Medical-claims databases in the design of a health-outcomes comparison of quetiapine ('Seroquel') and usual-care antipsychotic medication

Quetiapine, olanzapine and haloperidol affect human plasma lipid peroxidation in vitro

OBJECTIVE

Oxidative injury in schizophrenia may be caused not only by pathophysiological processes but partly also by treatment with antipsychotics. The purpose of the present study was to examine and to compare the effects of quetiapine (QUE), olanzapine (OLA) and haloperidol (HAL), at final concentrations corresponding to doses used for treatment of acute episodes of schizophrenia, on plasma lipid peroxidation in vitro, measured by the level of thiobarbituric acid-reactive substances (TBARS).

METHODS

Blood from 30 healthy volunteers was collected into ACD (citric acid/citrate/dextrose) solution. The drugs in form of active substances were dissolved in 0.01% dimethyl sulfoxide, added to plasma at the final concentrations [QUE (175 and 275 ng/ml), OLA (20 and 40 ng/ml), HAL (4 and 20 ng/ml)] and incubated for 1 and 24 h at 37 °C. The level of TBARS was measured spectrophotometrically (according to the Rice-Evans method, 1991).

RESULTS

The comparative study in vitro showed that QUE causes a decrease in the TBARS level in plasma, whereas HAL increases the plasma TBARS level. After 24 h of incubation of plasma with QUE or HAL (at lower and higher concentrations),thedifferences in TBARS levels between the drugs were significant (p = 5.9 × 10⁻⁴, p = 2.2 × 10⁻⁵, respectively).

CONCLUSION

QUE and OLA, contrary to the prooxidative action of HAL, did not induce oxidative stress; moreover, QUE has antioxidant properties.

Quetiapine for schizophrenia

BACKGROUND

Quetiapine is an atypical antipsychotic with, theoretically, a low propensity for movement disorder adverse effects. It is used for the treatment of schizophrenia and other psychoses.

OBJECTIVES

To determine the effects of quetiapine for schizophrenia in comparison to placebo, and other antipsychotics.

SEARCH STRATEGY

Electronic searches of the Cochrane Schizophrenia Group's Register of Trials (February 2003), Biological Abstracts (1982-2000), CINAHL (1982-2000), the Cochrane Library (2000, Issue 1),EMBASE (1980-2000), MEDLINE (1966-2000), PsycLIT (1974-2000), SIGLE on CD (1980-1997), SocioFile (1974-1997) and many conference proceedings and hand searches of specific journals were undertaken. We contacted AstraZeneca Pharmaceuticals for information regarding unpublished trials. The review was updated in February 2003.

SELECTION CRITERIA

All randomised controlled trials where adults with schizophrenia or similar illnesses were assigned to quetiapine, placebo or other neuroleptic drugs and where clinically relevant outcomes were reported.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were inspected independently by reviewers, papers ordered, re-inspected and quality assessed. We independently extracted data. We analysed data using fixed effects relative risk (RR) and estimated the 95% confidence interval (CI). Only homogeneous data were interpreted as favouring treatment or control. Where possible we calculated the number needed to treat (NNT) or number needed to harm statistics (NNH). We calculated relative risk (RR) for dichotomous data, and weighted mean differences (WMD) for continuous data.

