First-Episode Psychosis Treatment: Lots of Room for Improvement

Liam Davenport

December 09, 2014

Almost two fifths of all first-episode psychosis (FEP) patients are prescribed drug treatment that does not meet current recommendations, new research shows.

In an examination of first prescriptions among FEP patients entering a study of specialized treatment for the disorder, investigators found that prescriptions could have been improved in almost 40% of cases.

"This is an 'is the glass half full or is it half empty' question," lead researcher Delbert G. Robinson, MD, Division of Psychiatry Research, North Shore–LIJ Health System, the Zucker Hillside Hospital, Glen Oaks, New York, told Medscape Medical News:

"We found about 40% of people were getting prescriptions at the time that they entered the program that might not be optimal...but, then again, 60% were."

"Obviously, one would hope that all patients got optimal medication, so obviously the goal would be to have none that met that criteria," he added.

The study was published online December 4 in the American Journal of Psychiatry and is part of a wider project by the National Institute of Mental Health (NIMH) to develop an integrated treatment program for FEP schizophrenia spectrum disorders that is tested in the clinic rather than in the research setting.

Start Low, Go Slow

Current guidelines for FEP recommend that antipsychotics be prescribed in low doses and that strategies to minimize adverse effects that could lead to drug discontinuation be adopted.

The Early Treatment Program of the Recovery After an Initial Schizophrenia Episode (RAISE-ETP) study has 34 sites in 21 states. For the current article, prescription data at entry were gathered from 404 FEP schizophrenia patients aged 15 to 40 years who had been taking antipsychotic medication for no longer than 6 months.

The mean duration of cumulative lifetime antipsychotic treatment was 46.7 days, and 51 patients (12.6%) did not have prescriptions for any psychotropic medication at study entry.

The team found that 159 patients (39.4%) might have benefited from prescription modifications. Of these:

  • 14 (8.8%) had higher than recommended doses of recommended antipsychotics

  • 51 (32.1%) had prescriptions for olanzapine (multiple brands), often at high doses

  • 37 (23.3%) had prescriptions for both an antipsychotic and an antidepressant without a clear indication

  • 16 (10.1%) had prescriptions for psychotropic medications without an antipsychotic

  • 5 (1.2%) had prescriptions for stimulants

Clinical Challenge

Looking at how prescribing practices might be improved, Dr Robinson said:

"First-episode patients have a slightly different optimal medication treatment than people with multiepisode schizophrenia. The sequences are different, and the doses are different.

"One of the things about schizophrenia and actually most illnesses that have a long course is there are many more people who have multiepisode schizophrenia in a clinic than people who have first episode.

"If you are a very busy clinician working in a mental health center, your experience of treatment is overwhelmingly with multiepisode patients. So I think that the challenge for the field is how to get the knowledge about this sort of specialized patient population to these very busy clinicians.

"Everyone’s orientation always is to do the most," he added.

With respect to individual medications, Dr Robinson commented: "One of the prescription practices that we found was prescribers were using olanzapine, and they were using it, interestingly, at higher than recommended doses."

The nature of the study means that the investigators are not privy to the prescribing decisions and thought processes of the clinicians. Therefore, any suggestion as to why the prescribing patterns were less than optimal in so many cases is purely speculative.

Dr Robinson nevertheless commented: "One thing that may have happened is that especially impatient clinicians often give olanzapine and sort of 'push the dose' in an attempt to get people stable and get them out of the hospital.... We don't have data, but that might have been what happened."

"Olanzapine is a standard treatment for multiepisode schizophrenia, but it isn't a recommended initial medicine to try because of its metabolic side effects. That's an example of how you would need to try to educate clinicians that olanzapine isn't a first-line treatment in this particular patient population," he added.

Funding for the RAISE-ETP study was provided by the NIMH. The research was funded by the NIMH and by the Recovery Act. Additional support for the analyses in this study was provided by an NIMH Advanced Centers for Interventions and Services Research award. Dr Robinson has served as a consultant to Asubio and Shire and has received grants from Bristol-Myers Squibb, Janssen, and Otsuka.

Am J Psychiatry. Published online December 4, 2014. Abstract

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