Cost-effectiveness of first- v. second-generation antipsychotic drugs: results from a randomised controlled trial in schizophrenia responding poorly to previous therapy

Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis

BACKGROUND

Because of the debate about whether second-generation antipsychotic drugs are better than first-generation antipsychotic drugs, we did a meta-analysis of randomised controlled trials to compare the effects of these two types of drugs in patients with schizophrenia.

METHODS

We compared nine second-generation antipsychotic drugs with first-generation drugs for overall efficacy (main outcome), positive, negative and depressive symptoms, relapse, quality of life, extrapyramidal side-effects, weight gain, and sedation.

FINDINGS

We included 150 double-blind, mostly short-term, studies, with 21 533 participants. We excluded open studies because they systematically favoured second-generation drugs. Four of these drugs were better than first-generation antipsychotic drugs for overall efficacy, with small to medium effect sizes (amisulpride -0.31 [95% CI -0.44 to -0.19, p<0.0001], clozapine -0.52 [-0.75 to -0.29, p<0.0001], olanzapine -0.28 [-0.38 to -0.18, p<0.0001], and risperidone -0.13 [-0.22 to -0.05, p=0.002]). The other second-generation drugs were not more efficacious than the first-generation drugs, even for negative symptoms. Therefore efficacy on negative symptoms cannot be a core component of atypicality. Second-generation antipsychotic drugs induced fewer extrapyramidal side-effects than did haloperidol (even at low doses). Only a few have been shown to induce fewer extrapyramidal side-effects than low-potency first-generation antipsychotic drugs. With the exception of aripiprazole and ziprasidone, second-generation antipsychotic drugs induced more weight gain, in various degrees, than did haloperidol but not than low-potency first-generation drugs. The second-generation drugs also differed in their sedating properties. We did not note any consistent effects of moderator variables, such as industry sponsorship, comparator dose, or prophylactic antiparkinsonian medication.

INTERPRETATION

Second-generation antipsychotic drugs differ in many properties and are not a homogeneous class. This meta-analysis provides data for individualised treatment based on efficacy, side-effects, and cost.

Polypharmacy with second-generation antipsychotics: a review of evidence

OBJECTIVE

The objective of this study was to review the prevalence of polypharmacy with second-generation antipsychotics (SGAs) in clinical practice, pharmacological reasons for such practice, and the evidence for and against such polypharmacy.

METHODS

Clinical trial reports, case reports, and reviews were identified by a PubMed literature search from 1966 through October 2006, with retrieved publications queried for additional references. We excluded reports on augmentation with non-antipsychotic medications and polypharmacy involving combinations of SGAs and first-generation (conventional) antipsychotics (FGAs) or combinations of two FGAs. We identified 75 reports concerning SGA polypharmacy, from which we extracted data on study design, sample size, medications, rating scales, outcome, and conclusions. Data from randomized controlled trials and larger case series are presented in detail and case reports are briefly discussed.

CONCLUSIONS

Polypharmacy with SGAs is not uncommon, with prevalence varying widely (3.9% to 50%) depending on setting and patient population, despite limited support from blinded, randomized, controlled trials or case reports that employed an A-B-A (monotherapy-combination therapy-monotherapy) design and adequate dosing and duration of treatment. Rather than prohibiting or discouraging co-prescription of SGAs, needs of patients and clinicians should be addressed through evidence-based algorithms. Based on unmet clinical needs and modest evidence from case reports, combinations of two SGAs may merit future investigation in efficacy trials involving patients with schizophrenia who have treatment-resistant illness (including partial response) or who are responsive to treatment but develop intolerable adverse effects. Other areas that may merit future research are efficacy of SGA polypharmacy for schizophrenia accompanied by comorbid conditions (eg, anxiety, suicidal or self-injurious behavior, aggression) and for reducing length of stay in acute care settings.

Pharmacotherapy for schizophrenic inpatients in East Asia--changes and challenges

OBJECTIVES

(1) to review characteristics of prescription patterns of antipsychotic medication in China, Hong Kong, Japan, Korea, Singapore and Taiwan, (2) to examine the changes of prescriptions brought about by the introduction of second generation psychotropic drugs (SGA) in East Asia, (3) to analyse factors contributing to the characteristic use of antipsychotics, and (4) to suggest ways and means to improve the prescription practice of antipsychotics in East Asia.

METHODS

Authors of this study collaborated with psychiatrists in East Asia to undertake an international survey reviewing prescription patterns of psychotropic medications in East Asia. The REAP (Research on Asian psychotropic prescription patterns) study reviewed the prescription of a large number of schizophrenic inpatients in China, Hong Kong, Japan, Korea, Singapore and Taiwan in 2001 and 2004 using a unified research protocol and questionnaire.

