VIEWS & REVIEWS

Schizophrenia treatment less than ideal?

-Amanda Cameron-

The effective treatment of patients with schizophrenia is a worldwide public health challenge. Improvements in treatment can have a significant impact on patient morbidity, mortality and quality of life, as well as on both direct and indirect health costs. Recently, the US Schizophrenia Patient Outcomes Research Team (PORT)* conducted a survey that was designed to assess to what extent usual care for schizophrenia complies with the team's recent treatment recommendations. l The Schizophrenia PORT recommendations themselves are the result of a 5-year analysis of published research on schizophrenia conducted by more than 15 scientists from 3 major research centres in the US.2 According to the results of this landmark survey, fewer than 50% of US patients with schizophrenia receive adequate dosages of antipsychotic medications or appropriate psychosocial interventions.

The PORT survey also showed that: < 10% of families of outpatients with schizophrenia receive education and support; < 25% of patients with schizo­phrenia receive any kind of vocational rehabilitation; only 2-10% of patients with schizophrenia participate in assertive community treatment programmes; and African-American patients with schizophrenia are more likely to be overmedicated and to be denied antidepressive medication than their Caucasian counterparts.

PORT recommendations and survey The PORT survey involved 719 patients (aged

;;:: 18 years) with schizophrenia who were receiving usual care in either the acute inpatient (n = 279) or community (440) setting in 2 US states. Using medical record data supplemented by information gathered in face-to-face interviews, the PORT investigators determined whether treatment did or did not conform with the Schizophrenia PORT recom­mendations regarding antipsychotic medications, adjunctive pharmacotherapies, electroconvulsive therapy, psychological interventions, family interventions, vocational rehabilitation, assertive community treatment and assertive case management.

The following is a summary of the Schizophrenia PORT treatment recommendations regarding the use of pharmacotherapy in patients with schizophrenia.2

Compliance rates that were assessed in the Schizo­phrenia PORT survey are reported alongside the corresponding recommendation. 1

Treating acute symptom episodes • Antipsychotic drugs (other than clozapine) are

recommended as the first-line treatment to reduce psychotic symptoms. 89% of inpatients were pre­scribed an antipsychotic agent, including 9% who were prescribed clozapine.

• The dosage of antipsychotic agent should fall within the range of 300-1()()()mg chlorpromazine (CPZ) equivalents per day for;;:: 6 weeks; dosages at the lower end of this range are recommendedfor pariems experiencing their firST acute symptom episode. Among inpatients, 62% of those who were prescribed an antipsychotic at discharge received a dosage within the recommended range.

• Massive loading doses of antipsychotic medication should not be used.

• The choice of antipsychotic drug should be determined by patient acceptability, prior individual drug response, individual adverse effect profile, and the long-term treatment plan.

• Use of antiparkinsonian agents to reduce the incidence of extrapyramidal symptoms (EPS) should be determined on a case-by-case basis and monitored in an ongoing fashion. Of the 74% of inpatients who reported;;:: 1 EPS due to antipsychotic medication, 54% were prescribed an antiparkinsonian drug; of the 79% of outpatients who reported;;:: 1 EPS due to antipsychotic medication, 46% were receiving an anti parkinsonian drug.

Maintenance pharmacotherapy • Patients who experience acute symptom relief with

an antipsychotic should continue to receive this drug for ~ J year after symptom stabilisation. 92% of outpatients were prescribed an antipsychotic drug for this duration.

• The maintenance dosage of antipsychotic medication should be in the range of 300-600mg CPZ equivalents (oral or depot) per day. Only 29% of outpatients were prescribed a dosage in the recommended range.

• Reassessment of the dosage level or the need for maintenance antipsychotic therapy should be ongoing.

• Targeted, intermittent dosage maintenance strategies should not be used routinely (continuous dosage regimens are recommended).

