Change in antipsychotic usage pattern and risk of relapse in older patients with schizophrenia

How can we improve the care of patients with schizophrenia in the real-world? A population-based cohort study of 456,003 patients

An important step to improve outcomes for patients with schizophrenia is to understand treatment patterns in routine practice. The aim of the current study was to describe the long-term management of patients with schizophrenia treated with antipsychotics (APs) in real-world practice. This population-based study included adults with schizophrenia and who had received ≥3 deliveries of an AP from 2012-2017, identified using a National Health Data System. Primary endpoints were real-life prescription patterns, patient characteristics, healthcare utilization, comorbidities and mortality. Of the 456,003 patients included, 96% received oral APs, 17.5% first-generation long-acting injectable APs (LAIs), and 16.1% second generation LAIs. Persistence rates at 24 months after treatment initiation were 23.9% (oral APs), 11.5% (first-generation LAIs) and 20.8% (second-generation LAIs). Median persistence of oral APs, first-generation LAIs and second-generation LAIs was 5.0, 3.3, and 6.1 months, respectively. Overall, 62.1% of patients were administered anxiolytics, 45.7% antidepressants and 28.5% anticonvulsants, these treatments being more frequently prescribed in women and patients aged ≥50 years. Dyslipidemia was the most frequent metabolic comorbidity (16.2%) but lipid monitoring was insufficient (median of one occasion). Metabolic comorbidities were more frequent in women. Standardized patient mortality remained consistently high between 2013 and 2015 (3.3-3.7 times higher than the general French population) with a loss of life expectancy of 17 years for men and 8 years for women. Cancer (20.2%) and cardiovascular diseases (17.2%) were the main causes of mortality, and suicide was responsible for 25.4% of deaths among 18-34-year-olds. These results highlight future priorities for care of schizophrenia patients. The global persistence of APs used in this population was low, whereas rates of psychiatric hospitalization remain high. More focus on specific populations is needed, such as patients aged >50 years to prevent metabolic disturbances and 18-34-year-olds to reduce suicide rates.

Clinical and demographic factors associated with early relapse in patients with schizophrenia: a naturalistic observation study

Schizophrenia is a chronic psychiatric disorder progressing in relapses. Identification of many factors that may potentially increase the risk of relapse will be an important step in preventing relapses. The aim of this study was to determine the rate of early relapse in patients with schizophrenia and possible risk factors related to early relapse. The sample of this prospective study with the naturalistic observation design consisted of 308 patients with schizophrenia. The cutoff value for early relapse was determined as 1 year. The mean age of participants was 37.38 ± 12.28 years and 66.6% of them were male (n = 205). The early relapse rate was 38.3%. The age younger than 35 [hazard ratio (HR) = 2.313; 95% confidence interval (CI), 1.518-3.526; P < 0.001], use of psychoactive substance (HR = 2.200; 95% CI, 1.407-3.440; P = 0.001), previous attempt of suicide (HR = 1.565; 95% CI, 1.028-2.384; P = 0.037), bad adherence to treatment (HR = 3.102; 95% CI, 1.358-7.086; P = 0.007), long-acting injectables (LAIs) antipsychotics in the treatment (HR = 0.534; 95% CI, 0.351-0.812; P = 0.003), combination typical-atypical antipsychotics (HR = 0.326; 95% CI, 0.131-0.807; P = 0.015), number of episodes (HR = 1.088; 95% CI, 1.043-1.134), and the score on the Side Effect factor of the Clinical Global Impressions Scale (HR = 1.826; 95% CI, 1.357-2.458; P < 0.001) were identified as the independent predictors of early relapse. It is remarkable that treatment bad adherence, use of psychoactive substance, no LAIs antipsychotics included in the treatment, and the no presence of the combination of typical and atypical antipsychotics are alterable predictors of early relapse.

Does antipsychotic combination therapy reduce the risk of hospitalization in schizophrenia?

INTRODUCTION

: Despite treatment with antipsychotic medication, approximately 1/3 of individuals with schizophrenia will fail to have an adequate response. To treat these patients, a commonly utilized approach is antipsychotic combination therapy. Antipsychotic combination therapy is controversial with mixed efficacy and tolerability results. It is also unclear if antipsychotic combination therapy reduces or increases the risk of psychiatric hospitalization.

AREAS COVERED

: The authors review the prevalence, efficacy and tolerability concerns, and rationale behind antipsychotic combination therapy. Evidence comparing antipsychotic monotherapy vs polypharmacy using hospitalization as an outcome measure is summarized.

