Choice of antipsychotic treatment by European psychiatry trainees: are decisions based on evidence?

Abstract

Little is known about the factors influencing treatment choice in psychosis, the majority of this work being conducted with specialists (consultant) in psychiatry. We sought to examine trainees' choices of treatment for psychosis if they had to prescribe it for themselves, their patients, and factors influencing decision-making.
Cross-sectional, semi-structured questionnaire-based study.
Of the 726 respondents (response rate = 66%), the majority chose second-generation antipsychotics (SGAs) if they had to prescribe it for themselves (n = 530, 93%) or for their patients (n = 546, 94%). The main factor influencing choice was perceived efficacy, 84.8% (n = 475) of trainees stating this was the most important factor for the patient, and 77.8% (n = 404) stating this was the most important factor for their own treatment. Trainees with knowledge of trials questioning use of SGAs (CATIE, CUtLASS, TEOSS) were more likely to choose second-generation antipsychotics than those without knowledge of these trials (χ2 = 3.943; p = 0.047; O.R. = 2.11; 95% C.I. = 1.0-4.48). Regarding psychotherapy, cognitive behavioural therapy (CBT) was the most popular choice for self (33.1%; n = 240) and patient (30.9%; n = 224). Trainees were significantly more likely to prefer some form of psychotherapy for themselves rather than patients (χ2 = 9.98; p < 0,002; O.R. = 1.54; 95% CIs = 1.18-2.0).
Trainees are more likely to choose second-generation antipsychotic medication for patients and themselves. Despite being aware of evidence that suggests otherwise, they predominantly base these choices on perceived efficacy.

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Choice of antipsychotic treatment by European psychiatry trainees: are
decisions based on evidence?
BMC Psychiatry 2012, 12:27doi:10.1186/1471-244X-12-27
Sameer Jauhar (sameerjauhar@gmail.com)
Sinan Guloksuz (sguloksuz@yahoo.com)
Olivier Andlauer (olivier.andlauer@gmail.com)
Greg Lydall (greg.lydall@gmail.com)
Joao Gama Marques (anthropophobe@hotmail.com)
Luis Mendonca (lpmendonca@gmail.com)
Iolanda Dumitrescu (jolly_marc@yahoo.com)
Costin Roventa (croventa@yahoo.com)
Nele De Vriendt (nele.devriendt@opzcrekem.be)
Jeroen Van Zanten (jvanzanten@rkz.nl)
Florian Riese (florian.riese@bli.uzh.ch)
Izu Nwachukwu (izunwachukwu@hotmail.com)
Alexander Nawka (nawka@seznam.cz)
Raphael Psaras (raphaelpsaras@yahoo.gr)
Neil Masson (neil_masson@doctors.org.uk)
Rajeev Krishnadas (rajeev.krishnadas@gmail.com)
Umberto Volpe (umberto.volpe@unina2.it)
ISSN
1471-244X
Article type
Research article
Submission date
19 May 2011
Acceptance date
30 March 2012
Publication date
30 March 2012
Article URL
http://www.biomedcentral.com/1471-244X/12/27
Like all articles in BMC journals, this peer-reviewed article was published immediately upon
acceptance. It can be downloaded, printed and distributed freely for any purposes (see copyright
notice below).
Articles in BMC journals are listed in PubMed and archived at PubMed Central.
BMC Psychiatry
© 2012 Jauhar et al. ; licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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BMC Psychiatry
© 2012 Jauhar et al. ; licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Choice of antipsychotic treatment by European psychiatry
trainees: are decisions based on evidence?
Sameer Jauhar1*
* Corresponding author
Email: sameerjauhar@gmail.com
Sinan Guloksuz2
Email: sguloksuz@yahoo.com
Olivier Andlauer3
Email: olivier.andlauer@gmail.com
Greg Lydall4
Email: greg.lydall@gmail.com
João Gama Marques5
Email: anthropophobe@hotmail.com
Luis Mendonca6
Email: lpmendonca@gmail.com
Iolanda Dumitrescu7
Email: jolly_marc@yahoo.com
Costin Roventa8
Email: croventa@yahoo.com
Nele De Vriendt9
Email: nele.devriendt@opzcrekem.be
Jeroen Van Zanten10
Email: jvanzanten@rkz.nl
Florian Riese11
Email: florian.riese@bli.uzh.ch
Izu Nwachukwu12
Email: izunwachukwu@hotmail.com
Alexander Nawka13
Email: nawka@seznam.cz
Raphael Psaras14
Email: raphaelpsaras@yahoo.gr
Neil Masson15
Email: neil_masson@doctors.org.uk

