1
|
Bray G, Moncrieff J, Priebe S, Marston L, Lewis G, Haynes N, Pinfold V, Johnson S, Hunter RM. Cost-Utility Analysis of Antipsychotic Reduction and Discontinuation in Patients With Long-Term Schizophrenia and Psychosis in English Mental Health Trusts: The RADAR Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02800-6. [PMID: 39127250 DOI: 10.1016/j.jval.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVES The current recommended treatment for patients with recurrent episodes of schizophrenia and related conditions is antipsychotic medication. However, many antipsychotic users remain functionally impaired and experience serious physical and mental side effects. This study aims to assess the cost-effectiveness of a gradual antipsychotic reduction and discontinuation strategy compared with maintenance treatment over 24 months from mental health services, health and social care, and societal perspectives. METHODS Nineteen mental health trusts recruited patients to the Research into Antipsychotic Discontinuation and Reduction (RADAR) randomized controlled trial. Quality-adjusted life-years were calculated from patient-reported EQ-5D-5L, with years of full capability calculated from the patient-reported ICECAP-A. Mental health services use and medication was collected from medical records. Other resource use and productivity loss was collected using self-completed questionnaires. Costs were calculated from published sources. RESULTS A total of 253 participants were randomized: 126 assigned to antipsychotic dose reduction and 127 to maintenance. There were no significant differences between arms in total costs for any perspectives. There were no significant difference in quality-adjusted life-years (-0.035; 95% CI: -0.123 to 0.052), whereas years of full capability were significantly lower in the reduction arm compared with the maintenance arm (baseline-adjusted difference: -0.103; 95% CI: -0.192 to -0.014). The reduction strategy was dominated by maintenance for all analyses and was not likely to be cost-effective. CONCLUSIONS It is unlikely that gradual antipsychotic reduction and discontinuation strategy is cost-effective compared with maintenance over 2-years for patients with schizophrenia and other recurrent psychotic disorders who are on long-term antipsychotics.
Collapse
Affiliation(s)
- George Bray
- Office of Health Economics, London, England, UK
| | - Joanna Moncrieff
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, England, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, England, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Nadia Haynes
- Research and Development Department, North East London NHS Foundation Trust, London, England, UK
| | | | - Sonia Johnson
- Division of Psychiatry, University College London and North East London NHS Foundation Trust, London, England, UK
| | - Rachael Maree Hunter
- Research Department of Primary Care and Population Health, University College London, London, England, UK.
| |
Collapse
|
2
|
Moncrieff J, Crellin N, Stansfeld J, Cooper R, Marston L, Freemantle N, Lewis G, Hunter R, Johnson S, Barnes T, Morant N, Pinfold V, Smith R, Kent L, Darton K, Long M, Horowitz M, Horne R, Vickerstaff V, Jha M, Priebe S. Antipsychotic dose reduction and discontinuation versus maintenance treatment in people with schizophrenia and other recurrent psychotic disorders in England (the RADAR trial): an open, parallel-group, randomised controlled trial. Lancet Psychiatry 2023; 10:848-859. [PMID: 37778356 DOI: 10.1016/s2215-0366(23)00258-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Maintenance antipsychotic medication is recommended for people with schizophrenia or recurrent psychosis, but the adverse effects are burdensome, and evidence on long-term outcomes is sparse. We aimed to assess the benefits and harms of a gradual process of antipsychotic reduction compared with maintenance treatment. Our hypothesis was that antipsychotic reduction would improve social functioning with a short-term increase in relapse. METHODS RADAR was an open, parallel-group, randomised trial done in 19 National Health Service Trusts in England. Participants were aged 18 years and older, had a diagnosis of recurrent, non-affective psychotic disorder, and were prescribed an antipsychotic. Exclusion criteria included people who had a mental health crisis or hospital admission in the past month, were considered to pose a serious risk to themselves or others by a treating clinician, or were mandated to take antipsychotic medication under the Mental Health Act. Through an independent, internet-based system, participants were randomly assigned (1:1) to gradual, flexible antipsychotic reduction, overseen by treating clinicians, or to maintenance. Participants and clinicians were aware of treatment allocations, but assessors were masked to them. Follow-up was for 2 years. Social functioning, assessed by the Social Functioning Scale, was the primary outcome. The principal secondary outcome was severe relapse, defined as requiring admission to hospital. Analysis was done blind to group identity using intention-to-treat data. The trial is completed and has been registered with ISRCTN registry (ISRCTN90298520) and with ClinicalTrials.gov (NCT03559426). FINDINGS 4157 people were screened, of whom 253 were randomly allocated, including 168 (66%) men, 82 (32%) women, and 3 (1%) transgender people, with a mean age of 46 years (SD 12, range 22-79). 