate had several advantages, such as less frequent injections, less administration and planning and less focus on the illness. In addition, the participants described feeling more stability, being more physically and socially active, and that improvement processes were supported. For some, the use involved practical and economic challenges, and some worried whether the medicine ‘wore off’ before the next injection. According to the patients, switching to three-monthly paliperidone palmitate did not influence the frequency or content of patients’ interaction with health care professionals.

Conclusion

Switching from monthly to three-monthly injections with paliperidone palmitate seems to be experienced as advantageous for patients with schizophrenia.

Keywords:

• Psychiatry
• mental health
• schizophrenia
• paliperidone palmitate
• antipsychotic medication
• service user perspectives
• long-term antipsychotic injections

Introduction

Poor adherence to medication is a significant problem in the treatment of schizophrenia, and is a frequent cause of illness relapse, hospitalisation and worsening of the patient’s symptoms and function [1]. Several studies have investigated the pros and cons of oral medication versus long acting medication through injections (LAI) [2–9]. Compared to oral antipsychotic treatment, LAI significantly increases the time to symptomatic relapse and re-hospitalisation and reduces mortality [10–13].

Administration of paliperidone palmitate every third month (PP3M) is the longest injection interval available. It prolongs time to relapse compared to other paliperidone formulations [12], improves adherence and co-morbidity relapse [14], and is beneficial for the caregivers [15]. A three-monthly dosage was demonstrated to be non-inferior to administration once per month (PP1M), with a similar safety profile [12,15,16]. Hence, PP3M seems to be an effective maintenance treatment for this patient group [17].

Overall, research on the patients’ perspectives on and experiences with antipsychotic medication is scarce [18]. Studies have shown that health care professionals prescribing PP3M are mostly satisfied with the efficacy and tolerability of the medications [19,20]. However, investigations of the patients’ experiences with PP3M, as well as switching from PP1M to PP3M, are very limited. One study showed that patients preferred both monthly and three-monthly injectables to daily oral medication, but that they did not prefer three-monthly to monthly injections [20]. In contrast, a recent large scale post-hoc analysis of patients medication preference and a multi-country questionnaire study reported that patients had a higher inclination to prefer PP3M over PP1M due to convenience and better control [21,22]. This was supported by the results from interviews with 14 patients, showing that PP3M was perceived as more convenient and with benefits when compared to PP1M [21–23]. So far, when investigating patients’ perspectives, most studies have used questionnaires on health-related quality of life and patient satisfaction and have not utilized the potential of qualitative research methods. In some studies, the providers’ perspectives have been used as a proxy for the patients’ experiences with medication [19]. To date, only our research group has conducted in-depth exploration of the patients’ perceptions of switching from PP1M to PP3M, and of using the latter [24]. This knowledge is crucial for understanding the patients’ view on treatment with PP3M, and how it affects patients’ daily activities and quality of life. Exploring the patient perspective may add important information on the appropriateness and usefulness of this type of medication, as well as the perceived overall outcome for the patients. The aim of this study was therefore to explore in depth the patients’ experiences with the PP3M medication, and with switching from PP1M to PP3M. This is the first multi-centre study using a qualitative approach to explore the patient perspective on PP3M, and the switch from PP1M to PP3M.

Material and methods

Aim, design and setting

This study was a qualitative interview study exploring patients’ experiences of and perspectives on switching from PP1M to PP3M medication, and on using PP3M. This was part of a larger qualitative interview study, exploring the patients’ perspectives and experiences on several phenomena, such as mental illness and mental health services in general, as well as receiving antipsychotic treatment [24]. The study was conducted at nine different clinics in Scandinavia, one clinic in Norway, two clinics in Sweden, and six clinics in Denmark. The study sites included psychiatric outpatient clinics in different geographic areas in the three countries. The study sites are described in Table 1.

Table 1. Basic demographic profile of the study population.

