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Die Psychiatrie 2/2009 © Schattauer GmbH
80
Theme Article
Trends in drug prescription of young psychiatrists and
trainees
A survey of the European Federation of Psychiatric Trainees' Research group
S. Jauhar1; EFPT Research Group2
1Specialty Registrar in General Adult Psychiatry, Gartnavel Royal Hospital, Glasgow, Scotland;
2S. Gerber, O. Andlauer, J. G. Marques, L. Mendonca, I. Dumitrescu, C. Roventa, G. Lydall, S. Guloksuz, E. Dobrzynska, N. De Vriendt,
A. Mufic, J. Van Zanten F. Riese, G. Favre, A. Nazaralieva, M. Bendix, I. Nwachukwu, S. Soriano, A. Nawka
Keywords
Survey, trainees, deci-
sion-making, efficacy,
antipsychotics, antide-
pressants, mood stabi-
lisers
Summary
A Pan-European group of psychiatric trainees conducted a semi-structured web-based sur-
vey of factors influencing decision-making in relation to antipsychotic, antidepressant and
mood stabilizer prescribing. The acceptance of such a survey is in itself a positive result. In
the current climate of evidence based medicine and guidelines, preliminary results from this
survey suggest that, when asked regarding treatment choice for themselves, psychiatry trai-
nees preferred second-generation atypical antipsychotic medication, based on perceived ef-
ficacy. The results for mood stabilisers were less striking. The relevance of this survey, in the
context of recent evidence, may relate to trainees’ perceptions as opposed to evidence base.
Zusammenfassung
Eine paneuropäische Gruppe von Ärzten in psychiatrischer Facharztausbildung hat eine
halb-strukturierte, Internet-basierte Umfrage zur Verschreibungspraxis antipsychotischer,
antidepressiver und stimmungsstabilisierender Medikamente sowie der entsprechenden Ent-
scheidungsfindung durchgeführt. Die Akzeptanz, auf die die Umfrage selbst stieß, stellt an
sich schon ein erfreuliches Ergebnis dar. Im gegenwärtigen Klima evidenzbasierter Medizin
und Richtlinien weisen die vorläufigen Umfrageergebnisse darauf hin, daß – wenn es um die
Frage geht, welche Präparate im Falle einer Eigenbehandlung ausgewählt würden – atypische
Antipsychotika der zweiten Generation bevorzugt werden, wobei sich die Entscheidung der
befragten Mediziner an der (subjektiv) wahrgenommen Wirksamkeit orientiert. Die Ergebnis-
se hinsichtlich stimmungsstabilisierender Medikamente waren weniger auffällig. Die Bedeu-
tung der Umfrage könnte, im Kontext jüngster Forschungsergebnisse, auf den Faktor Wahr-
nehmung gegenüber evidenzbasierter Forschung hinweisen.
Verschreibungsverhalten von jungen Psychiatern und Ärzten in Ausbildung
Die Psychiatrie 2009; 6: 80–83
Schlüsselwörter
Umfrage, Ärzte in Aus-
bildung, Umfrage, Effek-
tivität, Antipsychotika,
Antidepressiva, Stim-
mungsstabilisierer
Treatment choices in psychiatry, from the days of insu-
lin coma therapy to electroconvulsive therapy, have al-
ways courted controversy, and this continues to the present
day. Stalwarts of “modern” psychiatric practice, such as
“second generation atypical” antipsychotic drugs have
been exposed to non industry-sponsored trials (1–3), a re-
cent meta-analysis questioning their very concept and per-
ceived benefits over older (more cost-effective) counter-
parts (4). It is worth noting that, though numerous studies
have looked at factors affecting treatment adherence in
major psychiatric illnesses, relatively few have looked at
factors influencing professionals’ decision making (5).
