The use of atypical antipsychotics in the treatment of schizophrenia in North Staffordshire

Global Neuropsychopharmacological Prescription Trends in Adults with Schizophrenia, Clinical Correlates and Implications for Practice: A Scoping Review

It is important to examine the psychotropic prescription practices in schizophrenia, as it can inform regarding changing treatment choices and related patient profiles. No recent reviews have evaluated the global neuropsychopharmacological prescription patterns in adults with schizophrenia. A systematic search of the literature published from 2002 to 2023 found 88 empirical papers pertinent to the utilization of psychotropic agents. Globally, there were wide inter-country and inter-regional variations in the prescription of psychotropic agents. Overall, over time there was an absolute increase in the prescription rate of second-generation antipsychotics (up to 50%), mood stabilizers (up to 15%), and antidepressants (up to 17%), with an observed absolute decrease in the rate of antipsychotic polypharmacy (up to 15%), use of high dose antipsychotic (up to 12% in Asia), clozapine (up to 9%) and antipsychotic long-acting injectables (up to 10%). Prescription patterns were mainly associated with specific socio-demographic (such as age), illness (such as illness duration), and treatment factors (such as adherence). Further work, including more evidence in adjunctive neuropsychopharmacological treatments, pharmaco-economic considerations, and examination of cohorts in prospective studies, can proffer insights into changing prescription trends relevant to different treatment settings and predictors of such trends for enhancement of clinical management in schizophrenia.

Association With Hospitalization and All-Cause Discontinuation Among Patients With Schizophrenia on Clozapine vs Other Oral Second-Generation Antipsychotics: A Systematic Review and Meta-analysis of Cohort Studies

IMPORTANCE

Recent meta-analyses of randomized clinical trials (RCTs) comparing clozapine with nonclozapine second-generation antipsychotics (NC-SGAs) in schizophrenia have challenged clozapine's superiority in treatment-resistant patients. However, patients in RCTs are not necessarily generalizable to those in clinical practice.

OBJECTIVE

To conduct a systematic review and meta-analysis to compare various outcomes of clozapine vs oral NC-SGAs in cohort studies.

DATA SOURCES

Systematic literature search in PubMed, PsycINFO, and CINAHL without language restriction from database inception until December 17, 2018.

STUDY SELECTION

Nonrandomized cohort studies reporting effectiveness and/or safety outcomes comparing clozapine with NC-SGAs in schizophrenia or schizoaffective disorder.

DATA EXTRACTION AND SYNTHESIS

Independent investigators assessed studies and extracted data. Using a random-effects model, the study calculated risk ratio (RR) unadjusted for covariates and follow-up duration, number needed to treat/number needed to harm (NNT/NNH) for dichotomous data, and standardized mean difference (SMD) or mean difference (MD) for continuous data.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes were hospitalization and all-cause discontinuation. Secondary outcomes included all effectiveness and safety outcomes reported in at least 3 analyzable studies.

RESULTS

Of 8446 hits, 68 articles from 63 individual cohort studies (n = 109 341) (60.3% male; mean [SD] age of 38.8 [6.5] years, illness duration of 11.0 [5.1] years, and study duration of 19.1 [23.3] months) were meta-analyzed. Compared with NC-SGAs, despite greater illness severity (17 studies [n = 38 766]; Hedges g, 0.222; 95% CI, 0.013-0.430; P = .04), clozapine was significantly associated with lower hospitalization risk (19 studies [n = 49 453]; RR, 0.817; 95% CI, 0.725-0.920; P = .001; NNT, 18; 95% CI, 12-40) and all-cause discontinuation (16 studies [n = 56 368]; RR, 0.732; 95% CI, 0.639-0.838; P < .001; NNT, 8; 95% CI, 6-12). Associations were statistically significant for comparisons with quetiapine fumarate and aripiprazole regarding hospitalization and all NC-SGAs, except aripiprazole, for all-cause discontinuation. Clozapine was also significantly associated with better outcomes regarding overall symptoms (SMD, -0.302; 95% CI, -0.572 to -0.032; P = .03) and Clinical Global Impressions scale severity (SMD, -1.182; 95% CI, -2.243 to -0.122; P = .03). Clozapine was significantly associated with increases in body weight (MD, 1.70; 95% CI, 0.31-3.08 kg; P = .02), body mass index (MD, 0.96; 95% CI, 0.24-1.68; P = .009), and type 2 diabetes (RR, 1.777; 95% CI, 1.229-2.570; P = .002; NNH, 27; 95% CI, 13-90).

CONCLUSIONS AND RELEVANCE

In cohort studies, despite more severely ill patients being treated with clozapine, use of clozapine was associated with better key efficacy outcomes and higher cardiometabolic-related risk outcomes vs NC-SGAs.

