Safety, effectiveness, and quality of life of olanzapine in first-episode schizophrenia: a naturalistic study

Attitudes to Medication-Treatment Among Patients and Caregivers: A Longitudinal Comparison of Bipolar Disorder and Schizophrenia From India

BACKGROUND

Attitudes toward medication treatment are thought to significantly influence adherence in bipolar disorder (BD) and schizophrenia. However, the actual impact of patients' treatment attitudes on adherence and determinants of attitudes is still uncertain.

METHODS

A longitudinal examination of treatment attitudes and their correlates was conducted among patients with BD and their caregivers compared with those with schizophrenia. Structured assessments of symptom severity, functioning, insight, medication side effects, knowledge of illness, medication adherence, treatment attitudes, and treatment satisfaction were performed among 176 selected patients (106 with BD and 70 with schizophrenia) and their caregivers. Participants were reassessed on these parameters at 3 and 6 months.

RESULTS

Rates of nonadherence at baseline varied widely between self-reports, clinician ratings, and serum levels. Though symptoms and functioning improved with treatment, overall rates of nonadherence increased in the first 3 months because of early dropouts and remained stable thereafter. However, treatment attitudes and treatment satisfaction remained largely unchanged among patients and caregivers. Both positive and negative attitudes were commonly held and patients' attitudes did not differ between BD and schizophrenia. Patients' attitudes were significantly associated with adherence, insight, knowledge about illness, treatment satisfaction, symptom severity, social disadvantage, and side effects together with caregivers' knowledge, attitudes, and satisfaction. Caregivers of patients with schizophrenia were more knowledgeable and had more positive attitudes than patients.

CONCLUSIONS

Patients' attitudes to medication treatment are associated with adherence over time. They are relatively enduring and mainly associated with insight, knowledge of illness, and treatment satisfaction among patients and their caregivers. These findings could inform psychosocial interventions aiming to improve treatment attitudes and adherence in BD and schizophrenia.

Safety and tolerability of olanzapine compared with other antipsychotics in the treatment of elderly patients with schizophrenia: a naturalistic study

Objective

To evaluate the safety and tolerability of olanzapine in the treatment of elderly patients with schizophrenia.

Methods

A total of 135 outpatients with schizophrenia ≥60 years of age were treated with olanzapine (n = 105) or another antipsychotic (n = 30) and followed up for 6 months. Safety measures included the recording of spontaneous adverse events and extrapyramidal symptoms (EPS). Clinical status and effectiveness of the medications were measured using the Clinical Global Impressions-Severity of Illness and the Global Assessment of Function (GAF) scales. Quality of life was assessed by means of the Spanish version of the EuroQol. The Awad scale was applied to evaluate patients’ subjective attitude towards medication.

Results

The incidence of overall adverse events and EPS was non-significantly lower in patients treated with olanzapine than in patients treated with other antipsychotics. The use of anticholinergic drugs was significantly lower (P = 0.04) in patients treated with olanzapine. Both groups of patients experienced similar improvements in Clinical Global Impressions-Severity and GAF scores. Non-significantly greater improvement in the acceptance of medication occurred at endpoint in olanzapine-treated patients than in control patients as measured by the Awad scale. The improvement in the EuroQol quality of life scale achieved at the end of study did not differ between both treatment groups.

Conclusions

Results from this naturalistic study showed that olanzapine was as safe and effective as other antipsychotic drugs in the treatment of elderly patients with schizophrenia.

Validity of the EQ-5D in assessing and valuing health status in patients with schizophrenic, schizotypal or delusional disorders

Purpose

The EQ-5D is a generic questionnaire generating a health profile and a single index score for health-related quality of life. This study aimed to analyse the discriminative ability and validity of the EQ-5D in patients with schizophrenic, schizotypal or delusional disorders.

Subjects and methods

One hundred sixty-six patients with schizophrenic, schizotypal or delusional disorders (ICD-10 F2) completed the EQ-5D. Measures of quality of life (WHOQOL-BREF), utility (TTO), subjective (SCL-90R) and objective (PANSS, CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of EQ-5D scores. Validity of the EQ-5D self-classifier was analysed by assessing differences in related other scores grouped by response levels of EQ-5D items. Validity of the visual analogue scale (EQ VAS) and the EQ-5D index (UK social tariff) was analysed by assessing their correlation with all other scores.

Results

Seventy-nine percent of respondents reported problems in at least one of the EQ-5D dimensions (anxiety/depression 57%, usual activities 45%, pain/discomfort 44%, self-care 29%, mobility 22%). The mean EQ VAS score/EQ-5D index was 65.7/0.71. The four most frequently reported EQ-5D health states covered 45% of all respondents. For almost all EQ-5D dimensions, different response levels were associated with significantly different scores of measures used for comparison. Correlation of EQ VAS score and EQ-5D index were largest with scores of subjective measures (SCL-90R: −0.50 and −0.73; WHOQOL mental subscore 0.62 and 0.58; always P < 0.001).