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Rajeev Krishnadas16
Email: Rajeev.Krishnadas@glasgow.ac.uk
Umberto Volpe17
Email: umberto.volpe@unina2.it
European Federation of Psychiatric Trainees’ Research Group
1 Chair, EFPT Research Group, Sackler Institute for Psychobiological Research,
Institute of Neurological Sciences, Southern General Hospital, 2nd Floor 1345
Govan Rd, Glasgow G51 4TF, UK
2 Department of Psychiatry and Psychology, Maastricht University Medical
Centre, P.O. Box 616, 6200, MD Maastricht, The Netherlands
3 EA 481 Laboratoire de Neurosciences, University of Franche-Comte, and
Department of Clinical Psychiatry, University Hospital of Besancon, F-25030
Besancon, France
4 Department of Molecular Psychiatry, Mental Health Sciences, University
College London, London W1T 4JF, UK
5 Centro Hospitalar Psiquiátrico de Lisboa, Psychiatry Educator at Faculdade de
Medicina de Lisboa, Lisboa, Portugal
6 Centro Hospitalar Psiquiatrico de Lisboa, Lisboa, Portugal
7 Hospital Pr Dr Al Obregia, Bucharest, Romania
8 Hospital Pr Dr Al Obregia, Bucharest, Romania
9 Openbaar Psychiatrisch Zorgcentrum Rekem, Rekem, Belgium
10 Department of Psychiatry, Neuroscience Campus Amsterdam, VU Medical
Center, Amsterdam, the Netherlands
11 Psychiatric University Hospital Zurich, Zurich, Switzerland
12 St Vincent’s University Hospital, Dublin 4, Ireland.
13 Department of Psychiatry, 1st Faculty of Medicine, Charles University in
Prague, Ke Karlovu 11, 128 00 Praha 2, Prague, Czech Republic
14 1st Psychiatric Department, Psychiatric Hospital of Attica, 374, Athinon
avenue, 12462 Athens, Greece
15 Wishaw Resource Centre, 48-54 Roberts Street, Wishaw, ML2 7JF, UK

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16 Sackler Institute for Psychobiological Research,, Institute of Neurological
Sciences, Southern General Hospital, 2nd Floor 1345 Govan Rd, Glasgow
G514TF, UK
17 Department of Psychiatry, University of Naples - SUN Largo Madonna delle
Grazie, 80138 Napoli, Italy
Abstract
Background
Little is known about the factors influencing treatment choice in psychosis, the majority of
this work being conducted with specialists (consultant) in psychiatry. We sought to examine
trainees’ choices of treatment for psychosis if they had to prescribe it for themselves, their
patients, and factors influencing decision-making.
Methods
Cross-sectional, semi-structured questionnaire-based study.
Results
Of the 726 respondents (response rate = 66%), the majority chose second-generation
antipsychotics (SGAs) if they had to prescribe it for themselves (n = 530, 93%) or for their
patients (n = 546, 94%). The main factor influencing choice was perceived efficacy, 84.8% (n
= 475) of trainees stating this was the most important factor for the patient, and 77.8% (n =
404) stating this was the most important factor for their own treatment. Trainees with
knowledge of trials questioning use of SGAs (CATIE, CUtLASS, TEOSS) were more likely
to choose second-generation antipsychotics than those without knowledge of these trials (χ2 =
3.943; p = 0.047; O.R. = 2.11; 95% C.I. = 1.0-4.48). Regarding psychotherapy, cognitive
behavioural therapy (CBT) was the most popular choice for self (33.1%; n = 240) and patient
(30.9%; n = 224). Trainees were significantly more likely to prefer some form of
psychotherapy for themselves rather than patients (χ2 = 9.98; p < 0,002; O.R. = 1.54; 95% CIs
= 1.18-2.0).
Conclusions
Trainees are more likely to choose second-generation antipsychotic medication for patients
and themselves. Despite being aware of evidence that suggests otherwise, they predominantly
base these choices on perceived efficacy.
Keywords
Antipsychotics, Drug therapy, Psychiatry trainees, Evidence-based medicine, Decision-
making, Efficacy, Psychotherapy, Psychosis, Treatment