	Norway n (%)	Denmark n (%)	Sweden n (%)	Sum n (%)
Country	2 (8.3)	15 (62.5)	7 (29.2)	24 (100)
City Size
Large city ≥ 50.000	0 (0)	13 (86.7)	4 (57.1)	17 (70.8)
Small city <50.000 – ≥15.000	2 (100)	1 (6.7)	53.0 (17.5)	2 (12.5)
Village < 15.000 – ≥1000	0 (0)	0 (0)	1 (14.3)	1 (4.2)
Countryside <1000	0 (0)	1 (6.7)	2 (28.6)	3 (12.5)
Type of Center
Out-patient	2 (100)	15 (100)	7 (100)	24 (100)
Age
Mean (SD)	39.5 (2.1)	35.1 (7.7)	52.7 (17.5)	42.2 (13.2)
Median	39	34	53	37
Minimum	38	26	30	26
Maximum	41	50	72	72
Gender
Male	1 (50)	11 (73.3)	4 (57.1)	16 (66.7)
Female	1 (50)	4 (26.7)	3 (42.9)	8 (33.3)
Residence
Independent apartment / house	2 (100)	11 (73.3)	4 (57.1)	17 (70.8)
With parents	0 (0)	1 (6.7)	0 (0)	1 (4.2)
Supported municipal housing	0 (0)	2 (13.3)	3 (42.9)	5 (20.8)
Other	0 (0)	1 (6.7)	0 (0)	1 (4.2)
Cohabitation
Alone	1 (50)	8 (53.3)	7 (100)	16 (66.7)
With spouse / partner	1 (50)	4 (26.7)	0 (0)	5 (20.8)
Others ≥ 18 years	0 (0)	3 (20.0)	0 (0)	3 (12.5)
Education
Not completed primary school	0 (0)	1 (6.7)	1 (14.3)	2 (8.3)
Completed primary school	1 (50)	10 (66.7)	1 (14.3)	12 (50.0)
High school	1 (50)	4 (26.7)	4 (57.1)	9 (37.5)
University /college	0 (0)	0 (0)	1 (14.3)	1 (4.2)
Employment / Social security benefits
Employed	0 (0)	0 (0)	0 (0)
Student	0 (0)	2 (13.3)	0 (0)	2 (8.3)
Unemployed	0 (0)	4 (26.7)	0 (0)	4 (16.7)
Sick leave	0 (0)	0 (0)	4 (57.1)	4 (16.7)
Disability pension	2 (100)	7 (46.7)	0 (0)	9 (37.5)
Other	0 (0)	2 (13.3)	3 (42.9)	5 (20.8)
Close Relationships
Yes	2 (100)	15 (100)	7 (100)	24 (100)
No	0 (0)	0 (0)	0 (0)	0 (0)
Type of Relationship
Professional	0 (0)	1 (6.7)	2 (28.6)	3 (12.5)
Private	0 (0)	2 (13.3)	5 (71.4)	7 (29.2)
Both	2 (100)	12 (80.0)	0 (0)	14 (58.3)
EQ-5D 5L Index Score* *Excluding Sweden, n = 17
Mean (SD)	0.61 (0.26)	0.74 (0.21)		0.72 (0.21)
Median	0.61	0.73		0.73
Minimum	0.43	0.32		0.33
Maximum	0.80	1.00		1.00
CI (95%) lower bound	−1.74	0.62		0.61
CI (95%) upper bound	3.00	0.85		0.83

Participants and recruitment

Eligible participants were adult men or women (≥18 years) who met the diagnostic criteria for schizophrenia according to the International Classification of Diseases, 10^th edition I (ICD-10). Participants had received at least two injections with PP3M after being stabilized for ≥4 months on PP1M. Participants were excluded from the study if they were treated involuntarily under any legal or mental health act. Study participants were recruited at purposively through their treating physician, contact person or responsible consultant.

Data collection

A total of 24 qualitative individual interviews (2 in Norway, 7 in Sweden, and 15 in Denmark) were conducted between April and November 2018. The interviews were conducted by two of the authors (AE in Sweden and LOS in Norway and Demark). The researchers were not familiar with the patients, and no information about the interviewers was given to the patients before the interview. The patients’ experiences with PP3M and the switch from PP1M to PP3M were explored through qualitative in-depth individual interviews. Although investigation of adverse events was not an aim of the present study, any spontaneously reported adverse events were handled in accordance with drug safety practices. Demographic data related to age, gender, living conditions, education, employment status and social relations were collected at the end of each interview. In addition, the informants’ health-related quality of life was assessed using the EuroQol five dimensions’ questionnaire (EQ-5D 5 L). An index score corresponding to quality of life was calculated (EQ-5D-5L Crosswalk Index Value Calculator, version 2) [25]. Due to clinical and practical reasons, the Swedish participants did not answer the EQ-5D-5L. Thus, the index scores of EQ-5D-5L were only included to describe the Norwegian and Danish sample.

