Variations in use of second-generation antipsychotic medication by race among adult psychiatric patients

OBJECTIVE: This study examined variations in the use of second-generation antipsychotic medication among African-American and non-Hispanic white patients in a national sample of adults who were treated by psychiatrists. METHODS: This study used data from studies of psychiatric patients and treatments that were conducted by the American Psychiatric Institute for Research and Education's (APIRE's) Practice Research Network (PRN). Psychiatrists provided detailed clinical data for 126 African-American patients and 574 white patients who were randomly selected and for whom antipsychotic medications were prescribed. The study assessed differences by race in the use of second-generation antipsychotic medication, adjusting for clinical, sociodemographic, and health-system characteristics, including patients' source of payment for treatment. RESULTS: African-American patients were less likely than white patients to receive second-generation antipsychotic medications (49 percent compared with 66 percent). After the analysis statistically adjusted for clinical, sociodemographic, and health-system characteristics, African-American patients remained less likely than white patients to receive second-generation antipsychotics. CONCLUSIONS: Because African Americans tended to receive medications that are not first-line recommended treatments and that have a greater risk of producing tardive dyskinesia and extrapyramidal side effects, African Americans could be expected to suffer diminished clinical status. This disparity may also contribute to lower rates of adherence and to more frequent emergency department visits and psychiatric hospitalizations among African Americans     

Ethnicity and prescription patterns for haloperidol, risperidone, and olanzapine

OBJECTIVE: Patients with schizophrenia may respond better to second-generation antipsychotics than to older antipsychotics because of their superior efficacy and safety profiles. However, the reduced likelihood among ethnic minority groups of receiving newer antipsychotics may be associated with reduced medication adherence and health service use, potentially contributing to poor response rates. This study examined whether ethnicity helped predict whether patients with schizophrenia were given a first- or a second-generation antipsychotic, haloperidol versus risperidone or olanzapine, and what type of second-generation antipsychotic was prescribed, risperidone or olanzapine, when other factors were controlled for. METHODS: Texas Medicaid claims were analyzed for persons aged 21 to 65 years with a diagnosis of schizophrenia or schizoaffective disorder who started treatment with olanzapine (N=1875), risperidone (N=982), or haloperidol (N= 726) between January 1, 1997 and August 31, 1998. The association between antipsychotic prescribing patterns among African Americans, Mexican Americans, and whites was assessed by using logistic regression analysis. Covariates included other patient demographic characteristics, region, comorbid mental health conditions, and medication and health care resource use in the 12 months before antipsychotic initiation. RESULTS: The results of the first- versus second-generation antipsychotic analysis indicated that African Americans were significantly less likely than whites to receive risperidone or olanzapine. Although not statistically significant, the odds ratio indicated that Mexican Americans were also less likely to receive risperidone or olanzapine. Ethnicity was not associated with significant differences in the prescribing patterns of risperidone versus olanzapine. CONCLUSIONS: When other factors were controlled for, African Americans were significantly less likely to receive the newer antipsychotics. Among those who received the newer antipsychotics, ethnicity did not affect medication choice.     

Adherence assessments and the use of depot antipsychotics in patients with schizophrenia

BACKGROUND: Antipsychotic medications significantly ameliorate the symptoms of schizophrenia, but patients are often noncompliant with these medications. Research evidence supports the use of depot antipsychotics in noncompliant patients. METHOD: Between January 9, 1991, and December 19, 1995, 1307 veterans with schizophrenia or schizoaffective disorder (ICD-9) were enrolled in a study of enhanced psychosocial programming at 14 Veterans Administration Medical Centers. All had a history of high inpatient use. At enrollment, clinicians listed patient medications, rated patient compliance, and completed a Brief Psychiatric Rating Scale (BPRS) and Global Assessment of Functioning (GAF). Patients reported medication side effects. We describe depot antipsychotic use among these patients and examine the relationship between depot use, assessed compliance, and patient characteristics. RESULTS: At enrollment, 18% of patients in this cohort were receiving depot antipsychotics; however, clinicians reported that 49% had been noncompliant with medication in the past year. Depot use varied significantly with treatment site; African Americans were more likely to receive depot antipsychotics and less likely to receive atypical antipsychotics than white patients. Patients on depot and oral agents had similar levels of psychiatric symptoms, but patients on depot antipsychotics were more likely to receive high doses and complain of side effects. CONCLUSION: Clinicians prescribed depot antipsychotics relatively infrequently, despite high rates of noncompliance and high levels of inpatient use. Variation in use with treatment site and ethnic group suggests barriers to implementing research-based recommendations for depot use in noncompliant patients. Quality improvement programs should consider facilitating the appropriate use of depots.     

