Brief Communication
Benefits of Switching From Typical to Atypical Antipsychotic Medications: A Longitudinal Study in a Community-Based Setting
Peter E Cook, MD, FRCPC1, Joel O Goldberg PhD2, Ryan J Van Lieshout BSc3
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Objective: This study examines the clinical and resource utilization effects of switching stable outpatients with schizophrenia from a typical to an atypical antipsychotic medication.
Method: We monitored 43 schizophrenia patients from a community mental health program who tolerated switching from typical to atypical antipsychotic medications. We used the Positive and Negative Syndrome Scale (PANSS), Lehman Quality of Life Interview (QOL), and service utilization data for 2 years before and 2 years after the switch.
Results: The switch to atypical antipsychotics was associated with significant improvements in positive symptoms, in general psychopathology, and in quality of life. Resource requirements, including case-management and crisis services and hospitalization days, were significantly reduced. We observed no changes in the sample’s already low levels of negative symptoms.
Conclusions: In stable outpatients with schizophrenia in a real-world setting, switching to an atypical antipsychotic can result in sustained, significant improvement in clinical response and quality of life, as well as in reduced need for hospitalization and community support.
(Can J Psychiatry 2002;47: 870–874)
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Clinical Implications
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Treating stable outpatients with atypical antipsychotics can result in further, sustained decreases in positive symptoms, as well as in general psychopathology and quality of life improvements.
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Using atypical antipsychotic medications can substantially reduce the need for hospitalization and supportive community service.
Limitations
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This study did not examine the comparative efficacy of the atypical antipsychotics.
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The study was based on patients who tolerated the switch from typical to atypical antipsychotic medications over the study period.
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We did not control for the adjunctive pharmacologic therapies or psychosocial rehabilitation interventions.
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Key Words: schizophrenia, atypical antipsychotic medication, longitudinal, community,
resource utilization
Résumé : Les avantages de changer un antipsychotique typique pour un atypique : une étude longitudinale dans un cadre communautaire
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Despite the efficacy of conventional antipsychotics in ameliorating the
positive symptoms of schizophrenia, up to 30% of individuals with schizophrenia
fail to respond to these medications (1). Further, 20% to 30% of patients
experience a relapse, despite adequate maintenance treatment with conventional
antipsychotic agents (2,3). The second generation antipsychotics, the atypicals,
were developed to address the shortcomings of the typical medications:
limited efficacy, possible worsening of negative symptoms, and troubling
side effects (4).
The atypical antipsychotic medications have contributed significantly to
the treatment of schizophrenia (5–13). For several reasons, however, published
research on the efficacy of antipsychotic medications is limited. First,
most clinical trials have been carried out in hospital settings (5), while
most patients with schizophrenia are treated in the community. Second,
the published studies provide evidence for the short-term efficacy of atypical,
compared with typical, antipsychotics. Long-term studies are particularly
relevant to patients with schizophrenia, because it is a chronic disorder
(14). Researchers and mental health professionals have highlighted the
need for investigations that go beyond tightly controlled efficacy trials
and do field studies performed under real-world conditions (5,15).
With these issues in mind, we set out to examine the effects on a sample
of community-based outpatients with schizophrenia of switching from typical
to atypical antipsychotic medications.
Method
Subjects
All 43 subjects who completed the study are patients of an urban, community-based
treatment and rehabilitation program in Ontario, the Hamilton Program for
Schizophrenia (HPS). The program’s patients have a diagnosis of schizophrenia
as a criterion for admission (16). Table 1 presents relevant clinical and
demographic information for the sample.
Inclusion criteria for this study were based on 3 parameters. First, patients
had to remain in the program for 4 consecutive years during the study period.
Second, patients completed the Positive and Negative Syndrome Scale (PANSS)
(1) and Quality of Life Interview (QOL) (17) and agreed that these scores
could be available for evaluation purposes each year. (All participants
provided informed consent before their PANSS and QOL interviews were conducted.)
Third, patients had to have taken a single typical antipsychotic for at
least 2 consecutive years before switching and a single atypical medication
for 2 consecutive years after switching. We selected a 2-year period because
of the relevance of long-term studies to patients with chronic disorders
who are treated in the community. Patients with comorbid conditions (for
example, other psychiatric diagnoses or substance abuse) were not excluded
from the study.
Measures
PANSS. The scale assesses positive and negative symptoms and general psychopathology
(1). We assessed participants annually and used the PANSS raw scores in
the statistical analysis (18).
Quality of Life. The Lehman QOL (17) was used as the quality-of-life measure.
This scale uses patients’ own ratings along several dimensions of life
and has been shown to be relevant to people with a psychiatric disability
who are living in the community (19). In this study, we used the scale’s
main quality-of-life measure, the subjective global satisfaction scale.
Management Information System (MIS). Service utilization is recorded routinely
as part of the HPS management information system. The variables examined
in this study included case-management time, crisis time (that is, minutes
of emergency case-management time provided over a 2-year period), and psychiatric
hospitalization days.
Procedure
Yearly PANSS and QOL interviews were gathered from 1992–3 until the end
of the study period in 1999. A trained rater who was independent of the
treating psychiatrists and blind to patient medication status conducted
the assessment.
The treating psychiatrist ordered the patient’s medication in the clinical
record, and this information was subsequently extracted by the researchers.
The 2 program psychiatrists were solely responsible for prescribing medications
and dosages. They based their decisions on patient symptoms, clinical presentation,
side effects, and response.
Patients were switched to clozapine, risperidone, or olanzapine if they
were not responding optimally to, or were experiencing side effects from,
the conventional antipsychotics or if the treating psychiatrist agreed
to their request to switch medications. Reflecting the high incidence of
comorbidity, this study included patients who received medications (for
example, antidepressants, anxiolytics, and mood stabilizers) for conditions
other than psychosis. Table 2 lists the medications prescribed in the preswitch
(typical antipsychotic) and postswitch (atypical antipsychotic) years.
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Table 1 Demographic and clinical details of the sample
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Meana
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SD
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Age (years):
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34.6
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7.2
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Number of years of illness
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14.4
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8.0
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Number of years patients were clients of HPS
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7.7
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4.9
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Number of years of formal education
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12.2
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2.4
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aValues above refer to mean values at year 1 of the study.
HPS = Hamilton
Program for Schizophrenia.
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Percentage of sample
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Sex
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Men
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79%
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Women
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21%
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Diagnosis (DSM-III-R)
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Schizophrenia
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84%
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Schizoaffective
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14%
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Other psychotic disorders
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2%
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Marital Status
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Single
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89%
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Married
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9%
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Separated or divorced
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2%
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Statistical Analyses
We analyzed the PANSS (Positive Symptoms, Negative Symptoms, and General
Psychopathology) and QOL measures, using a 2-way factorial ANOVA with independent
variables of time (first and second year on the drug) and drug type (typical
vs atypical). Clinical response rates for treatment with typical antipsychotics
(that is, improvement from preswitch year 1 to year 2) were compared with
those for treatment with atypicals (that is, improvement from year 2 to
year 4), using a chi-squared test. The Management Information System (MIS)
data were collapsed for the first 2 years (preswitch) and again for the
final 2 years (postswitch). The MIS pre- and postswitch data were then
analyzed using t-tests. Because the study hypothesized a priori improvements
with the switch to atypicals, 1-tailed tests were applied as indicated;
all other P-values are 2-tailed.
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