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Maudsley Hospital
Institute of Psychiatry
South London and Maudsley NHS Trust
Institute of Psychiatry, London SE5 8AF
D.T. has received unrelated consultancy fees from all manufacturers of atypical antipsychotics. L.P. has received unrelated and unrestricted charitable grants and lecture and consultancy fees from AstraZeneca, Eli Lilly, Novartis, Janssen Pharmaceuticals, Synthelabo and GlaxoSmithKline. She is also a Medical Research Council Senior Clinical Research Fellow.
Correspondence: (e-mail: l.pilowsky{at}iop.kcl.ac.uk )
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Abstract |
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 Top Abstract IntroductionMethodResultsConclusionsReferences |
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To evaluate the effectiveness of the antipsychotic medication review service (AMRS) at the Maudsley Hospital. Patient notes were analysed from the AMRS and estimates of Global Assessment Scale (GAS) scores were made from entries in the notes. Data on hospital admissions before and during attendance at the AMRS were obtained from the trust-wide computerised patient administration system.
RESULTS
A statistically significant improvement in GAS scores was seen for patients who stayed in contact with the AMRS. Patients who did not respond to the first atypical drug often made a good response to an alternative atypical antipsychotic. Patients attending the AMRS had fewer hospital admissions than they did before attendance, although this was not statistically significant.
CLINICAL IMPLICATIONS
Although more expensive on a dose-by-dose rate, atypical antipsychotics may be cost effective by improving compliance and reducing the number of relapses and hospital admissions. Specialised services with frequent patient contact can be effective in preventing relapse and improving global function.
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Introduction |
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TopAbstractIntroductionMethodResultsConclusionsReferences |
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The study was designed to compare treatment within the AMRS with that previously received by patients. The aims of the study were to verify the usefulness of atypical antipsychotics in a naturalistic setting as well as to evaluate a dedicated clinic as secondline treatment for patients who do not improve with standard out-patient care.
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Method |
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Clinical data collection
The reason for referral, the date of the referral and the length of time
seen in clinic were recorded, as was the diagnosis of each patient and whether
there was concurrent drug or alcohol misuse. The medication that each patient
was on before being admitted to clinic and the change in their medication
while they were being seen in clinic were also noted.
Instruments
A psychiatric rater (J.S.) applied the Global Assessment Scale (GAS) to the
notes as described by Dill et al
(1989) for the first assessment
in the AMRS and at monthly intervals for the first 6 months. For the second 6
months, ratings were applied at 3-monthly intervals and then 6-monthly up to 2
years. The outcome was recorded for each patient. Outcomes included recovery
and referral back to local carers (for patients who made a marked recovery on
the new treatment), assessment for medication review (for patients who were
referred for review of medication only), continuing treatment (for patients in
the clinic who made a response to medication but were still being followed
up), non-compliance (with medication or with attendance) and deterioration
despite compliance (including patients referred on to the clozapine clinic).
The notes were evaluated retrospectively and ratings were independent of the
clinical team.
Statistics
Data were analysed for charge in GAS after 1 month, 1 year and 18 months.
Tests of significance were made, where appropriate, using student's
t-test, the 
2 test and Fisher's exact test. Software
package SPSS version 8.0 was used to determine 95% Cls, to calculate
significance and to provide a graphical representation of results.
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Results |
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Clinical characteristics
Of those who attended, the diagnosis was recorded as schizophrenia in 49
cases, with 6 cases of psychosis (unspecified) and 3 of schizoaffective
disorder. The reason for referral was fairly evenly spread between treatment
resistance (n=24, 41.4%), treatment intolerance (n=20,
34.5%) and first-episode psychosis (n=14, 24.1%). Nine (15.5%)
patients had concurrent substance misuse.
Attendance
The mean duration of contact with the clinic was 200 days (n=58,
s.d.=245). The mean frequency of attendance (including those referred for
review only) was one appointment per 15.7 days of contact with the clinic
(n=58, s.d.=11.7).
A total of 13/58 (22%) patients left the clinic before formal discharge. The mean time of contact with the clinic for this group was 47 days (s.d.=42.1).