Characteristics and use patterns of patients taking first-generation depot antipsychotics or oral antipsychotics for schizophrenia

OBJECTIVE: Investigators compared patient characteristics and antipsychotic use patterns between individuals with schizophrenia treated in usual care with first-generation depot antipsychotics and those treated with oral antipsychotics (first- or second-generation or both). METHODS: Analyses used data from the U.S. Schizophrenia Care and Assessment Program, a large, prospective study of treatment for schizophrenia conducted July 1997 through September 2003. Participants were assessed at enrollment and every six months thereafter with patient self-report, validated psychiatric measures, and systematic extraction of medical records. Individuals treated with a first-generation depot antipsychotic at any time during the three-year study (N=569) were compared with those treated with only oral antipsychotics (N=1,617) on characteristics at enrollment and medication use pattern during the year after enrollment. RESULTS: Compared with patients receiving only oral antipsychotics, participants treated with depot medications (haloperidol or fluphenazine decanoate) were more likely to be African American (p<.001); less likely to be a veteran (p=.005); had more psychiatric hospitalizations in the year before enrollment (p<.001); and were more likely to have been arrested (p<.001), to use alcohol and illicit substances (p<.001), and to show higher psychopathology, particularly psychotic symptoms and disorganized thinking (p<.01 for both). In the year after enrollment, participants treated with depot medications had a high mean medication possession ratio (91%), and most of the medication regimens (68%) were augmented with oral antipsychotics for prolonged durations (median of 144 days). CONCLUSIONS: Patients with schizophrenia treated with first-generation depot antipsychotics differed from those treated with only oral antipsychotics. Findings suggest that first-generation depot antipsychotics might address some unmet needs of a unique subgroup of patients with schizophrenia.     

Antipsychotic use in Australia: the patients' perspective

OBJECTIVE: To describe patterns of self-reported medication use in a population-based sample of people with psychotic disorders; to establish correlates with clinical variables; to determine perceived side-effect burden; and investigate patient perception of efficacy for different classes of antipsychotic agent. METHODS: Using the Australian Low Prevalence (Psychosis) Study database we analysed patterns of psychotropic medication and examined their clinical correlates. We also determined rates of reported side-effects and perceived benefit or otherwise associated with the different antipsychotic drugs. RESULTS: Of the 1126 persons interviewed, 88.6% were on psychotropic medication; 54.3% were using "typical" antipsychotics (24.8% in depot form), while 8.3% were on clozapine, 13.3% on risperidone, and 8.8% on olanzapine. Around 30% of women, and 20% of men, were on mood stabilizers or antidepressants. Over half of respondents were on more than one agent. Of those on only one agent, nearly 80% reported at least one side-effect; the mean number of side-effects was 3.9 for typical antipsychotics, and 3.3 for atypicals. Atypicals, notably clozapine, tended to be rated by patients as more efficacious than typicals; depot preparations, in particular, tended to be seen as unhelpful, and were associated with a higher side-effect burden. CONCLUSIONS: This study presents an insight into patients' perception of efficacy and side-effects of antipsychotic medications. The findings have implications for clinicians, and can inform treatment options in people with psychotic disorders.     

Attitudes towards long-acting depot antipsychotics: A survey of patients,relatives and psychiatrists

In many countries fewer than 20% of individuals with schizophrenia receive depot antipsychotic medication. Frequently stated reasons are psychiatrist's, patient's and relative's objections to depot treatment. This is the first study that directly compares the attitudes to depot antipsychotics of psychiatrists, patients and relatives. A semi-structured questionnaire about their attitudes towards depot antipsychotics was completed by 255 participants (83 patients diagnosed with schizophrenic disorder, 81 psychiatrists in private practice and 91 relatives, not directly related to the patients). Patients were more negative towards depot injections than psychiatrists and relatives. They particularly fear to be constricted in their autonomy when treated with depot antipsychotics and that injections might be painful. About 67% of all patients in our sample did not receive information about depot antipsychotics from their psychiatrist. Less than 10% of psychiatrists offer depot treatment after a first psychotic episode. Psychiatrists use depot antipsychotics in a conservative way, although they attribute positive traits to the method. Patients' negative attitudes might relate to the low level of information. To enhance the use of depot antipsychotics, information practices of psychiatrists should be improved. Patients should be informed about different forms of treatment during early stages of the illness.     

