Patient characteristics and prescription patterns of atypical antipsychotics among patients with schizophrenia

Ethnic disparities in clozapine prescription for service-users with schizophrenia-spectrum disorders: a systematic review

Clozapine is the only licenced medication for treating treatment-resistant schizophrenia. Previous studies have suggested unequal rates of clozapine treatment by ethnicity among individuals with schizophrenia-spectrum disorders. One previous review has investigated this topic but was restricted to studies from the USA. This current review aims to synthesise the international literature regarding ethnic disparities in clozapine prescription amongst individuals with schizophrenia-spectrum disorders. We searched CINAHL, PubMed, Medline, Embase, APA PsycINFO and Open Grey and reviewed studies reporting on the proportion of service-users prescribed clozapine separately for different ethnic groups, in individuals with a primary diagnosis of schizophrenia or any schizophrenia-spectrum disorders. A narrative synthesis was conducted to integrate information from included studies. The review was registered in PROSPERO (Number: CRD42020221731). From 24 studies, there is strong, consistent evidence that Black and Hispanic service-users in the UK and the USA are significantly less likely to receive clozapine than White/Caucasian service-users after controlling for multiple demographic and clinical potential confounders. In New Zealand, Māori service-users were reported to be more likely to receive clozapine than those of White/European ethnicity. There is mixed evidence regarding Asian service-users in the UK. The mentioned disparities were observed in studies with TRS and non-TRS cohorts. The results imply that access to clozapine treatment varies among ethnic groups. These findings raise an ethical concern as they suggest a compromise of the standards of care in schizophrenia treatment practices. Interventions are needed to reduce clozapine prescribing disparities among ethnic communities.

Oral antipsychotic prescribing and association with neighbourhood-level socioeconomic status: analysis of time trend of routine primary care data in England, 2011-2016

BACKGROUND

Increasing rates of antipsychotic prescribing have been reported previously, particularly for second-generation antipsychotics (SGAs), which are generally better tolerated than the older first-generation antipsychotics (FGAs). Prescribers, however, may exert bias, favouring prescriptions of novel drugs for patients of higher socioeconomic status (SES). We aimed to examine time trends in: (1) prescriptions of oral FGAs vs. SGAs and (2) associations between antipsychotic prescriptions and neighbourhood-level SES in England between 2011 and 2016.

METHODS

We used publicly available data for prescriptions made in primary care and linked general practices' postcodes with the Index of Multiple Deprivation (IMD) as a measure for neighbourhood-level SES. Absolute numbers of antipsychotic prescriptions were calculated. Linear regression analysis was used to examine the association of SGA vs. FGA prescription pattern with time and with SES.

RESULTS

A total of 27,486,000 oral antipsychotics were prescribed during the study period, mostly SGAs (n = 21,700,000; 78.9%). There was a significant increase in the ratio of SGA/FGA prescriptions over time (β = 0.376, 95% CI 0.277-0.464, P < 0.001). Individual FGAs were increasingly prescribed in areas of lower SES and the converse for SGAs except amisulpride. During the study period, a significantly larger proportion of total SGA prescriptions relative to total FGAs were made in areas of higher SES (β = 0.182, 95% CI 0.117-0.249, P < 0.001).

CONCLUSION

Prescriptions of antipsychotics continue to rise overall, with SGAs taking preference especially in areas of higher SES. The pattern of antipsychotic prescription favouring people in areas of lower social deprivation carries implications on inequalities even among sub-groups of people with mental disorders.

Acupuncture as Add-On Treatment of the Positive, Negative, and Cognitive Symptoms of Patients with Schizophrenia: A Systematic Review

Background: Schizophrenia is a severe psychiatric disorder that has a large impact on patients' lives. In addition to Western medicine, the use of additional treatments, such as acupuncture, in treating the positive, negative, and cognitive symptoms is increasing. Methods: We conducted a systematic review on the use of acupuncture as an add-on treatment for patients with schizophrenia that are in regular care, with a special focus on the treatment of the often accompanying sleep disorders. In this study, we searched the Medline, ScienceDirect, Cochrane Library, Scopus, and ERIC databases with a cut-off date of 31 December 2017, thereby following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol. Results: Our search resulted in 26 eligible studies with 1181 patients with schizophrenia who received acupuncture treatment. Most studies showed limited evidence for the use of acupuncture as add-on therapy in the treatment of the positive, negative, and cognitive symptoms, but beneficial effects have been reported in the treatment of the accompanying sleep disorders. Conclusions: Limited evidence was found for the use of acupuncture as add-on therapy in the treatment of patients with schizophrenia; however, positive results were found in the treatment of sleep disorders, but this result needs to be confirmed in large, randomized, controlled trials.

