Prescribing pattern of antipsychotic medication for first-episode psychosis: a retrospective cohort study

Abstract

ObjectiveGuidelines for antipsychotic use in first-episode psychosis (FEP) recommend that medication be chosen initially on the basis of side effect profile with doses at the lower end of the range. Our objective was to describe the pattern of antipsychotic use in FEP over a period of 21 years in the context of changing clinical guidelines and the development of specialist early intervention in psychosis (EIP) services.SettingA community-based mental health service in South County Dublin (population 187 000) and a large private hospital.ParticipantsParticipants included 465 patients with FEP (146 from an epidemiological study (1995–1999) and 319 from a specialist EIP service (2005–2016)). Treatment with antipsychotic medication did not exceed 30 days at study entry.Outcome measuresThis is a descriptive study of prescribing practices in the context of service development and changing guidelines.ResultsFirst-generation antipsychotics were prescribed for 65% of the early cohort compared with 4.3% of the EIP cohort. Olanzapine was initially prescribed for 79.7% of EIP patients. Initial doses of medication were frequently low (≤50% British National Formulary (BNF) maximum) in both cohorts (71% and 78.6%). The demographic and clinical factors investigated did not influence the initial choice of antipsychotic medication significantly. Univariate logistic regression analysis suggested inpatient treatment setting was associated with a higher initial dose (>50% BNF maximum) of antipsychotic medication. Increasing dose requirements over the first month of engagement with an EIP service was associated with poorer global functioning at baseline, greater positive symptoms at baseline and the inpatient treatment setting. However, these associations were not seen in the multivariable model.ConclusionsSecond-generation antipsychotic prescribing predominates, but guidelines are often overlooked when choosing olanzapine notwithstanding lower initial dosages. EIP services should include proactive support for optimising medicines in line with evidence-based guidelines.

Worth the Weight? Olanzapine Prescribing in Schizophrenia. A Review of Weight Gain and Other Cardiometabolic Side Effects of Olanzapine

“…Due to its significant association with weight gain and other cardiometabolic abnormalities, since 2009 several international guidelines in Europe, the United States, Australia and New Zealand have advised against olanzapine's use as part of firstline psychosis management (17). However, today olanzapine continues to be one of the most popular antipsychotics, extensively prescribed in both FEP and chronic cases, across the spectrum of illness severity and in many jurisdictions (7)(8)(9). Considering the cardiometabolic adverse effects of olanzapine are well-documented, what might be the reasons underlying its popularity?…”

“…The overlapping confidence intervals between point estimates meant that efficacy differences favoring olanzapine were no longer considered significant for many comparisons (3). Despite the lack of supporting evidence, many clinicians prescribe olanzapine in the first instance for acute management of FEP (7)(8)(9). Its sedative and anxiolytic properties likely influence this preference (9).…”

“…Whilst research on the adverse physical health effects of olanzapine and comparative data demonstrating its lack of superiority over alternative antipsychotics has been accruing over two decades (6,12), subsequent change in prescribing practices, has not occurred at the same speed (7)(8)(9). To tackle such a complex problem, future management approaches will need to be multifaceted and scalable.…”

“…Adverse cardiometabolic side effects of antipsychotics, particularly second-generation antipsychotics (SGA), represent an undeniable contributor to the burden of cardiovascular morbidity and mortality amongst this cohort (5). Olanzapine, a SGA with one of the most significant cardiometabolic side effect profiles (5,6), continues to be one of the most popular antipsychotics prescribed in schizophrenia (7)(8)(9). This commentary will consider some of the most pertinent research assessing the efficacy of olanzapine in schizophrenia management; suggest potential reasons for incongruence observed between guideline recommendations and prescribing practices; and finally, make suggestions as to how olanzapine-induced weight gain-a side effect that often represents the beginning of a series of escalating cardiometabolic derangements-can be recognized and its effects ameliorated.…”

Effect of aripiprazole as an adjunct to atypical antipsychotics on weight and metabolic profile: a 12-week open-label trial

“… 4 – 6 Thus, the SGAs found quick acceptance and their usage increased rapidly, such that they are now the more commonly prescribed drugs in large parts of the world. 7 – 11 The distinction between atypical and typical antipsychotics has since been called into question as many atypicals behave like typicals, and a new classification among atypicals has been proposed, introducing the concept of spectrum of atypia that begins with risperidone (the least atypical) and ends with olanzapine and clozapine (the most atypical). 12 …”