Disparities in use of antipsychotic medications among nursing home residents in Arkansas

Pilot work was conducted to determine whether there were racial disparities in the use of second-generation antipsychotic medications in a sample of 2,717 residents of nursing homes in Arkansas in 2001. Chi square analysis and a logistic regression model were used to examine the relationship between residents' race and likelihood of receiving a second-generation antipsychotic. Other independent variables included in the model were age, gender, and the location of the nursing home. The results indicated racial disparities in use of second-generation antipsychotics among the nursing home residents, with African-American residents less likely to receive these medications than residents from other racial or ethnic groups.     

Racial disparities in the use of second-generation antipsychotics for the treatment of schizophrenia

OBJECTIVE: Despite recommendations that second-generation antipsychotics be used as first-line treatment for schizophrenia, previous studies have shown that blacks are less likely than whites to receive these newer drugs. This study determined the rate at which second-generation antipsychotics were prescribed to whites and blacks with schizophrenia who were treated as outpatients. METHODS: Data were collected from a community mental health clinic affiliated with an academic center in Rochester, New York. Multivariate logistic regression was used to examine the association between race and the receipt of a second-generation antipsychotic. RESULTS: Data were available for 456 patients: 276 whites and 180 blacks. Ninety-five percent received a second-generation antipsychotic. Whites were approximately six times more likely than blacks to receive a second-generation medication, after the analysis controlled for clinical and sociodemographic factors (p<.001). Most of this difference appeared to be driven by a disparity in the use of clozapine. CONCLUSIONS: In this sample, blacks were less likely than whites to receive second-generation antipsychotics, demonstrating a persistent gap in the quality of care for patients with schizophrenia.     

Pharmacological treatment of hospitalised schizophrenic patients in Belgium

Objective. The aim of the present study is two-fold: (1) evaluate to what degree antipsychotic prescribing patterns are in accordance with published treatment recommendations; (2) gain insight in factors determining guideline adherence or non-adherence. Method. The medication use at first assessment of 1215 psychotic in-patients, participating in a naturalistic prospective follow-up study, was registered. Results. In Belgium, use of novel antipsychotics is frequent (69.4%) in hospitalised schizophrenic patients. In the total sample 57.8% receive only one antipsychotic drug. The majority of patients are treated with drugs of only one antipsychotic drug group, either first-generation antipsychotics (FGA) (27.8%) or second-generation antipsychotics (SGA) (42.3%). Roughly one-quarter of patients combine different types of antipsychotic. Antipsychotic dosing is adequate for the majority of patients, but one-third receive a higher than recommended dose. The use of SGA is influenced by the patients’ age and duration of illness. Polypharmacy and the administration of high doses FGA are influenced by symptom severity and illness duration. No clear determinants of SGA overdosing were found. Conclusions. SGA are most frequently used for the treatment for schizophrenic psychosis. Polypharmacy and excessive dosing are still frequently observed and appear influenced by the patient's clinical condition and illness duration. Evidence-based guidelines have not been sufficiently implemented in daily clinical practice yet.     

Use and costs of public-sector behavioral health services for african-american and white women

OBJECTIVE: The purpose of this study was to identify differences between African-American and white women in the use of behavioral health services and factors associated with these differences. METHODS: In one large public behavioral health system, data on demographic characteristics, financial resources, clinical disorders, service use patterns, and costs of care were analyzed for 10,905 African-American and 19,069 white women between the ages of 18 and 59 years who received behavioral health services in 1997. RESULTS: The African-American women were more likely to be older, never married, unemployed, and eligible for Medicaid and to have a diagnosis of a psychotic disorder or a substance use disorder. African-American women were more likely than white women to receive inpatient substance abuse services and to receive more community-based day treatment services, medication services, and case management services. However, the costs of that care differed by only 2 to 4 percent from those for white women. Presence of a psychotic disorder and co-occurring substance use-need-related factors-were significant predictors of higher inpatient care costs for all the women in the sample. Presence of a psychotic or major affective disorder and eligibility for Medicaid-an enabling factor-were the most significant predictors of higher outpatient costs for the sample. Receipt of more community-based services was significantly and inversely related to inpatient care costs, regardless of race. CONCLUSIONS: In this sample of African-American and white women, consumers' needs were a significant predictor of service use. Patterns of care that were tailored to consumers' needs were not significantly more costly overall.     

