Guideline-Concordant Antipsychotic Use and Mortality in Schizophrenia

Department of Psychiatry and Behavioral Science, Johns Hopkins School of Medicine , Baltimore, MD
Schizophrenia Bulletin (Impact Factor: 8.45). 10/2012; 39(5). DOI: 10.1093/schbul/sbs097
Source: PubMed


To determine if care concordant with 2009 Schizophrenia Patient Outcomes Research Team (PORT) pharmacological recommendations for schizophrenia is associated with decreased mortality.

We conducted a retrospective cohort study of adult Maryland Medicaid beneficiaries with schizophrenia and any antipsychotic use from 1994 to 2004 (N = 2132). We used Medicaid pharmacy data to measure annual and average antipsychotic continuity, to calculate chlorpromazine (CPZ) dosing equivalents, and to examine anti-Parkinson medication use. Cox proportional hazards regression models were used to examine the relationship between antipsychotic continuity, antipsychotic dosing, and anti-Parkinson medication use and mortality.

Annual antipsychotic continuity was associated with decreased mortality. Among patients with annual continuity greater than or equal to 90%, the hazard ratio [HR] for mortality was 0.75 (95% confidence interval [CI] 0.57-0.99) compared with patients with annual medication possession ratios (MPRs) of less than 10%. The HRs for mortality associated with continuous annual and average antipsychotic continuity were 0.75 (95% CI 0.58-0.98) and 0.84 (95% CI 0.58-1.21), respectively. Among users of first-generation antipsychotics, doses greater than or equal to 1500 CPZ dosing equivalents were associated with increased risk of mortality (HR 1.88, 95% CI 1.10-3.21), and use of anti-Parkinson medication was associated with decreased risk of mortality (HR 0.72, 95% CI 0.55-0.95). Mental health visits were also associated with decreased mortality (HR 0.96, 95% CI 0.93-0.98).

Adherence to PORT pharmacological guidelines is associated with reduced mortality among patients with schizophrenia. Adoption of outcomes monitoring systems and innovative service delivery programs to improve adherence to the PORT guidelines should be considered.

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    • "These metabolic and cardiovascular abnormalities might take several years after SGAs use to appear leading subsequently to premature death (Weinmann et al., 2009). However, studies investigating the differences between FGAs and SGAs use in relation to mortality have yielded contradictory results (Cullen et al., 2013; Kiviniemi et al., 2013; Tiihonen et al., 2009). "
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    ABSTRACT: Background: Few studies have investigated the relationship between the use of different generations of antipsychotics and mortality with contradictory results. The aim of this study is to compare mortality among patients suffering schizophrenia taking different generations of antipsychotics in a nationwide population-based cohort study in Taiwan. Methods: A total of 812 patients suffering newly diagnosed schizophrenia under monotherapy of second generation antipsychotics (SGAs) comprised the group of cases. The matched controls were under monotherapy of first generation antipsychotics (FGAs). Each case was matched individually with their initial antipsychotics prescription calendar year and month, gender, and age. Cox regression analyses were applied to estimate survival time, adjusting for gender, age, residence, insurance premium, Charlson comorbidity index, hospital admission days, and hospital admission times. An analysis including the number of antipsychotic prescriptions, a proxy indicator of adherence, into the fully adjusted model to reveal the effect of adherence on survival of patients served as a sensitivity analysis. Results: Subjects receiving SGAs had lower admission times and inpatient days, more antipsychotic prescriptions, and longer follow-up time than FGAs. Compared with the FGAs group, the adjusted hazard ratio of mortality was 0.58 (95% confidence interval =0.34-0.96, p=.034) for SGAs group. After controlling for the number of antipsychotic prescriptions, the difference in mortality between antipsychotic generations was non-significant. Conclusions: The results of this study suggest that SGAs were better than FGAs in mortality among patients suffering schizophrenia. The difference in mortality can be explained by the better medication adherence of SGAs.
    Schizophrenia Research 10/2015; DOI:10.1016/j.schres.2015.10.005 · 3.92 Impact Factor
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    • "Strategies for early cancer detection should be prioritised and models of care developed to ensure that people with MNSDs receive the same level of physical health care and treatment as the rest of the population. Psychiatric treatments, specifically pharmacotherapies , may have some protective effect against excess mortality (Weinmann et al. 2009) although evidence suggests that this depends on use of medications according to best practice guidelines (Cullen et al. 2013). In contrast, some second generation antipsychotics may actually pose an elevated risk mediated by metabolic side effects (Newcomer, 2005; Smith et al. 2008; Rummel-Kluge et al. 2010). "
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    ABSTRACT: Aims: Mortality-associated burden of disease estimates from the Global Burden of Disease 2010 (GBD 2010) may erroneously lead to the interpretation that premature death in people with mental, neurological and substance use disorders (MNSDs) is inconsequential when evidence shows that people with MNSDs experience a significant reduction in life expectancy. We explore differences between cause-specific and excess mortality of MNSDs estimated by GBD 2010. Methods: GBD 2010 cause-specific death estimates were produced using the International Classification of Diseases death-coding system. Excess mortality (all-cause) was estimated using natural history models. Additional mortality attributed to MNSDs as underlying causes but not captured through GBD 2010 methodology is quantified in the comparative risk assessments. Results: In GBD 2010, MNSDs were estimated to be directly responsible for 840 000 deaths compared with more than 13 million excess deaths using natural history models. Conclusions: Numbers of excess deaths and attributable deaths clearly demonstrate the high degree of mortality associated with these disorders. There is substantial evidence pointing to potential causal pathways for this premature mortality with evidence-based interventions available to address this mortality. The life expectancy gap between persons with MNSDs and the general population is high and should be a focus for health systems reform.
    Epidemiology and Psychiatric Sciences 12/2014; 24(02):1-20. DOI:10.1017/S2045796014000687 · 3.91 Impact Factor
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    ABSTRACT: Nonadherence to appropriately prescribed medication for psychiatric disorders prevents patients from realizing the full benefits of their treatment and negatively impacts on individuals, their families and the healthcare system. Understanding and reducing nonadherence is therefore a key challenge to quality care for patients with psychiatric disorders. This review highlights findings regarding the prevalence and consequence of nonadherence, barriers to adherence and new intervention methods from 2012 onwards. Recent research has highlighted that nonadherence is a global challenge for psychiatry and has linked nonadherence to poorer outcomes, including hospital admissions, suicide and mortality. Optimizing medication regimens can reduce nonadherence; however, often a complex interplay of factors affects individuals' motivation and ability to follow their prescription. Psychiatrists can enable patients to develop an accurate model of their illness and treatment and facilitate adherence. However, nonadherence is often a hidden issue within consultations. Novel interventions using new technologies and tailoring techniques may have the potential to reduce nonadherence. Nonadherence remains a significant challenge for patients with psychiatric disorders, physicians and healthcare systems. New developments demonstrate the importance of developing tailored interventions to enable patients to overcome perceptual and practical barriers to adherence.
    Current opinion in psychiatry 07/2013; 26(5). DOI:10.1097/YCO.0b013e3283642da4 · 3.94 Impact Factor
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