Schizophrenia and Depression: A systematic Review of the Effectiveness and the Working Mechanisms Behind Acupuncture

OBJECTIVE

This systematic review assessed clinical evidence for the use of acupuncture as an add-on treatment in patients with depression and schizophrenia and for its underlying working mechanisms.

DATA SOURCES

Four databases (Medline, Scopus, ERIC, and the Cochrane Library) were searched with a cutoff date of March 31, 2014.

STUDY SELECTION

Systematic reviews and meta-analyses of acupuncture treatment for depression and schizophrenia were considered for inclusion. The scarcity of acupuncture research involving schizophrenia led to the inclusion of randomized controlled trials and case studies.

DATA EXTRACTION

The primary and secondary aims of this study were to evaluate the effects of acupuncture in treating patients with depression or schizophrenia and the possible working mechanisms underlying acupuncture through a systematic literature review.

DATA SYNTHESIS

The overall clinical results on using acupuncture to treat depression are promising, but only limited evidence for its effectiveness in treating schizophrenia was found. Acupuncture improves the quality of life, particularly that of sleep, in psychiatric patients. Brain research has revealed that acupuncture has a modulating and normalizing effect on the limbic-paralimbic-neocortical network (LPNN), including the default mode network. Because the LPNN is related to sleep and emotions, this might explain the improved qualities of life and sleep after acupuncture.

CONCLUSIONS

From the evidence found in this study, acupuncture seems to be an effective add-on treatment in patients with depression and, to a lesser degree, in patients with schizophrenia, but large well-designed studies are needed to confirm that evidence.

Health care resource utilization and direct medical costs for patients with schizophrenia initiating treatment with atypical versus typical antipsychotics in Tianjin, China

Background

It is uncertain whether the extra acquisition costs of atypical antipsychotics over typical antipsychotics are offset by their other reduced resource use especially in hospital services in China. This study compared the psychiatric-related health care resource utilization and direct medical costs for patients with schizophrenia initiating atypical or typical antipsychotics in Tianjin, China.

Methods

Data were obtained from the Tianjin Urban Employee Basic Medical Insurance database (2008–2010). Adult patients with schizophrenia with ≥1 prescription for antipsychotics after ≥90-day washout and 12-month continuous enrollment after first prescription was included. Psychiatric-related resource utilization and direct medical costs of the atypical and typical cohorts were estimated during the 12-month follow-up period. Logistic regressions, ordinary least square (OLS), and generalized linear models (GLM) were employed to estimate differences of resource utilization and costs between the two cohorts. One-to-one propensity score matching was conducted as a sensitivity analysis.

Results

1131 patients initiating either atypical (N = 648) or typical antipsychotics (N = 483) were identified. Compared with the typical cohort, the atypical cohort had a lower likelihood of hospitalization (45.8% vs. 56.7%, P < 0.001; adjusted OR: 0.58, P < 0.001) over the follow-up period. Medication costs for the atypical cohort were higher than the typical cohort ($438 vs. $187, P < 0.001); however, their non-medication medical costs were significantly lower ($1223 vs. $1704, P < 0.001). The total direct medical costs were similar between the atypical and typical cohorts before ($1661 vs. $1892, P = 0.100) and after matching ($1711 vs. 1868, P = 0.341), consistent with the results from OLS and GLM models for matched cohorts.

Conclusions

The atypical cohort had similar total direct medical costs compared to the typical cohort. Higher medication costs associated with atypical antipsychotics were offset by a reduction in non-medication medical costs, driven by fewer hospitalizations.

Choice of atypical antipsychotic therapy for patients with schizophrenia: An analysis of a medicaid population

BACKGROUND

In patients treated at Veterans Affairs facilities, demographicand clinical characteristics have been found to influence the choice of atypical antipsychotic drugs. However, little is known about the influences on the choice between olanzapine and risperidone in patients with schizophrenia enrolled in Medicaid.

OBJECTIVE

The aim of this study was to determine whether demographicand/or clinical characteristics and/or medical-service utilization before treatment were related to the choice of olanzapine versus risperidone therapy using data from a Medicaid population with schizophrenia.

METHODS

The study sample was identified in the North Carolina (NC)Medicaid claims database. Data were included from patients aged 18 to 64 years who were diagnosed with schizophrenia; had initiated treatment with olanzapine or risperidone between July 1, 1998, and October 31, 2000; had not used atypical antipsychotics during the 6 months before the start of treatment; and were continuously eligible in the NC Medicaid program during the 6 months before the start of treatment. Multivariate logistic regression models were used to estimate the likelihood of the choice of olanzapine or risperidone associated with patients' demographic and clinical characteristics and medical-service utilization during the 6 months before the initiation of treatment.