Medication on referral
The antipsychotic medication regimes on referral are summarised in
Fig. 1. Eighty-six per cent of
patients were being treated with an antipsychotic at referral (31% on atypical
antipsychotics, 41% on typical antipsychotics and 14% on polytherapy). Of
those on an atypical antipsychotic at referral, eight were referred because of
only having made a partial response, four were intolerant of their medication,
five had a first-episode psychosis that was partially treated and one was
non-compliant with medication.
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Antipsychotic polytherapy
Eight (14%) patients were being treated with more than one antipsychotic at
referral but after starting in the clinic and following the crossover period
to atypical antipsychotics all but one were on monotherapy. This difference
was statistically significant (n=58; 2 test,
P=0.015; Fisher's exact one-tailed test, P=0.015).
Anticholinergic use
Fifteen (26%) patients were being treated with oral anticholinergics when
referred to the clinic but none continued on these while in the clinic
(n=58; 2 test, P<0.001).
Medication started in clinic
A total of 47/58 (81%) patients were treated with an atypical antipsychotic
in the clinic. Twenty (42%) patients were started on quetiapine (mean dose 460
mg; s.d. 175.2). Eighteen (38%) were started on olanzapine (mean dose 14.4 mg,
s.d. 5.72), five (11%) on sertindole (mean dose 15.8 mg, s.d. 5.22) and four
(9%) on risperidone (mean dose 3 mg, s.d. 1.15).
The mean time in clinic before starting on an atypical antipsychotic (or being changed to a new atypical) was 16 days (s.d. 31.0). The mean period of time for which the two antipsychotic drugs were overlapped was 7 days (s.d. 27.3).
Switching between atypical antipsychotic drugs
Twenty-one patients were swapped from one atypical antipsychotic to another
while in the AMRS. This was due either to non-response or intolerance of the
first atypical tried. The outcome for these cases was that nine cases
recovered allowing referral back to their home team, five cases continued in
contact with the clinic with good response to the new medication, one
deteriorated on the new medication and six were non-compliant with medication
or clinic attendance.
Patients attending clinic who did not receive an atypical
antipsychotic
A total of 11/58 patients were not commenced on an atypical antipsychotic
medication while attending the clinic. The majority of these (7/11) attended
for the purpose of a second opinion and subsequently returned to their local
teams. The other four patients discharged themselves before being started on
an atypical antipsychotic.
Admission data
The patient administration system covers data on patient admissions
exclusively from the South London and Maudsley Trust and so analysis of
admission before and during contact with the clinic was limited to this
group.
Out of 44 patients referred from South London and Maudsley, four patients did not attend the clinic and so were excluded from the analysis and a further two patients had missing data. Of the remaining group 1 of 38 patients was an in-patient for 18 days while under follow-up by the clinic. In comparison, 5 of the 38 patients were admitted (a total of 182 in-patient days) in the same period of time before their attendance at the clinic (n=38; paired sample t=test, P=0.11; Fisher's one-tailed exact test, P=0.087).
Rating scores
There was a statistically significant improvement in GAS scores. The
improvement was significant after 1 month, increasing from 45 to 50
(n=45, P<0.001), and this improvement continued for the
time that the patients were followed in the clinic. Over 6 months the average
GAS score improved from 44 to 58 (n=21, P<0.001), and
over 12 months the average GAS score improved from 41.4 to 61.2
(n=13, P<0.001). Even though there are limited data on
patients who stayed in the clinic longer than a year, because many patients
were formally discharged from the clinic by this time, the change in GAS score
is statistically significant for 18 months, rising from 43 to 56
(n=7, P=0.021).
If data on the patients who self-discharged are included in the analysis of the clinic's effect on the GAS by carrying forward their last recorded GAS score (Fig. 2), the improvement is from 45.1 at time 0 to 52.9 at 6 months (n=58, P<0.001). When analysed separately, it is found that the group of patients who self-discharged had a mean GAS score at first contact with the clinic of 46.3 (n=13, s.d.=9.27) and that this had not changed significantly at their last contact (46.5, n=13, s.d.=10.0, P=0.874).