MAIN RESULTS

Despite the fact that 3443 people were randomised in 12 quetiapine studies, there are almost no data on service utilisation, economic outcomes, social functioning and quality of life. Over half of those within the quetiapine versus placebo comparison were lost to follow up (53% quetiapine vs 61% placebo, n=716, 4RCTs, RR 0.84 CI 0.7 to 0.9, NNT 11 CI 7 to 55) so it is impossible to interpret any ratings of global or mental state within this comparison with confidence. People allocated quetiapine, however, did not have more movement disorders than those given placebo (n=395, 2 RCTs, RR needing medication for EPSE 0.62 CI 0.3 to 1.2). The same applies to the comparison of >/= 250 mg/day quetiapine with < 250 mg/day quetiapine (49% dropout >/= 250 mg/day vs 58% < 250 mg/day, n=1066, 3 RCTs, RR 0.84 CI 0.8 to 0.9, NNT 11 CI 7 to 29). It should be noted that two deaths occurred in the higher dose group (n=618, 1 RCT, RR 0.1 CI 0.0 to 2.1). When quetiapine was compared with typical antipsychotics, about 36% of both groups failed to complete the short-term studies (n=1624, 6 RCTs, RR 0.87 CI 0.8 to 1.0). Average change in global state was heterogeneous and equivocal (n=762, 3 RCTs, WMD in short term 0.19 CI 0.00 to 0.38, I squared 76%). Mental state measures were also equivocal (n=1247, RR not improved 0.97 CI 0.9 to 1.1) including specific measures of negative symptoms (n=305, 1 RCT, MD change in SANS short term 0.94 CI -0.2 to 2.0). Movement disorders were less prevalent for those allocated quetiapine (n=1117, 4 RCTs, RR needing medication for extrapyramidal adverse effects 0.47 CI 0.4 to 0.6, NNT 4 CI 4 to 5, I squared 88%). Dry mouth (n=649, 2 RCTs, RR short term 2.85 CI 1.5 to 5.6, NNH 17 CI 7 to 65) and sleepiness (n=959, 3 RCTs, RR 1.51 CI 1.1 to 2.2, NNH 18 CI 8 to 181) may also be more prevalent for people given quetiapine compared with the older drugs. In the quetiapine versus risperidone comparison, over 30% of people left the study before completion (n=728, 1 RCT, RR 0.94 CI 0.7 to 1.2). Four people, all treated with quetiapine, died during the study (n=728, 1 RCT, RR 2.86 CI 0.2 to 52.8). Continuous mental state measures did not show clear differences between the two drugs (n=637, 1 RCT, MD PANSS 1.2 CI -2.0 to 4.4). However, considerably fewer people given quetiapine needed medication for extrapyramidal side effects compared with those allocated to risperidone (n=712, 1 RCT, RR 0.27 CI 0.2 to 0.5, NNT 11 CI 10 to 16). Quetiapine caused more dizziness (n=728, 1 RCT, RR 1.85 CI 1.0 to 3.3, NNH 18 CI 7 to 487), more dry mouth (n=728, 1 RCT, RR 2.11 CI 1.2 to 3.8, NNH 14 CI 6 to 82) and more sleepiness than risperidone (n=728, 1 RCT, RR 2.03 CI 1.4 to 2.9, NNH 7 CI 4 to 17).

REVIEWERS' CONCLUSIONS

Quetiapine is effective for the treatment of schizophrenia, but it is not much different from first-generation antipsychotics and risperidone with respect to treatment withdrawal and efficacy. In comparison to first-generation antipsychotics and risperidone, quetiapine has a lower risk of movement disorders but higher risks of dizziness, dry mouth and sleepiness. More clearly reported pragmatic randomised controlled trials should be carried out to determine its position in everyday clinical practice. Studies of medium and long-term effects, including cost-effectiveness, quality of life, social functioning and service utilisation, in comparison with the effects of typical and atypical antipsychotics should be priority areas.

Outcomes research in mental health. Systematic review

BACKGROUND

Outcomes research involves the secondary analysis of data collected routinely by clinical services, in order to judge the effectiveness of interventions and policy initiatives. It permits the study of large databases of patients who are representative of 'real world' practice. However, there are potential problems with this observational design.

AIMS

To establish the strengths and limitations of outcomes research when applied in mental health.

METHOD

A systematic review was made of the application of outcomes research in mental health services research.

RESULTS

Nine examples of outcomes research in mental health services were found. Those that used insurance claims data have information on large numbers of patients but use surrogate outcomes that are of questionable value to clinicians and patients. Problems arise when attempting to adjust for important confounding variables using routinely collected claims data, making results difficult to interpret.

CONCLUSIONS

Outcomes research is unlikely to be a quick or cheap means of establishing evidence for the effectiveness of mental health practice and policy.

The health economic implications of treatment with quetiapine: an audit of long-term treatment for patients with chronic schizophrenia

This retrospective, case series audit assessed the clinical and health-economic impact of long-term treatment with quetiapine ('Seroquel'), a new atypical antipsychotic, in patients with chronic schizophrenia. The study design was of a case series format, comprising patients entered from one centre into the open-label extension of a multicentre 6-week efficacy study. Twenty-one patients (15 male, six female; mean age 39 years) were studied, of whom 17 (81%) had been rated as 'partially responsive' to previous antipsychotics. Data on hospitalisations and information on symptoms were collected retrospectively for the 12 months before quetiapine treatment was initiated and for the 12 months after. Quetiapine was effective in reducing psychotic symptoms with mean BPRS scores reducing significantly, from 38 to 21 (P < 0.005). Motor function was also significantly improved with mean Simpson scale scores reducing from 15 to 12 (P < 0.005). Average inpatient days were reduced by 11% in year two (97 compared with 109 days) while the overall costs of treatment, including drug costs, fell by 5% (I pound sterling 20,843 to I pound sterling 19,827). Four patients had been hospitalised for longer than 5 years before starting quetiapine; these chronically institutionalised patients remained in hospital, despite improved clinical outcomes (mean BPRS scores after treatment of 34, compared with 43 before), for the full 12 months of quetiapine treatment. Were the data from this audit to be re-analysed excluding these four patients then average inpatient days would have been reduced by 33% (45 to 30 days) and overall cost of treatment by 19% (I pound sterling 8617 to I pound sterling 7011). This audit suggests that treatment with quetiapine over this 1-year period was associated with both clinical improvements and a decreased usage of inpatient services. The reduction in hospitalisation costs would appear to compensate for the increased cost of drug treatment. Significantly, potential savings appear to be greatest for those patients with a 'revolving door' pattern of repeated readmission.

