From clinical trials to real-world practice: use of atypical antipsychotic medication nationally in the Department of Veterans Affairs

Can multisite clinical trial results change clinical practice? Use of long-acting injectable risperidone nationally in the Veterans Health Administration

BACKGROUND

Multisite practical clinical trials evaluate treatments in real-world practice. A multisite randomized Veterans Health Administration (VHA) cooperative study (CSP#555) published in 2011 compared the first long-acting injectable (LAI) second-generation antipsychotic (SGA), Risperidone Consta®, in veterans with a diagnosis of schizophrenia or schizoaffective disorder, to oral antipsychotics, with unexpected null results for effectiveness and cost-effectiveness. Whether null results of this type could change VHA practice has not been studied.

METHODS

A longitudinal observational analysis was used to evaluate the impact of the trial findings on VHA clinical practices. National administrative data compared new starts on LAI risperidone during the 4 years before the publication of CSP#555 in 2011 to new starts on LAI risperidone during the 4 years after.

RESULTS

Among 119,565 Veterans with the indicated diagnoses treated with antipsychotics from 2007 to 2015, the number and proportion of new starts on LAI risperidone declined significantly following the study publication, as did the total number of annual users and drug expenditures. However, data from 2007 to 2010 showed the decline in new starts actually preceded the publication of CSP#555. This change was likely explained by the increase in new starts, total use, and expenditures on a newer medicine, LAI paliperidone, a 4-week LAI treatment, in the 2 years prior to the publication of CSP#555.

CONCLUSIONS

The declining use of LAI risperidone likely primarily reflects the substitution of a longer-acting LAI SGA, paliperidone, that came to market 2 years before the study publication, a substitution that may have been reinforced by null CSP#555 study results for LAI risperidone.

Provision of Mental Health Services in the Veterans Health Administration: A Nationwide Comparison With Other Providers

OBJECTIVE

Public interest in developing a national health care system has grown in the United States, but so have concerns that a large system would provide poor care. The Veterans Health Administration (VHA) is the largest national U.S. health care system, and several of its performance measures have been compared with those of non-VHA organizations. However, few studies have compared VHA's overall provision of mental health care services, and this study aimed to fill this gap.

METHODS

Using 2018 National Mental Health Services Survey data, the authors examined the differences in provision of 45 treatment modalities, specialized services, and dedicated programs between self-identified VHA facilities (N=459), non-VHA facilities that serve only adults (N=3,671), and non-VHA facilities that serve all ages (N=6,378).

RESULTS

Self-identified VHA facilities offered more services (including more treatment modalities, specialized services, and dedicated programs) (mean±SD=24.2±8.9 services) than both non-VHA adult-only facilities (15.4±6.8; Cohen's d=1.11, p<0.001) and non-VHA all-ages facilities (17.1±6.6; Cohen's d=0.90, p<0.001). Notably, VHA facilities were more likely to offer electroconvulsive therapy and telemedicine. VHA facilities were more likely to offer integrated primary care, chronic illness management, supportive housing, vocational rehabilitation, and psychiatric emergency services, among others. Last, VHA facilities were more likely to offer dedicated treatment programs for patients identifying as lesbian, gay, bisexual, or transgender, as well as for patients with posttraumatic stress disorder, traumatic brain injury, or dementia.

CONCLUSIONS

VHA facilities offer no fewer and possibly more comprehensive mental health services per facility than do non-VHA facilities, possibly because VHA represents an integrated and centralized health system.

Off-label prescribing in psychiatric practice

Drug treatment is an essential part of much of psychiatric practice, in patients from a wide age range, across many diagnostic groups and in a variety of settings. Despite the availability of many classes of psychotropic drug, significant numbers of patients remain troubled by distressing and disabling symptoms even after a succession of licensed pharmacological treatments. Psychiatrists may then consider the prescription of a psychotropic outside the narrow terms of its licence, as part of an overall management plan. This article reviews the nature and extent of this aspect of prescribing, outlines when it may be appropriate and makes recommendations for a suggested procedure when prescribing medication ‘off-label’.

A Non-Interventional Naturalistic Study of the Prescription Patterns of Antipsychotics in Patients with Schizophrenia from the Spanish Province of Tarragona

Background

The analysis of prescribing patterns in entire catchment areas contributes to global mapping of the use of antipsychotics and may improve treatment outcomes.

Objective

To determine the pattern of long-term antipsychotic prescription in outpatients with schizophrenia in the province of Tarragona (Catalonia-Spain).

Methods

A naturalistic, observational, retrospective, non-interventional study based on the analysis of registries of computerized medical records from an anonymized database of 1,765 patients with schizophrenia treated between 2011 and 2013.

Results

The most used antipsychotic was risperidone, identified in 463 (26.3%) patients, followed by olanzapine in 249 (14.1%), paliperidone in 225 (12.7%), zuclopenthixol in 201 (11.4%), quetiapine in 141 (8%), aripiprazole in 100 (5.7%), and clozapine in 100 (5.7%). Almost 8 out of 10 patients (79.3%) were treated with atypical or second-generation antipsychotics. Long-acting injectable (LAI) formulations were used in 44.8% of patients. Antipsychotics were generally prescribed in their recommended doses, with clozapine, ziprasidone, LAI paliperidone, and LAI risperidone being prescribed at the higher end of their therapeutic ranges. Almost 7 out of 10 patients (69.6%) were on antipsychotic polypharmacy, and 81.4% were on psychiatric medications aside from antipsychotics. Being prescribed quetiapine (OR 14.24, 95% CI 4.94–40.97), LAI (OR 9.99, 95% CI 6.45–15.45), psychiatric co-medications (OR 4.25, 95% CI 2.72–6.64), and paliperidone (OR 3.13, 95% CI 1.23–7.92) were all associated with an increased likelihood of polypharmacy. Being prescribed risperidone (OR 0.54, 95% CI 0.35–0.83) and older age (OR 0.98, 95% CI 0.97–0.99) were related to a low polypharmacy probability.

