Atypical Antipsychotics: The Debate Rages On

As new data emerge, the debate over whether atypical antipsychotics are superior to typical antipsychotics for treating patients with schizophrenia continues. The May 2008 issue of Psychiatric Services presented several studies that highlight current prescribing trends and opinions. One was a survey of psychiatrists on their use of atypical antipsychotics for treatment-resistant schizophrenia (TRS).¹ The other was an investigation of changes in prescribing patterns of antipsychotics for veterans with schizophrenia.² Both articles underscore the shift from higher prescribing rates for typical antipsychotics to those for atypical antipsychotics.

According to the survey of 431 psychiatrists, 97% reported prescribing atypical antipsychotics-most often for patients with TRS. Melissa R. Arbuckle, MD, PhD, and colleagues assessed physician attitudes about using an atypical antipsychotic for TRS, factors that affected the choice of agent, and familiarity with practice guidelines. The results were gathered from September 2003 to January 2004.

According to the researchers, most of the psychiatrists surveyed believed that at least 1 of the 5 atypical antipsychotics (olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole) could improve symptoms of schizophrenia after a failed trial of optimum treatment with oral haloperidol. In fact, only 3% of the respondents preferred to prescribe typical antipsychotics. Fewer than 1% identified clozapine as the most commonly prescribed antipsychotic. As many as 45% felt that all 5 atypical antipsychotics would offer improvement over haloperidol.

When choosing which medication to prescribe, 98% of the psychiatrists rated personal experience as the most influential factor. Other key factors included research on these antipsychotics, recommendations of colleagues, and practice guidelines. Although only 22% of physicians acknowledged the recommendations of drug representatives or advertisements as influences of prescribing trends, the authors speculated that this number may be larger.

The survey showed that psychiatrists who met with a pharmaceutical representative at least once a week were more likely to be highly optimistic about atypical antipsychotics (95% confidence interval [CI], 1.4 to 3.9; P = .001). Also, psychiatrists who reported familiarity with at least one of the practice guidelines for schizophrenia were more likely to report high levels of optimism (CI, 1.4 to 9.3; P = .009).

A commentary by Robert H. Howland, MD,³ urges readers to view survey results with a critical eye-especially in view of the findings about the influence of pharmaceutical company representatives on prescribing habits. Dr Howland notes that pharmaceutical representatives do not promote typical antipsychotics through office visits, distribution of brand-name drug samples and educational materials, or other "advertising efforts" as they do atypical antipsychotics. In addition, Dr Howland asks readers to consider whether patients with schizophrenia "are better off than they were 15 years ago" with the advent of the atypical agents. He urges treating physicians to choose options for each patient based "on the best unbiased clinical and scientific information available, together with sensitivity to practical cost considerations."

In a related study, Sernyak and Rosenheck² examined trends in the use of antipsychotics for outpatients with schizophrenia at a Veterans Affairs (VA) hospital. The researchers reviewed pharmacy records from 1999 to 2006 to determine the proportion of patients for whom typical or atypical antipsychotics were prescribed.

The percentage of patients for whom typical antipsychotics were prescribed decreased from 40.8% in 1999 to 16.8% in 2003 and remained nearly level, ending at 15.9% in 2006. Conversely, prescriptions of atypical antipsychotics consistently increased, with the exception of olanzapine. The data provide no evidence of a return to prescribing typical antipsychotics, despite several recent studies that did not show superiority over haloperidol and perphenazine of the newer agents. Findings suggest that worries about adverse effects are a key factor in prescribing patterns.

This study is not without limitations. The researchers note that the data only address the prescription of these medications for veterans with schizophrenia, and whether data for psychiatric practices outside the VA system would be comparable is unknown.

 

References:

References

1. Arbuckle MR, Gameroff MJ, Marcus SC, et al. Psychiatric opinion and antipsychotic selection in the management of schizophrenia. Psychiatr Serv. 2008;59:561-565.
2. Sernyak MJ, Rosenheck RA. Antipsychotic use in the treatment of outpatients with schizophrenia in the VA from fiscal years 1999 to 2006. Psychiatr Serv. 2008;59:567-569.
3. Howland RH. The need to guard against pharmaceutical industry influence. Psychiatr Serv. 2008; 59:566.