Comparison of treatment patterns in schizophrenia between China and Japan (2001-2009)

Analysis of the trends of polypharmacy and high-dose prescriptions in Japan

INTRODUCTION

After extensive research, this study explored whether high-dose prescriptions and polypharmacy remain more frequent in Japan than elsewhere. If confirmed, we aimed to identify the factors that contributed to this unique trend.

METHODS

The psychotropic drug prescription patterns for patients with schizophrenia in Japan were reviewed. This was based on a large sample collected from surveys of the Research on Asian Psychotropic Prescription Patterns, an international collaborative research project conducted by Asian psychiatrists to monitor prescriptions of psychotropic drugs for people with mental disorders, in 2001, 2004, 2008, and 2016.

RESULTS

The 2016 Research on Asian Psychotropic Prescription Patterns survey revealed that Japan continued to demonstrate the highest rate of polypharmacy and the highest dosages of psychotropic prescription drugs for patients with schizophrenia among the 15 countries and areas that participated in the survey.

DISCUSSION

The Research on Asian Psychotropic Prescription Patterns surveys demonstrated that science plays a limited role in the decision-making process for prescriptions of psychotropic medications. Such prescriptions are influenced by a wide range of factors, such as the national mental health policy, prescription-financing systems, the history of psychiatry in each country, and the prevailing culture. Hospital-based national mental health policies and mental health financing systems have been the primary obstacles to reducing polypharmacy in Japan.

The 12-year trend report of antipsychotic usage in a nationwide claims database derived from four million people in Japan

The current study aimed to describe the use of antipsychotics to clarify the gap between clinical guidelines and health care practice in Japan. We used data from the JMDC Claims Database (JMDC Inc., Tokyo, Japan), a nationwide claims database, from 2005 to 2016. Antipsychotics were defined as drugs coded as N05A with the Anatomical Therapeutic and Chemical (ATC) codes. We described the annual changes in proportions based on the number of patients prescribed any antipsychotics. From the database of 4,081,102 people, the data of 12,382 patients was extracted by applying the following exclusion criteria: no use of antipsychotics, missing the prescription date or dose, inpatients, prescribed antipsychotics only for use as needed, prescribed only injectable antipsychotics except for long-acting injections (LAIs), without schizophrenia as the primary disease, not exceeding 75 mg/day chlorpromazine equivalent, and less than 18 years old. The use of second-generation antipsychotics (SGA) has been expanding, while the use of first-generation antipsychotics has been decreasing. Aripiprazole accounted for the highest proportion of prescribed antipsychotics (31.9%) in 2016. Even though clozapine is categorized as a SGA, it accounted for a paltry 0.2%. The proportion of prescribed antipsychotics accounted for by LAIs was less than 5%. Although the use of antipsychotics for schizophrenia in Japan mostly corresponds to various clinical guidelines, limited use of clozapine and LAIs was identified. Further research focusing on the factors affecting the prescription of these underused antipsychotics may help advance the pharmacological therapy of schizophrenia.

Clozapine prescription pattern in patients with schizophrenia in Asia: The REAP survey (2016)

Clozapine is an effective antipsychotic medication for treatment resistant schizophrenia and is widely used in Asian countries. This study investigated clozapine prescription patterns and their associated factors in Asian countries and territories based on the database of the Research on Asian Psychotropic prescription study (REAP) conducted in 2016. Demographic and clinical information of 3744 schizophrenia patients in 15 Asian countries and territories was collected with a standardized data collection form. In total, 18.4% of the sample received clozapine, ranging from 2.6% in Japan to 32.3% in Hong Kong. Binary logistic regression analysis revealed that higher antipsychotic dose (OR = 1.002, P < 0.001), less frequent first admission in the sample (OR = 0.6, P < 0.001), more severe negative symptoms (OR = 1.4, P = 0.001) and less first generation antipsychotics (FGAs) (OR = 0.2, P < 0.001) were independently and significantly associated with clozapine prescription. Clozapine is frequently and increasingly prescribed for schizophrenia in Asia, with large variation across countries and territories. Given the diverse prescription patterns of clozapine found in Asian countries/territories, the clinical rationale of clozapine prescription needs careful consideration in Asia with more local input.