Conclusions

Polypharmacy is the most common pattern of antipsychotic use in this region of Spain. Use of atypical antipsychotics is extensive. Most patients receive psychiatric co-medications such as anxiolytics or antidepressants. Polypharmacy is associated with the use of quetiapine or paliperidone, use of a LAI, younger age, and psychiatric co-medication.

Antipsychotic-induced insulin resistance and postprandial hormonal dysregulation independent of weight gain or psychiatric disease

Atypical antipsychotic (AAP) medications that have revolutionized the treatment of mental illness have become stigmatized by metabolic side effects, including obesity and diabetes. It remains controversial whether the defects are treatment induced or disease related. Although the mechanisms underlying these metabolic defects are not understood, it is assumed that the initiating pathophysiology is weight gain, secondary to centrally mediated increases in appetite. To determine if the AAPs have detrimental metabolic effects independent of weight gain or psychiatric disease, we administered olanzapine, aripiprazole, or placebo for 9 days to healthy subjects (n = 10, each group) under controlled in-patient conditions while maintaining activity levels. Prior to and after the interventions, we conducted a meal challenge and a euglycemic-hyperinsulinemic clamp to evaluate insulin sensitivity and glucose disposal. We found that olanzapine, an AAP highly associated with weight gain, causes significant elevations in postprandial insulin, glucagon-like peptide 1 (GLP-1), and glucagon coincident with insulin resistance compared with placebo. Aripiprazole, an AAP considered metabolically sparing, induces insulin resistance but has no effect on postprandial hormones. Importantly, the metabolic changes occur in the absence of weight gain, increases in food intake and hunger, or psychiatric disease, suggesting that AAPs exert direct effects on tissues independent of mechanisms regulating eating behavior.

Veteran subjects willingness to participate in schizophrenia clinical trials

Predictive characteristics of subjects agreeing to be randomized into clinical trials for the treatment of schizophrenia and schizoaffective disorder have been little studied. In this study, we used data from the recruitment phase of a randomized trial that compared long acting injectable (LAI) risperidone to oral antipsychotic medications. Basic socio-demographic and clinical data were gathered from eligible patients and clinicians at the time of screening for trial entry. Bivariate comparisons and multivariate logistic regression were used to compare those who agreed to participate and those who refused. Altogether 446 veterans were eligible on preliminary screening, of these 382 (86 %) agreed to participate and 64 (14 %) declined. Eligible patients who agreed to be randomized were more willing to change medications without regard to their level of satisfaction with their current medication. Subjects reported as currently taking LAI medication and taking risperidone, in particular, were more likely to agree to participate. Factors that did not significantly predict participation included age, years on current medication, reported medication compliance, race, and gender. Veterans with schizophrenia or schizoaffective disorder who were actually more satisfied with their current medications and who were currently taking the experimental agent were more likely to agree to participate in this randomized clinical trial in contrast to expectations that individuals who are unsatisfied with their current treatment would be more likely to enroll in such studies.

Prevalence and correlates of antipsychotic polypharmacy: a systematic review and meta-regression of global and regional trends from the 1970s to 2009

OBJECTIVE

To assess the prevalence and correlates of antipsychotic polypharmacy (APP) across decades and regions.

METHODS

Electronic PubMed/Google Scholar search for studies reporting on APP, published from 1970 to 05/2009. Median rates and interquartile ranges (IQR) were calculated and compared using non-parametric tests. Demographic and clinical variables were tested as correlates of APP in bivariate and meta-regression analyses.

RESULTS

Across 147 studies (1,418,163 participants, 82.9% diagnosed with schizophrenia [IQR=42-100%]), the median APP rate was 19.6% (IQR=12.9-35.0%). Most common combinations included first-generation antipsychotics (FGAs)+second-generation antipsychotics (SGAs) (42.4%, IQR=0.0-71.4%) followed by FGAs+FGAs (19.6%, IQR=0.0-100%) and SGAs+SGAs (1.8%, IQR=0.0-28%). APP rates were not different between decades (1970-1979:28.8%, IQR=7.5-44%; 1980-1989:17.6%, IQR=10.8-38.2; 1990-1999:22.0%, IQR=11-40; 2000-2009:19.2% IQR=14.4-29.9, p=0.78), but between regions, being higher in Asia and Europe than North America, and in Asia than Oceania (p<0.001). APP increased numerically by 34% in North America from the 1980s 12.7%) to 2000s (17.0%) (p=0.94) and decreased significantly by 65% from 1980 (55.5%) to 2000 (19.2%) in Asia (p=0.03), with non-significant changes in Europe. APP was associated with inpatient status (p<0.001), use of FGAs (p<0.0001) and anticholinergics (<0.001), schizophrenia (p=0.01), less antidepressant use (p=0.02), greater LAIs use (p=0.04), shorter follow-up (p=0.001) and cross-sectional vs. longitudinal study design (p=0.03). In a meta-regression, inpatient status (p<0.0001), FGA use (0.046), and schizophrenia diagnosis (p=0.004) independently predicted APP (N=66, R(2)=0.44, p<0.0001).

CONCLUSIONS

APP is common with different rates and time trends by region over the last four decades. APP is associated with greater anticholinergic requirement, shorter observation time, greater illness severity and lower antidepressant use.

Comparing methods for identifying future high-cost mental health cases in Medicaid

OBJECTIVE

This article examines methods for identifying future high-cost cases of Medicaid-covered mental health care services.

METHODS

Florida Medicaid claims data are used to compare methods based on prior cost, and concurrent and prospective diagnosis-based models. Individuals with prior year expenditures in the top decile or with predicted expenditures in the top decile from the diagnosis-based models were expected to be high-cost individuals.

RESULTS

Individuals in the top decile of prior year costs averaged $13,684 (U.S. dollars) in costs in the following year with 50% remaining in the top decile of spending. Individuals classified as high cost by diagnosis-based models averaged $10,935 to $10,974, with 34% meeting the criteria for a high-cost case in the following year.

CONCLUSION

In contrast to research on high-costs cases for physical health care, prior cost was superior to diagnosis-based models at identifying future high cases for mental health care.

