Clinical practice variations in prescribing antipsychotics for patients with schizophrenia

Successful high dose antipsychotic treatment with cariprazine in patients on the schizophrenia spectrum: Real-world evidence from a Spanish hospital setting

Real-world evidence fills in an important gap by providing data on the effectiveness and tolerability of new medications in everyday patients. In this data collection form a Spanish hospital, the effectiveness and tolerability of cariprazine were evaluated in 14 patients who were admitted to the hospital due to an acute episode of schizophrenia or schizoaffective disorder. The collected data included demographic characteristics, history of disorder and previous treatment, and details of cariprazine therapy such as dosing, side effects and measurements of effectiveness via scales. Difference between admission and discharge on the Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression-Severity (CGI-S) scale scores were evaluated using the Wilcoxon Signed-Rank test. Significant improvement was detected in nearly all patients (one patient dropped out) as measured by the BPRS Total, Negative symptom, Positive symptom, and Hostility scores. At admission, patients were markedly-moderately ill and at discharge the severity was reduced to borderline ill and normal according to the CGI-S. The CGI-Improvement scale also indicated very much and much improvement at discharge. Importantly, patients left the hospital with high doses of cariprazine, i.e., 7.5 mg/day or even 9.0 mg/day, but this did not cause safety problems; cariprazine well-tolerated as only a few patients experienced side effects such as akathisia. The results provide novel evidence regarding the tolerability and effectiveness of cariprazine in high doses patients on the schizophrenia spectrum.

The effect of long-acting injectable antipsychotic medications compared with oral antipsychotic medications among people with schizophrenia: A systematic review and meta-analysis

Long-acting injectable (LAI) antipsychotic medications may be an important modality of reducing costs, improving symptoms, and fostering quality of life outcomes for those with schizophrenia. Our objective was to systematically review and conduct a meta-analysis of the effectiveness of LAIs compared with oral antipsychotics on medication adherence, symptom remission/relapse, rehospitalization, outpatient visits, emergency department visits, healthcare costs, and social functioning. We performed a systematic search of PsycInfo, CINAHL, PubMed, and Scopus databases to examine studies meeting inclusion criteria prior to August 30th, 2020. Randomized controlled trials, retrospective studies, prospective studies among people with schizophrenia with at least 6-month follow-up data were obtained. Overall effect sizes and associated 95% confidence intervals (CI) were estimated with random-effects modeling. We found 75 articles meeting our inclusion criteria, including 341 730 individuals with schizophrenia. Systematic review results indicated that LAIs compared with orals improved medication adherence (25/29 studies), symptom remission/relapse (10/18 studies), rehospitalizations (26/49 studies), emergency department visits (9/17 studies), medical costs (11/15 studies), and social functioning (5/9 studies); however, LAIs also increased outpatient visits (7/16 studies) and pharmacy costs (10/10 studies). Meta-analytic results of studies with similar outcome measures did not find differences between LAIs and orals in respect to outcomes, except lowering emergency department visits and increasing pharmacy costs. The differences between the results of the narrative synthesis and the meta-analyses were possibly because of the low availability of studies with similar outcomes in the pooled analyses. Our overall results suggest that LAIs are at least comparable to orals in supporting important healthcare outcomes for those with schizophrenia. These findings support clinical practice in encouraging providers to prescribe LAIs when indicated.

Dosing Cariprazine Within and Beyond Clinical Trials: Recommendations for the Treatment of Schizophrenia

Although the optimal dosing of an antipsychotic medication is known to be essential in the long-term management of schizophrenia, in case of novel drugs such as cariprazine, determining the right dosing strategy is not that simple. Without decades of experience with a particular compound, evidence regarding dosing and titration comes primarily from double-blind, placebo controlled clinical trials that are not necessarily mirroring the real-life experiences of doctors. Via summarizing data from both clinical data (n = 3275) and real-world evidence (observational study n = 116, case studies n = 29), this perspective paper aims to shed a light on the appropriate dosing strategies of cariprazine from treatment initiation through switching strategies to concomitant medications.