RESULTS

Prescription patterns of antipsychotic drugs differ greatly country by country and have recently experienced rapid changes. Our survey shows second generation antipsychotics are frequently used in East Asia. The introduction of SGA resulted in the combined use of first generation psychotropic drugs (FGA) and SGA in East Asia. These changing prescription patterns have created many challenges for psychiatrists in East Asia.

Who are the new users of antipsychotic medications?

OBJECTIVE

This study examined changes in the prevalence of antipsychotic medication use and the characteristics of antipsychotic users in the U.S. population between 1996 and 2005.

METHODS

Data from the Medical Expenditure Panel Survey from 1996-1997 and 2004-2005 were used to examine the rate of first- and second-generation antipsychotic medication use and changes in the characteristics of users of all ages. Trends were examined in the level of use by antipsychotic users, both in terms of defined daily dose units and number of prescriptions.

RESULTS

The rate of antipsychotic use has increased substantially between 1996-1997 and 2004-2005, but the average dose measured both by defined daily dose units and number of prescriptions has remained constant. The rapid diffusion of antipsychotic medications did not occur among individuals with schizophrenia, but rather it included substantial growth among those with newer on-label conditions (such as bipolar disorder) and a high, constant rate of off-label use. Demographic, financial, and insurance characteristics of users have remained fairly constant, with few exceptions. The average age of antipsychotic users declined during the study period, because more children were using these medications in 2004-2005. However, the gender, racial, ethnic, and insurance composition of users has been fairly stable over time.

CONCLUSIONS

The rapid diffusion of second-generation antipsychotic medications was achieved by large increases in the rate of use in certain subpopulations, most notably youths. Increasing understanding about the marginal efficacy and side-effect risks of newer and more expensive antipsychotic agents, even when prescribed as indicated, suggests that the dramatic increase in use warrants careful attention.

Cognitive-behavioural therapy for severe mental disorders: back to the future?

Like recent medication studies, it appears that when cognitive-behavioural therapy is tested in pragmatic effectiveness trials involving routine clinical populations it does not fare as well as in efficacy trials. Given the multitude of factors that can ;muddy the waters' in clinical trials, how do we best make sense of the findings?

CATIE and CUtLASS: can we handle the truth?

Two large, non-commercial clinical trials comparing first- and second-generation antipsychotic drugs for people with chronic schizophrenia in the US and UK have shown unexpected results. In general, the newer drugs were no more effective or better tolerated than the older drugs. Clozapine outperformed other second-generation drugs. The implications are considered.

World Psychiatric Association Pharmacopsychiatry Section statement on comparative effectiveness of antipsychotics in the treatment of schizophrenia

Data from two major government-funded studies of comparative antipsychotic effectiveness in schizophrenia contradict the widely prevalent belief that the newer second-generation medications are vastly superior to the older first-generation drugs. This has caused uncertainty among patients, clinicians and policy-makers about the relative utility of first- and second- generation antipsychotic agents in its treatment. To reduce confusion and provide a contextual understanding of the new data, the World Psychiatry Association Section on Pharmacopsychiatry comprehensively reviewed the literature on the comparative effectiveness of different antipsychotic treatments for schizophrenia and developed this update. Utilizing data from the approximately 1,600 randomized controlled trials of antipsychotic treatment in schizophrenia, we applied the two indirect and one direct method to comparing the effectiveness of 62 currently-available antipsychotic agents. The subclasses of 51 first-generation and 11 second-generation antipsychotics were both found to be very heterogeneous, with substantial differences in side-effect profiles among members. Second-generation antipsychotic agents were found to be inconsistently more effective than first-generation agents in alleviating negative, cognitive, and depressive symptoms and had a lower liability to cause tardive dyskinesia; these modest benefits were principally driven by the ability of second-generation antipsychotics to provide equivalent improvement in positive symptoms along with a lower risk of causing extrapyramidal side-effects. Clozapine was found to be more efficacious than other agents in treatment-refractory schizophrenia. There were no consistent differences in efficacy among other second-generation antipsychotic agents; if such differences exist, they are likely small in magnitude. Dosing was found to be a key variable in optimizing effectiveness of both first- and second- generation antipsychotic agents. There was enormous individual variability in antipsychotic response and vulnerability to various adverse effects. In contrast to their relatively similar efficacy in treating positive symptoms, there were substantial differences among both first- and second- generation antipsychotic agents with regard to their propensity to cause extrapyramidal, metabolic and other adverse effects; second-generation agents have a lower liability to cause acute extrapyramidal symptoms and tardive dyskinesia along with a tendency to cause greater metabolic side-effects than first-generation agents. Based on these data about the comparative effectiveness of different antipsychotic treatment options, we summarize elements of current best antipsychotic practice for the treatment of schizophrenia and discuss the role of government and the pharmaceutical industry in obtaining and disseminating information which can facilitate best practice.