Addressing the Controversial Use of Antipsychotic Drugs for Behavioral and Psychological Symptoms of Dementia

Objective:

To review relevant background information on behavioral and psychological symptoms of dementia (BPSD) and the antipsychotic drugs used to treat it, describe benefits versus risks of antipsychotic drugs for treatment of BPSD, and describe the latest management guidelines for patients with BPSD.

Data Sources:

A PubMed literature search (1998–October 2011) was conducted using the following MeSH search terms: dementia, elderly, antipsychotics, behavioral symptoms, and psychological symptoms. Tertiary references and prescribing information for included medications were used for pharmacology, adverse effects, and cost.

Data Selection and Data Extraction:

English-language reviews, tertiary references, and guidelines were reviewed; only articles that used pharmacotherapy in human models were included.

Data Synthesis:

There are no FDA-approved medications for treatment of BPSD; several classes of drugs are prescribed off-label, including selective serotonin reuptake inhibitors and certain anticonvulsants. Antipsychotics, particularly those from the atypical class, are also commonly used by clinicians as a pharmacologic intervention for dementia. Yet, since these are drugs with a wide array of potentially serious adverse effects, including increased risk for cerebrovascular accidents, clinicians treating patients with dementia must be especially cognizant of the benefits and risk of their use.

Conclusions:

Nonpharmacologic treatments should be first-line therapy for BPSD. When these approaches do not produce the desired results, clinicians must weigh the risks versus benefits of continued psychological disease and dangerous behavior with the use of an antipsychotic drug regimen.

Development of a Medicaid behavioral health case-mix model

Many Medicaid programs have either fully or partially carved out mental health services. The evaluation of carved out plans requires a case-mix model that accounts for differing health status across Medicaid managed care plans. This article develops a diagnosis-based case-mix adjustment system specific to Medicaid behavioral health care. Several different model specifications are compared that use untransformed, square root transformed, and log-transformed expenditures.

Prescribing and monitoring clozapine in Christchurch

OBJECTIVE

The aim of the study was to identify the pattern of usage of clozapine in Christchurch, New Zealand, including daily dose, indication and use of drug concentration monitoring.

METHOD

Patients (n=353) were identified retrospectively from the pharmacy computer system. Data gathered included patient demographics, the daily clozapine dose and the number of occasions that clozapine drug concentration monitoring occurred. In addition, each psychiatrist who had prescribed clozapine was surveyed, regarding their indications for the use of clozapine and their use of clozapine drug concentration monitoring.

RESULTS

The majority (63%) of patients on clozapine were male. The mean age of the patients was 43 years (range 15-88 years). The mean daily dose of clozapine was 325 mg (range 12.5-900 mg). Patients over the age of 65 years were on a significantly lower dose (mean=143 mg, 95% CI=103-183 mg) compared with those under 65 years of age (mean=350 mg, 95% CI=330-370 mg). The median duration of treatment on clozapine was 4 years. Fifty-one percent of patients had undergone drug concentration monitoring, the majority on multiple occasions. In females, increasing age correlated with an increase in dose-corrected plasma clozapine concentrations (r(2)=0.29, p<0.001). This was not demonstrated in the male population. Of the psychiatrists surveyed, 44% prescribed clozapine for unlicensed indications and 79% used clozapine drug concentration monitoring in their patients. This was most commonly performed to assess compliance or confirm toxicity.

CONCLUSIONS

The mean daily dose of clozapine of 325 mg was similar to that found in other studies. An age-related decline in dose was observed, probably due to different indications, with many of the elderly patients receiving clozapine for Parkinsonian related symptoms. There was also an age-related decline apparent in clearance in females. Clozapine was often used for unlicensed indications, and a clear majority of psychiatrists use drug concentration monitoring.

[Pattern and evolution of the prescription of olanzapine during one year: Results of the cohort study ECOL]

INTRODUCTION

The necessary evidence of new therapies of clinical interest extends beyond clinical trials in a less controlled population and closer to clinical practice justified since several years the need of conducting observational, noninterventional studies. Observational studies must include epidemiological (quantitative observational) data to define prevalence and natural history of the target conditions. Moreover, pharmacological interventions in "naturalistic" patients populations, selected by clinicians as per clinical judgment within the scope of the target disease will allow to generate data to complement clinical trials. Clinical trials designed to show robust data on efficacy and tolerability particularly during registration trials must be complemented by robust observational research to confirm and better describe clinical effectiveness in the target population. A noninterventional, observational trial is a study where the medicinal product(s) is (are) prescribed in the usual manner in accordance with the terms of the marketing authorization. The assignment of the patient to a particular therapeutic strategy is not decided in advance by a trial protocol but falls within current practice and the prescription of the medicine is clearly separated from the decision to include the patient in the study. No additional diagnosis or monitoring procedures shall be applied to the patients and epidemiological methods shall be used for the analysis of collected data. Olanzapine is a new antipsychotic therapy registered in Europe for the treatment of schizophrenia since 1996.

AIMS OF THE STUDY

The primary objective of this observational research was to study the evolution of the olanzapine dosage under naturalistic settings. Secondary objectives included patients characteristics, severity of disease, therapeutic evolution and coprescriptions, in a patient's cohort, suffering from schizophrenia, adult patients, diagnosis based on ICD-10; patients were followed during a total of 12 months.

DESIGN OF THE STUDY

The cohort study was conducted in France. Between the period of June 2000 and February 2001, 407 psychiatrics randomized to participate in the study had consolidated the patient's cohort.

RESULTS

A total of 1810 patients were included, 1093 (60, 4%) male, 717 (39, 6%) females. Age was recorded for a total of 1802 (99, 6%) patients, mean age was 37.8 years as per inclusion criteria and patients consent according to current regulations. Patients entered in the cohort as per clinicians decision underwent a treatment with olanzapine during an outpatient's consultation or at hospitalization. More than two thirds of the patients were followed up during 12 months after onset of this treatment. Clinical outcome was assessed at three, six, nine and 12 months following cohort inclusion using the following tools: CGI, PANSS, Calgary and GAF; as per CGI 78% of the patients cohort were severely ill, the mean PANSS score was 94.1. At second month of treatment clinicians were requested to very well document any changes in olanzapine dosage as well as reasons for the dosage modifications and potential coprescriptions.