171 (67%) participants were White, 52 (21%) were Black, 16 (6%) were Asian, and 12 (5%) were of other ethnicity. The median dose reduction at any point during the trial was 67% in the reduction group and zero in the maintenance group; at 24 months it was 33% versus zero. At the 24-month follow-up, we assessed 90 of 126 people assigned to the antipsychotic dose reduction group and 94 of 127 assigned to the maintenance group, finding no difference in the Social Functioning Scale (β 0·19, 95% CI -1·94 to 2·33; p=0·86). There were 93 serious adverse events in the reduction group affecting 49 individuals, mainly comprising admission for a mental health relapse, and 64 in the maintenance group, relating to 29 individuals. INTERPRETATION At 2-year follow-up, a gradual, supported process of antipsychotic dose reduction had no effect on social functioning. Our data can help to inform decisions about the use of long-term antipsychotic medication. FUNDING National Institute for Health Research.
Collapse
Affiliation(s)
- Joanna Moncrieff
- Division of Psychiatry, University College London, London, UK; North East London Foundation NHS Trust, London, UK.
| | | | - Jacki Stansfeld
- Division of Psychiatry, University College London, London, UK; North East London Foundation NHS Trust, London, UK
| | - Ruth Cooper
- NIHR Mental Health Policy Research Unit, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; East London NHS Foundation Trust, Newham Centre for Mental Health, London, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, UK; PRIMENT Clinical trials unit, University College London, London, UK
| | - Nick Freemantle
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK; PRIMENT Clinical trials unit, University College London, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Thomas Barnes
- Division of Psychiatry, Imperial College, London, UK
| | - Nicola Morant
- Division of Psychiatry, University College London, London, UK
| | | | | | | | | | - Maria Long
- Division of Psychiatry, University College London, London, UK; Department of Health Services Research and Management, City University, London, UK
| | - Mark Horowitz
- Division of Psychiatry, University College London, London, UK; North East London Foundation NHS Trust, London, UK
| | - Robert Horne
- School of Pharmacy, University College London, London, UK
| | - Victoria Vickerstaff
- Research Department of Primary Care and Population Health, University College London, London, UK; PRIMENT Clinical trials unit, University College London, London, UK
| | - Mithilesh Jha
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, London, UK
| |
Collapse
|
3
|
Ramsay G, Haime Z, Crellin NE, Stansfeld JL, Priebe S, Long M, Moncrieff J. Recruitment to a trial of antipsychotic reduction: impact of an acceptability study. BMC Med Res Methodol 2023; 23:78. [PMID: 36991350 PMCID: PMC10053425 DOI: 10.1186/s12874-023-01881-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/03/2023] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVES Pre-trial acceptability studies may boost recruitment, especially in trials comparing distinctly different interventions. We evaluated the impact of an acceptability study on recruitment to a randomised trial of antipsychotic reduction versus maintenance treatment and explored demographic and clinical predictors of subsequent enrolment. METHODS Participants with a diagnosis of a schizophrenia spectrum disorder who were taking antipsychotic medication were interviewed about their views of taking part in a future trial. RESULTS In a sample of 210 participants, 151 (71.9%) expressed an interest in taking part in the future trial, 16 (7.6%) said they might be interested, and 43 (20.5%) said they were not. Altruistic reasons were most commonly given for wanting to take part, and concern about randomisation for not wanting to. Ultimately 57 people enrolled in the trial (27.1% of the original sample). Eighty-five people who initially expressed an interest did not enrol due to declining or not being eligible (for clinical reasons). Women and people from a white ethnic background were more likely to enrol in the trial, but no illness or treatment-related characteristics were associated with enrolment. CONCLUSION An acceptability study can be a useful tool for recruitment to challenging trials, but it may over-estimate recruitment.
