In Depot regimes the injected neuro-leptic medication is held in detention and released subsequently. The method of preparation aims to release the active constituent slowly over a month. It is deposited by deep intra-muscle injection. This avoids the pass through the liver which happens first with oral medication. It means a smaller quantity of medication for that month than would be required an oral regime . The maximum delivery peak is after the second and third day , the blood level slowly falling away two or three days later till the next injection tops it up again.

When starting the regime , both the dose strength of each injection and the interval between injections are variables to be arrived at. The initial dosages selected follow from what was used successfully as the optimum oral dosage of an equivalent neuro-leptic drug. Experience has standardised equivalent systems - to some extent.

At the start the injections succeed each other and arrive on top of a residual blood level from the previous injection. It takes some time for the level to settle down to a steady state; breakdown in the body and elimination is balanced by the new arrival injection. A steady state is achieved at around three months.

- There are different preparations with more or less standardised equivalent products .

Present day admission ward stay is often for three to four weeks - not an adequate time in which to reach steadiness in blood levels or a confident observation of the neutralising influence on the illness.

In that case the experience of side-effects or recurrent illness can arrive after discharge, out of observation of the company of professional staff, requiring adjustment after discharge, sometimes damaging the confidence of the recipient in the system . Patients have subjective observations of general and local discomfort, and have suggested from that experience , adjustments in a schedule. One patient asked for and got a change from fortnightly dosages to weekly dosages at a lower volume and strength . The fluctuations in his subjective experience were 'ironed out' with the regime he suggested.

It is not common for a comment from the patient or their carers to be thus responded to - the professional system with its changes in personnel contact and supervision , lacks confidence in doing so, but such ' tailoring to the wearer ' helps to bring compliance and reward for all concerned.

There is no standard blood level for efficacy. There is however a lowest blood level for each product below which efficacy is in doubt. It is likely that if a certain regime is found to be successful in an individual , then the blood level achieved by that regime may well be the effective level for that patient , whilst for a different person , it could be at a different range . An estimation during recovery on treatment , would help subsequent maintenance or re-introduction . Blood level examination is rarely used .

Sampling of blood levels , taken just before an injection is due show that the expected steady blood levels for depot regimes are sometimes not there . Quite often , the blood level is at zero on the day before an injection is due . There are often un-predicted fluctuations .

Observation by recipients in community care conditions - often confirmed by the family carers , is that the patient may have and may complain of side-effects on the second or third day after an injection on a depot regime - restless legs , inner restlessness , stiffness , drooling and other complaints , which then go away . Observers living with the patients notice and recipients do not , that just before the injection is due , the illness shows itself again , settling again on the second and third day after the injection .

The depot regimen is introduced to take away the problems of poor compliance with an oral regime . [ It will be the basis of 'enforcement' when Compulsory Treatment Orders come in. At present they rely on the older preparations - with exposure to the neurological side effects -especially subjective ones not always accepted as present by professional observers- restless leg - akithisia - feelings. One of the newer preparations - Risperidone - may still bring that kind of side-effect -usage experience is not yet in . Another - Olanzipine - has just had its first stage of approval for a Depot trial from the American Food and Drugs overseers. ]

Sometimes that will be due to refusal to go on with the tablets at all , sometimes because the patient is better and feels therefore they do not need the medication , and that they will escape the side-effects . The benefit from the preparations can continue for some weeks after stopping an injection course , possibly the medication has some general fat storage , or for an unknown reason , but a common finding , thus giving confirmation to the patient that medication need not continue .

Patients who stop an injection regime often do feel even better because they lose the opprobrious subjective side-effects , before the beneficial effects run out . Injection programmes are often described as controlling , because it is there for some days in the future - outside any chance of withholding .

Many patients accept the depot routine as good for them because they know that an oral medication lapse can simply be from 'inattention' . They have experienced previous relapse into illness and compulsory admission to hospital , social failure and alienation , because of that forgetfulness .

The hospital where he awaited trial after his last court appearance , had decided Clunis required such a depot regime of aftercare, because of the story of his frequent exhibition of symptoms and many re-admissions because of that. When the Court case collapsed because the victim was not found to give evidence , they realised that Clunis , ill though he was , could return to the community - released from the custody imposed whilst awaiting trial. A Treatment detaining Order - applicable for up to one year - was put in place.

None of the NHS hospitals had made that decision . In the Private Hospital there was no pressure on them to accept more patients when its beds were full . NHS admission services have always to make way for other patients.

Management pressure for 'efficiency ' expressed itself in fewer and fewer NHS 'beds' , a quicker resort to medication, with less and less time to achieve this to the satisfaction of the recipients , who were not given the conditions nor the time to settle or to agree to adequate aftercare preparation .

Jonathan Newby ( inquiry 4. ) was known to be liable to be ill in the day before his injection was due . His last injection was delayed by a day.

Robert Viner ( inquiry 8. ) received his last injection on the day of the tragedy - when the blood levels would be at their lowest .He was to be readmitted the next day.

Andrew Robinson( inquiry 2. ) was in hospital . Depot regimes were instigated , with a changeover in product , but the time that passed before the tragedy , was less than that necessary to achieve a steady state.

The theoretical explanations of how medications work are often challenged by new ways of monitoring.

Recent brain imaging techniques can measure the degree to which effective medications occupy what are called D2 neurone receptor targets in particular parts of the brain . All the efficacious medications , so far , have in common that they have action at the D2 ( dopamine2 ) neuron cell receptor site . The depot regimes were supposed to provide continuous occupation , better than the irregular compliance with oral regimes . Intermittent oral regimes with 'drug holidays' for days at a time had been ineffective in neutralising the illness.

Recently it has been shown for oral new type medication ( quetiapine-Zyprexa ) that the standard daily oral dosage does not occupy the D2 receptors all through the day, but there are intervals when the sites are clear. Yet the particular drug , quetiapine, is as efficacious as some which occupy the sites all the time at a particular percentage occupancy.

But this is not to be taken as support for intermittent phased treatment regimes, or allowing medication levels to fall to zero or near zero between depot injections. The absence of neuron site occupation with oral quetipine is a matter of hours and minutes, not days.

So-called drug 'holiday' programmes did not work.

Some studies - and there have not been many under community care situations, show that the expected steady blood levels for depot regimes are not there. Quite often, the blood level is at zero on the day before an injection is due. Day-by-day carers will notice this as a return of illness ; 'users' will not always recognise that. The latter will often notice side-effects on day two or three when peaking occurs.

Differences in position of injection sites , in a changed body efficiency in eliminating the product , in faulty injection practices; are all likely explanations.

In any mandatory community Order it is likely depot regimes will be used,
The newer atypical medications are being prepared for this kind of delivery practice.
Olanzapine is ready with it's preparation.