Discussion and conclusion

The EQ-5D showed a moderate ceiling effect and seems to be reasonably valid in this patient group.

One-year outcomes in schizophrenia after switching from typical antipsychotics to olanzapine in Japan: an observational study

Background

The purpose of this study was to assess the 1-year clinical, functional, and safety-related outcomes following a switch to olanzapine of at least one typical antipsychotic drug in the previous regimen in the treatment of patients of schizophrenia in Japan.

Methods

Using data from a large 1-year prospective, multicenter, naturalistic study of olanzapine for the treatment of schizophrenia in Japan, patients who were switched from any oral typical antipsychotic to olanzapine were identified. Mixed models for repeated measures, controlling for baseline demographics, were utilized to assess outcomes for clinical and functional measures.

Results

Of the 262 patients who switched from typical antipsychotics to olanzapine, 41% were outpatients and 59% were inpatients. Most of these patients were switched due to poor medication efficacy (71.0%) or medication intolerability (25.6%). Most patients (71.4%) completed the 1-year study. Clinically and statistically significant (P < 0.01) improvements were observed in patient illness severity and health-related quality of life, including improvements in global symptom severity and in positive, negative, depressive, and cognitive symptoms. Over half of the patients (58.3%) demonstrated a treatment response to olanzapine and 47.4% achieved symptom remission. Mean weight gain from baseline to endpoint was 2.31 ± 4.72 kg, with 30.4% of patients experiencing clinically significant weight gain (at least 7% of baseline weight).

Conclusion

During this 1-year naturalistic treatment of schizophrenia patients in Japan, switching from typical antipsychotics to olanzapine resulted in significant improvements in patients’ clinical and functional outcomes. Approximately one-third of patients had clinically significant weight gain. These findings highlight the favorable benefit to risk profile of switching to olanzapine following failure on typical antipsychotics.

Effects of controlled-release formulations of atypical antipsychotics on functioning and quality of life of schizophrenic individuals

INTRODUCTION

Controlled-release formulations of atypical antipsychotics have recently been introduced into clinical practice. Clinical studies have indicated that these new therapies induce meaningful improvements in the functioning and quality of life of schizophrenic individuals.

AREAS COVERED

The present analysis makes an attempt to address the clinical relevance of these studies and their contribution to the understanding of the mechanisms of action of these new drugs. A Medline search was done using the keywords 'antipsychotic', 'plasma level', 'quality of life' and 'functioning'.

EXPERT OPINION

After reviewing the literature, it seems that symptom control and side effects may play a role in modulating the functioning and quality of life of schizophrenic individuals treated with controlled-release formulations of atypical antipsychotics. The analysis also highlights that these new drugs may possess peculiarities and similarities in regulating patient functioning. However, the low number of clinical analyses that have focused on these aspects of antipsychotic therapy limits the interpretation of the results. Additional comparative clinical trials are needed to evaluate how the pharmacokinetic/pharmacodynamic properties of antipsychotic drugs may modulate the functioning and quality of life of schizophrenic individuals, as well as to establish whether new clinical benefits may come from the use of these drugs in schizophrenia therapy.

Health outcomes of schizophrenia in Thailand: Health care provider and patient perspectives

BACKGROUND

Patient views are considered an important measure in schizophrenia. There are no studies of the association between patient and clinician perspectives in Thailand. The objectives of this study were to (a) describe the patterns of clinician-rated psychiatric symptoms and patient ratings of health related quality of life and (b) quantify the association between clinician and patient-rated measures.

METHOD

The cross-sectional study included a stratified representative sample of 307 patients with schizophrenia or schizoaffective disorder in treatment at mental health services during the survey period. Clinicians measured illness severity using the Brief Psychiatric Rating Scale-Expanded while patients rated their health-related quality of life using a six-dimensional EuroQoL instrument. Pearson correlation coefficient and hierarchical regression analyses were used to quantify the association between schizophrenia outcomes elicited from patients and health care providers.

RESULTS

There was only a modest association between patient-rated and clinician-rated outcomes. In a regression model clinician-rated symptoms explained 33% of patient satisfaction with their quality of life. Negative, cognitive and mood symptoms but not the positive symptoms were significant predictors of patient-rated quality of life.

CONCLUSION

Policy makers and clinicians need to be aware that clinician-rated and patient-rated outcomes are very different. Improving quality of life of people with schizophrenia requires greater attention be given to negative, cognitive and mood symptoms.