RESULTS

A total of 764 patients (383 women, 381 men; mean age, 42.1 years)were included in the analysis: 420 were initially prescribed olanzapine and 344 were prescribed risperidone. Men were more likely than women to be prescribed olanzapine compared with risperidone. Patients who had a hospitalization related to a psychiatric condition during the pretreatment period were more likely to be prescribed olanzapine compared with risperidone (OR = 1.530; P = 0.043). Significant regional variation in the likelihood of prescribing olanzapine or risperidone was found, with patients being prescribed risperidone at a higher rate compared with olanzapine in 2 counties with the largest schizophrenic populations.

CONCLUSIONS

In this study of data from patients with schizophrenia identified in the NC Medicaid claims database, sex, a history of psychiatric-related hospitalization, and geographic residence were found to be correlated with the selection of treatment with olanzapine versus risperidone. These findings need to be confirmed in large, randomized, prospective studies.

Change in level of productivity in the treatment of schizophrenia with olanzapine or other antipsychotics

BACKGROUND

When treating schizophrenia, improving patients' productivity level is a major goal considering schizophrenia is a leading cause of functional disability. Productivity level has been identified as the most preferred treatment outcome by patients with schizophrenia. However, little has been done to systematically investigate productivity levels in schizophrenia. We set out to better understand the change in productivity level among chronically ill patients with schizophrenia treated with olanzapine compared with other antipsychotic medications. We also assessed the links between productivity level and other clinical outcomes.

METHODS

This post hoc analysis used data from 6 randomized, double-blind clinical trials of patients with schizophrenia or schizoaffective disorder, with each trial being of approximately 6 months duration. Change in productivity level was compared between olanzapine-treated patients (HGBG, n = 172; HGHJ, n = 277; HGJB, n = 171; HGLB, n = 281; HGGN, n = 159; HGDH, n = 131) and patients treated with other antipsychotic medications (separately vs. haloperidol [HGGN, n = 97; HGDH, n = 132], risperidone [HGBG, n = 167; HGGN, n = 158], quetiapine [HGJB, n = 175], ziprasidone [HGHJ, n = 271] and aripiprazole [HGLB, n = 285]). Productivity was defined as functional activities/work including working for pay, studying, housekeeping and volunteer work. Productivity level in the prior 3 months was assessed on a 5-point scale ranging from no useful functioning to functional activity/work 75% to 100% of the time.

RESULTS

Chronically ill patients treated with olanzapine (OLZ) experienced significantly greater improvement in productivity when compared to patients treated with risperidone (RISP) (OLZ = 0.22 ± 1.19, RISP = -0.03 ± 1.17, p = 0.033) or ziprasidone (ZIP) (OLZ = 0.50 ± 1.38, ZIP = 0.25 ± 1.27, p = 0.026), but did not significantly differ from the quetiapine, aripiprazole or haloperidol treatment groups. Among first episode patients, OLZ therapy was associated with greater improvements in productivity levels compared to haloperidol (HAL), during the acute phase (OLZ = -0.31 ± 1.59, HAL = -0.69 ± 1.56, p = 0.011) and over the long-term (OLZ = 0.10 ± 1.50, HAL = -0.32 ± 1.91, p = 0.008). Significantly more chronically ill and first episode patients treated with olanzapine showed moderately high (>50%-75% of the time) and high levels of productivity (>75%-100% of the time) at endpoint, when compared to risperidone or haloperidol-treated patients (p < .05), respectively. Higher productivity level was associated with significantly higher study completion rates and better scores on the positive, negative, disorganized thoughts, hostility and depression subscales of the Positive and Negative Symptom Scale (PANSS).

CONCLUSIONS

Some antipsychotic medications significantly differed in beneficial impact on productivity level in the long-term treatment of patients with schizophrenia. Findings further highlight the link between clinical and functional outcomes, showing significant associations between higher productivity, lower symptom severity and better persistence on therapy.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT00088049; NCT00036088.