DISCUSSION

The daily mean dosage of olanzapine was 9.5mg at initiation of treatment, 10.5mg after one month and 11.2mg after 12 months of follow-up. The increase of the dosage after one month was associated with factors such as younger age, schizophrenia diagnosis and severity of the symptoms as measured by CGI and PANSS scores evolution, low initial dosage and hospitalization at treatment initiation. Within the 1810 participants included in the cohort, 1383 (76.5%) received a coprescrition of a psychotropic, for example, 811 (44.8%) a benzodiazepine, 506 (28.0%) an antidepressant. Among the patients cohort that were followed during 12 months, all the clinical and patient-functioning indicators progressed in the direction of a significant improvement.

Rethinking antipsychotic formulary policy

In this commentary, we review recent research suggesting that (a) second-generation antipsychotics (SGAs) may be no more effective than first-generation antipsychotics (FGAs), (b) the reduced risk of EPS and tardive dyskinesia with SGAs is more weakly supported by the research literature than has been appreciated, and (c) benefits may be offset by greater metabolic risks of some SGAs and their substantially greater cost. Bearing in mind, as well, that risperidone, currently the least expensive SGA, will soon be available as an even less expensive generic drug, we propose a new algorithm for maintenance antipsychotic therapy. We further outline a cautious implementation procedure that relies on standardized documentation and feedback, without a restrictive formulary that would limit physician choice. The algorithm outlined here and the process for its implementation are intended as a stimulus for discussion of potential policy responses, not as a finalized proposition.

Off-label use of antipsychotics: are we mad?

The off-label prescribing of antipsychotic drugs to psychiatric patients of all ages is very common. Such off-label use is a necessary part of the art of psychiatry but brings with it increased responsibilities for the prescriber as, if the patient suffered an adverse reaction, liability would rest with the prescriber and/or their employers. This article reviews the frequency and nature of the off-label prescribing of antipsychotic drugs for psychiatric indications to children, adults and the elderly. It also reviews the evidence base for doing so in a variety of common, and also some less common, clinical situations. The review is mainly concerned with off-label indications but a short section on high dose antipsychotics is also included. The review concludes that the off-label prescription of antipsychotics frequently lacks the support of robust clinical trials. When prescribing off-label, the prescriber must carry out a careful risk assessment of the risks and benefits for the individual patient. They should also inform the patient that the prescription is off-label.

Prevalence, utilization patterns, and predictors of antipsychotic polypharmacy: experience in a multistate Medicaid population, 1998-2003

OBJECTIVES

This study was conducted to estimate the prevalence of antipsychotic polypharmacy among fee-for service state Medicaid beneficiaries initiating antipsychotic drug therapy and to investigate psychiatric and demographic predictors of such polypharmacy.

METHODS

This was a retrospective cohort study employing Medicaid claims data from California, Nebraska, Oregon, Utah, and Wyoming for patients who filled >1 antipsychotic prescription between 1998 and 2003 and who were continuously eligible for benefits from 180 days before to 1 year after the index antipsychotic claim. Antipsychotic Polypharmacy was defined as initiation of multiple antipsychotic medications or at least 60 consecutive days of concomitant antipsychotic medication overlapping the index antipsychotic prescription at any time during the 365 days after the index drug claim. Primary and secondary diagnosis codes (International Classification of Diseases, Ninth Revision, Clinical Modification) were used to identify patients with mental disorders and mental health-related hospitalizations. Multivariate logistic regression, with adjustment for sex, age, race/ethnicity, state, mental health diagnoses, hospitalization, year, and type of index antipsychotic, was performed to identify predictors of polypharmacy. A multivariate Cox proportional hazards model was used to compare the cumulative incidence of polypharmacy by index antipsychotic drug.

RESULTS

The study cohort consisted of 55,481 individuals with > or =1 prescription claim for an antipsychotic drug. The mean prevalence of long-term antipsychotic polypharmacy in the year after initiating antipsychotic medication was 6.4%. Approximately half of those with polypharmacy were started on multiple antipsychotic drugs and half were started on monotherapy but received > or =2 antipsychotic drugs concomitantly in the year after drug initiation. Among the stronger predictors of polypharmacy were a diagnosis of schizophrenia (odds ratio [OR] = 2.95; 95% Cl, 2.43-3.58), recent mental health hospitalization (OR = 1.17; 95% Cl, 1.02-1.33), and the number of mental health diagnoses (OR = 1.07 per diagnosis; 95% CI, 1.06-1.08). Polypharmacy was more likely among male than female patients (OR = 1.26; 95% Cl, 114-1.39) and among those between the ages of 18 and 24 years. The cumulative incidence of polypharmacy was greater among patients initiating clozapine compared with those initiating other antipsychotics (P < 0.001).

CONCLUSIONS

In these fee-for-service Medicaid beneficiaries from 5 states, the prevalence of chronic antipsychotic polypharmacy was low in the year after the initiation of therapy. Polypharmacy was more common in patients with indicators of more severe mental illness.

Hospitalization risks in the treatment of bipolar disorder: comparison of antipsychotic medications

OBJECTIVES

This study compared the relative risk for hospitalization of patients with bipolar and manic disorders receiving atypical and typical antipsychotics.

METHODS

This retrospective study was based on administrative claims data extracted from the PharMetrics database during 1999 through 2003. Comparisons were made among atypical antipsychotics (risperidone, olanzapine, quetiapine or ziprasidone), as well as between each of these versus a combined group of the leading typical antipsychotics. Relative risk for hospitalization was estimated with Cox proportional regression, which adjusted for differences in patient characteristics.

RESULTS

Risperidone and olanzapine demonstrated higher risks for hospitalization than quetiapine [hazard ratio (HR) 1.19, p < 0.05 for both], translating into higher annual mental health inpatient charges of $260 per patient. Risperidone and olanzapine also showed higher estimated risks than ziprasidone, which approached the p < 0.05 threshold. Differences between each of the atypicals and the combined typicals were not significant. Patients with putative rapid cycling had a threefold greater risk for hospitalization than other patients with bipolar disorder. In these patients, comparisons among atypical antipsychotics showed that risperidone had a significantly higher hospitalization risk than olanzapine (HR 3.31, p < 0.05), resulting in higher annual mental health inpatient charges of $4,930 per patient.