A general prerequisite for prescribing PP3M is that the patient has obtained clinical stability on PP1M [26]. This gave the patients the opportunity to compare the different intervals of medication. A semi-structured interview guide was used throughout the interviewing process. The main topics in the interview guide are presented in Table 2. In line with qualitative interview methodology, the guide was slightly modified during the process to allow for new aspects and themes raised by the participants [27]. The main themes in scope for the present study were the patients’ experiences with PP3M treatment, the switch from PP1M to PP3M, and advantages and disadvantages of the antipsychotic medication.

Table 2. Main topics in interview guide.

Main topic	Example of questions
Experience with and relations to mental health services	Tell me about your contact with mental health services Why are you receiving mental health treatment? What are your previous experiences with mental health treatment? When did you have contact with mental health services for the first time?
Perspectives on the disease and antipsychotic treatment	What medications do you use? What effect do you feel your medication has? What benefits/disadvantages do the medication have? What are your goals with the treatment? What does it take to reach these goals? Why do you receive antipsychotic medication? In what way have you been involved in the choice of medication?
Experiences with PP3M medication	Tell me about your experiences with PP3M What experiences do you have with depot injections – previously and currently? What are your expectations to PP3M? Is the treatment as you expected? What are your experiences with daily oral medicine, injections every second week, injections every month and injections every third month, respectively?
Experiences with switching from PP1M to PP3M	Why did you switch from PP1M to PP3M? What was your experiences with switching medication? Who initiated the switch? Who did you discuss the switch with? In what way did you participate in the decision to switch medication? What sort of information should other patients get before they switch?
Influence from PP3M on everyday life and private social relations	Tell me how your everyday life is after switching to PP3M (activities, work/studies, leisure) Have there been any changes in your relationships with family, partner or friends? Have there been any changes in use of drugs or alcohol? Who are your most important collaborators in your treatment? Have there been any changes?
Influence from PP3M on the relationships with service providers	Have PP3M changed your relationships with doctor, contact person, therapist or other support persons?

Interviews were performed in the local language. Interviews were conducted at the clinic or nearby in the patient’s home, depending on the patient’s preference. Seven of the participants had a health care professional or another person they trusted present during the interview. All interviews were audio recorded and transcribed verbatim into the local language. All personal information was removed during the transcription. Data collection was conducted parallel with data analysis, and closed when saturation was met [27].

Data analysis

Qualitative data from the interviews were analysed according to content and textual analysis [27,28]. The initial analysis was conducted by two of the authors, both female (JM and LOS). Preliminary results in the form of themes and subthemes were presented and discussed in two consensus meetings where all authors took part. The group consisted of researchers with different professional and disciplinary backgrounds, e.g. research nurse, neuroscience, science of care pedagogics, and public health. One of the researchers hold an MSc, and all others a PhD. Two of the researchers in the group are male.

Quotes from the data material are used in the result section to illustrate and elaborate on the results. These quotes were translated from Scandinavian languages to English by JM, and a professional translator checked the translation. Quotes presented are only marked with participant ID in the form of consecutive numbers. To protect the patients’ and clinics’ anonymity no other characteristics are given. In line with this, and since most of the participants were male, all participants are described as ‘he’ in the results section.

Results

Twenty-four patients participated in individual interviews. The participants were between 26 and 72 years old (median = 37 and mean = 42.2, SD = 13.2). Sixteen of the participants were male and eight were female. Ten had completed high school. None of the participants had paid work. Seventeen of them lived in an independent home. All participants reported having what they described as close relationships (although the majority lived alone), and most informants reported having both close private and professional relationships. All participants received ambulant treatment, and most of them had experience with admissions to in-patient treatment. The participants received the PP3M injections in different settings, some from their professional contact in mental health services, some by nurses in their local health centre, and some by the nursing home caretakers. The mean index score on EQ-5D (excluding Swedish participants) was 0.72 (SD = 0.2) and the median was 0.73.