The Italian guidelines for early intervention in schizophrenia: development and conclusions

AIM

The effectiveness of early intervention in schizophrenia is still under discussion. The guidelines described in the present paper were aimed at contributing to the current debate by providing Italian practitioners, families, patients and health managers with evidence-based information on early intervention. They also examined the diagnostic tools that are currently available for assessing different stages of psychotic disorders.

METHODS

A multidisciplinary panel of experts (the Guidelines Development Group) used a set of key-questions to develop an explicit search strategy to conduct a systematic review of the literature published from January 2000 to June 2006. Trained personnel then selected papers from those yielded by the literature search. The Guidelines Development Group's final recommendations were scaled according to the Italian National Guidelines System grading system.

RESULTS

The evidence available up to the time of the literature search does not allow for recommendation of early intervention targeting prodromal or at-risk patients to prevent progression from the prodromal phase to acute, full-blown psychosis, nor to improve prognosis. Conversely, identification and timely treatment of first-episode psychotic patients through specific early intervention programmes are highly recommended.

CONCLUSIONS

The Italian Guidelines on early intervention in schizophrenia are based on a comprehensive assessment of an updated, large-scale body of literature. They draw specific, evidence-based conclusions to assist clinicians and stakeholders in the planning and implementation of appropriate intervention programmes. Further research is needed to ascertain the effectiveness of early intervention in delaying or preventing the conversion to psychosis and improving prognosis in prodromal or at-risk patients. Further investigation is also required for first-episode and critical period patients.

A review of second-generation antipsychotic discontinuation in first-episode psychosis

"All-causes discontinuation" refers to discontinuation of treatment for any reason, and adherence to medication is an important component of this measure. Two recent landmark studies suggest that adherence is a major issue in patients with first-episode psychosis (FEP) right from the onset of treatment. In this review, the incidence, reasons for, and clinical outcomes of medication discontinuation in FEP are considered. More than 40% of patients with FEP discontinue medication during the first 9 months of treatment, at which point the chances of relapse increase dramatically. Findings concerning predictors of medication discontinuation in this patient population that have been replicated in more than one study include severity of psychopathology, lack of insight into illness, negative attitudes towards medications, comorbid substance use, and medication side effects. Interventions that have the potential to decrease discontinuation rates in patients with psychotic disorders include orally disintegrating tablets, long-acting injectable drugs, cognitive-behavioral therapy, compliance therapy, family support/intervention, and peer support, although these strategies have largely been unexplored in FEP. In addition to the question of medication discontinuation in the acute treatment of FEP, another important issue is how long patients with FEP should be treated with antipsychotics once they have achieved remission; unfortunately, little evidence is available to guide the decision as to whether medication should be discontinued or maintenance treatment provided in this situation. Studies are therefore needed to identify predictors of patients with remitted FEP who are less likely to relapse when medication is discontinued. Taken together, the findings presented in this article underscore the importance of addressing issues related to medication discontinuation as a means of preventing long-term morbidity and enhancing remission and functional recovery in FEP.

Patterns of physician and patient rated quality of life during antipsychotic treatment in outpatients with schizophrenia

Quality of life (QoL) in patients with schizophrenia has been assessed both from physician and patient perspectives, but little is known about agreement between these perspectives and predictors of agreement. The aim of this study was to analyze a large sample of patients with schizophrenia to discover patterns of physician and patient-rated QoL in patients with schizophrenia and identify predictors for these patterns. This study (EASE) was designed to investigate the QoL and subjective well-being in out-patients with schizophrenia during antipsychotic treatment in a naturalistic setting. Assessments were carried out at baseline and at 3, 6, 9 and 12 months, using the quality of life scale (QLS) and the subjective well-being on neuroleptics scale (SWN-K). A hierarchical cluster analysis was used to define groups of patients based on the SWN-K and QLS total scores at all visits. 1174 patients were included in the cluster analyses that were based on SWN-K and QLS total scores over time. Four distinct clusters were identified: patients with: (1) continuously high QoL (23.2%), (2) continuously moderate QoL (45.8%), (3) continuously low QoL (11.2%), and (4) improving QoL (19.9%). Clusters 1-3 were stable in terms of QoL, whilst cluster 4 changed towards improvement. Various predictors for the four clusters were identified. In the cluster with improving QoL, the absence of treatment with an oral conventional antipsychotic pre-study and no medication change due to lack of efficacy at baseline were predictors for improvement. In the cluster with continuously high QoL, no medication change due to lack of efficacy and lowest CGI-S scores at baseline were predictors. Oral conventional antipsychotic treatment pre-study was predictive for the cluster with continuously moderate QoL. In the cluster with continuously low QoL, medication change due to lack of efficacy and highest CGI-S scores were predictors. These findings suggest that various factors may predict whether a patient with schizophrenia experiences a continuously high QoL, a continuously moderate QoL, a continuously low QoL, or improving QoL whilst on antipsychotic treatment.

