Most Psychiatrists Unlikely To Use Depot Antipsychotics

Less than 20 percent of psychiatrists prescribed a long-acting depot antipsychotic medication for patients with schizophrenia who were nonadherent with the original medication.

That was the finding of a nationwide survey by researchers with the American Psychiatric Institute for Research and Education (APIRE), Columbia University College of Physicians and Surgeons, and the University of Pennsylvania School of Social Policy and Practice. The study was conducted between September 2003 and January 2004.

Moreover, the decision to use depot medications appears to be a function of patient, physician, and practice-setting characteristics. For instance, initiation of depot medication was significantly and positively associated with public insurance, prior inpatient admission, proportion of time nonadherent, average or above average intellectual functioning, and living in a mental health residence. Psychiatrists who were optimistic about managing nonadherence were also more likely to prescribe long-acting antipsychotics for nonadherent patients.

The study appeared in the September Schizophrenia Bulletin.

“Patient and psychiatrist attitudes likely play a role in the generally low level of use of long-acting antipsychotic medications,” said psychiatrist and principal investigator Mark Olfson, M.D., M.P.H., of Columbia University. “One of the interesting findings from this study is that psychiatrists who are more optimistic about the effectiveness of long-acting injectable antipsychotic medications are more likely to use these preparations in their practices.”

In the study, psychiatrists were randomly selected from the AMA's Masterfile of Physicians. (The AMA Masterfile contains contact and practice information on all U.S physicians regardless of whether they are AMA members.) A random-number generator function was used to select 1,150 psychiatrists, and these were sent a screening postcard. Psychiatrists with undeliverable addresses and those with fewer than four patients with schizophrenia in their caseload were excluded, resulting in a final sample of 771.

Of these, 534 (69.3 percent) responded to a comprehensive survey about their practice and attitudes regarding antipsychotic medications.

Psychiatrists were also instructed to select the most recent eligible patient who was over age 18, under the psychiatrist's care for at least one year, nonadherent with oral antipsychotics at some point in the last year, and not prescribed a depot antipsychotic within two months prior to the episode of nonadherence.

Of the 534 who responded to the survey, 310 respondents reported on a specific patient. They were asked to report whether they started a long-acting antipsychotic injection medication to manage the patient's nonadherence and to rate the effectiveness of the intervention on a 1-5 Likert scale.

Results showed that just 17.6 percent of the nonadherent patients in the study were started on long-acting antipsychotic injections to manage their most recent episode of medication nonadherence. Statistical analysis revealed that patients living in mental health residences were significantly more likely to begin taking long-acting injections than were patients who paid for their medications with public insurance or sources other than private insurance.

“The findings indicate that among schizophrenia patients with a known history of medication nonadherence, long-acting injectable medications tend to be used when nonadherence is persistent and consequential,” Olfson told Psychiatric News. “In this regard, patients who had been medication nonadherent for at least one-quarter of the time under the psychiatrist's care were more than twice as likely to be treated with long-acting injectables as those who had less nonadherence.

“Similarly, patients who had been hospitalized as a consequence of medication nonadherence were more than three times as likely as those without such a history to receive long-acting injectable antipsychotics,” he said.

“The reasons for the associations between public insurance and use of depot medications are not known, but it is possible that publicly insured patients, as a group, have longer periods of active illness and may therefore have had a longer period of time to demonstrate persistent nonadherence to oral medications,” Olfson said.

In the report, the researchers state that innovative strategies to train more psychiatrists and their staff in the use of depot antipsychotics may help promote their use in different settings and in patients who are less severely ill but are still medication nonadherent.

“Depot antipsychotics offer considerable benefits over oral antipsychotics for nonadherent patients with schizophrenia,” Joyce West, Ph.D., APIRE senior scientist and first author of the report, told Psychiatric News.

But she added that new clinical practices that mark a departure from routine practice—as the use of depot medications does for many clinicians accustomed to dispensing oral medications and psychotherapeutic treatments—typically take time to be commonly adopted as the norm.

In the paper, the authors contended that “greater opportunities for first-hand observation and hands-on training may be needed. One approach is to set up specialty long-acting antipsychotic injection clinics in private and public outpatient settings that accept referrals. Mobile outreach services provide another option for delivering long-acting injections.”

“Use of Depot Antipsychotic Medications for Medication Nonadherence in Schizophrenia” is posted at<http://schizophreniabulletin.oxfordjournals.org/cgi/content/full/34/5/995>.▪