Prescription practices in the treatment of first-episode schizophrenia spectrum disorders: data from the national RAISE-ETP study

Abstract

Objective: Treatment guidelines suggest distinctive medication strategies for first-episode and multiepisode patients with schizophrenia. To assess the extent to which community clinicians adjust their usual treatment regimens for first-episode patients, the authors examined prescription patterns and factors associated with prescription choice in a national cohort of early-phase patients.

Method: Prescription data at study entry were obtained from 404 participants in the Recovery After an Initial Schizophrenia Episode Project's Early Treatment Program (RAISE-ETP), a nationwide multisite effectiveness study for patients with first-episode schizophrenia spectrum disorders. Treatment with antipsychotics did not exceed 6 months at study entry.

Results: The authors identified 159 patients (39.4% of the sample) who might benefit from changes in their psychotropic prescriptions. Of these, 8.8% received prescriptions for recommended antipsychotics at higher than recommended dosages; 32.1% received prescriptions for olanzapine (often at high dosages), 23.3% for more than one antipsychotic, 36.5% for an antipsychotic and also an antidepressant without a clear indication, 10.1% for psychotropic medications without an antipsychotic, and 1.2% for stimulants. Multivariate analysis showed evidence for sex, age, and insurance status effects on prescription practices. Racial and ethnic effects consistent with effects reported in previous studies of multiepisode patients were found in univariate analyses. Despite some regional variations in prescription practices, no region consistently had different practices from the others. Diagnosis had limited and inconsistent effects.

Conclusions: Besides prescriber education, policy makers may need to consider not only patient factors but also service delivery factors in efforts to improve prescription practices for first-episode schizophrenia patients.

Trial registration: ClinicalTrials.gov NCT01321177.

Figure 1. Factors Associated with Prescription Patterns Log Odds Ratios and 95% Credible Intervals

Odds ratios in aqua are from multivariate analyses with selected % of 50% or greater but less than 75% (some evidence of association) Odds ratios in green are from multivariate analyses with selected % of 75% or greater but less than 95% (positive evidence of association) Odds ratios in red are from multivariate analyses with selected % of 95% or greater but less than 99% (strong evidence of association) Antipsychotic prescription = prescription of one or more antipsychotics versus no antipsychotic prescribed 2 or more antipsychotics = prescription for 2 or more antipsychotics among subjects prescribed antipsychotics. Multiple formulations of the same antipsychotic were counted as a single antipsychotic. Long acting antipsychotic = prescription for long acting antipsychotic or a long acting antipsychotic plus an oral antipsychotic among subjects prescribed antipsychotics 1^st generation antipsychotic = prescription for a first generation antipsychotic or both a first and second generation antipsychotic among subjects prescribed antipsychotics Risperidone prescription = prescription for risperidone among subjects prescribed only 1 antipsychotic. Multiple formulations of the same antipsychotic were counted as a single antipsychotic. Olanzapine prescription = prescription for olanzapine among subjects prescribed only 1 antipsychotic. Multiple formulations of the same antipsychotic were counted as a single antipsychotic. Antidepressant prescription = prescription for one or more antidepressants. Caucas = Caucasian Others = racial categories other than Caucasian and African-American AA = African-American Hisp = Hispanic Non-Hisp. = not of Hispanic ethnicity Psych. NOS = psychosis NOS SCZ = schizophrenia SCZform = schizophreniform SCzaff = schizoaffective disorder Pvt = private Anxty or Depr. Symps (N-Y) = presence of anxiety or depressive symptoms (not present versus present)

Figure 2. Factors Associated with Dosing Patterns For Oral Risperidone or Olanzapine Beta and Z Scores and 95% Credible Intervals

Dosing data (expressed as total daily dose) are from prescriptions requiring patients to take a single antipsychotic solely in an oral formulation Doses in aqua are from multivariate analyses with selected % of 50% or greater but less than 75% (some evidence of association) CrI = Credible Interval Caucas = Caucasian Others = racial categories other than Caucasian and African-American AA = African-American Hisp = Hispanic Non-Hisp. = not of Hispanic ethnicity Psych. NOS = psychosis NOS SCZ = schizophrenia SCZform = schizophreniform SCzaff = schizoaffective disorder Smoking = smoking cigarettes at study entry Alcohol, Marijuana and Other drugs = use of these substances at study entry