Quality of life in schizophrenic patients

In the last decades, there has been increased interest in the field of quality of life in mental disorders in general, and particularly in schizophrenia. In addition, the appearance of the atypical antipsychotic drugs (amisul pride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone) with different therapeutic and side-effect profiles, has promoted a greater interest in assessing the quality of life of schizophrenic patients. In this paper we will briefly summarize the difficulties in assessing quality of life in schizophrenic patients, as well as the results concerning their quality of life and the influence of psychopathology, especially negative and depressive symptoms, on it. We will also review data from recent clinical trials showing the impact of antipsychotic treatments and their side effects upon quality of life.

Quality of life and subjective well-being during treatment with antipsychotics in out-patients with schizophrenia

OBJECTIVE

To assess the Quality of Life (QOL) in outpatients with schizophrenia under antipsychotics from two perspectives: a "subjective" perspective as rated by the patient and an "objective" perspective as rated by the physician.

METHOD

EASE (External Assessment of Quality of Life in Out-patients with Schizophrenia) is a 12-month, prospective, naturalistic study of the QOL in patients on antipsychotic treatment for schizophrenia in an out-patient setting in Germany. The study included 1462 patients who were initiated on a new antipsychotic or switched to another antipsychotic. The Subjective Well-being under Neuroleptics scale (SWN) and the Quality of Life Scale (QLS) were used to assess the QOL in these patients. The Clinical Global Impression (CGI) scale was used to assess overall symptom severity. Four cohorts were identified and evaluated: (a) patients treated with olanzapine monotherapy (N=1007), (b) another atypical antipsychotic as monotherapy (N=335), (c) a typical antipsychotic as monotherapy (N=32) and (d) combination therapy with more than one antipsychotic (N=88).

RESULTS

QOL as assessed by both SWN and QLS improved in all treatment cohorts. SWN responses in the respective cohorts were (a) 52.3%, (b) 38.8%, (c) 31.3% and (d) 44.3%, whilst the QLS responses were (a) 58.2%, (b) 45.1%, (c) 59.4% and (c) 40.9%. Symptom severity as assessed by the CGI also improved over time regardless of the type of antipsychotic. An increase of one point on the CGI corresponded to a change in SWN total score of -9.67 points and a change in QLS total score of -13.36 points.

CONCLUSIONS

Both QOL and symptom severity improved over the 12-month study period, regardless of the type of antipsychotic taken. QOL improvement as perceived both from a "subjective" and an "objective" perspective was greatest in the cohort on olanzapine monotherapy.

Correlation of physician and patient rated quality of life during antipsychotic treatment in outpatients with schizophrenia

Perception of quality of life (QOL) may differ depending on the perspective. This 12-month, prospective, naturalistic study compared QOL ratings in outpatients on antipsychotic treatment for schizophrenia both from a "subjective" patient rated and an "objective" physician rated perspective. Included were 1462 patients. Two scales were used to assess patient and physician perspectives: the Subjective Well-being on Neuroleptics (SWN) scale and the Quality of Life Scale (QLS). Linear correlation was found between both ratings: 10 points on the SWN corresponded to 9.35 points on the QLS. Spearman's correlation coefficients increased over time up to r=0.71 at Month 12. Patients were grouped into four cohorts depending on the degree of concordance between SWN and QLS ratings. Several factors affecting the concordance of both ratings were identified. Compared to the cohort with QLS=SWN, higher QOL ratings by the physician (QLS>>SWN) were more likely in females than in males (OR=1.36; 95% CI 1.00 - 1.85) and in older than in younger patients (<or=30 years vs. >50 years: OR=0.58, 95% CI 0.34 - 0.998), but less likely in patients with high baseline CGI-severity (CGI >4; OR=0.63; 95% CI 0.47 - 0.86) or treatment with oral typicals before baseline (OR=0.53; 95% CI 0.31 - 0.91). Higher QOL ratings by the patient (SWN>>QLS) were less likely in patients with psychotherapy before baseline (OR=0.54; 95% CI 0.36 - 0.81), medication intolerability before baseline (OR=0.53; 95% CI 0.36 - 0.78) or patient request of treatment change at baseline (OR=0.64; 95% CI 0.42 - 0.96). The combination of several factors predicted concordant ratings, including male sex, young age, high CGI at baseline, and psychotherapy prior to the study.