The participant sample included patients with approximately 10 or more years of experience with receiving treatment for severe mental illness. Hence, the participants had vast experience with several types of antipsychotic medications. In the interviews, participants described and compared experiences with medications in different forms: First versus second-generation antipsychotics, oral medications versus long-acting injectables, and injections every month versus every three months. In this result section, we focus mainly on the participants’ experiences with PP3M treatment, and the switch from PP1M to PP3M administration.

Switching medications from PP1M to PP3M

According to most of the participants, it was the mental health care professionals who were the main contact for the patient (either a psychiatrist or a nurse), who suggested and initialized the switch from PP1M to PP3M. The participants said that the professionals’ arguments were that PP1M and PP3M were the same medication, and that PP3M had practical advantages, compared to PP1M. Two of the participants had suggested the switch themselves, one after having heard about injections every three months from a nurse, and one from reading about it online. During the interviews, it became clear that the participants had important and trustful relationships with their professional contacts, and that this influenced the patients’ decision to switch medication. Several emphasized that a good relationship with the health care professionals made them trust their judgment.

Yes, my contact with them [mental health care professionals] is good, we get on well and I am pleased to be here [in the outpatient service]. If they tell me that they think it might be a good idea [switching to PP3M], then …, yes….

(Participant ID 15)

‘It is the same medicine’

All participants had received PP1M before changing to PP3M, and repeatedly described that PP3M contained the same active component as PP1M. Their descriptions appeared to mirror the professionals’ arguments, as well as the patients’ own experiences. Receiving the same medicine, but not as often, seemed to be a strong and plausible argument, motivating the patients to accept the change in medication.

I think what tempted me most was the fact that I could have it [the medication] as an injection… that it was the same [component] as I had before, but not as frequently. I think this was what mattered the most to me.

(Participant ID 15)

Although the participants described different needs and wishes for information, nearly all participants said that they had received enough information about the new medication. Only one participant said that the information he had received was insufficient, and that he had to find information about adverse events on his own. Several participants said that they did not want to receive more information than necessary, and that they did not want to be informed about every single potential adverse event.

Everyone else seems to make more of it than I do…. I mean, you [the interviewer] turn up, my nurse explains this and that, but really… for me it is enough to know that this is medication I will be given every third month.

(Participant ID 23)

Advantages of PP3M medication

The participants described several advantages to receiving injections every three months. They emphasized practical aspects as well as aspects regarding efficacy. Mostly, descriptions of advantages were spontaneous during the interviews.

Less frequent medication

Many of the participants described that they preferred receiving less frequent injections. Fearing needles and injections implied that receiving an injection every three months was preferable. Some described that this was known by the health care professionals who recommended the switch.

[…] then he [the psychiatrist] asked if I would like to try [PP3M], because he knows that I fear needles, and then of course it was difficult for me not to accept.

(Participant ID 21)

Many participants emphasized that it was very important that the person administering the injections had experience with the procedure, ensuring that the injection was as painless as possible.

For some, the reduction in administration and organization to receive the medication was very welcome. Many participants described coordinating, reserving and picking up the medication, and subsequently meeting at the health services to receive the injection, as stressful. Overall, receiving an injection every third month lightened the planning and administration of the medications. Participants described that longer intervals between the injections entailed benefits for the patient, as well as for the health care professionals:

Then there are fewer dates to remember … It gives a longer breathing space … that is more time between each injection, … there are about 15 days on each side, which provides flexibility, both for the patient and for the nurse who administers it.

(Participant ID 11)

In addition, some described that receiving medication every three months felt like ‘less medicine’ compared to receiving it every month, implying that they felt the amount of medication was ‘reduced’ in a positive way. These descriptions were in line with several participants describing that both PP3M and PP1M were ‘mild’ medicines, compared to ‘strong’ antipsychotics they had received previously. While this was not necessarily a comparison of PP1M and PP3M, the participants linked a reduction in the number of injections to the ‘milder’ side in their comparison of ‘mild’ and ‘strong’ medicines. Less frequent injections thus implied ‘milder’ or ‘less’ medication, which was described as highly preferable.