Targeted cognitive training improves auditory and verbal outcomes among treatment refractory schizophrenia patients mandated to residential care

Computerized targeted cognitive training (TCT) of auditory processing has been shown to improve verbal learning in several clinical trials of schizophrenia outpatients. Less is known, however, about the effectiveness of this promising intervention in more chronic, treatment-refractory patients who are treated in non-academic settings. This study aimed to determine whether TCT improves auditory processing, verbal learning, and clinical symptoms in SZ patients mandated to receive care at a locked residential rehabilitation center. Secondarily, potential factors that moderate TCT's effectiveness including age, symptom severity, antipsychotic medication load, and duration of illness were examined. Schizophrenia patients were randomized to treatment as usual (TAU; n = 22) or TAU augmented with TCT (TAU + TCT; n = 24). Outcomes included a measure of auditory perception (Word-In-Noise test, WIN), verbal learning domain scores from the MATRICS Consensus Cognitive Battery (MCCB), and clinical symptoms (Scale for the Assessment of Positive Symptoms, SAPS; Scale for the Assessment of Negative Symptoms, SANS). TCT produced significant improvements in auditory perception (d = 0.67) and verbal learning (d = 0.65); exploratory analyses revealed a statistically significant reduction in auditory hallucinations (d = -0.64). TCT's effects were only weakly, and mostly non-significantly, moderated by age, clinical symptoms, medication, and illness duration. These findings indicate that even highly symptomatic, functionally disabled patients with chronic illness benefit from this emerging treatment. Ongoing studies will examine the predictive utility of neurophysiological biomarkers and other characteristics assessed at baseline.

Tying comparative effectiveness information to decision-making and the future of comparative effectiveness research designs: the case for antipsychotic drugs

The outcome of comparative effectiveness research on antipsychotic drugs, specifically the National Institute of Mental Health-funded CATIE trial, has raised questions regarding the value of second-generation antipsychotic drugs and has sparked a debate regarding their accessibility through public insurance. We reviewed the evidence on the impact of access restrictions for antipsychotic drugs in Medicaid programs and found that such restrictions resulted in increases in overall costs and a possible decline in the quality of care. We attribute this unwanted outcome to limitations in comparative effectiveness research designs that fail to inform either clinical or policy decision-making. We enumerate these limitations and illustrate the potential for more innovative comparative effectiveness research designs that may be in line with clinical decision-making using an original analysis of the CATIE trial data. The value of genomic information in enabling better trial design is also discussed.

Polypharmacy in psychiatry: a review

Psychiatric polypharmacy refers to the prescription of two or more psychiatric medications concurrently to a patient. It can be categorised as same-class, multi-class, adjunctive, augmentation and total polypharmacy. Despite advances in psychopharmacology and a better understanding of the principles of therapeutics, its practice is increasing rapidly. The prevalence of polypharmacy in psychiatry varies between 13%-90%. There are various clinical and pharmaco-economic factors associated with it. Dealing with polypharmacy requires an understanding of its associated factors. Education, guidelines and algorithms for the appropriate management of various conditions are effective ways to avoid irrational polypharmacy.

Long-acting antipsychotic drugs for the treatment of schizophrenia: use in daily practice from naturalistic observations

BACKGROUND

Current guidelines suggest specific criteria for oral or long-acting injectable antipsychotic drugs (LAIs). This review aims to describe the demographic and clinical characteristics of the ideal profile of the patient with schizophrenia treated with LAIs, through the analysis of nonrandomized studies.

METHODS

A systematic review of nonrandomized studies in English was performed attempting to analyze the factors related to the choice and use of LAIs in daily practice. The contents were outlined using the Cochrane methods for nonrandomized studies and the variables included demographic as well as clinical characteristics. The available literature did not allow any statistical analysis that could be used to identify the ideal profile of patients with schizophrenia to be treated with LAIs.

RESULTS

Eighty publications were selected and reviewed. Prevalence of LAI use ranged from 4.8% to 66%. The only demographic characteristics that were consistently assessed through retrieved studies were age (38.5 years in the 1970's, 35.8 years in the 1980's, 39.3 years in the 1990's, to 39.5 years in the 2000's) and gender (male > female).Efficacy was assessed through the use of various symptom scales and other indirect measurements; safety was assessed through extrapyramidal symptoms and the use of anticholinergic drugs, but these data were inconsistent and impossible to pool. Efficacy and safety results reported in the different studies yielded a good therapeutic profile with a maximum of 74% decrease in hospital admissions and the prevalence of extrapyramidal symptoms with LAIs consistently increased at 6, 12, 18, and 24 months (35.4%, 37.1%, 36.9%, and 41.3%, respectively).