The "Seroquel" Outcomes Study (SOS): Efficacy and tolerability of quetiapine in a long-term, naturalistic study of patients with schizophrenia

Objective. The "Seroquel" Outcomes Study (SOS) aimed to assess the efficacy and tolerability of quetiapine in patients with schizophrenia in the clinical practice setting. Methods. A 6-month, non-comparative, open-label study in adults with schizophrenia in a standard care setting in Spain. Outpatients received flexibly dosed quetiapine. Efficacy was evaluated using the Brief Psychiatry Rating Scale (BPRS) and the Clinical Global Impression (CGI) scale. BPRS response was defined as≥30% decrease from baseline. Tolerability was assessed using the Simpson-Angus Scale (SAS) and a modified Udvalg for Kliniske Undersogelser (UKU) side-effects scale. Results. A total of 2029 patients enrolled. Significant changes from baseline to Month 6 were recorded for BPRS total and subscale scores (P<0.001). Compared with doses of≥600 mg/day, doses of<400 mg/day were a strong predictor of a lower response rate (OR 0.62; 95% CI: 0.48, 0.82) and higher withdrawal rate (OR 3.3; 95% CI: 2.5, 4.4). Mean change in weight was minimal (+0.4 kg). Somnolence (26.7%), asthenia (12.5%), and constipation (9.8%) were the most common adverse events. Conclusion. Quetiapine was found to improve symptoms of schizophrenia, as indicated by a significant decrease in BPRS scores, and was well tolerated by patients in clinical practice.

The effectiveness and predictors of response to antipsychotic agents to treat impaired quality of life in schizophrenia: A 12-month naturalistic follow-up study with implications for confounding factors, antidepressants, anxiolytics, and mood stabilizers

OBJECTIVE

This study examined specific predictors of the efficacy of risperidone (RP), olanzapine (OL) and first-generation antipsychotic agents (FGAs), the role of confounding factors, and concomitant agents such as antidepressants, anxiolytics, and mood stabilizers in the treatment of health related quality of life (HRQL) impairment of schizophrenia patients.

METHOD

This was a community-based, open label, parallel group naturalistic study of 124 schizophrenia outpatients who received either RP, OL, FGA, or combined agents (CA). Evaluations were performed at baseline and 12 months later. They included the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), the Positive and Negative Syndrome Scale (PANSS), the Distress Scale for Adverse Symptoms, and inventories for the assessment of distress severity, subjective tolerability, and self-efficacy.

RESULTS

OL was found to be superior to RP, FGAs and CA in terms of quality of life. FGAs revealed greater therapeutic benefit than RP, which was more beneficial than combined therapy. Improvement in Q-LES-Q was revealed in patients who received antidepressants and anxiolytics, but not mood stabilizers, or anti-Parkinson drugs. This effect was independent of treatment groups and gender. Regression models revealed that changes in emotional distress and side effects were common predictors for HRQL changes across treatment groups. Specific predictors of HRQL efficacy included self-efficacy for OL, negative and positive symptoms for RP, dysphoric mood and positive symptoms, daily doses and self-efficacy for FGA treated patients.

CONCLUSION

These findings suggest that OL is beneficial in the treatment of HRQL impairment in schizophrenia compared with RP, FGAs and CA. Special attention should be paid to specific predictors of HRQL efficacy for each antipsychotic agent, and to concomitant treatment with antidepressants and anxiolytics.

[Comparative evaluation of quality of life in patients with schizophrenia treated with conventional versus atypical neuroleptics: results of a transversal study]

AIM

The World Health Organization has defined quality of life as "the perception of an individual, his/her place in life, in the context of the culture and the system of values in which he/she lives and in relation to his/her objectives, expectations, standards and concerns". The quality of life of the schizophrenic patients has been largely studied for the evaluation of their medical, social and therapeutic needs. The impact of neuroleptics, in particular atypical neuroleptics, on the subjective quality of life of these patients remains to be specified. The aim of this study was to compare the subjective quality of life of schizophrenic patients treated with classical neuroleptics (CN) or atypical neuroleptics (AN).

METHODS

One hundred patients meeting DSM IV criteria for the diagnosis of schizophrenia (American Psychiatric Association, 1994) were included in the study. Sixty-four schizophrenic patients were treated with CN and thirty-six with AN. The symptomatology of the patients was assessed using the Positive And Negative Syndrome Scale, (PANSS, Kay et al., 1987) and the Schedule for the Deficit Syndrome (SDS, Kirkpatrick et al., 1989). The extra-pyramidal symptoms were assessed using the Extrapyramidal Symptom Rating Scale (Chouinard et al., 1980). The Subjective quality of life was studied using the Lehman Quality of Life Interview (QOLI, Lehman, 1988) translated and validated in France.

RESULTS

The patients treated by CN did not differ from the patients treated by AN in terms of severity of the positive and negative symptoms. The patients treated with AN presented significantly less extrapyramidal side effects than the patients treated with CN. No significant difference in terms of quality of life was found between both groups of patients.

CONCLUSION

The kind of neuroleptic (CN vs AC) does not seem to influence the quality of subjective life of schizophrenic patients.