CONCLUSIONS

In the treatment of bipolar and manic disorders, risperidone and olanzapine were associated with a higher risk for hospitalization than quetiapine, and possibly ziprasidone. In the treatment of putative rapid cyclers, olanzapine was associated with a lower risk for hospitalization than risperidone.

Health care resource utilization and expenditures associated with the use of insulin glargine

BACKGROUND

Newer insulins, such as long-acting analogues, offer promise of better glycemic control, reduced risk for diabetes complications, and moderation of health care use and costs.

OBJECTIVE

We studied initiation of insulin glargine to evaluate its association with subsequent health service utilization and estimated expenditures.

METHODS

Patients of the Veterans Health Administration, US Department of Veterans Affairs (VA) who initiated insulin glargine (n=5064) in 2001-2002 were compared with patients receiving other insulin (n=69,944), matched on prescription month (index date). Inpatient and outpatient VA care in the 12 months after a patient's index date was evaluated using Tobit regression, controlling for prior utilization, demographic characteristics, comorbidities, glycosylated hemoglobin (HbA(1c)) levels, and diabetes severity. National average utilization costs and medication acquisition costs were used to estimate the value of VA expenditures.

RESULTS

Compared with other insulin users, insulin glargine initiators had higher HbA(1c) values (8.72% vs 8.16%) prior to the index date, but greater subsequent HbA(1c) reduction (-0.50% vs -0.22%). After adjustment for age, prior utilization, HbA(1c) levels, and other factors, insulin glargine initiation was associated with 2.4 (95% CI, 1.1-3.7) fewer inpatient days for patients with any hospital admission (US $820 lower costs per initiator), 1.6 (1.2-1.9) more outpatient encounters ($279 higher costs per initiator), and $374 ($362-$387) higher costs for diabetes medications. The net difference was an average lower VA cost of $166 (-$290 to $622) per patient.

CONCLUSIONS

Insulin glargine use was associated with decreased inpatient days but increased outpatient care, and the value of the net change in utilization to VA offset the additional medication expenditures. Initiation of insulin glargine improves glycemic control and may reduce time in hospital without additional use of health resources.

Development and Validation of a Psychiatric Case-Mix System

BACKGROUND

Although difficulties in applying risk-adjustment measures to mental health populations are increasingly evident, a model designed specifically for patients with psychiatric disorders has never been developed.

OBJECTIVE

Our objective was to develop and validate a case-mix classification system, the "PsyCMS," for predicting concurrent and future mental health (MH) and substance abuse (SA) healthcare costs and utilization.

SUBJECTS

Subjects included 914,225 veterans who used Veterans Administration (VA) healthcare services during fiscal year 1999 (FY99) with any MH/SA diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 290.00-312.99, 316.00-316.99).

METHODS

We derived diagnostic categories from ICD-CM codes using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition definitions, clinical input, and empiric analyses. Weighted least-squares regression models were developed for concurrent (FY99) and prospective (FY00) MH/SA costs and utilization. We compared the predictive ability of the PsyCMS with several case-mix systems, including adjusted clinical groups, diagnostic cost groups, and the chronic illness and disability payment system. Model performance was evaluated using R-squares and mean absolute prediction errors (MAPEs).

RESULTS

Patients with MH/SA diagnoses comprised 29.6% of individuals seen in the VA during FY99. The PsyCMS accounted for a distinct proportion of the variance in concurrent and prospective MH/SA costs (R=0.11 and 0.06, respectively), outpatient MH/SA utilization (R=0.25 and 0.07), and inpatient MH/SA utilization (R=0.13 and 0.05). The PsyCMS performed better than other case-mix systems examined with slightly higher R-squares and lower MAPEs.

CONCLUSIONS

The PsyCMS has clinically meaningful categories, demonstrates good predictive ability for modeling concurrent and prospective MH/SA costs and utilization, and thus represents a useful method for predicting mental health costs and utilization.

Patient characteristics and the likelihood of initiation on olanzapine or risperidone among patients with schizophrenia

Although pharmacologic treatments are available for patients with schizophrenia, little is known about how prescription patterns of atypical antipsychotic agents are related to patient characteristics. In this study, we examined the association between patient characteristics and the likelihood of being initiated on olanzapine or risperidone, two of the most frequently prescribed atypical agents for schizophrenia. We selected patients who were diagnosed with schizophrenia or schizoaffective disorder based on > or = 1 inpatient or > or = 2 outpatient ICD-9-CM codes (> or = 7 days apart) between 7/1/98 and 6/30/99 from the Veterans Health Administration (VA). We classified patients into one of three types of initiation: (a) not on olanzapine or risperidone, (b) not on any atypical agents, or (c) not on any antipsychotic agents for 6 months, and then subsequently being prescribed the target drugs. Using logistic regression, we examined whether the odds ratio of being initiated on olanzapine versus risperidone are related to patient sociodemographic and clinical characteristics. Compared to risperidone initiators, olanzapine initiators used more drugs for psychiatric conditions (including antiparkinsonian agents, typical antipsychotics, and mood stabilizers) than risperidone initiators. On the other hand, risperidone initiators had more medical comorbidities and more non-psychiatric hospitalizations. Olanzapine and risperidone appear to be prescribed to patients with different characteristics. Initiation of risperidone was more common among patients who presented with more medical comorbid conditions, whereas initiation of olanzapine was more common among patient who presented with more mental comorbid conditions. Future research needs to determine the reasons for those differences.