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Background
Historically, treatments in psychiatry have invariably been controversial, from the days of
insulin coma and leucotomy to the use of psychotropic medication in the modern era.
Recently the spotlight has fallen on use of antipsychotics (or more accurately, the choice of
antipsychotic medication) for the treatment of psychosis.
The inception of Chlorpromazine, in 1950, signified a paradigm shift in the management (and
our understanding) of schizophrenia. Although several other antipsychotics were developed
over the following years, it took till the 1980s for clear evidence of benefit for one specific
antipsychotic (Clozapine) to emerge [1]. Subsequently, another class of antipsychotics, the
(so-called) “atypical” antipsychotics (or second-generation antipsychotics (SGA)) were
developed. At the time of their introduction these drugs were promoted as having superior
efficacy and better side-effect profiles to their older counterparts [2]. This came at a price:
these drugs were initially priced much higher than their older counterparts, though, guidelines
continued to recommend their use [3].
However, following the publication of at least two recent large effectiveness trials [4,5], these
assumptions have been significantly challenged. Moreover, the effectiveness of SGAs (with
the exception of Clozapine) has been shown to be roughly equivalent to their first-generation
counterparts, with differing side-effect profiles, with one recent trial being discontinued on
account of metabolic side-effects observed with one of the SGAs [6].
Despite this evidence, it is difficult to tell how any of the recent notions of efficacy and
tolerability of SGAs have impacted on clinical practice, and if this has influenced actual
clinical decision-making. In contrast to the burgeoning literature on antipsychotics, relatively
few studies have examined decision-making in the context of psychosis. Methods used for
this include semi-structured interviews with psychiatrists, and preference for psychiatrists’
own treatment [7-9]. The majority of this work has been conducted locally (in one case a
national survey), predominantly with psychiatry consultants/specialists. To date, there has
been little work examining trainee psychiatrists’ views on treatment, and no examination of
their views on psychotherapy. Moreover, populations that have been looked at have only
included those from the United Kingdom and Germany [8-10]. Thus, further work is
warranted.
The aim of this study was to ascertain choices of psychiatric trainees from various European
countries regarding antipsychotic treatments, the factors influencing their choices, and
whether treatment choices were altered when trainees were asked which treatment they would
choose for their own care.
Methods
Study participants
Participants were given a guarantee that every attempt would be made to ensure that
responses to the questionnaire would be confidential. In view of these conditions, returning a
pseudo-anonymised questionnaire was considered to be indicative of informed consent.
These considerations are in keeping with the ethical principles set out in the Declaration of
Helsinki [11].