The METEOR study of diabetes and other metabolic disorders in patients with schizophrenia treated with antipsychotic drugs. I. Methodology

Patients with schizophrenia present a two- to three-fold higher prevalence of diabetes, of metabolic syndrome and of cardiovascular morbidity. The reason for this increased prevalence may involve intrinsic vulnerability, lifestyle factors and iatrogenic effects of antipsychotic drugs. The objective of this multinational, cross-sectional, pharmacoepidemiological study was to determine the prevalence of diabetes, lipid disorders, obesity, hypertension and the metabolic syndrome in patients with schizophrenia treated with antipsychotic drugs. Particular attention was taken to acquire data on a wide a range as possible of demographic, clinical and lifestyle variables that may influence the risk of metabolic disorders, which were taken into account in the calculation of prevalence data by propensity scoring. The study included 2270 subjects from 16 European countries, predominantly from Central and Eastern Europe. The proportion of subjects presenting the pathologies of interest was relatively high, ranging from 28% for glycaemic disorders to 70% for lipid disorders.

Patterns of clozapine prescribing in a mental health service in New Zealand

OBJECTIVE

To describe clozapine prescribing in a mental health service in Auckland, New Zealand and compare it with national and international treatment guidelines.

SETTING

A large public mental health service for adults in Auckland, New Zealand.

METHOD

A retrospective cross-sectional study of all adult outpatients and stable inpatients being treated with clozapine on 31st March 2007 in one mental health service in Auckland, New Zealand. Data on patient characteristics, diagnosis, duration of illness, number of hospitalisations, legal status relating to their treatment, living situation, marital status and occupational activity were recorded from case notes. Data collected on clozapine included date of initiation, dose and duration of treatment. Prior antipsychotic use and information on all other psychotropic drugs prescribed was also collected. Data were entered into a custom-designed Microsoft Access database and analysed using SPSSv15.0.

MAIN OUTCOME MEASURES

Clozapine prescribing patterns and concordance with best practice recommendations for clozapine use.

RESULTS

402 adult mental health outpatients and stable inpatients were eligible for inclusion. The mean daily dose of clozapine was 383 (SD 166) mg. For those first presenting after universal government funding, the mean time between presentation and initiation of clozapine, was 2.8 (SD 1.9) years, compared to 5.7 (SD 3.3) years prior to funding. Of those presenting after universal government funding, approximately two-thirds (69.0%) had < or = 2 trials with other antipsychotics prior to commencing clozapine; of whom the majority (62.0%) received only second-generation antipsychotics (SGA). Both the number of antipsychotic agents trialled and the time to clozapine initiation has fallen since government subsidy was introduced in 1999. Based on a analysis of annualised hospitalization rates, it appears that shortening the delay to receiving clozapine leads to fewer hospitalisations in this treatment-resistant population, although this did not achieve statistical significance in our study.

CONCLUSIONS

Contemporary management of patients with treatment resistant schizophrenia in New Zealand is broadly in line with national and international best practice guidelines. There is some evidence, based on hospitalisation rates, to support the assertion that shorter delays in accessing clozapine leads to better outcomes. This needs further evaluation using measures of clinical outcome including objective measures of functioning.

Cost-effectiveness model comparing olanzapine and other oral atypical antipsychotics in the treatment of schizophrenia in the United States

BACKGROUND

Schizophrenia is often a persistent and costly illness that requires continued treatment with antipsychotics. Differences among antipsychotics on efficacy, safety, tolerability, adherence, and cost have cost-effectiveness implications for treating schizophrenia. This study compares the cost-effectiveness of oral olanzapine, oral risperidone (at generic cost, primary comparator), quetiapine, ziprasidone, and aripiprazole in the treatment of patients with schizophrenia from the perspective of third-party payers in the U.S. health care system.

METHODS

A 1-year microsimulation economic decision model, with quarterly cycles, was developed to simulate the dynamic nature of usual care of schizophrenia patients who switch, continue, discontinue, and restart their medications. The model captures clinical and cost parameters including adherence levels, relapse with and without hospitalization, quality-adjusted life years (QALYs), treatment discontinuation by reason, treatment-emergent adverse events, suicide, health care resource utilization, and direct medical care costs. Published medical literature and a clinical expert panel were used to develop baseline model assumptions. Key model outcomes included mean annual total direct cost per treatment, cost per stable patient, and incremental cost-effectiveness values per QALY gained.

RESULTS

The results of the microsimulation model indicated that olanzapine had the lowest mean annual direct health care cost ($8,544) followed by generic risperidone ($9,080). In addition, olanzapine resulted in more QALYs than risperidone (0.733 vs. 0.719). The base case and multiple sensitivity analyses found olanzapine to be the dominant choice in terms of incremental cost-effectiveness per QALY gained.