Methods used include semi-structured interviews with psy-
chiatrists (5), and, more recently, preference for psychia-
trists’ own treatment (6–8). Results from these studies have
shown that clinicians may challenge evidence-base and
guidelines, based on a number of factors, including clinical
experience. The majority of this work has been at a local
level (in one case a national survey), and all but one survey
pertained only to the prescription of antipsychotic medi-
cation. A vast proportion of responses were from Consul-
tants/Specialists. The responders based their choices on
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Theme Article
Die Psychiatrie 2/2009 © Schattauer GmbH
Country Responses
Netherlands 19
Poland 19
Portugal 50
Romania 69
Belgium 25
Croatia 17
England 30
France 50
Russia
Scotland
Switzerland
Turkey
Total
5
50
9
38
381
perceived efficacy (7, 8), in addition to side effect profile
and cost. Though a National survey exists with regard to
treatment choices, to date there has been little work exam-
ining trainee psychiatrists’ views on treatment. Moreover,
populations that have been looked at have only included
those from the United Kingdom and Germany (6–8). In this
context our Pan-European Research Group, composed ex-
clusively of trainees, sought to ascertain treatment choices of
trainees from various countries, the factors influencing these,
and whether treatment choices were uniform when trainees
were asked which treatment they would choose to receive.
The European Federation of Psychiatric Trainees (EFPT)
is a trainee organisation, encompassing official represen-
tatives from 24 different countries. At the Annual meeting
of the General Assembly (held in Gothenburg in 2008) a re-
search group was incepted, with the express aim of facili-
tating trainee-led collaborative research, focusing on work
that had implications for psychiatric trainees across Europe.
The group produced a mission statement, and was original-
ly composed of 9 members. A web-based research environ-
ment was created, and the composition of the group in-
creased to 19, with representation from 16 different Euro-
pean countries. Following discussion from amongst the
group it was decided to focus initially on trainee surveys,
facilitated by online resources. The EFPT forum represents a
unique opportunity for trainees to discuss training and
wider issues with “like-minded” colleagues from differing
countries and cultures, and following a number of dis-
cussions pertaining to differing clinical practices, it was
agreed to focus on treatment choices and guideline imple-
mentation amongst European trainees.
Methods
Within the research group various methodologies were dis-
cussed, a semi-structured survey being considered optimal,
utilising findings from prior work (6,7,8), The survey was
piloted with delegates attending the Forum in Gothenburg,
resulting in an agreed revised format. We invited all 24
countries to participate. To ensure adequate reliability, a
sample size of 50 was agreed upon from each country, from
a sample deemed by the representative to be homogenous.
A response rate of 50% was set as a minimum for results to
be collated. The survey was distributed in English, via a
web-link, and in some cases representatives chose to dis-
tribute the survey using paper copies, data being entered
into the online survey tool manually.
The survey consisted of questions on:
●a) demographics (country, number of years in training,
gender, specialty).
●b) guidelines; whether National or International guide-
lines existed, and whether they were implemented (if
not, reasons for this)
●c) preferred choice of antipsychotic/mood stabiliser/
antidepressant to treat patients in given scenarios, and
factors influencing choice (rating preferences between
cost, efficacy, side effect profile and other factors). For
antipsychotics, participants were asked if recent trials
Fig. 1 Trainee’s choice of antipsychotic for their own treatment
(expressed as percentage)
Fig. 2 Trainee’s choice of mood stabiliser for their own treatment
(expressed as percentage)
100
80
60
40
20
0
Atypical antipsychotic
Typical antipsychotic
Clozapine
Antipsychotic chosen by trainee
45
40
35
30
25
20
15
10
5
0Mood stabiliser chosen by trainee
Lithium
Valproate
Semisodium Valproate
Li and Valproate
Carbamazepine
Lamotrigine
2nd Generation
Atypical antipsychotic
Tab. 1 Survey responses, classified by Country (Nb survey awaiting
dissemination in Ireland, Italy, Germany, Spain and Sweden)
Die Psychiatrie 2/2009 © Schattauer GmbH
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Theme Article
(CATIE [2], CUtLASS [1] and TEOSS [3]) influenced their
decisions.
●d) preferred choice of psychotherapy for treating pa-
tients with psychosis or mood disorder
●e) physician’s own choice of the above pharmacological
and psychological therapies, should they develop the
conditions specified in c).