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Inclusion criteria
To ensure adequate reliability, a minimum sample of 50 trainees from each country was
agreed on. Each country participant was asked to sample a group of trainees that included
trainees from a similar institution or area, and this represented an opportunistic sample. A
minimum response rate for inclusion into the study was set (50%).
Survey
Based on guidelines for surveys [12] and prior work [9,10] that utilised semi-structured
questionnaires asking about choice for oneself, patients and factors influencing choice, an ad
hoc semi-structured survey was developed. This survey was piloted with psychiatric trainees
attending the EFPT (European Federation of Psychiatric Trainees) Annual Forum. The survey
was distributed in English, via a web-link and via paper copy, for six months, between
October 2008 and March 2009. During this period, country representatives were regularly
updated on response rates to the web survey, and were permitted to contact participants. The
full survey is given in Additional file 1: Appendix 1, and included
i) Demographic details (gender, country, adult or child and adolescent trainee, years of
training).
ii) Antipsychotic choice for patients presenting with a psychotic episode lasting longer
than one month (typical, atypical).
iii) Generic drug name for antipsychotic chosen.
iv) Factors influencing choice (cost, efficacy, side effect profile, other).
v) Whether any recent trials had influenced decision-making (given choice of CATIE,
CUtLASS, TEOSS or other). These trials were chosen on account of their topical
nature, large numbers and perceived influence.
vi) Whether adjunctive psychotherapy would be considered (and reasons for doing so).
vii) Trainees’ choice of antipsychotic if they developed a psychotic episode lasting one
month or longer (class, generic drug) and factors influencing choice, and
adjunctive psychotherapy.
Through the web forum, agreement was reached on operational definitions (and
understanding) of the terms “antipsychotic”, “typical antipsychotic”, “atypical antipsychotic”
and “psychotic episode”.
Analysis
Output from the web-survey tool was analysed using Predictive Analytics Software Statistics
Programme (PASW; version 18.0). Given the exploratory nature of our analysis, chi-square
tests, or Fisher’s exact tests when relevant, were used to compare categorical data. Statistical
significance was set at p < 0.05. The qualitative responses on choice of psychological
treatments were analysed using content analysis, with comparisons being made between the
reasons for the treatment chosen, according to set criteria. This was performed separately by
SG, and SJ and NM, and the results were compared and revised to increase reliability.

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Results
Of the 18 countries originally participating in the survey, only 12 met inclusion criteria listed
above. Countries that participated but were not included were Croatia, Germany, Italy,
Russia, Spain and Sweden. These countries were excluded on account of being unable to
collect samples meeting the inclusion criteria. Reasons for this included “research fatigue” (a
number of other surveys were being conducted at the current time).
The included countries and response rates are given in Table 1.
Table 1 Countries meeting inclusion criteria and response rates
Country
Number of participants/
Total number sampled
Belgium 52/104
Czech Republic 60/92
England 53/98
France 60/100
Greece 75/100
Holland 54/75
Ireland 51/72
Portugal 52/94
Romania 74/99
Scotland 54/75
Switzerland 83/124
Turkey 58/70
Total 726/1103
(Countries that participated but were not included were Croatia, Germany, Italy, Russia, Spain
and Sweden). 1Estimated response rate, based on variable reliability of email addresses
Response rate (%)
50%
65%
54%
60%
75%
72%
71%
40-55%1
75%
72%
67%
83%
66%
Demographic characteristics
Of the 726 trainees, 84.4% (n = 613) were adult psychiatry trainees and 15% (n = 109) were
child and adolescent psychiatry trainees. 54.8% (n = 398) of the sample were females. The
mean duration of completed training was 2.97 (s.d. = 1.57) years. More than half of the
trainees were in the first half of their training (n = 438; 60%).
Oral antipsychotic choice
Antipsychotic choice for patients and trainees themselves, grouped by class and generic
name, are presented in Table 2. Given recent evidence, underlining that the “atypical” and
“typical” antipsychotics are heterogeneous entities [13], and that some atypical antipsychotics
may have more efficacy than others, we examined choices of specific antipsychotics.
Regarding the class of antipsychotic (atypical, typical or no antipsychotic), there were no
differences between trainees’ treatment choices for their patients or for themselves (Figure 1).