Analysis of psychotropic drug-related deaths in south Osaka

Objective

The aim of this study was to investigate the occurrence of deaths due to psychotropic drugs in south Osaka during a 10-year period and discuss societal factors from a medical viewpoint.

Methods

Psychotropic drug-related deaths were retrospectively investigated based on the forensic postmortem data of 1,746 decedents in 2005-2014, and we excluded cases in which stimulant drugs were detected. Of these, 133 cases (7.6%) were found to be psychotropic drug-related deaths and were analyzed.

Results

Psychotropic drug-related deaths occurred in 78 males (59%; age range, 14-95 years) and 55 females (41%; 20-84 years). The direct cause of death was acute drug intoxication in many cases, and of these, acute combined drug intoxication due to the use of multiple drugs accounted for 76% of the deaths. Most of these victims were found to have gastrointestinal and cardiovascular diseases. Cases of psychotropic drug-related deaths had especially poor medical conditions. In addition, tests were positive for blood alcohol in 23% of the cases.

Conclusion

The descriptive results revealed several factors that may be related to psychotropic drug-related deaths. To prevent drug abuse, several factors were deemed to be important, including improvements in the medical state of an individual, the avoidance of social isolation, and from a medical standpoint, the management of prescription drugs by medical personnel.

ECT augmentation of clozapine for clozapine-resistant schizophrenia: A meta-analysis of randomized controlled trials

Treatment-resistant schizophrenia (TRS) is common and debilitating. A subgroup of patients even has clozapine-resistant schizophrenia (CRS). We aimed to evaluate the efficacy and safety of electroconvulsive therapy (ECT) augmentation of clozapine for CRS. Systematic literature search of randomized controlled trials (RCTs) reporting on ECT augmentation of clozapine in CRS. Co-primary outcomes included symptomatic improvement at post-ECT assessment and study endpoint. Eighteen RCTs (n = 1769) with 20 active treatment arms were identified and meta-analyzed. Adjunctive ECT was superior to clozapine regarding symptomatic improvement at post-ECT assessment (Standardized Mean Difference (SMD) = -0.88, 95% Confidence Interval (CI): -1.33 to -0.44; I² = 86%, P = 0.0001) and endpoint assessment (SMD: -1.44, 95%CI: -2.05 to -0.84; I² = 95%, P < 0.00001), separating as early as week 1-2 (SMD = -0.54, 95%CI: -0.88 to -0.20; I² = 77%, P = 0.002). Adjunctive ECT was also superior regarding study-defined response at post-ECT assessment (53.6% vs. 25.4%, Risk Ratio (RR) = 1.94, 95%CI: 1.59-2.36; I² = 0%, P < 0.00001, number-needed-to-treat (NNT) = 3, 95%CI: 3-5) and endpoint assessment (67.7% vs. 41.4%, RR = 1.66, 95%CI: 1.38-1.99; I² = 47%, P < 0.00001, NNT = 4, 95%CI: 3-8), and remission at post-ECT assessment (13.3% vs. 3.7%, RR = 3.28, 95%CI: 1.80-5.99; I² = 0%, P = 0.0001, NNT = 13, 95%CI: 6-100) and endpoint assessment (23.6% vs. 13.3%, RR = 1.80, 95%CI: 1.39 to 2.35; I² = 5%, P < 0.0001, NNT = 14, 95%CI: 6-50). Patient-reported memory impairment (24.2% vs. 0%; RR = 16.10 (95%CI: 4.53-57.26); I² = 0%, P < 0.0001, number-needed-to-harm (NNH) = 4, 95%CI: 2-14) and headache (14.5% vs 1.6%; RR = 4.03 (95%CI: 1.54-10.56); I² = 0%, P = 0.005, NNH = 8, 95%CI: 4-50) occurred more frequently with adjunctive ECT. No significant group differences were found regarding discontinuation and other adverse effects. Despite increased frequency of self-reported memory impairment and headache, ECT augmentation of clozapine is a highly effective and relatively safe treatment for CRS.

REGISTRATION NUMBER

CRD42018089959.