CONCLUSION

The utilization of olanzapine is predicted in this model to result in better clinical outcomes and lower total direct health care costs compared to generic risperidone, quetiapine, ziprasidone, and aripiprazole. Olanzapine may, therefore, be a cost-effective therapeutic option for patients with schizophrenia.

Adherence and persistence to typical and atypical antipsychotics in the naturalistic treatment of patients with schizophrenia

OBJECTIVE

To compare adherence and persistence to typical versus atypical antipsychotics and between specific atypical agents in the usual care of schizophrenia and to examine the association between adherence and persistence.

METHOD

Data were drawn from a 3-year prospective, nonrandomized, noninterventional study of schizophrenia conducted during 1997-2003. Initiators on haloperidol, risperidone, olanzapine, quetiapine, and clozapine with at least 1 year of follow-up were included (n = 878). Adherence (Medication Possession Ratio, MPR) and persistence (time to all-cause medication discontinuation) were assessed using medical record prescription information. Analyses employed multivariate statistics adjusted for group differences.

RESULTS

Overall, 58% of the patients were deemed adherent (MPR >80%). Adherence rates were higher: for atypical (59.4%) than typical antipsychotics (34.5%, p < 0.001), for clozapine (77%) than each comparator excluding olanzapine (p < 0.01), and for olanzapine (64%) than risperidone (57%, p = 0.027) and quetiapine (52%, p = 0.019). Differences between risperidone and quetiapine were not statistically significant. Adherence and persistence were highly correlated (r = 0.957, p < 0.001).

CONCLUSION

In the usual care of schizophrenia, medication adherence and persistence appear to be highly correlated and to significantly differ between typical and atypical antipsychotics and among atypical agents. The choice of antipsychotic may play a meaningful role in patients' adherence to and persistence with antipsychotic medications.

An alternative approach to measuring treatment persistence with antipsychotic agents among patients with schizophrenia in the Veterans Health Administration

Prior studies have demonstrated the importance of treatment persistence with anti-psychotic agents in sustaining control of schizophrenic symptoms. However, the conventional approach in measuring treatment persistence tended to use only the first prescription episode even though some patients received multiple prescriptions (or multiple treatment episodes) of the same medication within one year following the initiation of the index drug. In this study, we used data from the Veterans Health Administration in the United States to assess the extent to which patients received multiple prescriptions. The study found that about a quarter of the patients had two or more treatment episodes and that levels of treatment persistence tended to vary across treatment episodes. Based on these results, we offered an alternative approach in which we calculated treatment persistence with typical and atypical antipsychotic agents separately for patients with one, two, or three treatment episodes. Considering that patients with different number of treatment episodes might differ in disease profiles, this treatment episode-specific approach offered a fair comparison of the levels of treatment persistence across patients with different number of treatment episodes. Future research needs to extend the analyses beyond two antipsychotic classes to individual antipsychotic agents. A more comprehensive assessment using appropriate analytic methods should help physicians make prescription choices that will ultimately improve the care of patients with schizophrenia.

The relationship of antipsychotic medication class and adherence with treatment outcomes and costs for Florida Medicaid beneficiaries with schizophrenia

While some studies show a significant advantage in adherence rates with use of atypical versus typical antipsychotic medication, others show no advantage or mixed results (Jones et al. (2006). Archives of General Psychiatry, 63, 1079-1087; Rosenheck, (2006). Archives of General Psychiatry, 63, 1074-1076). This study examined treatment outcomes and costs associated with adherence rates by antipsychotic medication class for adult Medicaid beneficiaries in Florida diagnosed with schizophrenia. Outcomes examined include arrests, involuntary commitments, and physical and behavioral healthcare costs. Study findings demonstrate that medication adherence for persons with schizophrenia may be as important to treatment costs and benefits as the class of medication used.

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.

Dissemination of Methods and Results From the Veterans Health Study

The Veterans Health Study (VHS) followed a cohort of patients receiving ambulatory care in the Veterans Affairs healthcare system for up to 5 years. One of the principal aims of this study was to develop a library of methodologies including general and disease-specific health outcome questionnaires for use in monitoring the quality of healthcare and for research purposes. The cornerstone for this work is the Veterans RAND 36 and 12 Item Health Surveys (VR-36 and VR-12), a general measure developed in the VHS for measuring the physical and psychologic well-being of the patient. A comprehensive set of disease-specific assessments has also been developed as part of this study for the purposes of monitoring specific chronic conditions more commonly seen in routine ambulatory care settings. Since 1996, more than 2 million questionnaires have been administered in the VA for quality monitoring purposes, using the VR-36 and VR-12. Research studies that have used these batteries span randomized clinical trials in the VA cooperative studies program and clinical effectiveness research. Health assessments using VHS batteries are being disseminated for widespread use outside the VA. Chief among the assessments used is the VR-12, which has recently been included in the 2006 Health Plan Employer Data and Information Set (HEDIS) as part of the Medicare Health Outcomes Survey for monitoring the Medicare Advantage Program. The methods and batteries developed in the VHS are in the public domain and provide a framework for future patient monitoring using standard measures of health.

