CURRENT ISSU ES

Combine QOL and psychopathology to assess the impact of drugs

Evaluations of drug therapy to treat severe chronic mental illness require combined measurement of quality of life (QOL) and psychopathological symptoms. reports Dr Marion Becker from the University of Wisconsin· Madison, Wisconsin US.

QOL assessment can measure the impact of drugs on patients' lives in a reliable manner, as well as measure the benefits from the money invested in drug treatment. However, she claims that research on QOL outcomes in individuals with severe chronic mental illness is inconclusive.

Some investigators have fou nd a poor correlation between psychi atric symptoms and QOL, and the data are extremely complex and difficult to interpret. Also, QOL research is new to psychiatry. Thus. it is difficult to make recommendations about specific QOL instruments or about the interpretations of questionnaire results, comments Dr Becker.

Understanding the complex interaction She believes that psychopathology definitely

impacts on QOL and vice versa, and that further conceptual research needs to be undertaken to help understand this complex interaction. The link between psychopathology and QOL is inherent in any attempt to assess QOL in patients with severe chronic mental illness, she says.

Furthermore, there is a need to standardise QOL methods, definitions and instruments, according to Dr Becker. She adds that such an approach will allow meta-analyses of data from various studies. as well as increase understanding of how drug treatment can improve QOL for 'real people '.

Instruments currently used to assess QOL among patients with severe chronic mental illness include the Quality of Life Index for Mental Health, the Oregon Quality o f Life Questionnaire, the Quality of Life Scale, the Quality of Life lnterview and the Quality of Life Checklist. Becker M. Quality-of-life instroments for severe chrmi<: mental i]lness: implications for phannatoWnpy. Pbumaco&ooomics 7: 229-237, Mar

"" -Cost considerations ...

• Cost-effedive management of hypertension is possible, especially if low-cost agents can be used. says Dr DCH Stander from the Pelonomi Polyclinic in Bloemfontein, South Africa. Among 1338 patients with hypertension presenting to the clinic over a 2-month period, BP was adequately controlled with a thiazide diuretic in 53.5%. Combined therapy with a thiazide diuretic and reserpine controlled BP in an additional 26.5% of patients. The remaining patients were treated with other agents. Dr Stander recommends that the addition of reserpine be considered if thiazide diuretics alone are insufficient. Stander OCH. COilt-effc:WYe manqernenl ofhypertension. South African Medical Journal8S: ll S-1l6, ~b I99S -.-

Withdrawal of antihypertensive therapy seen as 'appealing'

Withdrawal of antihypertensive agents for selected patients is 'appealing '. conclude the authors of a review article looking at this issue,

Lawrence Krakoff and Sylvia Wassertheil-Smoller from the US believe that it is feasible. and potentially desirable, to discontinue antihypertensive agents in selected patients if their long-term outcome is not adversely affected, Such patients include those who are compliant, had mild hypertension at baseline (pretreatment diastolic BP < IOOmm Hg) without target organ damage and whose BP has remained in the normal range during several years' therapy.

Economic considerations Discontinuing antihypertensive therapy might

impact on the overall cost effectiveness of managing a population. The authors outlined the facto rs that might be assessed in such calculations. including: • reduced spending on medications • reduced costs relating to reduced adverse drug

reactions • increased quality of life because of the cessation of

subjective drug-related symptoms • risk of increased BP after drug withdrawal • possible changes in nonhypertensive risk factors

after drug withdrawal • cost of nonpharmacological interventions or

lifestyle changes and unforseen changes in cost or quality indices. Current estimates suggest that a nonpharmaco­

logical, nutritional intervention programme would add to the cost of therapy. However. such a program me might also produce a positive cost­effectiveness or cost-benefit projection fo r keeping those withdrawn from drug therapy at low BPs without medication.

Low-cost srrategies should be designed to promote patient choice to achieve the nurritional goals necessary to sustain BP reduction after drug withdrawal, suggest the authors. KrUoff LR. Wassertheil-5moUer S. Dc:f.run,; the patiellt group for cost· effective withdnwal of &lltihypenemive lhenpy. Plwmao:.:o&ooomics 7: 22] -228. Mar I99S ...... ".

Explicit guidelines needed for lllpatientpsychiabiccare

Although managed care organisations claim to optimise cost effectiveness, cli nical experience indicates an almost exclusive focus on cost containment. according to US-based investigators. For example. there are concerns that physicians are sometimes pressured by managed care utilisation reviewers to discharge patients early.

The investigators believe that there is a definite trend towards diminishing inpatient care in the area of psychiatric disorders. Although there is no strong evidence to show that shorter hospital stay has a detrimental impact on the quali ty of life of patients with these disorders, none of the existing studies

PHARMIGORESOURCES 25 1M, IfiS

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