The growth of psychopharmacology in the 1990s: evidence-based practice or irrational exuberance

The rapid growth in sales of psychotropic medications during the late 1980s and 1990s, eventually reaching $20 billion/year, reflected the increased use of seritonin reuptake inhibitors for depression and atypical antipsychotics for schizophrenia. Recently, however, some of the therapeutic claims for these medications have been challenged, and under-appreciated risks have turned out to be significant liabilities. Drug manufacturers increasingly dominate clinical trials research and evidence suggests that study designs and data presentations have been slanted to show products in a favorable light while unfavorable data were suppressed. At the same time, during the 1990s, potentially independent voices did not effectively or consistently present countervailing views. The extensive financial ties between the pharmaceutical industry and academic researchers, professional associations, and consumer groups may also have discouraged expression of critical views. Additionally, the narrow legal mandate of the FDA to evaluate the safety and efficacy of new drugs only in comparison to placebo (rather than in comparison to other treatments) probably limited its contribution. In the absence of reliable, impartial research on the risk and benefits of psychotropic medications, both before and after they are brought to market, pharmacy benefits management cannot achieve its goal of maximizing health care benefits per dollar spent. Further institutional support is needed for independent research, either conducted or funded by the federal government.

U.S. national trends in the use of antipsychotics during office visits, 1998-2002

BACKGROUND

There is a paucity of studies on U.S. national trends in the use of antipsychotic medications in the 21st century. This study examined national trends in the prescribing of antipsychotic drugs in office-based physician practices.

METHODS

National probability sample survey data from 1998-2002 National Ambulatory Medical Surveys were used to analyze the prescribing trends. The weighted visit estimates and percentages were compared across the years using z-test.

RESULTS

The number of antipsychotic-related visits was found to increase significantly and nearly two-fold, from 4.6 million in 1998 to 8.6 million in 2002. During the same period, the number of visits for second-generation antipsychotic drugs nearly tripled. The proportion of visits for the second-generation agents, as a percentage of visits for all antipsychotic drugs, rose sharply from about 48% in 1998 to 84% in 2002. Correspondingly, the percentage of visits involving first-generation antipsychotic drugs declined. The growth in the number of visits involving antipsychotic drugs over the 5-year period was substantial (120%) in visits with non-psychiatrist physicians, but not in visits involving psychiatrists.

CONCLUSIONS

The trend of growth in prescription of antipsychotic drugs in office visits, accounted by increased use of second-generation antipsychotics, has persisted into the 21st century. Increased prescribing of these agents by non-psychiatrists is also apparently fueling this trend. This trend of shift from first-to-second generation antipsychotic agents, though not unambiguously supported by extant safety and efficacy data, is endorsed by guidelines based on expert-consensus and limited data. Given the high-level use of second-generation drugs, more practical studies of these drugs, focusing on effectiveness or long-term outcomes, are needed.

Incidence of new-onset diabetes mellitus among patients receiving atypical neuroleptics in the treatment of mental illness: evidence from a privately insured population

The purpose of this study is to determine sociodemographic, clinical, and pharmacotherapeutic characteristics, especially use of atypical antipsychotics, associated with incident diabetes mellitus in a population of privately insured patients with mental health diagnoses. Patients with a mental health diagnosis stably medicated for a 3-month period during January 1999 through October 2000 and having no diabetes were followed through December 2000. Cox proportional hazards models were developed to identify antipsychotic medications associated with newly diagnosed diabetes. Of the 7381 patients identified, 339 developed diabetes, representing an annual incidence rate of 4.7%. Diabetes risk among the entire sample was lowest for risperidone (hazard ratio [HR] = 0.69; p < 0.05), while quetiapine (HR = 0.74), olanzapine (HR = 0.95), and clozapine (HR = 1.22) were not significantly different from first-generation antipsychotics. Diabetes risk was significantly lower among males receiving risperidone (HR = 0.49; p < 0.01) or quetiapine (HR = 0.50; p < 0.10), while diabetes risk among females did not differ significantly from first-generation antipsychotics for any atypical examined. These findings are substantially different from other reports.

Adjunctive use of atypical antipsychotics and anticholinergic drugs among patients with schizophrenia

BACKGROUND

Treatment of schizophrenia with antipsychotics is often associated with extrapyramidal symptoms (EPS), a disorder involving involuntary muscle movement. Because EPS are often associated with the use of antipsychotics, anticholinergic agents are often indicated.

OBJECTIVE

In this observational, retrospective study, we examined whether the initiation of olanzapine or risperidone, the two most widely prescribed atypical antipsychotics, is related to the adjunctive use of anticholinergic agents.

METHOD

We identified patients with schizophrenia from outpatient clinics in the Veterans Health Administration (VA) and defined initiation of olanzapine or risperidone as patients who were not on any antipsychotics for 6 months and subsequently initiated on the target drug between 1/4/1999 and 31/3/2000. The data were analysed using tests of means or chi-square tests.

RESULTS

The study yielded two major findings. First, compared with risperidone initiators, there were significantly fewer olanzapine initiators who used at least one anticholinergic agent adjunctively. Secondly, among olanzapine or risperidone initiators, patients who used at least one anticholinergic agent adjunctively tended to stay on the target drug significantly longer than those who did not use any anticholinergic agent adjunctively with the target drug.

CONCLUSION

As the use of anticholinergics is a proxy for the presence of EPS, these findings suggest that risperidone may be more associated with EPS than olanzapine. However, to assess the benefits and side effects associated with olanzapine or risperidone, future research needs to examine various patient outcomes resulting from the initiation of each drug.

Initiation of atypical antipsychotic agents and health outcomes in patients with schizophrenia

BACKGROUND

Although pharmacological treatments are available for patients with schizophrenia, there is a lack of systematic and comprehensive evaluation of health outcomes following the initiation of atypical antipsychotic agents.

OBJECTIVE

To assess the effects of the initiation of olanzapine or risperidone, the two most widely prescribed atypical antipsychotics, on patients' health outcomes, as measured by changes in patient clinical characteristics between 6 months prior to and post-initiation.