Impact on everyday life and social relations

Many of the participants described very positive experiences with switching from first to second-generation antipsychotics, thus sometimes referring to a positive development, which was not necessarily connected specifically to the PP3M or PP1M. Nevertheless, most participants also described positive changes after switching to PP3M.

Some of the participants had problems describing specifically or elaborating in detail how the changes in medication had influenced their lives. They thus described the positive changes in very general terms; for example, that it had ‘changed the way they lived’ (Participant ID 4, ID 5, ID 6). Other participants were able to describe this more elaborately. One said that the new medication had increased the nuances and ‘colour’ in his life (Participant ID 9), while another emphasized an increased ‘abundancy’ in his life (Participant ID 15).

I feel [….] more joyful again, in a way [.] I’ve regained my sensitivity… my joy is greater, my quality of life is greater….

(Participant ID 9)

Some said that they had become more active after switching medication, including an increase in both physical and social activities. One described that he had become happier and more positive, and that this influenced his social activities and relations.

[…] it’s like I’ve become a completely different person…[.] the better I get, the more I feel I am getting more and more of my life back again…[.] So I can handle being with people and start to become myself again…

(Participant ID 19)

Feeling of increased stability and less focus on illness

The participants described very different ways to cope and live with the fluctuations, limitations and consequences of having a severe long-term disease. Overall, the impression from the participants’ descriptions was that receiving antipsychotics as injections, specifically with long intervals, diminished the risk of relapse. The reduced risk of relapse seemed to support feelings of safety and security. According to the participants, treatment with PP3M implied safety and fewer worries about relapse.

It makes me feel more secure, right? So, I don’t get worse, right? […] you can see over a longer period which way it goes, right?

(Participant ID 13)

The advantage is that I don’t get ill again - It’s a safety net for me. It helps me to stay in balance.

(Participant ID 4)

Many participants talked about changes that had evolved over a long time. According to them, stability in symptoms was followed by more energy, more activity such as cooking, housework, being with other people, exercising, being outdoors, and contemplating taking up work. Some said that these changes had helped them become more independent. According to the participants, the PP3M medication contributed to strengthening their improvement processes. The participants described that this improvement evolved over time, and that PP3M added to and enhanced a positive development that was established over time. Some described their illness as improving and stabilizing over a very long period.

I feel that I am really doing well… in the bigger picture, more or less … things are moving in the right direction. In the long run, I have gained more control.

(Participant ID 16)

In addition to a feeling of increased stability, some of the participants also emphasized that less frequent medication weakened the focus on illness.

Yes, it’s something I give less attention. It is not something I think about every day […] when I had to take the tablets every single day I was reminded daily that I had a disease.

(Participant ID 18)

Contacts and interaction with mental health care professionals

The results showed great differences between the participants in how frequently they had contact with mental health professionals. While some had four contacts during a week, others had contact every fortnight, and others every six weeks. One of the participants was in contact with mental health professionals only every six months. However, he lived in a residential home and interacted with members of the staff.

When being asked specifically whether the less frequent administration of medication had changed the contact with the mental health care services, all participants said that neither the frequency nor type of contact (in person or telephone follow-ups) were changed. The participants also said that the introduction of PP3M had not influenced the content in the interactions, such as psychiatric nursing, milieu therapy, social skills training, activities of daily living or therapeutic conversations. A few of the participants described that the frequency of contacts had diminished over a longer period. However, this was not related to the use of PP3M, but related to general improvements and stability in their conditions.

Disadvantages with PP3M medication

The participants described very few disadvantages with switching from PP1M to PP3M. Such descriptions appeared mainly after being prompted by the interviewers and were thus not spontaneous. When asked explicitly whether they experienced any disadvantages with PP3M, some answered that they only had positive experiences, while some described aspects they regarded as challenging. Several said that fearing needles and the injection itself was a disadvantage. At the same time, they emphasized the benefit of less frequent injections, and that injections were preferable to oral medicines, which they described as easy to forget. A few of the participants described economic challenges in having to pay (lay out) for the costly medication, although reimbursement was available in all Nordic countries. Another participant worried about the medication’s high costs for society.