Preliminary Results
At the time of submission, the study was still underway, and
therefore results given are preliminary, and are liable to
change as the study progresses. The main areas presented in
this article relates to treatment choices trainees would
chose to receive themselves. Country responses are given in
Table 1; only responses from those countries that met inclu-
sion criteria (50 responses with at least 50% response rate)
are included. Countries included in this preliminary analy-
sis are France, Portugal, Romania and Scotland (n=219).
Preliminary analyses are presented below.
Treatment choice of antipsychotic
95% (n=208) of trainees would choose to receive an “atypi-
cal” antipsychotic (excluding Clozapine), 5% (n=10) choos-
ing a “typical” antipsychotic, one trainee choosing Cloza-
pine as first-line therapy. This is summarized in figure 1.
It should be noted that 28% (n=61) of those trainees
choosing to receive antipsychotic medication for a psy-
chotic episode stated their decision was influenced by the
CATIE trial.
Treatment choice of mood stabiliser
39% (n=85) of trainees would choose to receive Lithium,
20% (n=44) chose Sodium Valproate (n=44), 25 % (n=55)
chose Semisodium Valproate (Depakote), 3% (n=7) chose
Lithium and Valproate, 3% (n=7) chose Carbamezapine, 5%
(n=11) choosing Lamotrigine. Other responses included
variable combinations of the above treatments. These re-
sults are summarized in figure 2.
Factors influencing the choice of one’s own treatment
Factors influencing choice mapped onto three main do-
mains: efficacy, side-effect profile and cost (less than 5%
gave other reasons).
For antidepressants, 83% (n=182) felt efficacy most im-
portant, 50% (n=110) felt side effect profile most important
and 5% (n=11) felt cost to be the most important variable
(note that responders could rate more than one factor as
most important).
For antipsychotics, 81% (n=177) felt efficacy most im-
portant, 48% (n=105) felt side-effect profile most important
and 3% (n=7) considered cost of paramount importance.
For mood stabilizers, 81% (n=177) judged efficacy as the
most important factor, 47% (n=103) viewed side-effect pro-
file as most important and 5% (n=11) viewed cost as the most
important factor. These results are summarized in figure 3.
Discussion
It is heartening to note that trainees can collaborate on an In-
ternational basis, and that work can be carried out using dif-
fering information technologies, including online surveys and
web-forums. Though we are still progressing through data col-
lection, the inclusion criteria would seem justified, and should
be attainable in other countries. The results presented suggest
that trainees would prefer to receive 2nd generation “atypical”
antipsychotic medication, and that their decision-making is
based on presumptions of improved efficacy and side-effect
profile of these compounds, in keeping with previous work (7,
8). This is despite a proportion of trainees stating that they
were influenced by trials, such as CATIE, and in the context of
recent evidence suggesting there is no significant difference in
tolerability of side effects or efficacy (4, 9). The finding that
most trainees would choose Lithium as a mood stabiliser,
based on efficacy is not surprising, given the predominance of
literature suggesting this (10), though the high number who
based their decision-making on side-effect profile is interest-
ing, given the relative tolerability of other mood stabilisers. In
both treatment choices cost did not figure significantly.
It would be interesting to correlate these findings with pres-
ence and implementation of guidelines. The relevance of
guidelines with specific reference to cost-effectiveness needs
to be acknowledged. Recent literature may lead to paradigm
shifts in our decision-making (4, 11). Further analysis of this
data may shed some light on the interplay of factors influenc-
ing decision-making of trainees, with reference to the treat-
ment options they would elect to receive.
We would like to thank Dr. Amit Malik (President, EFPT) and Martina
Rojnic (President-Elect, EFPT) for their support and guidance.
We appreciate the support of trainees who completed the survey.
Fig. 3 Factors influencing treatment choices for trainees’ own
treatment (expressed as percentages)
100
80
60
40
20
0
Cost
Side effect
profile
Efficacy
Antidepressant Mood Stabiliser Antipsychotic
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Die Psychiatrie 2/2009 © Schattauer GmbH
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Correspondence to
Sameer Jauhar
Gartnavel Royal Hospital
1055 Great Western Road
Glasgow, Scotland
G12 0HX
E-Mail: sameerjauhar@googlemail.com