CONCLUSIONS

This analysis of the available literature strongly suggests that further observational studies on patients with schizophrenia treated with LAIs are needed to systematically assess their demographic and clinical characteristics and the relationships between them and patient outcome.Besides the good efficacy and safety profile of LAIs, health care staff must also take into account the importance of establishing a therapeutic alliance with the patient and his/her relatives when selecting the most appropriate treatment. LAIs seem to be a good choice not only because of their good safety and efficacy profile, but also because they improve compliance, a key factor to improving adherence and to establishing a therapeutic alliance between patients with schizophrenia, their relatives, and their health care providers.

Clinical decision making in exercise prescription for fall prevention

BACKGROUND

Physical therapists often prescribe exercises for fall prevention. Understanding the factors influencing the clinical decision-making processes used by expert physical therapists working in specialist fall and balance clinics may assist other therapists in prescribing exercises for fall prevention with greater efficacy.

OBJECTIVES

The objective of this study was to describe the factors influencing the clinical decision-making processes used by expert physical therapists to prescribe exercises for fall prevention.

DESIGN

This investigation was a qualitative study from a phenomenological perspective.

METHODS

Semistructured telephone interviews were conducted with 24 expert physical therapists recruited primarily from the Victorian Falls Clinic Coalition. Interviews focused on 3 exercise prescription contexts: face-to-face individual therapy, group exercise programs, and home exercise programs. Interviews elicited information about therapist practices and the therapist, patient, and environmental factors influencing the clinical decision-making processes for the selection of exercise setting, type, dosage (intensity, quantity, rest periods, duration, and frequency), and progression. Strategies for promoting adherence and safety were also discussed. Data were analyzed with a framework approach by 3 investigators.

RESULTS

Participants described highly individualized exercise prescription approaches tailored to address key findings from physical assessments. Dissonance between prescribing a program that was theoretically correct on the basis of physiological considerations and prescribing one that a client would adhere to was evident. Safety considerations also were highly influential on the exercise type and setting prescribed. Terminology for describing the intensity of balance exercises was vague relative to terminology for describing the intensity of strength exercises.

CONCLUSIONS

Physical therapists with expertise in fall prevention adopted an individualized approach to exercise prescription that was based on physical assessment findings rather than "off-the-shelf" exercise programs commonly used in fall prevention research. Training programs for people who prescribe exercises for older adults at risk of falling should encompass these findings.

Race and long-acting antipsychotic prescription at a community mental health center: a retrospective chart review

OBJECTIVE

There has been concern that racial minorities are disproportionately prescribed long-acting injectable antipsychotic drugs.

METHOD

Comprehensive administrative data and clinician survey were used to identify all patients with a DSM-IV diagnosis of schizophrenia who received long-acting antipsychotic prescriptions from July 2009 to June 2010 at a community mental health center. Charts were reviewed retrospectively to validate long-acting antipsychotic prescription (eg, medication, dosage) and merged with administrative data from all center patients documenting sociodemographic characteristics (ie, age, race, gender) and comorbid diagnoses. We used bivariate χ2, t tests, and multivariate logistic regression to compare the subsample of patients receiving long-acting injectable drugs (n = 102) to patients not receiving long-acting injectable drugs (n = 799) who were diagnosed with schizophrenia for the same period.

RESULTS

White patients were significantly less likely to receive long-acting antipsychotic prescriptions than minority patients (OR = 0.52, P < .007); ie, nonwhites were 1.89 times more likely to receive such drugs. Age, gender, and comorbid diagnoses, including substance abuse, were unrelated to long-acting injectable prescription, and race/ethnicity was not associated with use of specific agents (haloperidol decanoate, fluphenazine decanoate, or risperidone microspheres) (P = .73).

CONCLUSIONS

Racial minorities are more likely than other patients with schizophrenia to receive long-acting injectionable antipsychotics, a finding that suggests their prescribers may consider them less adherent to antipsychotic prescriptions.