EXPERT OPINION

: Psychiatric rehospitalization is a useful measure of treatment effectiveness, incorporating aspects of treatment efficacy and tolerability. The evidence comparing the impact of antipsychotic monotherapy vs combination therapy on rehospitalization is mixed. Evidence is primarily retrospective in nature, and there is high heterogeneity between studies, which could partially explain the mixed results. There is likely a subset of patients for whom antipsychotic combination therapy reduces the risk of hospitalization greater than antipsychotic monotherapy. Patients should be treated individually taking into account their specific pattern of response.

Prescription practices in the treatment of agitation in newly hospitalized Chinese schizophrenia patients: data from a non-interventional naturalistic study

BACKGROUND

Data on the pharmacological management of acute agitation in schizophrenia are scarce. The aim of this study is to investigate the prescription practices in the treatment of agitation in Chinese patients with schizophrenia.

METHODS

We conducted a large, multicenter, observational study in 14 psychiatry hospitals in China. Newly hospitalized schizophrenia patients with the PANSS-EC total score ≥ 14 and a value ≥4 on at least one of its five items were included in the study. Their drug treatments of the first 2 weeks in hospital were recorded by the researchers.

RESULTS

Eight hundred and 53 patients enrolled in and 847 (99.30%) completed the study. All participants were prescribed antipsychotics, 40 (4.72%) were prescribed benzodiazepine in conjunction with antipsychotics and 81 were treated with modified electric convulsive therapy (MECT). Four hundred and 12 (48.64%) patients were prescribed only one antipsychotic, in the order of olanzapine (120 patients, 29.13%), followed by risperidone (101 patients, 24.51%) and clozapine (41 patients, 9.95%). About 435 (51.36%) participants received antipsychotic polypharmacy, mostly haloperidol + risperidone (23.45%), haloperidol+ olanzapine (17.01%), olanzapine+ ziprasidone (5.30%), haloperidol + clozapine (4.37%) and haloperidol + quetiapine (3.90%). Binary logistic regression analysis suggests that a high BARS score (OR 2.091, 95%CI 1.140-3.124), severe agitation (OR 1.846, 95%CL 1.266-2.693), unemployment or retirement (OR 1.614, 95%CL 1.189-2.190) and aggressiveness on baseline (OR 1.469, 95%CL 1.032-2.091) were related to an increased antipsychotic polypharmacy odds. Male sex (OR 0.592, 95%CL 0.436-0.803) and schizophrenia in older persons (age ≥ 55 years, OR 0.466, 95%CL 0.240-0.902) were less likely to be associated with antipsychotic polypharmacy.

CONCLUSION

The present study demonstrates that monotherapy and polypharmacy display equally common patterns of antipsychotic usage in managing agitation associated with schizophrenia in China. The extent and behavioral activities of agitation and several other factors were associated with polypharmacy.

Claims-based proxies of patient instability among commercially insured adults with schizophrenia

Objective

Schizophrenia (Sz) patients are among the highest utilizers of hospital-based services. Prevention of relapse is in part a treatment goal in order to reduce hospital admissions. However, predicting relapse is a challenge, particularly for payers and disease management firms with only access to claims data. Understandably, such organizations have had little success predicting relapse. A tool that allows payers to identify patients at elevated risk of relapse could facilitate targeted interventions prior to relapse and avoid rehospitalization. In this study, a series of proxy measures of patient instability, calculated from claims data were examined for their utility in identifying Sz patients at elevated risk of relapse.

Methods

Aetna claims were used to assess the relationship between instability of Sz patients and valence and magnitude of antipsychotic (AP) medication change during a 2-year period. Six proxies of instability including hospital admissions, emergency department visits, medication utilization patterns, and use of outpatient services were identified. Results were replicated using claims data from Truven MarketScan^®.

Results

Patients who switched AP ingredient had the highest overall instability at the point of switch and the second steepest decline in instability following switch. Those who changed to a long-acting injectable AP showed the second highest level of instability and the steepest decrease in instability following the change. Patients augmented with a second AP showed the smallest increase in instability, up to the switch. Results were directionally consistent between the two data sets.

Conclusion

Using claims-based proxy measures to estimate instability may provide a viable method to better understand Sz patient markers of change in disease severity. Also, such proxies could be used to identify those individuals with the greatest need for treatment modification preventing relapse, improving patient outcomes, and reducing the burden of illness.