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In the United States, second-generation antipsychotics have become the most widely used drugs in the treatment of schizophrenia, with total annual costs of over $12 billion. While the main CATIE analysis showed that patients stayed on olanzapine longer than two other second-generation antipsychotics, none of four second-generation antipsychotics, showed any advantage over the first-generation antipsychotic perphenazine on measures of symptoms. The cost-benefit analysis presented here, which combines cost and benefit data in a single analysis, found perphenazine to be superior to each of the four second-generation antipsychotics with which it was compared. While cost-effectiveness analysis evaluates the health benefits per additional dollar expended using the measures of quality of life, cost-benefit analysis attempts to put monetary value on the health benefits of treatment and thus monetizes all outcomes. Antipsychotic medication costs were based on wholesale prices for the specific capsule strengths used in CATIE, adjusted downward for discounts and rebates.
This chapter reviews findings from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study as it compares the effects of olanzapine, perphenazine, quetiapine, risperidone, and ziprasidone on psychosocial functioning as measured on the Quality of Life Scale (QLS). In assessing psychosocial functioning, it was hypothesized that improvement would be different among treatments. The CATIE study was initiated by the National Institute of Mental Health (NIMH) to determine the effectiveness of antipsychotic drugs. For the Psychosocial Functioning Study presented in this chapter, we hypothesized that there would be differences among olanzapine, perphenazine, quetiapine, risperidone, and ziprasidone in improvement in psychosocial functioning as measured by the QLS total scale. The QLS is a clinician-rated scale of social functioning, interpersonal relationships, and psychological well-being, originally developed to measure schizophrenic deficit syndrome. Many diverse approaches to evaluate psychosocial functioning and quality of life for individuals with schizophrenia make comparisons across schizophrenia studies difficult.
There are claims that second-generation antipsychotics produce fewer
extrapyramidal side-effects (EPS) compared with first-generation
To compare the incidence of treatment-emergent EPS between
second-generation antipsychotics and perphenazine in people with
Incidence analyses integrated data from standardised rating scales and
documented use of concomitant medication or treatment discontinuation for
EPS events. Mixed model analyses of change in rating scales from baseline
were also conducted.
There were no significant differences in incidence or change in rating
scales for parkinsonism, dystonia, akathisia or tardive dyskinesia when
comparing second-generation antipsychotics with perphenazine or comparing
between second-generation antipsychotics. Secondary analyses revealed
greater rates of concomitant antiparkinsonism medication among
individuals on risperidone and lower rates among individuals on
quetiapine, and lower rates of discontinuation because of parkinsonism
among people on quetiapine and ziprasidone. There was a trend for a
greater likelihood of concomitant medication for akathisia among
individuals on risperidone and perphenazine.
The incidence of treatment-emergent EPS and change in EPS ratings
indicated that there are no significant differences between
second-generation antipsychotics and perphenazine or between
second-generation antipsychotics in people with schizophrenia.
Violence is an uncommon but significant problem associated with schizophrenia
To compare antipsychotic medications in reducing violence among patients with schizophrenia over 6 months, identify prospective predictors of violence and examine the impact of medication adherence on reduced violence
Participants (n=1445) were randomly assigned to double-blinded treatment with one of five antipsychotic medications. Analyses are presented for the intention-to-treat sample and for patients completing 6 months on assigned medication
Violence declined from 16% to 9% in the retained sample and from 19% to 14% in the intention-to-treat sample. No difference by medication group was found, except that perphenazine showed greater violence reduction than quetiapine in the retained sample. Medication adherence reduced violence, but not in patients with a history of childhood antisocial conduct. Prospective predictors of violence included childhood conduct problems, substance use, victimisation, economic deprivation and living situation. Negative psychotic symptoms predicted lower violence
Newer antipsychotics did not reduce violence more than perphenazine. Effective antipsychotics are needed, but may not reduce violence unrelated to acute psychopathology
Research has uncovered many characteristics related to violence committed by people with mental illness. However, relatively few studies have focused on understanding the connection between violence and dynamic, malleable variables such as a patient's level of treatment engagement.
To explore the link between community violence and patients' beliefs about psychiatric treatment benefit.
A sample of 1011 adults receiving out-patient treatment for a psychiatric disorder in the public mental health systems of five US states were interviewed.
Bivariate analyses revealed community violence was inversely related to treatment adherence, perceived treatment need and perceived treatment effectiveness. Multivariate analyses showed these three variables were associated with reduced odds of violent and other aggressive acts.
The results suggest clinical consideration of patients' perceptions of treatment benefit can help enhance violence risk assessment in psychiatric practice settings.
Measures have not taken account of the relative importance patients place on various outcomes.
To construct and evaluate a multidimensional, preference-weighted mental health index.
Each of over 1200 patients identified the relative importance of improvement in six domains: social life, energy, work, symptoms, confusion and side-effects. A mental health index was created in which measures of well-being in these six domains were weighted for their personal importance.
The strongest preference was placed on reducing confusion and the least on reducing side-effects. There was no significant difference between the unweighted and preference-weighted mental health status measures and they had similar correlations with global health status measures. Patients with greater preference for functional activities such as work had less preference for medical model goals such as reducing symptoms and had less symptoms.
A preference-weighted mental health index demonstrated no advantage over an unweighted index.
Violent behaviour among persons with severe mental illness (SMI) causes public concern and is associated with illness relapse, hospital recidivism and poor outcomes in community-based treatment.
To test whether involuntary out-patient commitment (OPC) may help to reduce the incidence of violence among persons with SMI.
One-year randomised trial of the effectiveness of OPC in 262 subjects with psychotic or major mood disorders and a history of hospital recidivism. Involuntarily hospitalised subjects awaiting OPC were randomly assigned to release or court-ordered treatment after discharge. Those with a recent history of serious assault remained under OPC until expiry of the court order (up to 90 days); then OPC orders were renewed at clinical/court discretion. Control subjects had no OPC. Four-monthly follow-up interviews with subject, case manager and collateral informant took place and service records were collected.
A significantly lower incidence of violent behaviour occurred in subjects with ⩾6 months' OPC. Lowest risk of violence was associated with extended OPC combined with regular out-patient services, adherence to prescribed medications and no substance misuse.
OPC may significantly reduce risk of violent behaviour in persons with SMI, in part by improving adherence to medications while diminishing substance misuse.
Previous estimates of the prevalence of seasonal affective disorder (SAD) in community samples have been in the range 2–10%, using methods not derived from DSM algorithms. We report the first community-based study to estimate major and minor depression with a seasonal pattern in a community-based sample using a diagnostic instrument derived from DSM–III–R.
A modified version of the Composite International Diagnostic Interview was administered to 8098 subjects in the 48 coterminous states of the USA (the National Comorbidity Survey) to assess the prevalence of major and minor depression with a seasonal pattern.
The lifetime prevalence of major depression with a seasonal pattern was 0.4%, and the prevalence of major or minor depression with a seasonal pattern was 1.0%. Among respondents with major depression, male gender and older age were associated with a higher prevalence with a seasonal pattern.
Prevalence estimates of major and minor depression with a seasonal pattern are much lower than those found in previous studies of SAD in the community probably due to the approach to diagnosis used in the present study which more accurately represents DSM–III–R criteria for major depression with a seasonal pattern. The distribution of the disorder is similar to that found in previous studies except for the higher prevalence among males.
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