Some of the participants expressed concerns related to a decreasing effect of the PP3M. They described feeling that the effect ‘wore off’ or decreased before three months had passed, worrying about this decrease. One said that he felt like he was ‘running dry’ and feeling worse at the end of the three-month period.

I don’t know if it’s something I imagine, but I feel like…the last days before a new injection, I feel that I am going down a bit, that my body is lacking something. It might just be something I am imagining …but I am not sure if it’s because the level of medicine in my blood has decreased…

(Participant ID 15)

These participants added that the mental health care professionals had adjusted the interval between injections to accommodate the participants’ experiences of a subsiding effect.

Discussion

The results showed that, according to the patients, PP3M had several advantages, such as less frequent injections, less administration and planning and less focus on the illness. In addition, the patients described feeling more stability, being more physically and socially active, and that improvement processes were supported. For some, the use involved practical and economic challenges, and some worried whether the medicine ‘waned off’ before the next injection. According to the patients, switching to PP3M did not influence the frequency or content of patients’ interaction with health care professionals.

Result discussion

An important argument for the switch was that PP1M and PP3M involved the same active component, and that frequency was the main difference. This is in line with the findings in Lai and Margolese [23] and a recent large-scale patient-reported questionnaire study [21]. The results also showed that most switches from PP1M to PP3M were recommended by the patients’ health care providers, and that trusting the professionals was imperative for this decision. In addition to these findings a recent questionnaire study showed that both physicians and patients felt that patients were highly involved in the decision to switch to PP3M [22]. This is in line with previous research highlighting the importance of perceiving the source of information as reliable [29] and of having good relationships with health care professionals [18]. Most participants in our study had close relationships to both private and professional contacts (Table 1). Since secure attachment in general is associated with better functioning [30], this may have had a positive impact on the results and should be considered when interpreting them.

The results showed that some of the patients did not want to be informed about every single potential adverse effect from the medication. This is in line with previous research on shared decision-making, showing that not all patients want to participate in decision-making processes or receive all information [31,32]. Nevertheless, offering necessary information and the opportunity to take part in decision-making has the potential to improve knowledge and attitudes towards treatment [31], as well as empowering the patients [33].

Although this study did not aim to investigate any adverse effects with the PP3M medication, it was noted that very few participants described adverse effects. Disadvantages or challenges described were mainly related to practical issues. This finding is in line with Kikkert et al.’s model of adherence, describing that the decision to adhere to the medication depends on and could be hampered by financial and practical barriers [29]. Concerns about potential additional costs have also been described previously [23]. The findings also underline the importance of providing medication that is accessible and affordable. Stable medication [34,35] requires limitations of the practical and financial barriers.

This study did not show any changes in frequency or content of contact with mental health care professionals after switching to PP3M. Thus, according to this study, fewer contacts to administer medication do not alter the contact frequency as such. LAI antipsychotics with less frequent administration may offer several advantages from a patient, caregiver and prescriber point of view. In line with this, publications on PP3M have argued that the requirement for only 4 injections per year would allow more time for patients and physicians to address other important treatment objectives aside from pharmacological treatment such as psychosocial treatment, substance abuse treatment, vocational rehabilitation etc. [16,36]. Still, it may be an underlying concern among prescribers that less frequent dosing could lead to fewer interactions with patients. In the current study we found no changes in frequency or content of contact with health care professionals after switching to PP3M. Thus, according to our results, fewer dosing appointments did not alter or interfere with the overall contact frequency. This implies increased time to focus on other treatment aspects, such as supporting personal recovery [37] and thereby promote well-being [38].

The results showed that some participants felt that the effect from the medication ‘wore off’ when approaching the next injection. However, as this study was based on patient experience it is difficult to conclude whether the cause of this perception was rooted in pharmacological or psychological factors. Using the possibility for individualization of medication intervals, in collaboration with the patients, could strengthen the involvement in the treatment process, potentially supporting empowerment [33].