Numbers-needed-to-treat analysis: an explanation using antipsychotic trials in schizophrenia

The evaluation of treatment effects is important to both the clinician and the patient. However, outcomes in randomised trials are often difficult to apply to the clinic. The number needed to treat (NNT) is one method that facilitates the interpretation of clinical trials in a meaningful way. When combined with the number needed to harm (NNH), the balance between the risks and benefits of a particular treatment can be appreciated. We illustrate the use of these concepts by focusing on recent large pragmatic studies of antipsychotics, including CATIE, EUFEST and CUtLASS.

Antipsychotic long-acting injections: A community-based study from 2007 to 2014 of prescribing trends and characteristics associated with initiation

OBJECTIVE

To explore the impact of the introduction of newer antipsychotic long-acting injections (LAIs) on trends in LAI prescribing and characteristics associated with initiation of LAIs in naturalistic conditions.

METHODS

The study was performed using reimbursement data from the French Insurance Healthcare system. Prescribing trends were investigated from 2007 to 2014 in 382,572 persons aged 18years and over. Characteristics associated with delay in transition from oral antipsychotic to LAIs were explored in a cohort of 6904 persons newly treated with an oral antipsychotic using multivariate survival analyses.

RESULTS

LAI prescribing rates slightly increased over the study period. The likelihood of being prescribed LAIs was stable for FGA LAIs (around 1.8 per 1000) (aOR=0.99, 95%CI 0.98-1.00) and increased for SGA LAIs from 0.5 to 1 per 1000 (aOR=1.11, 95%CI 1.08-1.14). In persons initiating an LAI (n=288), shorter transition from oral antipsychotic to LAI was independently predicted by male gender, younger age, dispensing of an oral SGA and a higher number of oral antipsychotics dispensed over the follow-up. Transition was longer in persons dispensed antidepressants or mood-stabilizers over the follow-up. Male gender, low income and higher number of antipsychotics were associated only with shorter transition to FGA LAIs, while initial prescription by a public practitioner, no mood-stabilizer dispensing and lack of somatic severe chronic condition were associated only with SGA LAIs dispensing.

CONCLUSIONS

It is of interest to explore whether similar prescribing trends are observed in other countries and to further assess the effectiveness of new LAIs in real-life conditions.

Clozapine use pattern in persons with and without treatment for Parkinson's disease in real-world conditions: a naturalistic study in a community-based sample

OBJECTIVE

To explore the pattern of clozapine use in persons with severe mental illness and in persons with Parkinson's disease and the characteristics associated with early discontinuation in naturalistic conditions.

METHOD

A historical fixed cohort study of persons newly treated with clozapine was performed on a representative community-based sample of persons affiliated to the French health insurance system (n = 611,393). Treatment for Parkinson's disease was used as a proxy for this condition and lack of such treatment as a proxy for severe mental illness (SMI).

RESULTS

The prevalences of antipsychotic and clozapine use were 4.4% and <0.1% respectively. Of the 237 persons with a new outpatient prescription of clozapine, 25% were prescribed an antiparkinsonian treatment. In persons with SMI, the median duration of the index episode of clozapine treatment was 4.9 months (Interquartile range 1.0-20.5). Longer duration was independently associated with coprescription of anxiolytics or antidepressant. Few new additions of antipsychotics were observed during the clozapine episode.

CONCLUSION

Efforts have to be made to optimize clozapine treatment in real-world conditions. Considering the high frequency of persons with Parkinson's disease among clozapine users, further studies have to be performed in this population.

Discontinuation of clozapine: a 15-year naturalistic retrospective study of 320 patients

OBJECTIVE

Clozapine is underutilized in the management of treatment-resistant schizophrenia. To understand contributing factors, we analyzed the frequency and causes of clozapine discontinuations that occurred over a 15-year period in a clinical setting.

METHOD

Data were extracted from computerized records and from mandatory termination reports for discontinuation events 1993-2007. The reasons for termination were analyzed.

RESULTS

Over half of the patients (n = 183/320; 57%) had at least one discontinuation (median time 609 days). The two most common causes for discontinuation were non-adherence (35%) and side-effects (28%). Hematological side-effects accounted for 45% of all side-effect associated discontinuations; most such patients remained eligible for clozapine treatment, and a significant fraction remained on clozapine after rechallenge. Central nervous system side-effects accounted for 35% of side-effect induced discontinuations. General factors significantly associated with discontinuation were African American race, older age at initiation of clozapine and less improvement in psychiatric symptoms.

CONCLUSION

In addition to anticipating and addressing causes of non-adherence, psychiatrists should consider clozapine rechallenge in eligible patients and implement measures to mitigate clozapine-associated sedation, seizures, and other side-effects. Future studies should particularly address why African American and older patients may be more likely to discontinue clozapine.