• Depot antipsychotic maintenance therapy may be used as afirst-option maintenance strategy and should be strongly consideredfor patients who find it difficult to comply with oral medication or who prefer a depot regimen. Among the 48% of inpatients reporting a low level of noncompliance, 13% were receiving depot antipsychotic medication; among the 8% of inpatients reporting a high level of noncompliance, 50% were receiving depot medication. Similarly, among the 40% of outpatients reporting a low level of noncompliance, 25% were receiving depot antipsychotic medication; among the 5% of outpatients reporting a high level of non­compliance, 35% were receiving depot medication.

New antipsychotic drugs • A trial of clozapine should be offered to patients

with schizophrenia or schizoaffective disorder whose positive symptoms, or violent behaviour and psychotic symptoms, do not respond to trials with 2 different classes of antipsychotic medication, and to patients who require antipsychotic therapy but who experience intolerable adverse effects with use of other antipsychotic drugs.

3

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4 VIEWS & REVIEWS

• A trial of risperidone should be offered to patients who achieve an adequate reduction in positive symptoms on conventional antipsychotic treatment, but who have significant EPS that do not respond adequately to an antiparkinsonian agent.

Adjunctive pharmacotherapies • Patients who experience persistent and clinically

significant symptoms of anxiety, depression or hostility should receive a trial of adjunctive pharmacotherapy. Of the 48% of inpatients and the 43% of outpatients with depression, 34 and 46%, respectively, were prescribed an antidepressant. Of the 18% of inpatients and the 23% of outpatients with anxiety, 33 and 41 %, respectively, received an anxiolytic. 23% of inpatients and 14% of outpatients who had persistent psychotic symptoms received either lithium or an anticonvulsant.

Benefits for state of Georgia In an accompanying article, Dr John Kane from the

Long Island Jewish Medical Center, New York, US, writes that the Schizophrenia PORT has made a ' valuable contribution' to the field of schizophrenia treatment and research.3 Indeed, Dr Thomas Hester from the Georgia Department of Human Resources, Atlanta, US, reports that the public mental health system of Georgia has already benefited from its participation in the Schizophrenia PORT project.4

However, the data also revealed a number of gaps and limitations. In particular, the Schizophrenia PORT recommendations may be limited by their reliance on medical science since they do not consider potential relevant findings from other fields, comments

Dr Michael Hogan from the Ohio Department of Mental Health, Columbus, US.s

Consumer and family guidelines prepared Outdated prescribing practices are a major

contributing factor to the well-documented problem of relapse in patients with schizophrenia and much of the noncompliance and resulting disability might be reduced dramatically if providers adhered to the PORT medication recommendations, according to Laurie Flynn, Executive Director for the National Alliance for the Mentally III (NAMI), Virginia, US.6

To this end, the NAMI has outlined the PORT recommendations in an easy-to-understand format in the 'NAMI Consumer and Family Guide to Schizophrenia Treatment'. The guide is being distributed to the advocacy group's affiliates, and to state and community mental health facilities, mental health providers, hospitals, and managed-care companies throughout the US.

* The Schizophrenia PORTW(L5 established in 1992 by the US Agency for HealJh Care Policy and Research and the NazionaJ Insritute of Menlal HealJh to develop evidence-based recommendations for the treatmenJ of paJient.s with schizophrenia.

1. Lehman AF. et aI. PatIerns of usual care for schizopbrenia: initial results from the SchizopIlrenia Patient Outromes Research Team (POKT) client survey.

Schizophrenia Bulletin 24: 11 -20. No. I, 1998 2 Lehman AF, et aI. At issue: translating research into practice: the Schizophrenia Outcomes Research Team (POKT) treaImetlt recommendations. Schizophrenia Bulletin 24: 1-10. No. I,

19983. Kane 1M. Commenwy by. Schizophrenia Bulletin 24: 20-23, No. I. 1998

4. Hesler TW. Commenwy. Schizophrenia Bulletin 24: 25-27, No. I, 1998

S. Hogan MF. Commentary. Schizophrenia Bulletin 24: 27-30, No. I, 1998

6. National Alliance for the Mentally ill. Millions with schizophrenia not getting basic trealment, landmark swdy shows care Lags far behind science. Media Release:

[3 pagesJ. 24 Mar 1998 Il006'''''

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