Risperidone versus olanzapine for schizophrenia

BACKGROUND

Antipsychotic medication is a mainstay of treatment for schizophrenia. Risperidone and olanzapine are popular choices among the new generation drugs.

OBJECTIVES

To determine the clinical effects, safety and cost effectiveness of risperidone compared with olanzapine for treating schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (Sept 2005) which is based on regular searches of, amongst others, BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were inspected for further trials. We also contacted relevant pharmaceutical companies for additional information.

SELECTION CRITERIA

We included all clinical randomised trials comparing risperidone with olanzapine for schizophrenia and schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat/harm (NNT/H) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

We found no difference for the outcome of unchanged or worse in the short term (n=548, 2 RCTs, RR 1.00 CI 0.88 to 1.15). One study favoured olanzapine for the outcome of relapse/rehospitalisation by 12 months (n=279, 1 RCT, RR 2.16 CI 1.31 to 3.54, NNH 7 CI 3 to 25). Most mental state data showed the two drugs to be as effective as each other (n=552, 2 RCTs, RR 'no <20% decrease PANSS by eight weeks' 1.01 CI 0.87 to 1.16). Both drugs commonly cause adverse events: 75% given either drug experience an adverse event; 20% anticholinergic symptoms; both groups experienced insomnia although it was more frequent with risperidone (n=1588, 5 RCTs, RR 1.41 CI 1.15 to 1.72, NNH 15 CI 9 to 41); about 30% experienced sleepiness (n=1713, 6 RCTs, RR 0.92 CI 0.79 to 1.07). People given either drug often experienced some extrapyramidal symptoms (n=893, 3 RCTs, RR 1.18 CI 0.75 to 1.88); 25% of people using risperidone required medication to alleviate these symptoms (n=419, 2 RCTs, RR 1.76 CI 1.25 to 2.48, NNH 8 CI 4 to 25). People allocated to risperidone were less likely to gain weight compared with those given olanzapine and the weight gain was often considerable and of quick onset (n=984, 2 RCTs, RR gain more than 7% of their baseline weight in short term 0.47 CI 0.36 to 0.61, NNH 7 CI 6 to 10). Risperidone participants were less likely to leave the study due to metabolic side effects and weight gain compared with olanzapine (n=667, 1RCT, RR 0.19 CI 0.08 to 0.45). Patients on risperidone were more likely to experience abnormal ejaculation (n=370, 2 RCTs, RR 4.36 CI 1.38 to 13.76, NNH 20 CI 6 to 176). Both drugs are associated with high attrition rates; in the long term consistent findings show that 66% of those allocated risperidone left the study early compared with 56% given olanzapine (n=1440, 5 RCTs, RR 1.17 CI 1.08 to 1.27, NNH 11 CI 7 to 23).

AUTHORS' CONCLUSIONS

We know very little of the effects of these drugs regarding service outcomes, general functioning and behaviours, engagement with services and treatment satisfaction from evaluative studies. There was generally a high rate of attrition in the trials and there appears to be little to differentiate between risperidone and olanzapine except on issues of adverse effects. Both drugs are associated with a reduction in psychotic symptoms but both commonly cause unpleasant adverse effects.

Patient characteristics and the likelihood of initiation on olanzapine or risperidone among patients with schizophrenia

Although pharmacologic treatments are available for patients with schizophrenia, little is known about how prescription patterns of atypical antipsychotic agents are related to patient characteristics. In this study, we examined the association between patient characteristics and the likelihood of being initiated on olanzapine or risperidone, two of the most frequently prescribed atypical agents for schizophrenia. We selected patients who were diagnosed with schizophrenia or schizoaffective disorder based on > or = 1 inpatient or > or = 2 outpatient ICD-9-CM codes (> or = 7 days apart) between 7/1/98 and 6/30/99 from the Veterans Health Administration (VA). We classified patients into one of three types of initiation: (a) not on olanzapine or risperidone, (b) not on any atypical agents, or (c) not on any antipsychotic agents for 6 months, and then subsequently being prescribed the target drugs. Using logistic regression, we examined whether the odds ratio of being initiated on olanzapine versus risperidone are related to patient sociodemographic and clinical characteristics. Compared to risperidone initiators, olanzapine initiators used more drugs for psychiatric conditions (including antiparkinsonian agents, typical antipsychotics, and mood stabilizers) than risperidone initiators. On the other hand, risperidone initiators had more medical comorbidities and more non-psychiatric hospitalizations. Olanzapine and risperidone appear to be prescribed to patients with different characteristics. Initiation of risperidone was more common among patients who presented with more medical comorbid conditions, whereas initiation of olanzapine was more common among patient who presented with more mental comorbid conditions. Future research needs to determine the reasons for those differences.