Collapse
Affiliation(s)
- Georgina Ramsay
- Research and Development, North East London NHS Foundation Trust, Ilford, Essex, UK
| | - Zoë Haime
- University College London, Bloomsbury , UK
| | | | - Jacki L Stansfeld
- Research and Development, North East London NHS Foundation Trust, Ilford, Essex, UK
- University College London, Bloomsbury , UK
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary University of London, Mile End, East London, UK
| | - Maria Long
- Research and Development, North East London NHS Foundation Trust, Ilford, Essex, UK
- University College London, Bloomsbury , UK
| | - Joanna Moncrieff
- Research and Development, North East London NHS Foundation Trust, Ilford, Essex, UK.
- University College London, Bloomsbury , UK.
| |
Collapse
|
4
|
Deckler E, Ferland M, Brazis S, Mayer MR, Carlson M, Kantrowitz JT. Challenges and Strategies for the Recruitment of Patients With Schizophrenia in a Research Setting. Int J Neuropsychopharmacol 2022; 25:924-932. [PMID: 36037521 PMCID: PMC9452184 DOI: 10.1093/ijnp/pyac058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND With numerous potentially novel targets and pharmacodynamic biomarkers for schizophrenia entering late-stage testing, the next decade will bring an urgent need for well-conducted clinical trials. A critically important step for the successful execution of clinical research trials is timely and appropriate recruitment of participants. Patients with schizophrenia can be especially challenging to recruit because of the disability inherent in psychotic spectrum disorders. Research on how best to recruit for clinical trials is understudied. Clearly defining a model for recruitment procedures would be valuable for researchers and, by extension, the patient populations that may benefit from the insight gained by future clinical research. METHODS This article aims to offer suggestions for recruitment based on years of experience at the Columbia Schizophrenia Research Clinic (CSRC), a hub for clinical trials focusing on the etiology and treatment of various psychotic disorders. RESULTS The present report provides practical, step-by-step recommendations for implementing the highly effective CSRC recruitment model, including the benefits of 2 recruitment initiatives that were instituted in 2018: hiring a dedicated recruiter and targeted chart reviews at affiliated clinics. Other topics discussed include our umbrella protocol and database, advertising, and tips for collaborating with external sites. CONCLUSIONS Despite ongoing complications from coronavirus disease 2019, these strategies have been successful, increasing the rate of both consents and study enrollments by approximately 40% and enabling the CSRC to conduct multiple studies simultaneously.