METHOD

We identified patients with schizophrenia by >1 inpatient or > or = 2 outpatient ICD-9-CM codes (> or = 7 days apart) between 1 July 1998 and 30 June 1999, and those who were initiated on olanzepine or risperidone during the period 1 April 1999 to 31 March 2000 inclusive. We then subdivided these patients into three groups: (i) those who were not on olanzapine or risperidone, (ii) those who were not on any atypical agents, and (iii) those who were not on any antipsychotic agents, for 6 months prior to being issued with the new prescription. Using test of means or chi-square tests, we examined whether the initiation of olanzapine or risperidone is related to different changes in patient clinical indicators, such as number of drugs for psychiatric conditions, use of psychiatric services, and use of non-psychiatric services.

RESULTS

Between pre- and post-initiation, olanzapine initiators had a greater decrease in the number of psychiatric hospitalizations and use of psychotropic agents, whereas risperidone initiators had a greater reduction in the number of non-psychiatric hospitalizations. The initiation of olanzapine and risperidone appear to be associated with different patient health outcomes. Compared with olanzapine initiators, risperidone initiators had a greater increase in the use of treatments related to mental health, but had greater decrease in the use of treatments related to physical health.

CONCLUSION

Despite olanzapine and risperidone being often perceived as similar antipsychotic agents, our results suggest that the clinical outcomes associated with their use are different. Outcome data from routine clinical practice are required to provide a more comprehensive assessment of these drugs.

Olanzapine versus fluphenazine in an open trial in patients with psychotic combat-related post-traumatic stress disorder

RATIONALE

Combat-related post-traumatic stress disorder (PTSD) is often complicated with other psychiatric comorbidities, and is refractory to treatment.

OBJECTIVE

The aim of an open, comparative 6-week study was to compare olanzapine and fluphenazine, as a monotherapy, for treating psychotic combat-related PTSD.

METHOD

Fifty-five male war veterans with psychotic PTSD (DSM-IV criteria) were treated for 6 weeks with olanzapine (n=28) or fluphenazine (n=27) in a 5-10 mg/day dose range, once or twice daily. Patients were evaluated at baseline, and after 3 and 6 weeks of treatment, using Watson's PTSD scale, Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Severity Scale (CGI-S), Clinical Global Impression Improvement Scale (CGI-I), Patient Global Impression Improvement Scale (PGI-I) and Drug Induced Extra-Pyramidal Symptoms Scale (DIEPSS).

RESULTS

At baseline, patient's data (age, duration of combat experience and scores in all measurement instruments) did not differ. After 3 and 6 weeks of treatment, olanzapine was significantly more efficacious than fluphenazine in reducing symptoms in PANSS (negative, general psychopathology subscale, supplementary items), Watson's PTSD (avoidance, increased arousal) subscales, CGI-S, CGI-I, and PGI-I scale. Both treatments affected similarly the symptoms listed in PANSS positive and Watson's trauma re-experiencing subscales. Fluphenazine induced more extrapyramidal symptoms. Prolongation of the treatment for 3 additional weeks did not affect the efficacy of either drug.

CONCLUSIONS

Our data indicate that both fluphenazine and olanzapine were effective for particular symptom profile in psychotic combat-related PTSD. Olanzapine was better than fluphenazine in reducing most of the psychotic and PTSD symptoms, and was better tolerated in psychotic PTSD patients.

A comparison of olanzapine and risperidone on the risk of psychiatric hospitalization in the naturalistic treatment of patients with schizophrenia

Background

Decreasing hospital admissions is important for improving outcomes for people with schizophrenia and for reducing cost of hospitalization, the largest expenditure in treating this persistent and severe mental illness. This prospective observational study compared olanzapine and risperidone on one-year psychiatric hospitalization rate, duration, and time to hospitalization in the treatment of patients with schizophrenia in usual care.

Methods

We examined data of patients newly initiated on olanzapine (N = 159) or risperidone (N = 112) who continued on the index antipsychotic for at least one year following initiation. Patients were participants in a 3-year prospective, observational study of schizophrenia patients in the US. Outcome measures were percent of hospitalized patients, total days hospitalized per patient, and time to first hospitalization during the one-year post initiation. Analyses employed a generalized linear model with adjustments for demographic and clinical variables. A two-part model was used to confirm the findings. Time to hospitalization was measured by the Kaplan-Meier survival formula.

Results

Compared to risperidone, olanzapine-treated patients had significantly lower hospitalization rates, (24.1% vs. 14.4%, respectively, p = 0.040) and significantly fewer hospitalization days (14.5 days vs. 9.9 days, respectively, p = 0.035). The mean difference of 4.6 days translated to $2,502 in annual psychiatric hospitalization cost savings per olanzapine-treated patient, on average.

Conclusions

Consistent with prior clinical trial research, treatment-adherent schizophrenia patients who were treated in usual care with olanzapine had a lower risk of psychiatric hospitalization than risperidone-treated patients. Lower hospitalization costs appear to more than offset the higher medication acquisition cost of olanzapine.

Impact of side-effects of atypical antipsychotics on non-compliance, relapse and cost

Atypical antipsychotics generally have milder side-effects than conventional antipsychotics, but also differ among themselves in this respect. This study aimed to compare the impact of different side-effect profiles of individual atypical antipsychotics on non-compliance, relapse and cost in schizophrenia. A state-transition model was built using literature data supplemented by expert opinion. The model found that quetiapine and ziprasidone were similar in estimated non-compliance and relapse rates. Olanzapine and risperidone had higher estimated non-compliance and relapse rates, and incremental, 1-year, per-patient direct costs, using US-based cost data, of approximately $530 (95% confidence interval [CI] approximately $275, $800), and approximately $485 (95% CI approximately $235, $800), respectively, compared with quetiapine. Incremental costs attributable to different side-effect profiles were highly significant. This study shows that differing side-effect profiles of the newer antipsychotic agents are likely to lead to different compliance rates, and consequent variation in relapse rates. The cost implications of these heterogenous clinical outcomes are substantial.

Differential effects of antipsychotic agents on the risk of development of type 2 diabetes mellitus in patients with mood disorders

BACKGROUND

Atypical antipsychotics are being used increasingly in the management of mood disorders.

OBJECTIVE

The objective of this study was to investigate the association between exposure to antipsychotic therapy and newly reported type 2 diabetes mellitus in patients with mood disorders.