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Table 2 Antipsychotics chosen by trainee in given scenario and for own care
Antipsychotic chosen
Physician’s choice for
patient
Atypical 546 (94%)
Typical 35 (6%)
No antipsychotic 4 (0.7%)
Olanzapine 167 (210)
Risperidone 154 (202)
Haloperidol 28 (33)
Aripiprazole 25 (33)
Amisulpiride 17 (21)
Quetiapine 22 (36)
Clozapine 6 (8)
No response given regarding generic
drug
Electroconvulsive therapy (ECT) 0
Ziprasidone 0
Sertindole 0
Percentages given are of those who responded to the question. Some respondents chose one or
more antipsychotics concurrently; numbers in brackets include these additions. The table
illustrates that the “atypical” class of antipsychotics were the most popular choice for patients and
trainees themselves
Physician’s choice if they
developed psychosis
530 (93%)
40 (7%)
0
39.9% 100 (120), 26.2%
36.8% 123 (141), 32.3%
6.7% 21 (23), 5.5%
6% 65 (73) 17%
4.1% 19 (24) 5%
5.3% 25 (37) 6.6%
1.4% 22 (24) 5.8%
304 202
1 0.3%
4 1%
1 0.3%
Figure 1 Type of antipsychotic chosen by trainees, for patients or for trainees
themselves
Olanzapine was the most popular choice for the patient in the scenario, and Risperidone the
most popular choice for trainees themselves (Figure 2). Trainees were more likely to
prescribe olanzapine for patients (χ2 = 16.83, p < 0.0001, O.R. = 1.9, 95% C.I. = 1.38-2.53),
and aripiprazole for themselves (χ2 = 24.48, p < 0.001, O.R. = 3.2, 95% C.I. = 2.0-5.2). Only
one typical antipsychotic drug (haloperidol) was chosen. Forty-five (6%) trainees did not
choose a generic antipsychotic, stating that the decision would depend on characteristics of
the patient and their symptom profile (e.g., need for sedation and side-effects experienced).
No difference was seen between males and females for antipsychotic choice for patient or
self.
Figure 2 Percentages of drug chosen by trainees, for patients or for trainees themselves
Differences between countries
Differences between countries and antipsychotic choice were examined, using chi-square
tests. Trainees from Holland were more likely to prescribe typical antipsychotics for patients
than those from other countries, (χ2 = 16.18; p = 0.01; O.R. = 4.76; 95% C.I. = 2.08-10.86).
Dutch trainees were also more likely to choose typical antipsychotics for their own treatment,
compared to trainees from other countries, (χ2 = 51.6; p < 0.001; O.R. = 10.9; 95% C.I. = 5-
23.8). A similar finding was found with trainees from Turkey, in regard to treatment for the
patient in the given scenario, (χ2 = 32.35; p < 0.001; O.R. = 6.90; 95% C.I. = 3.26-14.7).

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Antipsychotic class
528 trainees filled in both questions “antipsychotics for self” and “antipsychotics for
patients”. Trainees were no more likely to prescribe an atypical for themselves (93.6%) than
they would for patients (94.5%) (χ2 = 0.42; p = 0.5, OR = 0.84 (95% C.I. = 0.5-1.4). As
detailed above there were multiple entries for specific antipsychotics, and therefore it was not
possible to include these in the calculation of odds ratios, as those who selected two
antipsychotics did not consider one to be superior to the other.
Factors influencing choice of antipsychotic
Factors influencing choice mapped onto the three main domains given in the questionnaire:
cost, efficacy and side-effect profile. Less than 5% of trainees gave other reasons. Results are
summarised in Table 3. Efficacy was the most important factor influencing choice for treating
patients as well as for oneself, followed by side effect profile and then cost. When
considering their own treatment (as opposed to a patient), trainees were significantly more
inclined to think of side-effect profile (χ2 = 15.49; p < 0.0001; O.R. = 1.64; 95% C.I. = 1.28-
2.10), and less inclined to think of efficacy (χ2 = 8.69; p = 0.03; O.R. = 0.63; 95% C.I. = 0.46-
0.86). Factors influencing specific antipsychotic choice are summarized in Table 4. Trainees
favoured efficacy over side-effect profile for all drugs, except Aripiprazole for patients and
themselves, and Quetiapine for themselves. For these two drugs, side-effect profile was the
most important criterion.
Table 3 Factors influencing choice of antipsychotic for patient/self