Clozapine use in children and adolescents

BACKGROUND

Although the role of clozapine is well established for treatment-resistant schizophrenia, it is rarely used in pediatric populations, mainly due to its potentially serious adverse effects.

OBJECTIVE

To summarize practical aspects of use of clozapine in treating children with schizophrenia and management of associated adverse effects.

METHODS

Available studies in the literature using clozapine in the pediatric population are summarized and the NIMH experience in treating refractory childhood-onset schizophrenia cases with clozapine is discussed.

CONCLUSION

Despite a higher incidence of adverse effects in children, clozapine appears to be a uniquely beneficial second-line agent for treating children with refractory schizophrenia.

Cost-utility analysis of treatment with olanzapine compared with other antipsychotic treatments in patients with schizophrenia in the pan-European SOHO study

OBJECTIVE

To determine the cost utility of treating schizophrenic patients with olanzapine compared with other antipsychotics in a naturalistic outpatient setting.

METHODS

The pan-European SOHO study is a 3-year, prospective, outpatient, observational study of outcomes associated with antipsychotic treatment, focusing on olanzapine, in ten European countries. For the cost-utility analysis, healthcare resource use (inpatient care, day care, outpatient psychiatric consultations and antipsychotic and concomitant medication use) and EQ-5D data were collected at baseline and at 3, 6 and 12 months. The perspective was that of the health service payer. UK healthcare unit costs (year 2004 values) were applied to the resource use data for the ten countries. UK population tariffs were applied to the EQ-5D data to determine utility values.An Epoch analysis was used to analyze the longitudinal data. Multivariate regression analyses that adjusted for baseline covariates were used to estimate the incremental cost and utility gains for patients treated with olanzapine compared with each of the other antipsychotics (risperidone, quetiapine, amisulpride, clozapine and oral or depot typical antipsychotics).

RESULTS

A total of 10 972 patients were enrolled at baseline, of which 9107 completed the 12-month study period. Treatment with olanzapine was more effective in terms of QALYs gained than all of the other antipsychotic treatments. Treatment with olanzapine dominated quetiapine and amisulpride. The incremental cost for olanzapine compared with risperidone was pound sterling 226 per patient over 12 months and the incremental cost per QALY gained was pound 5156, with bootstrap analyses showing 100% of the replications falling below a pound sterling 30 000 per QALY gained threshold. Compared with treatment with clozapine, olanzapine was found to be marginally more effective, at an additional cost of pound sterling 13 per patient over 12 months and to have an incremental cost per QALY gained of pound sterling 775. Bootstrap analyses showed that 81% of replications fell below a pound sterling 30 000 per QALY gained threshold. Comparing olanzapine with oral and depot typical antipsychotics, the incremental cost was pound sterling 849 and pound sterling 1106 per patient over 12 months and the incremental cost per QALY gained was pound sterling 15 696 and pound sterling 23 331, respectively. Bootstrap analyses showed that 98% of the replications fell below a pound sterling 30 000 per QALY gained threshold for the comparison with oral typical antipsychotics, and 79% of replications for the comparison with depot preparations.

CONCLUSIONS

Among SOHO patients, if a funding threshold of pound sterling 30 000 per QALY gained is assumed, this analysis suggests that olanzapine has a high probability of being the most cost-effective treatment compared with other antipsychotic treatments. However, comparison of olanzapine with clozapine and typical depot antipsychotics should be viewed with caution because clozapine is a second-line treatment and depot treatment is used for patients who do not adhere to their oral medication.

"The trouble with QALYs..."

This paper summarises the use of QALYs in evaluating changes in mental health states, highlighting the benefits and challenges of their use in this field. The general principles underlying the QALY measure and the most common methods of measuring QALYs are discussed briefly. Evidence of the usefulness and problems of using this generic measure of health-related quality of life are provided from a sample of recent studies relating to depression, schizophrenia, attention deficit hyperactivity disorder and dementia. In each case, attempts were made to use QALYs to measure changes in health states. While in principle, the QALY is enormously attractive, its suitability for measuring changes in many mental health conditions remains open to doubt as existing tools for generating QALY scores such as the EQ-5D have tended not to perform sufficiently well in reflecting changes in many mental health states. New developmental work is needed to construct better QALY-measuring tools for use in the mental health field. Both the conceptualisation and measurement of QALYs need to be built on a valid, comprehensive model of quality of life specific to a mental health disorder, to ensure that the resultant tool is sensitive enough to pick up changes that would be expected and seen as relevant in the course of the illness.