The new atypical antipsychotics: a review of pharmacoeconomic studies

The pharmacoeconomic evaluation of atypical antipsychotics for the treatment of schizophrenia involves documentation of clinical effectiveness, quality of life and medical cost outcomes. The findings of pharmacoeconomic studies assist psychiatrists and mental healthcare decision-makers in identifying therapies that provide the greatest benefit to patients at the most acceptable cost. The cost-effectiveness of the newer atypical antipsychotics has been examined using non-controlled cohort studies (either retrospective or prospective), modelling studies or randomised clinical trials. The evidence, from a variety of studies, indicates that clozapine is a cost-effective treatment for neuroleptic refractory schizophrenia. Risperidone and olanzapine may be cost neutral, or at best slightly cost saving, compared with conventional antipsychotics, although they do improve patient clinical effectiveness and quality of life outcomes. There is too little data on pharmacoeconomic outcomes for sertindole and quetiapine to make any conclusions about their cost-effectiveness in treating schizophrenia.

Quetiapine for schizophrenia

BACKGROUND

Quetiapine is a novel atypical antipsychotic with low propensity for movement disorder adverse effects. It is used for treatment of schizophrenia and other psychoses.

OBJECTIVES

To determine the effects of quetiapine for schizophrenia in comparison to placebo, classical and other atypical antipsychotics.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1997), CINAHL (1982-1997), the Cochrane Library (1998, Issue 1), the Cochrane Schizophrenia Group's Register of trials (1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1974-1997), SocioFile (1974-1997) and many conference proceedings and hand searches of specific journals were undertaken. Zeneca Pharmaceuticals was contacted for information regarding unpublished trials.

SELECTION CRITERIA

All controlled trials where adults with schizophrenia or similar illnesses were randomised to quetiapine, placebo or other neuroleptic drugs and where clinically relevant outcomes were reported.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were also independently extracted. For homogeneous dichotomous data the Peto odds ratio (OR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) was calculated on an intention-to-treat basis.

MAIN RESULTS

Seven trials of short duration are included (31 reports) and seven are excluded (15 reports). Apart from that of 'leaving the study early', all other results may be prone to bias and should be viewed with caution since dropout rates are high (48-61%) in each arm of all studies. There are data suggesting less people allocated quetiapine leave the study early (53%) than those in the placebo group (61%) (OR 0.67 CI 0.48-0. 95). Data incorporating considerable assumptions about the many people who left early suggest that global state and psychotic symptoms - both positive and negative - may be more helped by quetiapine than placebo. Although some of these data reach statistical significance their clinical importance is difficult to interpret. While the incidences of extrapyramidal side effects are not different between quetiapine and placebo, side effects such as dizziness and dry mouth are more prevalent in the quetiapine treated group. High proportions of trial participants also leave when quetiapine is compared to chlorpromazine or haloperidol (57% by six weeks). Quetiapine is as potent as chlorpromazine and haloperidol as regards global and mental state but it may cause higher incidences of dry mouth and sleepiness. Extrapyramidal side effects are the same as those of chlorpromazine but may be less than haloperidol. High dose quetiapine is better than low dose quetiapine with regard to leaving the study early, and limited data suggest that the higher dose is also better at marginally improving global state (n = 1, OR 0.70, CI 0.50-0.99, NNT 11). There are no clear differences between high and low dose groups in respect of extrapyramidal side effects.

REVIEWER'S CONCLUSIONS

The high dropout rates are a large problem in interpreting any results other than 'leaving the study early' since about half the data were not available at the end of studies. Before quetiapine's use can be recommended, we need more large, well conducted trials that provide short, medium and long term outcomes relevant to carers and clinicians.

Phenomenology and treatment of psychotic disorders in the psychiatric emergency service

The emergency evaluation of a psychotic patient calls on all of the skills of the psychiatrist. The immediate control of dangerous behavior takes place at the same time that clinicians evaluate patients for delirium. A screening physical examination, a brief mental status examination, and a high index of suspicion for medical diseases are essential tools in the first few minutes of a patient's stay in the psychiatric emergency service. Drugs of abuse are often part of a patient's presentation. Here, too, the first task is to rule out delirium, particularly from sedative or alcohol withdrawal. As soon as a patient's condition is stabilized, the psychiatrist should review all of the available information, develop a working diagnosis, and initiate definitive treatment of the presumed disorder. With fewer emergency patients being hospitalized and with shorter lengths of hospital stay, these initial decisions acquire increasing significance for patient outcome.