Efficacy

Patient Self
Most
important (84.8%) (77.8%)
2nd most
important (15%) (22.2%)
Least
important (0.2 %)
Respondents could choose more than one factor at each stage of importance; percentages reported
are for those responding to the question
Side-effect profile
Patient
191
(34.5%)
326
(59%)
36
(6.5%)
Cost
Self
237
(46.4%)
258
(50.1%)
16
(3.1%)
Patient
17
(3.2%)
91
(17.2%)
422
(79.6%)
Self
13
(2.7%)
69
(14.2%)
405
(83.2%)
475 404
84 115
1 0

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Table 4 Factors influencing the choice of a specific antipsychotic for patient/self
Olanzapine
Risperidone
P S P
Efficacy
most
important


Haloperidol
P
Quetiapine
P
Aripiprazole
P
Amisulpiride
P
Clozapine
P S S S S S S
155
(92.8%)
93
(93%)
129
(83.8%)
118
(76.1%)
23
(82.1%)
15
(78.9%)
16
(72.7%)
14
(56%)
10
(40%)
32
(49.2%)
16
(94.1%)
16
(84.2%)
6
(100%)
20
(90.9%)
Side effect
profile most
important
P refers to patient; S refers to self
(Note: some trainees chose more than one factor at a time)
38
(22.8%)
25
(25%)
39
(25.3%)
70
(45.2%)
6
(21.4%)
6
(31.6%)
13
(59.1%)
19
(76%)
16
(64%)
44
(67.7%)
4
(23.5%)
7
(36.8%)
0
3
(13.6%)

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Prior knowledge of effectiveness trials
The percentage of trainees who reported that prior knowledge of effectiveness trials (CATIE,
CUtLASS and TEOSS) had influenced their antipsychotic choice was 33.8% (n = 246), 8.1%
(n = 59) and 1.5% (n = 11), respectively. Trainees with prior knowledge of at least one
effectiveness trial chose atypical antipsychotics for the patient in the scenario more than
trainees with no prior knowledge of any of these effectiveness trials (96.1% versus 92.3%; χ2
= 3.943; p = 0.047; O.R. = 2.11; 95% C.I. = 1.0-4.48).
Influence of trainee seniority and type of trainee
No differences in class of antipsychotic chosen for patients were seen between trainees in the
first and second halves of training (92.3% versus 95.3%; χ2 = 2.12; p = 0.15; O.R. = 1.70;
95% C.I. = 0.83-3.3.40), and no statistically significant difference was observed between
child and adolescent psychiatry trainees and adult trainees (97.4% versus 93.4%; Fisher exact
p = 0.13).
Choice of adjunctive psychotherapy
Choices of psychotherapy for both the patient in the scenario and for oneself are given in
Table 5. Cognitive behavioural therapy (CBT) was the most popular choice for self and
patient. Trainees were significantly more likely to prefer some form of psychotherapy for
themselves rather than patients (χ2 = 9.98; p < 0,002; O.R. = 1.54; 95% C.I. = 1.18-2.0).
Psychodynamic psychotherapy was chosen more by trainees for themselves than for the
patient in the scenario (χ2 = 15.53; p < 0.001; O.R. = 2.63; 95% C.I. = 1.6-4.3).
Table 5 Choice of psychotherapy for patient/self