The relationship between patient satisfaction and treatment outcomes in schizophrenia

In recent years, the goals of treatment in schizophrenia have evolved from objective improvements in psychotic symptoms to encompass patient-related factors such as subjective response and quality of life. In order to examine factors that influence patient satisfaction with treatment, subjective quality of life and subjective response to treatment, two literature searches were performed using PubMed. The first searched for articles of any kind with no time limits using the search parameters 'schizophrenia AND satisfaction', 'antipsychotic AND satisfaction', 'schizophrenia AND subjective response', 'schizophrenia AND therapeutic alliance', 'schizophrenia AND psychosocial OR psychoeducation'. Secondly, PubMed was searched between January 1990 and December 2005 using the key words 'satisfaction', 'subjective response' and 'quality of life' in combination with an array of atypical agents. Results demonstrated that patient satisfaction with antipsychotic therapy is influenced by multiple factors. The most frequently reported reasons for dissatisfaction include drug side effects, lack of involvement in treatment planning or decision-making and lack of involvement of family members in the care plan. The majority of studies have demonstrated that the atypical antipsychotics are associated with significant improvements in quality of life, functional status and patient satisfaction compared with conventional agents. The therapeutic alliance is key to achieving optimal outcomes, by providing information and education to meet patients' needs, while facilitating compliance with drug therapy to ensure better clinical outcomes. A long-acting atypical antipsychotic that can ensure medication delivery will provide a platform for psychosocial interventions, and thus may further increase patient satisfaction and, ultimately, improve long-term outcomes in schizophrenia.

Randomized, double-blind 6-month comparison of olanzapine and quetiapine in patients with schizophrenia or schizoaffective disorder with prominent negative symptoms and poor functioning

This study compared the effects of olanzapine (OLZ) with those of quetiapine (QUE) for improving negative symptoms in patients diagnosed with schizophrenia or schizoaffective disorder who had prominent negative symptoms and marked deficits in social or occupational functioning. In this 6-month, multicenter, double-blind clinical trial, patients were randomized to treatment with OLZ (n = 171, 10-20 mg/d) or QUE (n = 175, 300-700 mg/d). Patients were treated at community mental health centers and assigned case managers who developed individualized psychosocial treatment plans. The primary efficacy measure was the reduction in negative symptoms using the Scale for the Assessment of Negative Symptoms. Secondary measures assessed changes in functioning, psychopathology, and treatment tolerability. Treatment with OLZ or QUE led to a significant reduction in negative symptoms, with no between-group difference (P = 0.09). Both treatment groups also showed significant improvement on most efficacy measures. Olanzapine-treated patients showed significantly greater improvement on positive symptoms and on several measures of functioning including Global Assessment of Functioning Scale, Quality of Life Instrumental Role domain, and level of effort in psychosocial or occupational rehabilitation programs. Significantly more OLZ-treated patients completed the study (52.6% OLZ, 37.7% QUE, P = 0.007). Treatment differences in safety were relatively small and not thought to be clinically relevant. Patients with schizophrenia who manifest prominent negative symptoms and marked functional deficits demonstrated significant improvement in negative symptoms after treatment with OLZ or QUE. Greater improvement in positive symptoms and a greater study completion rate may hold relevance to enhanced functional outcomes observed after OLZ therapy.

A decision model to compare health care costs of olanzapine and risperidone treatment for schizophrenia in Germany

Second-generation atypical antipsychotics such as clozapine, olanzapine, risperidone, quetiapine, ziprasidone, amisulpride and ariprazole offer the potential to reduce the significant health care resource demands in the treatment of schizophrenia through improved levels of initial clinical response and reduced levels of long-term acute relapse. However, the optimal sequencing of these drugs remains unclear. To consider this issue from a health economic viewpoint a decision model approach was used comparing healthcare costs and clinical outcomes when treating patients with alternative sequences of atypical antipsychotic treatment. Treated patients were assumed to be in a current acute episode with at least a 10-year history of disease and to be naive to previous atypical treatments. Treatment strategies were based on either first-line olanzapine or risperidone with switching to the alternative drug as second-line treatment following an inadequate clinical response to first-line drug therapy. Clinical response data were derived from a pivotal published comparative study of both olanzapine and risperidone. Published data on the long-term use of antipsychotic drugs where used wherever possible to populate the model for relapse rates during the maintenance phase. Health care resource data were defined for Germany based on expert clinical opinion. A treatment strategy of first-line olanzapine was shown to be cost saving over a 1-year period, with additional clinical benefits in the form of avoided relapses. The model suggests that over the first year of treatment a strategy of first-line olanzapine is associated with lower risk of additional relapse (0.33 fewer acute relapses per 100 patients per year) and with cost savings (euro 35,306 per 100 patients per year). There is a need for longer term direct in-trial comparisons of atypical antipsychotics to confirm these indicative results.