Psychiatric polypharmacy: a clinical approach based on etiology and differential diagnosis

Polypharmacy is common clinical practice in the United States for many psychiatric conditions and for many reasons. In this article we encourage clinicians to use the familiar practice of differential diagnosis to systematically identify etiological factors contributing to polypharmacy. We offer a clinical approach based on (1) reviewing the four main factors responsible for polypharmacy (the disease, the patient, the physician, and society) and (2) answering two questions about optimizing medication regimens (What can I do without explicit permission from the patient or others? What can I do with permission from them?). We contend that all physicians share a professional responsibility for prescribing medications judiciously because unnecessary prescribing exposes patients to unwarranted risks and squanders valuable and scarce resources. Psychiatrists can ask themselves a Kantian question: would my way of prescribing lead to good, socially acceptable outcomes if followed by all physicians treating similar patients?

Previous hospital admissions and disease severity predict the use of antipsychotic combination treatment in patients with schizophrenia

BACKGROUND

Although not recommended in treatment guidelines, previous studies have shown a frequent use of more than one antipsychotic agent among patients with schizophrenia. The main aims of the present study were to explore the antipsychotic treatment regimen among patients with schizophrenia in a catchment area-based sample and to investigate clinical characteristics associated with antipsychotic combination treatment.

METHODS

The study included 329 patients diagnosed with schizophrenia using antipsychotic medication. Patients were recruited from all psychiatric hospitals in Oslo. Diagnoses were obtained by use of the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). Additionally, Global Assessment of Functioning (GAF), Positive and Negative Syndrome Scale (PANSS) and number of hospitalisations and pharmacological treatment were assessed.

RESULTS

Multiple hospital admissions, low GAF scores and high PANSS scores, were significantly associated with the prescription of combination treatment with two or more antipsychotics. The use of combination treatment increased significantly from the second hospital admission. Combination therapy was not significantly associated with age or gender. Regression models confirmed that an increasing number of hospital admission was the strongest predictor of the use of two or more antipsychotics.

CONCLUSIONS

Previous hospital admissions and disease severity measured by high PANSS scores and low GAF scores, predict the use of antipsychotic combination treatment in patients with schizophrenia. Future studies should further explore the use of antipsychotic drug treatment in clinical practice and partly based on such data establish more robust treatment guidelines for patients with persistently high symptom load.

Determinants of first- and second-generation antipsychotic drug use in clinically unstable patients with schizophrenia treated in four European countries

The present study investigated the use of antipsychotics in a sample of clinically unstable patients with schizophrenia who were recruited in four European sites. The study aimed: (i) to test whether the length of previous antipsychotic exposure was associated with the choice of antipsychotic medication; (ii) to test whether the severity of illness was associated with the use of second-generation antipsychotic agents (SGAs) or with the concomitant use of both first-generation antipsychotics (FGAs) and SGAs; and (iii) to investigate differences between study sites. Participants were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (The Netherlands) and Leipzig (Germany). Clinically unstable patients with a clinical diagnosis of schizophrenia and a research diagnosis of schizophrenia, established using the Item Group Checklist of the Schedule for Clinical Assessment in Neuropsychiatry, were enrolled. Sociodemographic and clinical data, including current antipsychotic drug therapy, psychopathology, adherence, insight, side-effects, attitudes towards medication and quality of life, were gathered. Three hundred and ninety patients were analysed in total. Almost 60% received SGAs, less than one-third FGAs, and less than 15% received both drug classes. Those receiving SGAs were younger and with a shorter length of antipsychotic drug therapy, whereas those receiving both drug classes were more often separated or widowed, unemployed and with a long history of antipsychotic drug therapy. The distribution of patients receiving FGAs, SGAs and both drug classes by illness-related variables showed that patients receiving both drug classes were more severely ill and complained of more side-effects. Using patients receiving FGAs as the reference category, multinomial logistic regression analysis showed that the length of antipsychotic treatment was negatively correlated with receiving SGAs, and that the severity of illness and being separated/widowed were positively correlated with receiving both drug classes. Compared with patients in Leipzig, patients in Amsterdam, Croydon and Verona were less frequently treated with SGAs and with combinations of both drug classes. Consistent with current clinical uncertainty with respect to what pharmacological treatment should be provided, patients with a long history of antipsychotic exposure were receiving FGAs, SGAs and combinations of both drug classes. Physicians tended to reserve polypharmacy for difficult-to-treat patients (i.e. for managing situations where, despite the lack of an evidence base, there is a pressing need to provide clinical answers).

