Differences in Antipsychotic Prescriptions Between Centers in Young Outpatients With Schizophrenia

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To the Editors
We know that there is a gap in life expectancy between the general population and people with severe mental disorders (SMDs),1 and therefore, major efforts are invested to improve physical health in this group. We welcome this development and will add to the discussion that an important part of these efforts is to disseminate evidence-based guidelines on psychopharmacological treatment because adverse effects of antipsychotic treatment are well-known risk factors for many physical disorders.2 Deliberate choice of antipsychotic treatment is essential to minimize negative impact on physical health. The Schizophrenia Patient Outcomes Research Team in the United States has made recommendations based on extensive review of literature,3 and the British Association for Psychopharmacology has recently published guidelines considering both efficacy and risk of adverse effects from antipsychotic treatment together with handling of these.4 In Denmark, national guidelines for antipsychotic treatment were made by an expert group based on evidence of both efficacy and safety.5 According to these guidelines, most patients with psychotic disorders should be treated with atypical antipsychotics (amisulpride, aripiprazole, lurasidone, paliperidone, quetiapine, or risperidone) because of their favorable balance between efficacy and safety. After treatment failure on the 2 different aforementioned atypical antipsychotics, monotherapy with clozapine as a third-line drug should be considered, unless it is not a suitable option for safety reasons. In cases where clozapine is not an option, other atypical antipsychotics (olanzapine, sertindole, or ziprasidone) or typical antipsychotics (haloperidol, perphenazine, or zuclopenthixole) should be considered. Only hereafter, antipsychotic polypharmacy is considered a rational choice, to lower the psychotic symptoms. We sense, from everyday clinical practice, that this sequence is not always the case but have so far not had any real-life data in support of this. A recent paper in this journal by Edlinger et al6 identified differences in prescription patterns between patients in inpatient and outpatient settings, and in another recent study, Joshi et al7 documented a high degree of psychotropic polypharmacy, especially antipsychotic, among individuals with schizoaffective disorder. We have also learned some interesting aspects of antipsychotic prescription practice among outpatient units during a large-scale quality program aiming to improve general health of patients with SMDs8,9 and further to implement new research-generated knowledge into clinical practice.10 In this program, detailed information on all prescriptions was collected from case records and clinical interviews. The focus of the present paper is to document antipsychotic prescription practice, because this is a potentially modifiable risk factor for physical disorders that are within the hands of us as psychiatrists.
We had access to data from 118 consecutively referred young outpatients with schizophrenia: 69 from center A and 49 from center B, both of them in the region of Central Denmark. All patients were diagnosed with schizophrenia, and the cohorts were similar in age (median age, 25 vs 23 years) and gender distribution (male, 64% vs 63%). We found remarkable differences among these patients concerning prescription patterns even though the 2 different outpatient psychosis units were organized in the same administrative region, treating similar patients and operating under the same prescription guidelines. We found that the median total dose of antipsychotic medication was significantly higher at center A at the beginning of treatment (index) (1.58 vs 1.33 defined daily dose [DDD], P = 0.02, Mann-Whitey U test [Fig. 1, part a]). At the final consultation within this project (follow-up), this difference in median total doses was still present, but no longer to a significant degree (1.32 vs 1.07 DDD, P = 0.52, Mann-Whitey U test [Fig. 1, part a]).
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