First episode psychosis : Are we prescribing well?

17.03.2015

There are suggestions that we should adopt different pharmacological strategies for first episode schizophrenia and multi episode illness.The state of present practice in treating first episode is important to see how we stick to guidances and what factors  are associated with choices we make.

Delbert G. Robinson et al report  prescription practices in USA, using data from NIMH funded RAISE-ETP (Recovery After an Initial Schizophrenia Episode (RAISE) Project :Early Treatment Program (ETP)) study.Patients included were those between ages 15 yrs-40yrs with diagnosis of non affective psychosis with no previous discrete psychotic episode. Site randomisation was used to compare a  specialty care treatment program for first-episode psychosis that includes medical management guided by a decision support system and community care where treatment is by physician choice.Thirty-four  community treatment sites in 21 US states participated.

Results

There were 404 patients in the sample.12.6% did not have prescriptions for any psychotropic medications at study entry. of the 337 patients who were on antipsychotics at entry, 12% received First Generation Antipsychotic (FGA)including those who had both FGA and Second Generation Antispychotic (SGA).10% were on LA depot injections: half of this were  paliperidone depot and one third were haloperidol depot.Nearly 90% received only one antipsychotic agent.10% had two antipsychotics. Risperidone accounted for one-third of antipsychotic monotherapy. 17% were for olanzapine. Aripiprazole, Paliperidone, and Quetiapine, each accounting for around 10% of prescriptions.Few patients received higher than recommended doses. This was particularly more if they were on olanzapine. 21% of those who received antipsychotics also had perception for anticholinergic agents.11% of those pn antipsychotics also received anti anxiety medications.One third of those on antipsychotics also received antidepressants i.e. 115/337, though only half them had any documented life time depression/anxiety disorders.Negative symptoms possibly explained only 10% of the remaining 58 patients ( after accounting for depression).

Women were more likely to get lower doses. They were more likely to be on depot and receive antidepressants. African Americans were  more likely to get FGA.Young patients were more likely to get risperidone. Specific diagnosis had no effect on choice of medications.

Prescriptions were initiated mostly by inpatients units, after which patients were referred to community centres. Information on decision making reasons/indications /patient choices is not available to offer further interpretations.

A large number of first episode patients received antidepressants without clear indications.Preference for SGA is clear. Choice of agents with in SGA,  esp with regard to metabolic side effects need to be considered.

Potentially problematic prescribing was identified in 40% of the sample.This include 1. use of antidepressants where there was no clear indication 2. use of olanzapine (PORT recommends against using olanzapine as first choice due to metabolic side effects) 3. use of more than one antipsychotic.

It is important to audit and reflect on local prescribing patterns. It is essential that  patients and their families are engaged in a comprehensive discussion of the risks and benefits of different medication choices. This is the only way to ensure well-informed decisions are made.

Prescription Practices in the Treatment of First-Episode Schizophrenia Spectrum DisordersData From the National RAISE-ETPStudy.

Robinson DG, Schooler NR, John M, Correll CU, Marcy P, Addington J, Brunette MF, Estroff SE, Mueser KT, Penn D, Robinson J, Rosenheck RA, Severe J, Goldstein A, Azrin S, Heinssen R, Kane JM.

Am J Psychiatry. 2015 Mar 1;172(3):237-48.

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