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

National trends in metabolic risk of psychiatric inpatients in the United States during the atypical antipsychotic era

Although the cardiometabolic effects of atypical antipsychotics have been well-described in clinical samples, less is known about the longer-term impacts of these treatments. We report rates of metabolic syndrome in a nationally representative sample of U.S. adult inpatients 1993-2018 admitted for schizophrenia-spectrum disorders (n = 1,785,314), any mental health disorder (n = 8,378,773), or neither (n = 14,458,616) during a period of widespread atypical antipsychotic use. Metabolic syndrome, derived from additional diagnoses, was defined as three or more of hypertension, dyslipidemia, type II diabetes, hyperglycemia, and overweight or obese. Using an ecological age and period design, a 4-level period variable was constructed to proxy for atypical antipsychotic exposure as the minimum of age minus 20 years or the calendar year minus 1997 in accord with the disease course for schizophrenia-spectrum illness and the market share of atypical antipsychotics in the U.S. Logistic regression models, adjusted for age, year, and exposure main effects, estimated odds ratios (ORs) of metabolic syndrome. Relative to other mental health or other discharges, schizophrenia-spectrum discharges had an elevated risk for metabolic syndrome regardless of potential atypical antipsychotic exposure (OR = 1.46; 95 % CI, 1.30-1.64). For schizophrenia-spectrum discharges, periods of potential atypical antipsychotic exposure conferred additional metabolic syndrome risk OR = 1.21; 95 % CI, 1.04-1.41 for exposures of 1-2 years, OR = 1.29; 95 % CI, 1.13-1.46 for 3-7 years, OR = 1.27; 95 % CI, 1.12-1.44 for 8-12 years, and OR = 1.10; 95 % CI 0.98-1.24 for >12 years. In summary, cardiometabolic disease and related risks were elevated among a nationally representative sample of adult inpatients with schizophrenia-spectrum disorders during a period of pervasive atypical antipsychotic use.

Psychiatrist and Psychiatric Pharmacists Beliefs and Preferences for Atypical Antipsychotic Treatments in Patients With Schizophrenia and Bipolar Disorders

BACKGROUND

Selection of schizophrenia or bipolar disorder treatments is complicated by treatment-effect heterogeneity.

OBJECTIVES

This study assessed how clinicians' beliefs and health system/ insurace policies impact choice of atypical antipsychotic agent in schizophrenia and bipolar disorder.

METHODS

A cross-sectional survey was conducted of members of the American College of Clinical Pharmacy and College of Psychiatric & Neurologic Pharmacists. Beliefs regarding atypical antipsychotic effectiveness and safety, impact of comorbidity on drug selection, and factors influencing atypical antipsychotic therapy selection were assessed.

RESULTS

Twenty-four psychiatric pharmacists and 18 psychiatrists participated. Mean age was 39.6 years, 57.1% were female. Most clinicians (64.3%) believed medication effectiveness and safety equally important, while 26.2% believed safety and 9.4% believed effectiveness more important. The most important medication properties for schizophrenia were reducing positive symptoms (92.7%) and hospitalizations (87.8%) and for bipolar disorder were reducing manic episodes (87.8%), episode relapse (53.7%), and hospitalizations (53.7%). Agranulocytosis (78.1%), arrhythmias (70.7%), and extrapyramidal side effects (68.3%) were most concerning. Restrictions affected antipsychotic choice at 80.5% of sites and were believed to affect medication adherence (55.0%) and outcomes (53.4%).

CONCLUSION

Efficacy and safety were considered equally important when choosing atypical antipsychotics. Formulary restrictions were perceived as impacting treatment choice and outcomes.

Lack of tolerable treatment options for patients with schizophrenia

PURPOSE

Atypical antipsychotics (AAs), an effective treatment for schizophrenia, have a range of pharmacologic properties leading to differences in tolerability as well as heterogeneity in treatment response. Individual patient characteristics must be considered when making treatment choices, especially from an adverse event (AE) or tolerability perspective. Despite the availability of numerous AAs, after appraising patient characteristics at the time of treatment selection, physicians may quickly run out of tolerable treatment options.

PATIENTS AND METHODS

AE risk factors, defined as having either a prior history of an AE or a risk factor for that AE, were determined for Medicaid-insured and Commercially insured patients using database analysis. Patients receiving AA treatment between January 1, 2010 and December 31, 2012 defined the index date of first observed AA prescription during this period. Nine AAs were evaluated for association with AE risk factors as informed by drug prescribing information from the different manufacturers and published meta-analyses. The proportion of patients with pre-index AE risk factors prescribed an AA associated with that risk factor was then determined.

RESULTS

A high proportion of patients (>80%) were prescribed an AA associated with extrapyramidal symptoms or akathisia despite experiencing extrapyramidal symptoms or akathisia prior to AA treatment initiation. Similar trends were observed among patients with diabetes (>60%) and obesity (>40%). From the nine treatment options available, the number of optimal choices for individual patient segments were limited based on their prior history, including those with cardiometabolic and cardiovascular comorbidities (four); experiencing prolactin elevation-related problems (seven); needing to avoid excessive sedation (four); or at risk of extrapyramidal symptoms or akathisia (two). Options were then further restricted among patients in more than one segment when multiple pre-index AE risk factors were combined.

CONCLUSION

When combining patient risk profile with antipsychotic AE profile, physicians may quickly run out of tolerable treatment options for individual patients, despite the availability of many AAs, suggesting a need for additional treatment options with better tolerability and without compromising efficacy.