{"id":14167,"date":"2011-10-02T10:17:23","date_gmt":"2011-10-02T14:17:23","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=14167"},"modified":"2011-10-02T13:19:48","modified_gmt":"2011-10-02T17:19:48","slug":"and-leave-it-at-that","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/10\/02\/and-leave-it-at-that\/","title":{"rendered":"and leave it at that…"},"content":{"rendered":"
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Time to discontinuation of first- and second-generation antipsychotic medications in the treatment of schizophrenia.<\/font><\/a><\/strong>
by Kreyenbuhl J, Slade EP, Medoff DR, Brown CH, Ehrenreich B, Afful J, Dixon LB.<\/sup>
Schizophrenia Research<\/font><\/strong>. 2011 131(1-3):127-32.<\/div>\n

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BACKGROUND<\/font><\/strong><\/u>: Continuous adherence to antipsychotic treatment is critical for individuals with schizophrenia to benefit optimally, yet studies have shown rates of antipsychotic discontinuation to be high with few differences across medications. We investigated discontinuation of selected first- and second-generation antipsychotics among individuals with schizophrenia receiving usual care in a VA healthcare network in the U.S. mid-Atlantic region.
METHODS<\/font><\/strong><\/u>: We identified 2138 VA patients with schizophrenia who initiated antipsychotic treatment with one of five non-clozapine second-generation antipsychotics or either of the two most commonly prescribed first-generation agents between 1\/2004 and 9\/2006. The dependent variable was duration of continuous antipsychotic possession from the index prescription until the first gap of more than 45 days between prescriptions. We used the Cox proportional hazards model to compare the hazard of discontinuation among the seven antipsychotics controlling for patient demographic and clinical characteristics. The reference group was olanzapine.
RESULTS<\/font><\/strong><\/u>: The majority of patients (84%) discontinued their index antipsychotic during the follow-up period (up to 33 months). In multivariable analysis, only risperidone had a significantly greater hazard of discontinuation compared to olanzapine (Adjusted hazard ratio=1.15, 95% CI: 1.02-1.30, p=.025). Younger age, non-white race, homelessness, substance use disorder, recent inpatient mental health hospitalization, and prescription of another antipsychotic were also associated with earlier discontinuation.
CONCLUSIONS<\/font><\/strong><\/u>: Examination of a usual care sample of individuals with schizophrenia revealed short durations of antipsychotic use, with only risperidone having a shorter time to discontinuation than olanzapine. These findings demonstrate that current antipsychotic agents have limited overall acceptability by patients in usual care.<\/sup><\/div>\n<\/blockquote>\n
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Compare their results with C.A.T.I.E. and the European Schizophrenia Study.<\/div>\n


[C.A.T.I.E.]<\/sup><\/p>\n


[European Schizophrenia Study]<\/sup><\/p>\n

While the curves may differ from each other for a variety of reasons, the message of all three data sets is nonetheless clear. While the notion of continuous treatment of Schizophrenia with neuroleptics  may be a recommendation of some, it’s only true in their fantasy lives. The Schizophrenic vote is in. No thanks.<\/div>\n
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Among an observational sample of VA patients with schizophrenia beginning a new episode of antipsychotic treatment, the overwhelming majority (84%) discontinued their medication during the study period. This finding is consistent with the CATIE Schizophrenia study (Lieberman et al., 2005), in which 74% of pati\\ents discontinued antipsychotic treatment within 18 months, and supports the results of studies in similar usual care samples ( [Cooper et al., 2005] , [Mullins et al., 2008] and [Moisan and Gr\u00c3\u00a9goire, 2010] ). Although several studies document similarly high rates of antipsychotic discontinuation, it is striking that only 16% of patients who discontinued their index antipsychotic in this study had a prescription filled for a different antipsychotic agent within 45 days. This suggests that a majority of patients had an interruption in antipsychotic treatment which increased their risk for serious adverse outcomes. Taken together, these findings suggest that despite the introduction of several new antipsychotic medications over the past 15 years, available treatments may not address the needs and preferences of most individuals with schizophrenia.<\/sup><\/div>\n<\/blockquote>\n
The authors comment further:<\/div>\n
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Although evidence-based treatment guidelines for schizophrenia<\/span> recommend ongoing antipsychotic treatment for all patients and the risks of antipsychotic discontinuation can be considerable, it should not be assumed that every decision to interrupt treatment is necessarily irrational. For example, the decision to discontinue a treatment that is not providing adequate relief of target symptoms or whose side effect profile is intolerable and thus impeding rather than facilitating recovery may be a logical response, signaling the need for the patient and clinician to jointly consider an alternate treatment strategy…<\/sup><\/div>\n

Contrary to our hypothesis, we found the median length of treatment for each of the SGAs and FGAs evaluated in this study to be generally similar to that of olanzapine<\/span>. The only exception was risperidone<\/span>, which demonstrated a statistically significantly greater risk of discontinuation compared to olanzapine<\/span>, a finding that was observed in CATIE and some … but not all … previous observational studies. Our results add to the accumulating evidence that the effectiveness of olanzapine<\/span>, and possibly aripiprazole<\/span> and ziprasidone<\/span>, may be superior in some ways to that of risperidone<\/span>…<\/sup><\/p>\n

Our results did not confirm earlier findings … of a greater risk of treatment discontinuation for quetiapine<\/span>, nor did we observe any specific advantages for olanzapine<\/span> over the two most recently introduced SGAs during the study period, ziprasidone<\/span> and aripiprazole<\/span>. In contrast to earlier research …, we also did not find evidence of a greater rate of discontinuation for the two most frequently prescribed FGAs, haloperidol and chlorpromazine, relative to olanzapine<\/span>….<\/sup><\/div>\n<\/blockquote>\n
Certainly, to someone who did a residency in the 1970s, it was just assumed that the right course of action in Schizophrenia was to stay on medications forever. When a new admission was presented, the "cause" of the recent psychotic episode was often explained by "he stopped his medication x months ago" said in a somewhat pejorative way – called non-compliance<\/em>. The authors of this paper suggest an alternative possibility: a medication "not providing adequate relief of target symptoms or whose side effect profile is intolerable." Robert Whitaker [Madness in America<\/font><\/strong>, Anatomy of an Epidemic<\/font><\/strong>] argues that constant medication of Schizophrenic patients is actually not a positive thing – that it worsens the prognosis. So, since the introduction of the neuroleptics, the discussion has centered on blame – either the patients are non-compliant<\/em> or their doctors are given to a controlling over-medication<\/em> – an abuse of power. Both arguments imply an understanding that we really don’t have. These authors state the obvious, "Taken together, these findings suggest that despite the introduction of several new antipsychotic medications over the past 15 years, available treatments may not address the needs and preferences of most individuals with schizophrenia,<\/em>" and leave it at that…<\/div>\n
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