Collapse
Affiliation(s)
| | | | | | | | - Marlene Carlson
- New York State Psychiatric Institute, New York, USA,Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Joshua T Kantrowitz
- Correspondence: Joshua Kantrowitz MD, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032 ()
| |
Collapse
|
5
|
Taipale H, Schneider-Thoma J, Pinzón-Espinosa J, Radua J, Efthimiou O, Vinkers CH, Mittendorfer-Rutz E, Cardoner N, Pintor L, Tanskanen A, Tomlinson A, Fusar-Poli P, Cipriani A, Vieta E, Leucht S, Tiihonen J, Luykx JJ. Representation and Outcomes of Individuals With Schizophrenia Seen in Everyday Practice Who Are Ineligible for Randomized Clinical Trials. JAMA Psychiatry 2022; 79:210-218. [PMID: 35080618 PMCID: PMC8792792 DOI: 10.1001/jamapsychiatry.2021.3990] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Most evidence about efficacy and safety of antipsychotics in schizophrenia spectrum disorders relies on randomized clinical trials (RCTs). However, owing to their strict eligibility criteria, RCTs represent only a part of the real-world population (ie, unselected patients seen in everyday clinical practice), which may result in an efficacy-effectiveness gap. OBJECTIVE To quantify the proportion of real-world individuals with schizophrenia spectrum disorders who would be ineligible for participation in RCTs, and to explore whether clinical outcomes differ between eligible and ineligible individuals. DESIGN, SETTING, AND PARTICIPANTS This study applied eligibility criteria typically used in RCTs for relapse prevention in schizophrenia spectrum disorders to real-world populations. Individuals with diagnoses of schizophrenia spectrum disorders recorded in national patient registries in Finland and Sweden were identified. Individuals who had used antipsychotics continuously for 12 weeks in outpatient care were selected. Individuals were followed up for up to 1 year while they were receiving maintenance treatment with any second-generation antipsychotic (excluding clozapine). Follow-up was censored at treatment discontinuation, initiation of add-on antipsychotics, death, and end of database linkage. MAIN OUTCOMES AND MEASURES Proportions of RCT-ineligible individuals with schizophrenia spectrum disorders owing to any and specific RCT exclusion criteria. The risk of hospitalization due to psychosis within 1-year follow-up in ineligible vs eligible persons were compared using hazard ratios (HR) and corresponding 95% CIs. RESULTS The mean (SD) age in the Finnish cohort (n = 17 801) was 47.5 (13.8) years and 8972 (50.4%) were women; the mean (SD) age in the Swedish cohort (n = 7458) was 44.8 (12.5) years and 3344 (44.8%) were women. A total of 20 060 individuals (79%) with schizophrenia spectrum disorders would be ineligible for RCTs (Finnish cohort: 14 221 of 17 801 [79.9%]; Swedish cohort: 5839 of 7458 [78.3%]). Most frequent reasons for ineligibility were serious somatic comorbidities and concomitant antidepressant/mood stabilizer use. Risks of hospitalization due to psychosis was higher among ineligible than eligible individuals (Finnish cohort: 18.4% vs 17.2%; HR, 1.14 [95% CI, 1.04-1.24]; Swedish cohort: 20.1% vs 14.8%; HR, 1.47 [95% CI, 1.28-1.92]). The largest risks of hospitalization due to psychosis were observed in individuals ineligible owing to treatment resistance, tardive dyskinesia, and history of suicide attempts. Finally, with more ineligibility criteria met, larger risks of hospitalization due to psychosis were observed in both countries. CONCLUSIONS AND RELEVANCE RCTs may represent only about a fifth of real-world individuals with schizophrenia spectrum disorders. Underrepresented (ineligible) patients with schizophrenia spectrum disorders have moderately higher risks of admission due to psychosis while receiving maintenance treatment than RCT-eligible patients. These findings set the stage for future studies targeting real-world populations currently not represented by RCTs.
Collapse
Affiliation(s)
- Heidi Taipale
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland,Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Justo Pinzón-Espinosa
- Department of Mental Health, Parc Tauli University Hospital, Sabadell, Barcelona, Spain,Department of Medicine, University of Barcelona School of Medicine, Barcelona, Spain,Department of Clinical Psychiatry, University of Panama School of Medicine, Panama City, Panama
| | - Joaquim Radua
- Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERSAM, Barcelona, Spain,Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland,Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Christiaan H. Vinkers
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ellenor Mittendorfer-Rutz
- Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Narcís Cardoner
- Department of Mental Health, Parc Tauli University Hospital, Sabadell, Barcelona, Spain,Institut d’Investigació I Innovació Parc Tauli (I3PT), CIBERSAM, Sabadell, Barcelona, Spain,Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Pintor
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERSAM, Barcelona, Spain,Department of Psychiatry and Psychology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland,Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anneka Tomlinson
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy,OASIS Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Eduard Vieta
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERSAM, Barcelona, Spain,Department of Psychiatry and Psychology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland,Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Jurjen J. Luykx
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands,Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands,Outpatient second opinion clinic, GGNet Mental Health, Warnsveld, the Netherlands
| |
Collapse
|