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Outcome
Seventeen patients (27%) referred to the clinic recovered and were referred
back to their own team for follow-up. Sixteen (25.4%) were non-compliant with
treatment and 11 (17.5%) were still under monitoring by the clinic. Of the
remaining 19 patients, 13 (20.6%) were referred for medication review only,
five (8%) did not attend the clinic and one (2%) deteriorated despite full
compliance with treatment (Fig.
3). Substance misuse did not have a significant effect on
outcome.
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Conclusions |
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TopAbstractIntroductionMethodResultsConclusionsReferences |
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Only one patient who was compliant with attendance and medication at the clinic failed to improve and required referral to the local clozapine clinic. This suggests that the atypical antipsychotics other than clozapine are an effective treatment for the majority of patients with psychosis, including those refractory to treatment with other typical or atypical antipsychotics. It is unclear whether improvement was due solely to the medication used or to some other effect from attendance at the AMRS. It may be that attendance at the AMRS led to increased compliance with medication, possibly through making patients feel more empowered in their choice of treatment, but further work is required to clarify this.
This study has shown that atypical antipsychotic drugs used as monotherapy are an effective treatment for psychosis in patients at various stages of illness. The use of atypicals in the AMRS allowed the discontinuation of anticholinergic medication, the use of which can have a negative effect on cognitive function (Borison, 1996; Mizusawa, 1998). Although more expensive on a dose-by-dose rate, atypical antipsychotics may be cost effective by improving compliance and reducing the number of relapses and hospital admissions. Specialised services such as the AMRS can be a feasible and effective way of maintaining improvement and preventing relapse in patients with psychosis.
A relatively high proportion of patients became non-compliant with medication or failed to attend the clinic after initial assessment. This is not a new finding for patients with psychiatric illness and is not specific to the AMRS (Killaspy et al, 2000). The non-compliance rate for the AMRS after initial attendance, although high (25%), compared favourably with data suggesting a 40% rate of non-attendance at follow-up in a general psychiatric clinic (Killaspy et al, 2000) and with drop-out rates in clinical trials of 36-50% on a variety of atypical medications (Geddes et al, 2000). Factors that may have led to lower drop-out rates than clinical trials or routine adult general psychiatric settings include systematic and formal assessment of patients, with high-quality dialogue between staff and patients concerning choices of medication, and the continuity of involvement of relatively senior psychiatric staff in treatment and follow-up. Both carers and patients were given time to discuss concerns over medication.
The findings of this study are in keeping with previous work, which has demonstrated the benefits of atypical antipsychotics over typical antipsychotics when used in closely controlled but less naturalistic settings (Stanniland & Taylor, 2000; Worrel et al, 2000). It is hoped that these data will aid further service development and will assist in defining elements of the AMRS that are transferable to standard community mental health team or depot clinic settings.
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Acknowledgments |
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References |
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BORISON, R. L. (1996) The role of cognition in the risk—benefit and safety analysis of antipsychotic medication. Acta Psychiatrica Scandinavica Supplement, 389, 5-11.[Medline]
GEDDES, J., FREEMANTLE, N., HARRISON, P., et al
(2000) Atypical antipsychotics in the treatment of schizophrenia:
a systematic overview and meta-regression analysis.
BMJ, 321,
1371-1376.
KILLASPY H. BANERJEE, S., KING, M., et al
(2000) Prospective controlled study of psychiatric out-patient
non-attendance. Characteristics and outcomes. British Journal of
Psychiatry, 176,
160-165.
MIZUSAWA, H. (1998) Anticholinergic drugs and cognitive functions. Internal Medicine, 37(6), 514-518.
STANNILAND, C. & TAYLOR, D. (2000) Tolerability of atypical antipsychotics. Drug Safety, 22(3), 195-214.[CrossRef][Medline]
WORREL, J. A., MARKEN, P. A., BECKMAN, S. E., et al
(2000) Atypical antipsychotic agents: a critical review.
American Journal of Health Systems and Pharmacy,
57(3),
238-255.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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