None
Any kind of psychotherapy
Cognitive Behavioural Therapy (CBT)
Interpersonal Therapy
Mindfulness-based Therapy
Psychodynamic Psychotherapy
Not responded
**: p < 0.01 ; ***: p < 0.001
Treatment for patient
187 (25.8%)
331
240 (33.1%)
50 (6.9%)
17 (2.3%)
24 (3.3%)
208 (28.7%)
Treatment for self
133 (18.7%)
362**
224 (30.9%)
56 (7.7%)
26 (3.5%
56 (7.7%)***
231 (31.8%)
Qualitative analysis of psychotherapy
289 trainees gave qualitative responses. There was no difference in the qualitative responses
between psychotherapy treatments chosen by trainees for themselves or for their patients. The
factors influencing a trainee not to use psychotherapy included a lack of evidence base/
guidelines (n = 6), clinical experience (n = 9), lack of access to the treatment (n = 2), the
opinions and practice of senior psychiatrists (n = 2) and the fact that the patient may be too
unwell (n = 3). Many trainees described the usefulness of using unstructured forms of therapy
such as supportive psychotherapy and of waiting until the psychotic symptoms had settled
before considering therapy. Factors influencing choice of CBT included evidence
base/guidelines (n = 63), availability (n = 2), low cost (n = 3), structured and less intensive

Page 13

approach (n = 2). Reasons for interpersonal therapy included allowing patients to cope (n =
3). Their clinical experience of using mindfulness-based treatment (n = 3) was used as a
reason for its use.
Those favouring psychodynamic psychotherapy did so mostly because that was the treatment
they were trained in (n = 6), with little mention of its evidence base (n = 2). As some trainees
were already receiving psychodynamic psychotherapy they stated they would want this to
continue if they developed a psychotic episode (n = 11).
Discussion
Pharmacotherapy
Our results suggest trainees prefer to prescribe, and receive SGAs, based on assumptions of
improved efficacy and side-effect profile. These assumptions have been challenged by recent
evidence [13]. What is striking is that, despite knowledge of recent evidence (trials that
suggest small difference between classes), trainees would not change their prescribing
practice. Although they would broadly choose the same class of antipsychotic for patients and
themselves, some would wish to be treated with differing antipsychotics to their patients,
basing this decision on side-effect profile. There was a general trend for more emphasis on
side-effect profiles when the treatment was prescribed for trainees themselves.
The results regarding antipsychotics are similar to those of other studies, conducted in
England, Germany and Scotland [8-10]. In all the previous studies “atypical” antipsychotics
were preferred, with olanzapine and risperidone the most popular choices.
Factors influencing choice are generally similar to those reported elsewhere, with efficacy
and side-effect profile/tolerability viewed as most important [8,9], a naturalistic study finding
that physicians were more likely to base antipsychotic choice in clinical practice on side-
effects [14]. This was reflected in our sample, when trainees chose their medication they
would prefer to receive (significantly less choosing olanzapine and significantly more
choosing aripiprazole), a possible reason for this being the difference in side-effects between
these compounds, though this was not examined in further detail.
Decision-making was also examined in face to face interviews with German psychiatrists, the
only distinguishing factor amongst participants being age, with older doctors being more
likely to prescribe typical antipsychotics [7]. This was not found in our study, though we
would suggest trainees with more experience have no significant exposure to the older
compounds, unlike those in the German study.
Psychotherapy
Findings regarding psychotherapy are that trainees chose to receive therapy for themselves
more often than for patients, and that this was based on personal experience. CBT was the
most popular choice, and evidence base was cited as the reason for this. A number of trainees
who had received psychodynamic therapy for themselves wanted to receive this if they
developed psychosis. Though did not choose this for the patient in the given scenario.