Risperidone versus olanzapine for schizophrenia

BACKGROUND

Antipsychotic medication is a mainstay of treatment for schizophrenia and risperidone and olanzapine are the most popular treatment choice of the new generation drugs.

OBJECTIVES

To determine the clinical effects, safety and cost effectiveness of risperidone compared with olanzapine for treating schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (June 2004) which is based on regular searches of, amongst others, BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were inspected for further trials. We also contacted relevant pharmaceutical companies for additional information.

SELECTION CRITERIA

We included all clinical randomised trials comparing risperidone with olanzapine for schizophrenia and schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat/harm (NNT/H) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

We found no difference for the outcome of unchanged or worse in the short term (n=548, 2 RCTs, RR 1.00 CI 0.88 to 1.15). One study, sponsored by the manufactures of olanzapine, favoured this drug for the outcome of relapse/rehospitalisation by 12 months (n=279, RR 2.16 CI 1.31 to 3.54, NNT 7 CI 4 to 25). Most mental state data showed the two drugs to as effective as each other (n=552, 2 RCTs, RR 'no <20% decrease PANSS by eight weeks' 1.01 CI 0.87 to 1.16). At least two thirds of people given risperidone or olanzapine experienced an adverse event (n=300, 2 RCTs, RR 1.16 CI 0.70 to 1.94). About 20% had anticholinergic symptoms (n=719, 3 RCTs, RR 1.12 CI 0.77 to 1.63) and 20% of both groups experienced insomnia (n=594, 3 RCTs, RR 1.33 CI 0.95 to 1.85) and approximately 33% sleepiness (n=719, 4 RCTs, 0.99 CI 0.79 to 1.23). One third of people given either drug experienced some extrapyramidal symptoms (n=893, 3 RCTs, RR 1.18 CI 0.75 to 1.88) but 25% of people using risperidone require medication to alleviate extrapyramidal adverse effects (n=419, 2 RCTs, RR 1.76 CI 1.25 to 2.48, NNH 8 CI 4 to 25). People allocated to risperidone were less likely to gain weight compared with those given olanzapine and the weight gain resulting from olanzapine can be considerable and of rapid onset (n=377, 1 RCT, RR gain more than 7% of their baseline weight 0.40 CI 0.23 to 0.70, NNT 8 CI 6 to 17). Risperidone may cause more sexual dysfunction than olanzapine (n=370, 2 RCTs, RR abnormal ejaculation 4.36 CI 1.38 to 13.76, NNH 20 CI 6 to 176; n=31, 1 RCT, RR impotence 2.43 CI 0.24 to 24.07). Within trials both drugs are associated with equal attrition (n=1217, 7 RCTs, RR leaving the study early 1.17 CI 0.92 to 1.49).

AUTHORS' CONCLUSIONS

Data regarding quality of life and economic outcomes are difficult to interpret, and for both these highly marketed new drugs we know very little from evaluative studies regarding service outcomes, general functioning and behaviour, engagement with services and treatment satisfaction. There is little to differentiate between risperidone and olanzapine except on the issue of adverse effects and both these drugs have unpleasant adverse effects. Risperidone is particularly associated with movement disorders and sexual dysfunction. Olanzapine can cause considerable rapid weight gain.This review highlights the need for large, independent, well designed, conducted and reported pragmatic randomised studies.

Prescription of psychotropic drugs to patients with schizophrenia: an Italian national survey

OBJECTIVES

This study aims to: (a) describe the type and doses of psychotropic drugs received by outpatients with schizophrenia in Italy; (b) explore the relationship between prescription and patients' clinical conditions, disability and socio-demographic characteristics; and (c) estimate the percentage of patients receiving polypharmacy and antipsychotics within the official recommended ranges.

METHODS

A total of 682 patients with schizophrenia were consecutively recruited in 30 Italian mental health departments, randomly selected taking into account the geographic location and population density of their catchment areas.

