Psychotropic Medication Use Among Adults With Schizophrenia and Schizoaffective Disorder in the United States

Inpatient antipsychotic medication switching and rehospitalization risk among patients with schizophrenia-spectrum disorders

OBJECTIVE

To describe patterns of antipsychotic switching among patients hospitalized for schizophrenia and to correlate antipsychotic switching with hospital readmission risk.

METHODS

We identified 3295 patients with index hospitalizations for schizophrenia or schizoaffective disorder from New York State Medicaid claims 2017-2018 who had filled at least one prescription for an antipsychotic in both the 44 days (one month +14 day grace period) prior to and after their admission. We identified patients who had kept or switched any of their antipsychotic medication between the pre- and post-periods surrounding their index hospitalization. We compared the kept and switched any groups, adjusting for patient characteristics.

RESULTS

Of patients who had filled antipsychotic prescriptions in both the 44 days prior to and after their hospitalization, 1599 (48.6 %) had switched at least one antipsychotic and 1215 (36.8 %) had switched their primary antipsychotic. Switching any antipsychotic was associated with increased hazards of readmission, HR = 1.21, 95%CI 1.09-1.35, which was slightly concentrated during the first 90 days after hospital discharge.

CONCLUSIONS

Switching antipsychotic medications during hospitalization occurs commonly and is associated with higher rehospitalization risk following hospital discharge.

Efficacy of psychotropic medications on suicide and self-injury: a meta-analysis of randomized controlled trials

Using psychotropic medications to treat and prevent self-injurious thoughts and behaviors (SITBs) has become increasingly popular, but conclusive evidence supporting the efficacy this approach remains elusive. To empirically examine whether psychotropic medications are efficacious treatments for SITBs, the present meta-analysis comprehensively summarizes all published randomized controlled trials (RCTs) that have reported the causal effects of psychotropic medications on suicide and self-injury. A total of 251 papers from 718 unique RCTs were included. A frequentist pairwise approach was adopted for meta-analyses. Potential effect modifiers were examined via met regressions and potential biases were evaluated through sensitivity analyses. On average, medications yielded an 8% reduction in SITB frequency and a reduction of 0.2 standard deviations in symptoms and severity. Findings were largely consistent across potential effect modifiers, and significant evidence of publication bias was not detected. Only one medication class (i.e., antipsychotics) and two specific medications (i.e., citalopram, ketamine) produced larger-than-average treatment effects. Psychostimulants and typical antipsychotics may produce iatrogenic effects. Less than 4% of included studies required individuals to exhibit SITBs, and nearly half of analyzed effects were drawn from studies that excluded individuals on the basis of SITB risk. Taken together, findings suggest that psychotropic medications produce small treatment effects on SITBs; however, these findings should be considered in light of the methodological constraints of the existing literature, including the lack of studies intentionally including individuals with SITBs. It is critical for future RCTs to prioritize including individuals with existing SITBs to further clarify treatment effects in self-injurious and suicidal populations. Additional research is needed to better understand the treatment mechanisms of psychotropic medications and identify the causal processes underlying SITBs.

Variation in Psychotropic Medication Prescription for Adults With Schizophrenia in the United States

OBJECTIVE

Variation in prescription of psychotropic medications to patients with schizophrenia spectrum disorders may underlie health inequities. Using a national U.S. Medicaid sample, the authors examined prescription patterns of psychotropic medications commonly used for managing schizophrenia.

METHODS

Data from the 2011-2012 Medicaid Analytic eXtract were examined for demographic predictors of and variation across states in psychotropic medication prescription among adult patients diagnosed as having schizophrenia spectrum disorders (N=357,914). Percentages of patients in each state who filled prescriptions of at least 15 days of any antipsychotic, clozapine, antidepressant, benzodiazepine, mood stabilizer, or long-acting injectable (LAI) antipsychotic medication were determined after adjustment for demographic and clinical covariates. Multivariate regressions of clinical and demographic factors predicting prescription patterns were conducted.

RESULTS

Prescribing patterns for all types of psychotropic medications varied across states. Clozapine and LAI prescriptions showed the most dramatic differences across states and among patients with different demographic characteristics. Across states, adjusted proportions of prescriptions ranged from 4% to 22% for LAIs and from 1% to 11% for clozapine. Non-Hispanic Blacks and people of other race-ethnicities were more likely than non-Hispanic Whites to fill prescriptions for LAIs, and non-Hispanic Whites were more likely than individuals from other racial-ethnic groups to fill prescriptions for clozapine and all other medications.

CONCLUSIONS

Considerable variation in prescribing patterns of LAIs and clozapine by race-ethnicity and across states suggests uneven quality of care for individuals with schizophrenia spectrum disorders in the United States. A better understanding of what causes this variation could inform policy makers to improve treatment for this vulnerable population.

Age-Specific Prevalence and Incidence of Dementia Diagnoses Among Older US Adults With Schizophrenia

IMPORTANCE

People with schizophrenia are at high risk of receiving a diagnosis of dementia. Understanding the magnitude and timing of this increased risk has important implications for practice and policy.

OBJECTIVE

To estimate the age-specific incidence and prevalence of dementia diagnoses among older US adults with schizophrenia and in a comparison group without serious mental illness (SMI).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used a 50% random national sample of Medicare beneficiaries 66 years or older with fee-for-service plans and Part D prescription drug coverage from January 1, 2007, to December 31, 2017. The cohort with schizophrenia included adults with at least 12 months of continuous enrollment in fee-for-service Medicare and Part D and at least 2 outpatient claims or at least 1 inpatient claim for schizophrenia during the qualifying years. The comparison group included adults with at least 12 months of continuous enrollment in fee-for-service Medicare and Part D and without a diagnosis of schizophrenia, bipolar disorder, or recurrent major depressive disorder during the qualifying year. Data were analyzed from January 1 to July 31, 2020.

MAIN OUTCOMES AND MEASURES

Dementia was defined using the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse diagnosis codes for Alzheimer disease and related disorders or senile dementia. Incident diagnoses were defined by at least 12 consecutive eligible months without a qualifying code before meeting dementia criteria.

RESULTS

The study population of 8 011 773 adults 66 years or older (63.4% women; mean [SD] age, 74.0 [8.2] years) included 74 170 individuals with a diagnosis of schizophrenia (56.6% women) and 7 937 603 without an SMI diagnosis (63.5% women) who contributed 336 814 and 55 499 543 person-years of follow-up, respectively. At 66 years of age, the prevalence of diagnosed dementia was 27.9% (17 640 of 63 287) among individuals with schizophrenia compared with 1.3% (31 295 of 2 389 512) in the group without SMI. By 80 years of age, the prevalence of dementia diagnoses was 70.2% (2011 of 2866) in the group with schizophrenia and 11.3% (242 094 of 2 134 602) in the group without SMI. The annual incidence of dementia diagnoses per 1000 person-years at 66 years of age was 52.5 (95% CI, 50.1-54.9) among individuals with schizophrenia and 4.5 (95% CI, 4.4-4.6) among individuals without SMI and increased to 216.2 (95% CI, 179.9-252.6) and 32.3 (95% CI, 32.0-32.6), respectively, by 80 years of age.

CONCLUSIONS AND RELEVANCE

In this cohort study, compared with older adults without SMI, those with schizophrenia had increased risk of receiving a diagnosis of dementia across a wide age range, possibly because of cognitive and functional deterioration related to schizophrenia or factors contributing to other types of dementia. High rates of dementia among adults with schizophrenia have implications for the course of illness, treatment, and service use.