Extrapyramidal side effects with atypical neuroleptics in bipolar disorder

OBJECTIVE

To examine, in a real-world clinical setting, the risk of extrapyramidal symptoms (EPS) with atypical neuroleptics in bipolar patients.

METHODS

The authors assessed 51 individual patient trials of atypical neuroleptic agents (17 risperidone, 13 olanzapine, 11 quetiapine, 8 ziprasidone, and 2 aripiprazole) in 37 bipolar patients (type I or type II). Risk of EPS was assessed using the Abnormal Involuntary Movement Scale, Barnes Akathisia Rating Scale, and the Simpson-Angus Scale. Mean duration of treatment was 25.5 weeks (range 3-107 weeks) and 60.8% of patients were female.

RESULTS

62.7% of trials resulted in moderate to severe EPS. EPS and discontinuation frequencies were similar between specific neuroleptic agents or between high potency (risperidone/ziprasidone/aripiprazole; 52.9%, 27/51 trials) and low potency (quetiapine/olanzapine; 47.1%, 24/51 trials) agents. In a multiple regression model adjusted for confounders, akathisia was less common with low potency agents. Younger age was associated with more akathisia. 31.4% (11/35) of trials discontinued due to side effects. 7.8% (4/51) of trials led to mild de novo tardive dyskinesia.

CONCLUSIONS

Over one-half of bipolar patients experienced EPS in this real world clinical setting. This rate is much higher than the 5-15% range reported in clinical trials, suggesting potential problems with clinical trial generalizability.

Effectiveness and tolerability of schizophrenia treatment in Central and Eastern Europe: results after 1 year from a prospective, observational study (IC-SOHO)

Objective. The Intercontinental Schizophrenia Outpatient Health Outcomes (IC-SOHO) study is intended to complement smaller, shorter-term observational studies and randomised controlled clinical trials in providing information on the treatment of schizophrenia in various geographies that have not been well studied previously. Methods. Interim results after 12 months are presented for a subset of patients from eight Central and Eastern European (CEE) countries initiating or switching to olanzapine, risperidone, or typical antipsychotic monotherapy at Baseline (n=1387). Results. Patients initially prescribed olanzapine and risperidone experienced significantly greater improvements in a broad range of schizophrenia symptom domains compared with patients prescribed typicals. Furthermore, patients in the olanzapine group showed significantly greater improvements in overall and negative symptom domains compared with the risperidone group (all P≤0.05). While patients in the olanzapine group gained more weight than the other two groups, they had significantly lower odds of developing extrapyramidal symptoms, loss of libido, and sexual dysfunction. Patients initially prescribed olanzapine were also significantly less likely to have changed or added antipsychotics during 12 months of treatment compared with the risperidone and typicals groups. Conclusion. In this CEE sample, schizophrenia treatment outcomes after 12 months varied between patients initially prescribed different antipsychotics.

Effect of switching antipsychotics on antiparkinsonian medication use in schizophrenia: population-based study

BACKGROUND

The extent to which atypical antipsychotics have a lower incidence of extrapyramidal symptoms than typical antipsychotics has not been well-evaluated in community practice.

AIMS

To examine the effects of switching antipsychotics on antiparkinsonian medication use among individuals with schizophrenia in UK general practices.

METHOD

We included those switched from typical to atypical antipsychotics (n=209) or from one typical antipsychotic to another (n=261) from 1994 to 1998.

RESULTS

Antiparkinsonian drug prescribing dropped by 9.2% after switching to atypical antipsychotics (P<0.0001). Switching to olanzapine decreased the rate by 19.2% (P<0.0001), but switching to risperidone had no impact. After switching from one typical antipsychotic to another, antiparkinsonian drug prescribing increased by 12.9% (P<0.0001).

CONCLUSIONS

Reduction in antiparkinsonian medication use after switching to atypical antipsychotics was substantial in community practice but not as large as in randomised controlled trials. The rate of reduction varied according to the type of medication.

Pharmacological treatment and other predictors of treatment outcomes in previously untreated patients with schizophrenia: results from the European Schizophrenia Outpatient Health Outcomes (SOHO) study

The present study aimed to compare health outcomes and tolerability according to antipsychotic medication (olanzapine, risperidone or an oral typical antipsychotic) after 6 months of treatment in a group of 919 schizophrenic patients who had never previously been treated with antipsychotics. Demographic and clinical predictors of outcome were also identified. Data were extracted from the Schizophrenia Outpatient Health Outcomes (SOHO) study, a prospective, observational study of schizophrenia treatment in 10 European countries. Patients who initiated olanzapine were more likely to have a clinical response than those in the risperidone cohort, and had a greater improvement in quality of life than patients in the risperidone or typical antipsychotic cohorts. High negative and depression symptom scores at baseline and the presence of extrapyramidal symptoms at baseline predicted a worse clinical response, whereas hostile behaviour, paid employment and substance abuse predicted a better clinical outcome. The olanzapine cohort gained more weight than patients in the risperidone cohort, but no significant difference in weight gain was observed between olanzapine and the oral typical antipsychotic cohort. The results should be interpreted conservatively due to the observational study design.