RESULTS

Of the sample, 98% were in treatment with neuroleptics, 47% received benzodiazepines, 25% were on anticholinergics, 10% were prescribed antidepressants and 8% were on mood stabilisers. Polypharmacy was found in 29% of the sample. Patients treated with one neuroleptic received this within therapeutic doses in 77% of cases. In patients who received two neuroleptics (24%), the former was prescribed within the official range in 71% of cases and the latter in 46%. Polytherapy was more frequently prescribed in patients treated with typicals (60% versus 34%) and in those who also received benzodiazepines (61% versus 41%) and anticholinergics (44% versus 16%). Patients in treatment with atypicals (45%) were mainly younger and lived in highly populated areas. Depot medications (25%) were more frequently prescribed to patients living in areas of low population density, who were older and who had a lower educational level, a longer duration of illness and milder anxiety/depression symptoms.

CONCLUSIONS

The consistent percentage of patients receiving polypharmacy and neuroleptics outside the therapeutic doses highlights the need to promote interventions aimed at increasing a rational use of psychotropic drugs among mental health professionals.

Initiation of atypical antipsychotic agents and health outcomes in patients with schizophrenia

BACKGROUND

Although pharmacological treatments are available for patients with schizophrenia, there is a lack of systematic and comprehensive evaluation of health outcomes following the initiation of atypical antipsychotic agents.

OBJECTIVE

To assess the effects of the initiation of olanzapine or risperidone, the two most widely prescribed atypical antipsychotics, on patients' health outcomes, as measured by changes in patient clinical characteristics between 6 months prior to and post-initiation.

METHOD

We identified patients with schizophrenia by >1 inpatient or > or = 2 outpatient ICD-9-CM codes (> or = 7 days apart) between 1 July 1998 and 30 June 1999, and those who were initiated on olanzepine or risperidone during the period 1 April 1999 to 31 March 2000 inclusive. We then subdivided these patients into three groups: (i) those who were not on olanzapine or risperidone, (ii) those who were not on any atypical agents, and (iii) those who were not on any antipsychotic agents, for 6 months prior to being issued with the new prescription. Using test of means or chi-square tests, we examined whether the initiation of olanzapine or risperidone is related to different changes in patient clinical indicators, such as number of drugs for psychiatric conditions, use of psychiatric services, and use of non-psychiatric services.

RESULTS

Between pre- and post-initiation, olanzapine initiators had a greater decrease in the number of psychiatric hospitalizations and use of psychotropic agents, whereas risperidone initiators had a greater reduction in the number of non-psychiatric hospitalizations. The initiation of olanzapine and risperidone appear to be associated with different patient health outcomes. Compared with olanzapine initiators, risperidone initiators had a greater increase in the use of treatments related to mental health, but had greater decrease in the use of treatments related to physical health.

CONCLUSION

Despite olanzapine and risperidone being often perceived as similar antipsychotic agents, our results suggest that the clinical outcomes associated with their use are different. Outcome data from routine clinical practice are required to provide a more comprehensive assessment of these drugs.

Comparison of risperidone and olanzapine as used under "real-world" conditions in a state psychiatric hospital

As a follow-up to our previous study of clozapine, medical records of a state psychiatric hospital were reviewed for patients who were prescribed an atypical antipsychotic. From that sample, demographic and clinical data were obtained for individuals with an initial score of 35 or greater on the Brief Psychiatric Rating Scale (BPRS), and at least two additional successive monthly BPRS ratings. A total of 100 patients met the criteria. Most received either olanzapine (46%) or risperidone (36%), with few administered quetiapine (11%) or clozapine (7%). Most also received adjunctive medications, including conventional antipsychotics, anticonvulsants/mood stabilizers, antidepressants, and antiparkinsonian agents. The number of patients whose BPRS total scores decreased by 20% or more from baseline was significantly greater for those who received olanzapine than those who received risperidone. However, there was no difference between the two antipsychotics in the number of patients who maintained that degree of improvement, in the average latency to achieve that decrease (1.67 and 1.47 months, respectively), or the average length of stay (LOS; 332 and 376 days, respectively). These results indicate a modest therapeutic advantage of olanzapine compared to risperidone, and a substantial degree of polypharmacy in the use of atypical antipsychotics. This uncontrolled "real-world" evaluation supports data from controlled clinical trials, showing that either risperidone or olanzapine would be a reasonable first choice in patients with treatment-resistant schizophrenia, with the decision based on the least adverse side effect profile and economic constraints. When compared to our previous clozapine study, we confirm a slight advantage for the effectiveness of clozapine in the treatment of this refractory population.