Strengths and limitations

This is the first multi-centre study using a qualitative approach to explore the patient perspective on PP3M, and the switch from PP1M to PP3M. The sizeable patient sample, as well as clinics and participants from three different countries, strengthen the study. The choice of qualitative methodology allowed for an in-depth exploration of the patients’ experiences with the PP3M medication, a perspective that has been lacking so far. Unfortunately, the recruitment of clinics or patients in Norway and Sweden proved challenging, limiting the number of participants in these countries.

The sample represented diversity in age and gender and three different countries. This, together with the participants’ extensive experience with medication for mental illness, strengthens the usefulness of the findings. This study only included patients that accepted and currently received treatment with PP3M, which excluded any exploration of patient arguments for declining a switch to a longer treatment interval, or any reasons for discontinuing or stopping PP3M treatment. It is imperative to address these aspects in future studies to create a broader understanding of patients’ perception of longer treatment intervals and help guide health care professionals in the decision-making process.

It is important to note that the participants in this study verbalized their experiences and perceptions in various ways. Overall, they described the PP3M medication as helpful and positive. Nevertheless, some of the participants had difficulties wording more precisely what was helpful or positive, leaving their descriptions rather limited. This could be attributed to limitations in cognitive functioning linked to the illness [39]. The results thus reflect the experiences of patients with long-term mental illness. Conducting interviews at only one time point limits the focus on medication change as a process. Further studies should have a longitudinal approach and include interviews both before and after switching medication, as well as more long-term follow-up. Here, focusing on quality of life and participation in society could be useful.

The data collection was conducted by AE and LOS, and the first part of the data analysis was conducted by LOS and JM. The findings were discussed in two rounds in a research group involving professionals with different backgrounds. The multidiciplinarity in the author group strengthened the analysis process and subsequently the interpretation of the results.

Conclusions

This is the first multi-center study using a qualitative approach to explore the patient perspective on PP3M and the switch from PP1M to PP3M. The health care professionals’ role was important for indicating and supporting a switch from monthly to three-monthly injections, with a trusting relationship as a crucial factor. While the switch from PP1M to PP3M seems to be advantageous for patients with schizophrenia, it did not involve any changes in patients’ interactions with health care professionals. Using the possibility for individualization of injection intervals could support the patient’s involvement and empowerment.

Ethics approval and consent to participate

All informants received oral and written information about the project before signing a consent form. All were informed that participation in this study would not affect their treatment or clinical pathway, that participation was voluntary, and that they had the right to refuse participation and to withdraw from the study at any time. Ethical approvals of this study were given in all three countries (Norway: Regional Committee for Medical and Health Research Ethics, South-East, 2017/1816/REK Sør-Øst; Denmark: De Videnskabsetiske Komitéer for Region Syddanmark, S-20172000-191; Sweden: Regionala etikprövningsnämnden i Göteborg, NOMA RRA-20638; DN 1101-17).

Consent for publication

Not applicable.

Author contributions

All authors (MRB, LOS, BH, AE, KS, JR, EJ and JM) took part in the planning and design of the study and in the data analysis and contributed to the presentation of the results. LOS and AE collected the data material. LOS and JM were in charge of the data analyses and wrote the initial report on which the manuscript is based. KS analyzed and presented the demographic and EQ-5D data. MBR was in charge of writing the manuscript. All authors (MRB, LOS, BH, AE, KS, JR, EJ and JM) collaborated on revisions and completion of and approved the final manuscript.

Acknowledgements

The authors thank the patients who participated in this study, and to members of staff as well as heads of clinic for valuable support in recruiting informants. Due to patient confidentiality names of clinics or units cannot me mentioned. The authors also thank Frederik Alkier Gilberg for taking part in the early stages of the planning of this study.

Disclosure statement

KS, JR and EJ are employed at the funder Janssen Cilag AB. They were involved in study content and design and critical revision of the manuscript for important intellectual content. Their authorship roles adhere to ICMJE criteria. MBR, LOS, AE, BH and JM declare that they have no competing interests.

Data availability statement

Due to the sample size and the vulnerability of the patient group, the data material is not available.

Additional information

Funding

The study was funded by Janssen Cilag.