METHODS

Claims data for the period January 1996 through December 1997 were analyzed for patients with mood disorders in 2 large US health plans. Logistic regression models were used to determine the odds of reporting diabetes in patients exposed to risperidone, olanzapine, or high- or low-potency conventional antipsychotics compared with untreated patients, taking into account duration of treatment and dosage. Some of the covariates used in the models were concurrent use of antipsychotics, use of other psychotropic drugs, age, sex, and length of observation.

RESULTS

Based on the claims data, 849 patients were exposed to risperidone, 656 to olanzapine, 785 to high-potency conventional antipsychotics, and 302 to low-potency conventional antipsychotics; 2644 patients were untreated. The odds of newly reported type 2 diabetes in patients who received risperidone were not significantly different from those in untreated patients (12-month odds ratio [OR] = 1.024; 95% CI, 0.351-3.015). The odds in patients treated with high-potency conventional antipsychotics also did not differ significantly from those of untreated patients (12-month OR = 1.945; 95% CI, 0.794-4.786). Unlike patients who received risperidone or high-potency conventional antipsychotics, patients who received olanzapine (12-month OR = 4.289; 95% CI, 2.102-8.827) and low-potency conventional antipsychotics (12-month OR = 4.972; 95% CI, 1.967-12.612) had significantly higher odds for the development of type 2 diabetes compared with untreated patients.

CONCLUSIONS

These findings suggest that some antipsychotics may increase the risk for the development of type 2 diabetes in patients with mood disorders and that the effect may vary by drug. In contrast to olanzapine and low-potency conventional antipsychotics, risperidone and high-potency conventional antipsychotics were not associated with an increased risk for development of type 2 diabetes in this patient population.

Mental Health QUERI Initiative: expert ratings of criteria to assess performance for major depressive disorder and schizophrenia

The purpose of this study was to examine mental health care experts' opinions about performance measures and associated data elements that could serve as the basis of an information system for monitoring the implementation of clinical practice guidelines for major depressive disorder (MDD) and schizophrenia in the Veterans Health Administration (VHA). Nineteen mental health care experts rated the meaningfulness and validity of performance measures and automated data elements. For MDD, experts rated the following measures as very meaningful and valid: (a) the results of depression screening, (b) the occurrence and results of diagnostic assessment for MDD, (c) the provision of antidepressant medication or psychotherapy, and (d) whether antidepressant medications were prescribed within the therapeutic dose range recommended by practice guidelines. For schizophrenia, expert reviewers rated therapeutic doses of antipsychotic medication and assessment for antipsychotic medication side effects as being very meaningful and valid. Performance measures that evaluate clinically significant aspects of care using specific, valid data elements are the most meaningful. Translation efforts by the VHA's Mental Health Quality Enhancement Research Initiative program include additional studies of the validity of some of the proposed data elements and the development of national clinical reminders for performance measures judged to be meaningful.

Patient characteristics and prescription patterns of atypical antipsychotics among patients with schizophrenia

BACKGROUND

Schizophrenia, one of the leading causes of disability, contributes substantially to the use of medical and mental health services. The treatment of schizophrenia is therefore particularly important to reduce deficits across a large number of neurocognitive domains.

OBJECTIVE

To describe the prescription (e.g. initiation and switching) patterns of atypical antipsychotic agents and examine the extent to which patient sociodemographic and clinical characteristics are associated with the prescription patterns of atypical antipsychotics among patients with schizophrenia.

METHODS

Using unique data sources from the Veterans Health Administration (VA), the study identified 89 107 patients with schizophrenia based on at least one inpatient or more than or equal to two outpatients' ICD-9-CM codes (> or =7 days apart). We defined a prior 6-month (1/1/99 to 6/30/99) and a post 6-month (7/1/99 to 12/31/99) period to describe patterns of initiation and switching of atypical antipsychotics.

RESULTS

Only a small number of patients were on clozapine (1.8%) and quetiapine (1.4%). More patients were prescribed olanzapine (23%) than risperidone (20%) (P < 0.001). Compared with patients who were on risperidone, those who were on olanzapine were younger (P < 0.001), more likely Hispanic (P < 0.001), more likely married (P < 0.05), had more service-connected disability (P < 0.001), had fewer numbers of physical comorbidities (P < 0.001), and a lower body mass index (BMI) (P < 0.05).

CONCLUSION

Olanzapine and risperidone appear to be prescribed to patients with different sociodemographic and clinical characteristics. Future research needs to explore the reasons for those differences.

Switching from conventional to novel antipsychotic drugs: results of a prospective naturalistic study

OBJECTIVE

We examined the long-term consequences of switching patients from conventional to novel antipsychotic drugs, from a patient's perspective.

METHODS

In a prospective, single-blinded, naturalistic study, a cohort of subjects (n=150) with schizophrenia or schizo-affective disorder (DSM-IV) were switched from conventional neuroleptic drugs to either risperidone (n=50), olanzepine (n=50) or quetiapine (n=50), and monitored for a period of 2 to 6 years. The ensuing natural history of transitions in treatments was charted, and the outcomes including symptoms, side effects, subjective tolerability of drugs and their impact on quality of life were documented with standardized rating scales.

RESULTS

Majority (85%) of the subjects benefited from a switch to the novel antipsychotic drugs, though some preferred to return to their original neuroleptic (8%), and others eventually required clozapine (7%) therapy. Novel antipsychotic drugs were significantly tolerated better, and had a positive impact on treatment-adherence, psychosocial functioning and quality of life. Among the novel drugs, risperidone was significantly better in improving negative symptoms, while olanzepine was particularly well tolerated and effective against comorbid anxiety and depressive symptoms. Patients treated with quetiapine reported fewer side effects, and showed a significantly greater improvement in neurocognitive deficits.

CONCLUSION

Novel antipsychotics emerged as the drug of choice in view of their overall effectiveness, though conventional neuroleptics and clozapine will continue to have a limited but distinct role in the management of schizophrenia. The challenge for clinicians lies in matching a patient's clinical and biochemical profile with that of a drug's pharmacological actions, in order to achieve optimum outcomes.