Treatment-completion rates with olanzapine long-acting injection versus risperidone long-acting injection in a 12-month, open-label treatment of schizophrenia: indirect, exploratory comparisons

BACKGROUND

Little is known about the comparative effectiveness of atypical antipsychotics in long-acting injection formulation. Due to the absence of head-to-head studies comparing olanzapine long-acting injection and risperidone long-acting injection, this study was intended to make exploratory, indirect, cross-study comparisons between the long-acting formulations of these two atypical antipsychotics in their effectiveness in treating patients with schizophrenia.

METHODS

Indirect, cross-study comparisons between olanzapine long-acting injection and risperidone long-acting injection used 12-month treatment-completion rates, because discontinuation of an antipsychotic for any cause is a recognized proxy measure of the medication's effectiveness in treating schizophrenia. Following a systematic review of the literature, two indirect comparisons were conducted using open-label, single-cohort studies in which subjects were stabilized on an antipsychotic medication before depot initiation. The first analysis compared olanzapine long-acting injection (one study) with pooled data from nine identified risperidone long-acting injection studies. The second analysis was a "sensitivity analysis," using only the most similar studies, one for olanzapine long-acting injection and one for risperidone long-acting injection, which shared near-identical study designs and involved study cohorts with near-identical patient characteristics. Pearson Chi-square tests assessed group differences on treatment-completion rates.

RESULTS

Comparison of olanzapine long-acting injection data (931 patients) with the pooled data from the nine risperidone long-acting injection studies (3950 patients) provided almost identical 12-month treatment-completion rates (72.7% versus 72.4%; P = 0.87). When the two most similar studies were compared, the 12-month completion rate for olanzapine long-acting injection was significantly higher than for risperidone long-acting injection (81.3% versus 47.0%; P < 0.001). However, any conclusions drawn from this comparison may be limited by differences in the studies' geographic catchment areas.

CONCLUSION

Using treatment-completion rates as a proxy measure of medication effectiveness, olanzapine long-acting injection did not differ significantly from risperidone long-acting injection when including all eligible studies. However, the findings of this exploratory analysis should be interpreted with caution, considering the methodological limitations of these indirect, cross-study comparisons.

Examining the effectiveness of antipsychotic medication in first-episode psychosis

The regular use of antipsychotic medication is known to improve overall outcomes and diminish risk of relapse, but applying the results of randomised controlled trials (RCTs) into routine clinical practice is not always straightforward. Furthermore, psychiatrists, service users and policy makers can have trouble keeping up with the burgeoning and, at times, conflicting results from research trials, meta-analysis and systematic reviews. In this paper we examine the differences between efficacy and effectiveness trials with regard to antipsychotic medication with a focus on first-episode psychosis, after reviewing the relative contribution of antipsychotic medication to outcomes in schizophrenia.

Predictors of continuation with olanzapine during the 1-year naturalistic treatment of patients with schizophrenia in Japan

PURPOSE

Treatment continuation is considered an important measure of antipsychotic effectiveness in schizophrenia, reflecting the medication's efficacy, safety, and tolerability from both patients' and clinicians' perspectives. This study identified characteristics of patients with schizophrenia who continue olanzapine therapy for a 1-year period in Japan.

METHODS

In a large (N = 1850), prospective, observational study, Japanese patients with schizophrenia who initiated treatment with olanzapine were followed for 1 year. Baseline characteristics were compared using t-tests and chi-square tests. Stepwise logistic regression was used to identify independent baseline predictors of treatment continuation.

RESULTS

Most patients (68.2%) continued with olanzapine therapy for the full 1-year study period, with an average duration of 265.5 ± 119.4 days. At baseline, patients who continued were significantly more likely to be male, older, and inpatients; have longer illness duration, higher negative and cognitive symptoms, better health-related quality of life, and prior anticholinergic use. Continuers were significantly less likely to engage in social activities, live independently, work for pay, or have prior antidepressant use. Continuers showed significantly greater early (3-month) improvement in global symptom severity. Logistic regression found that continuation was significantly predicted by longer illness duration, lower positive symptoms, higher negative symptoms, and better health-related quality of life.

CONCLUSIONS

In this large naturalistic study in Japan, most patients with schizophrenia stayed on olanzapine therapy for the full 1-year study period. Treatment completion with olanzapine was independently predicted by longer illness duration, lower positive symptoms, higher negative symptoms, and better health-related quality of life.

Compliance and schizophrenia: the predictive potential of insight into illness, symptoms, and side effects

BACKGROUND

Personal beliefs about medication compliance have been reliably associated with emotional and behavioral response to mental health problems and health outcomes. This notion has been extensively explored in relation to mental illness. In the current study, a questionnaire designed to assess beliefs about medication compliance (the medication adherence rating scale [MARS]) was translated into Taiwanese to explore beliefs about compliance in schizophrenic patients.