Antipsychotic prescribing practices in Connecticut's public mental health system: rates of changing medications and prescribing styles

We characterized prescribing in Connecticut's State public mental health system to assess the feasibility of implementing an evidence-based medication algorithm. Medication records for a random sample of outpatients with diagnoses of schizophrenia spectrum disorders showed prescribing patterns similar to the entire United States. The base rate of changing antipsychotic medications was moderate. Over half of patients received decanoate medications, polypharmacy was nontrivial, and there was variability in prescribing patterns across physicians. Caucasian patients were more likely to receive an atypical antipsychotic and less likely to have a decanoate medication, and Latino patients were less likely to change medications. Because the base rate of changing medications was moderate and a considerable proportion of patients were prescribed newer antipsychotic medications, introducing a research-derived medication algorithm with newer atypical antipsychotics as first line agents may fit well with current practice. Further, implementing such an algorithm may reduce racial and ethnic disparities in prescribing patterns.     

Olanzapine response in psychotic depression

BACKGROUND: Psychotic depression is more common than is generally realized, occurring in an estimated 16% to 54% of depressed patients. In controlled studies of patients with schizophrenia, the atypical antipsychotic olanzapine has been shown to be superior in efficacy to haloperidol at doses of 10 mg/day. Since olanzapine may have antidepressant effects in addition to its antipsychotic properties, the purpose of this study was to assess the safety and efficacy of olanzapine in the treatment of psychotic depression. METHOD: Hospitalized patients with the discharge diagnosis of DSM-IV psychotic depression (major depression with psychotic features or bipolar I disorder, depressed phase...with psychotic features) who had been treated with olanzapine during the first 9 months of its availability in the United States were identified. An age- and sex-matched sample of hospitalized patients with psychotic depression treated with other antipsychotics during the same time period was also identified. The medical records were expunged of all references to medication treatment and then reviewed and scored in a blind fashion for indications, doses, response, and side effects. RESULTS: Fifteen psychotic depression patients (10 women, 5 men), aged 36.9 +/- 10.1 years, who were treated with olanzapine were retrospectively compared with 15 psychotic depression patients (10 women, 5 men), aged 35.0 +/- 8.2 years, treated with other antipsychotics. Ten (67%) of 15 patients taking olanzapine were much or very much improved upon discharge compared with only 4 (27%) of 15 patients taking other antipsychotics (Fisher exact test, p = .037). Olanzapine was well tolerated: no patient discontinued the medication because of side effects. Twelve (80%) of 15 patients in each group were taking antidepressants in addition to the antipsychotic. Of the 3 patients taking olanzapine but not taking an antidepressant, 2 were much or very much improved (1 patient taking olanzapine alone, 1 taking olanzapine plus valproate sodium). CONCLUSION: Olanzapine appears to be effective and safe for patients with psychotic depression. Further prospective studies are warranted to ascertain whether olanzapine's unique pharmacologic profile may make it particularly useful for the treatment of psychotic depression either alone or in combination with antidepressants.     

Are patients with schizophrenia under-treated with second-generation antipsychotics? A pilot study of the prescription practices of German psychiatrists

INTRODUCTION: Patients' and relatives' associations, psychiatrists, and pharmaceutical companies are complaining about a deficiency in the care of psychiatric patients with innovative medications in Germany. They estimate that only about 10- 30 % of all patients with schizophrenia receive second-generation antipsychotics, a figure that lies significantly below the international average. METHODS: In order to determine the frequency of use of second-generation antipsychotics in the actual care of schizophrenic patients, we conducted the following investigations:--Discharge papers of schizophrenic inpatients from a university hospital and from a district hospital were studied with regard to the antipsychotic discharge medication.--Practicing psychiatrists were contacted and asked whether during the first 3 months after discharge they had continued the antipsychotic discharge medication that was proposed by the hospital. RESULTS: The investigation of a total of 200 discharge papers and the subsequent questioning of the psychiatrists who carried out the follow-up treatment showed that 166 patients (83 %) received a second-generation antipsychotic upon discharge. Only 5 % of these patients were switched to conventional antipsychotics in the outpatient treatment. Thus, contrary to our expectations, there was no noteworthy change from second-generation to classical antipsychotics. DISCUSSION: Therefore, in the sample analyzed the second-generation antipsychotics were far more frequently prescribed than would have been expected according to general estimates, and it was not possible to verify the often-heard complaints of an under-treatment with second generations in this study. Our findings suggest, however, that only 60 % of the patients still receive their discharge medication 3 months after discharge from the hospital. This raises the important question as to how continuity of the antipsychotic treatment could be better ensured.