Condensed version of the Quality of Life Scale for schizophrenia for use in outcome studies

The Quality of Life Scale (QLS(21)) is widely used in clinical trials involving schizophrenia patients. This study aimed to identify a core subset of QLS(21) items that maintains the validity and psychometric properties of the complete version. A parsimonious subset of items from the QLS(21) that can accurately predict the total scale score was sought and evaluated in 133 schizophrenia patients, using the heuristic algorithm for a regression model. Two additional data sets were used for model validation: a subset of 124 patients who participated in the model construction and who completed the QLS(21) 1 year later as well as a new sample of 40 inpatients. Patients were examined with the Positive and Negative Syndrome Scale (PANSS), the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), the Talbieh Brief Distress Inventory (TBDI), the Extrapyramidal Symptom Rating Scale (ESRS) and the Global Assessment of Functioning Scale (GAF). Using only five QLS items (social initiatives, adequacy, acquaintances, motivation, and time utilization; QLS(5)) as predictors, the correlation was 0.9805 between the predicted and true QLS totals. Two validation samples confirmed this finding. Additional analyses indicate that the QLS(5) exhibited similar performance to the QLS(21) regarding construct validity, test-retest reliability and responsiveness to changes over time. Thus, the five-item condensed Quality of Life Scale for schizophrenia maintains the validity of the full QLS, and has the advantage of shorter administration time. Utilization of the revised QLS(5) in routine care and clinical trials may potentially facilitate evaluation of treatment outcomes in schizophrenia.

The treatment of schizophrenia: from premorbid manifestations to the first episode of psychosis

To achieve the best therapeutic results in schizophrenia--like most other disorders--primary prevention is preferable to early and prompt treatment, which, in turn, is preferable to treatment of chronically established illness. Unfortunately, there currently exist no accurate markers that can provide information regarding the future course of illness and guide treatment in asymptomatic or mildly symptomatic individuals. Therefore, most treatment efforts are currently focused on patients who have already experienced their first psychotic episode. This paper reviews the efforts to identify accurate markers heralding psychotic illness, as well as treatment considerations in the early phase of the disease.

Olanzapine in subjects with a first-episode psychosis non-responsive, intolerant or non-compliant to a first-line trial of risperidone

Objective. Investigation of the efficacy and tolerability of olanzapine (OLZ) as second-line treatment in subjects with a first-episode psychosis (FEP) who had been non-responsive, intolerant or non-compliant to Risperidone (RIS). Methods. The Early Psychosis Prevention and Intervention Centre in Melbourne admitted 786 FEP subjects between 1998 and 2000. Data were collected from subjects' medical records (MR). The objective was to evaluate the efficacy of OLZ as measured by CGI-S, GAF, SOFAS and remission rates as well as tolerability. Results. A total of 104 subjects were switched because of non-response (38%), non-compliance (15%), or intolerance (47%). Independent of reasons for switch, significant symptomatic and functional improvements were detected. Overall, 46 subjects (44%) achieved full remission. Regression analysis indicated that reason for switch did not predict full remission. Significantly more extrapyramidal side effects (P<0.001) were related to previous RIS and significantly more weight gain to the subsequent OLZ treatment (P<0.001). Conclusions. OLZ may be an effective alternative for FEP patients who are non-responsive, intolerant or non-compliant to RIS. The decision to switch to OLZ must be weighted against the greater risk of weight gain with its risks for medical complications and its psychosocial consequences.

Clinical effectiveness in first-episode patients

Managing patients with first-episode schizophrenia is a challenging task for psychiatrists. Early diagnosis and effective intervention are vital to achieving long-term positive clinical outcomes among first-episode patients. Although these patients are the most responsive to treatment, they are also more susceptible to adverse events. The efficacy and improved tolerability associated with the newer atypical antipsychotics means that these drugs can be used successfully in the treatment and long-term management of schizophrenia from the onset of illness. However, as well as managing the symptoms of the disease, pharmacological treatments need to meet the broader requirements of clinical effectiveness that encompass all of the outcome domains associated with schizophrenia. This article will discuss available data on atypical antipsychotics in first-episode patients and present the primary results from the F1RST (Southwark first-onset psychosis) study, which examined the use of quetiapine for the first-line management of schizophrenia as part of a specialist episode psychosis service.