Evaluation of a community mental health carepath for early psychosis

PURPOSE

To implement a carepath for early psychosis across all community mental health centres through the Early Psychosis Intervention Programme in the Fraser South Area of British Columbia, Canada.

METHODS

Prior to developing the carepath, chart reviews and interviews were performed to assess for adherence to published guidelines for early psychosis intervention. This assessment revealed the inadequacies of narrative recording and that core psychosocial interventions were inconsistently provided. The carepath developed included prompts for interventions and standardized assessments and ultimately replaced the charting system used in the mental health centres for early psychosis clients.

RESULTS AND CONCLUSIONS

One-year evaluation revealed some improvements in clinical practice but also identified other areas that require further improvement. This project demonstrated that it is possible to successfully implement a carepath in community mental health and that doing so provides a standardized method for ongoing improvements in care.

A collaborative approach to targeted treatment development for schizophrenia: a qualitative evaluation of the NIMH-MATRICS project

INTRODUCTION

In 2002, the National Institute of Mental Health (NIMH) initiated a multistakeholder research process designed to stimulate the development and evaluation of medications targeting the cognitive deficits associated with schizophrenia. The first phase, Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS), sought consensus on laboratory measures for cognition, clinical trial outcome measures, and drug registration requirements. MATRICS constitutes a unique drug development model because it targeted a specific endophenotype of schizophrenia and because it engaged academic, industry, and government stakeholders in a consensus-oriented process. This study offers a preliminary qualitative evaluation of the NIMH-MATRICS project.

METHOD

Interview data are used to describe how MATRICS participants regard 3 aspects of the development of cognitive medications: the definition of the treatment target, stakeholders' role in the early development process, and anticipated dissemination complexities.

RESULTS

MATRICS participants describe the treatment target in highly varied ways and envision a wide range of public health benefits. MATRICS is perceived as inclusive, despite minimal representation from some end users. According to informants, clinical detection, documentation, and monitoring of cognition and functioning may prove problematic. More thoroughly than non-industry-employed informants, industry-employed MATRICS participants articulate strategies by which treatments can be integrated into clinical practice.

DISCUSSION

The MATRICS process did not produce a clinical concept of cognitive impairment in schizophrenia, and significant challenges remain to be addressed regarding the rational clinical use of novel pharmaceuticals for cognition. Broader inclusion of end users in translational science projects may streamline implementation and facilitate improvements in real-world outcomes.

Análisis de la correlación entre la calidad de la prescripción de antipsicóticos y el estado clínico en pacientes con esquizofrenia

OBJECTIVE

The aim of this study is to describe the psychopharmacological aspects of psychiatric practice in a group of schizophrenic patients and to evaluate whether or not practice agrees with treatment guidelines. The study also intends to objectively measure the psychopathological state of patients in order to establish correlation between different pharmacological aspects of treatment and their clinical outcomes.

METHOD

We have elaborated six recommendations concerning the pharmacological treatment of schizophrenia, taken from several guides, which are based on evidence. The psychopathological state of patients has been evaluated with the Brief Psychiatric Rating Scale (BPRS) and real prescription practice has been analysed. BPRS rates are compared depending on compliance with guidelines.

RESULTS

More than 60% of patients do not comply with at least 4 of 6 evidence-based recommendations; compliance with recommendations being associated with a minor BPRS punctuation. Differences in BPRS punctuation between compliant and not compliant groups for 3 recommendations (maintenance antipsychotic dosage, antipsychotic association and drugs with a negative effect on cognitive functions), are statistically significant(p < 0,05; bilateral).

DISCUSSION

Medical practice which closely follows treatment guidelines results in satisfactory clinical outcomes.

Use of electronic medical record data for quality improvement in schizophrenia treatment

An understanding of the strengths and limitations of automated data is valuable when using administrative or clinical databases to monitor and improve the quality of health care. This study discusses the feasibility and validity of using data electronically extracted from the Veterans Health Administration (VHA) computer database (VistA) to monitor guideline performance for inpatient and outpatient treatment of schizophrenia. The authors also discuss preliminary results and their experience in applying these methods to monitor antipsychotic prescribing using the South Central VA Healthcare Network (SCVAHCN) Data Warehouse as a tool for quality improvement.