METHODS

In this cross-sectional study, 104 patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for schizophrenic disorders were recruited and independently interviewed. We first determined the psychometric properties of the translated MARS, including internal consistency, test-retest reliability, and construct validity. In addition, we investigated the relationships between medication compliance and clinical variables through correlation and regression analyses.

RESULTS

We found that the translated MARS was a simple and reliable self-reported compliance scale. Furthermore, in this exploratory study, we found that patients with better medication compliance had better insight into mental illness, less severe psychopathologic condition, and less negative subjective response to side effects of antipsychotics.

CONCLUSIONS

Additional research focusing on these patient outcomes will be of great interest and value in elucidating the role of medication compliance in management of schizophrenic patients.

Adverse effects of antipsychotics as outcome measures

BACKGROUND

Antipsychotic drugs are associated with adverse effects that can lead to poor medication adherence, stigma, distress and impaired quality of life.

AIMS

To review the use of adverse effects of antipsychotic drugs as outcome measures, with a particular emphasis on methodological issues.

METHOD

Review of data on adverse effects from sources including randomised controlled trials (RCTs), post-marketing surveillance and naturalistic studies.

RESULTS

All have advantages and disadvantages and the best overview comes from considering all sources of data together. Adverse effects are inconsistently reported, hampering cross-study comparisons. Many outcome measures lack clinical meaning. In both naturalistic studies and RCTs adverse effects often account for less treatment discontinuation than lack of efficacy.

CONCLUSIONS

Standardisation in the reporting of adverse effects is needed. Patients' subjective experience of medication should be given more consideration. Total discontinuation rates provide a useful global outcome measure that incorporates tolerability and efficacy as well as patient and clinician viewpoints. Patients should be informed of common side-effects prior to treatment and monitored for their occurrence during treatment.

All-cause treatment discontinuation in schizophrenia during treatment with olanzapine relative to other antipsychotics: an integrated analysis

OBJECTIVES

Treatment continuation, as measured by time to all-cause treatment discontinuation, is a broad measure of overall treatment effectiveness. This integrated analysis compared the likelihood of discontinuation from olanzapine treatment versus other antipsychotics among patients with schizophrenia.

METHODS

Clinical trials of all sponsors were included if they met the following criteria: double-blind, randomized, comparative; duration of 12 weeks or longer; no mandatory discontinuation before 12 weeks; and schizophrenia-spectrum disorders; 20 patients or more per treatment. Weighted mean hazard ratios and 95% confidence intervals were calculated from discontinuation time. Meta-analyses were performed for the following comparators that had at least 2 studies: haloperidol (5 studies), risperidone (5 studies), ziprasidone (2 studies), clozapine (3 studies), and perphenazine (2 studies) (13 studies in total; 3 included more than 1 comparator). Only 1 eligible published study was found for fluphenazine, amisulpride, and quetiapine; therefore, meta-analyses could not be performed for these comparators.

RESULTS

Significantly (P < 0.05) greater likelihood of discontinuation relative to olanzapine treatment (hazard ratio [95% confidence interval]) was observed for haloperidol (1.4 [1.2-1.7]), risperidone (1.3 [1.1-1.6]), ziprasidone (1.6 [1.4-2.0]), and quetiapine (1.4 [1.1-1.9]), but not clozapine (1.2 [0.9-1.6]), fluphenazine (1.8 [0.8-4.3]), perphenazine (1.3 [0.7-2.1]), or amisulpride (1.1 [0.8-1.6]).

CONCLUSIONS

These data suggest that patients with schizophrenia and related disorders may continue olanzapine treatment longer than haloperidol, risperidone, ziprasidone, or quetiapine treatment.

Treatment of schizophrenia patients: comparing new-generation antipsychotics to each other

PURPOSE OF REVIEW

Although the debate on whether new antipsychotics have advantages over the old neuroleptics has recently been refueled by the first publication of the Clinical Antipsychotic Trials of Intervention Effectiveness results, one of the new challenges in the pharmacological management of schizophrenia patients is to choose among the new-generation drugs.

RECENT FINDINGS

Earlier work has compared these medications primarily to traditional antipsychotics and until very recently there was little published information on the relative efficacy/safety of new-generation antipsychotics.

SUMMARY

This review covers studies wherein therapeutic effects and adverse events of these drugs in schizophrenia patients were compared in head-to-head studies and that were published in 2005. Information is clearly more homogenous on the safety profile side, while the available evidence still offers little help for the clinicians' daily struggles to find the optimally effective antipsychotic for an individual schizophrenia patient.