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“Evidence-based medicine”
The finding in regard to knowledge of effectiveness trials is counter-intuitive, and may reflect
concerns trainees may have had with the trials themselves, and their interpretation of the
results, owing to methodological issues, that have been highlighted elsewhere [15]. It may
also reflect wider concerns, regarding the philosophical underpinnings of EBM itself, which
have been eloquently argued elsewhere [16]. Briefly, this consists of theoretical constructs
(EBM) versus clinical observation. This probably has relevance to our sample, as a number of
trainees stated that both clinical experience and evidence had affected their choice of
psychotherapy.
To our knowledge this is the only study that has examined choice of psychotherapy in
psychosis, none of the above studies examining this question. This area is worth examining,
especially in the context of recent literature that questions efficacy of CBT in psychosis,
querying if any benefit is seen in well-conducted studies [17], and recent guidelines that
advocate for its use.
The finding that physicians would have differing preferences for their own care has been
examined in detail in a recent German study of 515 psychiatrists, who were randomised to
various groups [18]. In that study, when given a scenario involving a patient with a relapse of
psychosis in schizophrenia, physicians chose watchful waiting and oral antipsychotic
medication, as opposed to depot antipsychotic medication when asked about treatment for a
patient, or themselves.
Weaknesses of this study pertain to its design (cross sectional, arbitrary survey with an
opportunistic sample), which lacks the thoroughness and validity of a face-to-face interview.
The results from all the countries were pooled, but we have to keep in mind that the training
systems, health systems, and the availability of the drugs, are different between the different
countries. Although efforts were made to recruit an adequate sample that was felt to be
representative, the fact that only a small proportion of the total trainees in Europe were
surveyed tempers the generalisability of these results. Furthermore, the validity of a sample
of 50 in a country like Portugal would be greater than those for a country like England, which
has significantly more trainees.
We would point out, however, that this is, to our knowledge, the largest study conducted
examining choice, and the only one involving exclusively psychiatric trainees. This is
relevant since most psychiatry trainees have had more exposure to the second-generation
antipsychotics [19], and have less clinical experience to base their decisions on. Moreover,
psychiatric trainees are tomorrow’s psychiatrists, and therefore these results give us an
overview of what future European prescription patterns might be. We were also in a
favorable position to ask about changes in the recent evidence-base, owing to the close
proximity of the questionnaire to the findings from effectiveness trials like CATIE.
Conclusions
European psychiatry trainees appear to base treatment decisions on factors other than purely
evidence-base, and would choose similar treatments for psychosis (atypical antipsychotics)
for themselves and their patients. Differences appear to exist in the individual compounds
they would choose to receive for themselves, possibly reflecting concerns about side-effects,

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such as weight gain. Future work would focus on what influences perceptions of efficacy and
side effect profile, and what role the pharmaceutical industry and opinion leaders may play in
these assumptions.
Competing interests
SJ, SG, GL, JM, LM, ID, CR, NDV, NI, JVZ, AN, RP, NM, RK, UV declare no conflict of
interest. FR has received a speaker’s fee from Lundbeck (Switzerland). In the past five years,
OA has received reimbursements, fees or funding from: Eli Lilly, Lundbeck, BMS/Ostuka,
Janssen-Cilag.
Authors’ contributions
SJ, SG, OA, GL, JGM, LM, ID, CR, AW, IN, FR, JVZ, NDV and RP carried out data
collection, and contributed to the writing of the manuscript. SJ, SG, NM and RK carried out
data analysis and the writing of the manuscript. UV carried out interpretation of the data and
writing of the manuscript. All authors read and approved the final manuscript.
Authors’ information
The EFPT Research group is a working group, under the umbrella of the European
Federation of Psychiatric Trainees, a trainee-led, non-governmental organisation, dedicated to
improving training and education of psychiatric trainees across Europe. The Research group
was incepted to provide meaningful research opportunities for psychiatry trainees from
different European countries, and to foster collaboration on a European basis.
Acknowledgements
We would like to thank all those who completed the survey. We would like to thank Drs.
Amit Malik and Martina Rojnic (Past Presidents, EFPT) for their assistance in the inception
and support given to the EFPT Research Group.
Dr. Sinan Guloksuz would like to acknowledge the support of European Community’s
Seventh Framework Program under grant agreement No. HEALTH-F2-2009-241909 (Project
EU-GEI).
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