Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study

Abstract

Objective: To study the association between prescribed antipsychotic drugs and outcome in schizophrenia or schizoaffective disorder in the community.

Design: Prospective cohort study using national central registers.

Setting: Community care in Finland.

Participants: Nationwide cohort of 2230 consecutive adults hospitalised in Finland for the first time because of schizophrenia or schizoaffective disorder, January 1995 to December 2001.

Main outcome measures: Rates of discontinuation of drugs (all causes), rates of rehospitalisation, and mortality associated with monotherapy with the 10 most commonly used antipsychotic drugs. Multivariate models and propensity score methods were used to adjust estimates of effectiveness.

Results: Initial use of clozapine (adjusted relative risk 0.17, 95% confidence interval 0.10 to 0.29), perphenazine depot (0.24, 0.13 to 0.47), and olanzapine (0.35, 0.18 to 0.71) were associated with the lowest rates of discontinuation for any reason when compared with oral haloperidol. During an average follow-up of 3.6 years, 4640 cases of rehospitalisation were recorded. Current use of perphenazine depot (0.32, 0.22 to 0.49), olanzapine (0.54, 0.41 to 0.71), and clozapine (0.64, 0.48 to 0.85) were associated with the lowest risk of rehospitalisation. Use of haloperidol was associated with a poor outcome among women. Mortality was markedly raised in patients not taking antipsychotics (12.3, 6.0 to 24.1) and the risk of suicide was high (37.4, 5.1 to 276).

Conclusions: The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.

Fig 1

Relative risk of rehospitalisation by treatment. Adjusted for sex, calendar year, age at onset of follow-up, number of previous relapses, duration of first hospitalisation, and length of follow-up by a multivariate regression model alone (adjusted column) and by multivariate regression and the propensity score method (fully adjusted column)

Fig 2

Relative risk of rehospitalisation associated with the initiated use of each antipsychotic drug. Adjusted for sex, calendar year, age at onset of follow-up, number of previous relapses, duration of index hospitalisation, and length of follow-up by a multivariate regression model alone (adjusted column) and by multivariate regression and the propensity score method (fully adjusted column)