Survey on schizophrenia treatment in Mexico: perception and antipsychotic prescription patterns

BACKGROUND: Since the introduction of antipsychotics, especially the so called atypicals, the treatment of schizophrenia has shown important improvements. At the present time, it is preferred to label clozapine and other antipsychotics sharing similar profiles as second-generation antipsychotics (SGAs). These medications have been proposed by some experts as a first line treatment for schizophrenia. It is critical to have reliable data about antipsychotic prescription in Mexico and to create management guidelines based on expert meetings and not only on studies carried out by the pharmaceutical industry. Only this approach will help to make the right decisions for the treatment of schizophrenia. METHODS: A translated version of Rabinowitz's survey was used to evaluate antipsychotic prescription preferences and patterns in Mexican psychiatrists. The survey questionnaire was sent by mail to 200 psychiatrists from public institutions and private practice in Mexico City and Guadalajara, Mexico. RESULTS: Recommendations for antipsychotics daily doses at different stages of the treatment of schizophrenia varied widely. Haloperidol was considered as the first choice for the treatment of positive symptoms. On the contrary, risperidone was the first option for negative symptoms. For a patient with a high susceptibility for developing extrapyramidal symptoms (EPS), risperidone was the first choice. It was also considered that SGAs had advantages over typical antipsychotics in the management of negative symptoms, cognitive impairment and fewer EPS. Besides, there was a clear tendency for prescribing typical antipsychotics at higher doses than recommended and inadequate doses for the atypical ones. CONCLUSIONS: Some of the obstacles for the prescription of SGAs include their high cost, deficient knowledge about their indications and dosage, the perception of their being less efficient for the treatment of positive symptoms and the resistance of some Mexican physicians to change their prescription pattern. It is necessary to reach a consensus, in order to establish and standardize the treatment of schizophrenia, based on the information reported in clinical trials and prevailing economic conditions in Mexico

First episode psychosis with extrapyramidal signs prior to antipsychotic drug treatment

Extrapyramidal movement disorders are common in chronic schizophrenia, and may be an intrinsic feature of the illness as well as related to antipsychotic drug treatment. Similar dysfunctions at illness onset may have implications for outcome, and for understanding the mechanisms of illness. The objectives were to examine the clinical correlates of pre-treatment movement disorders at first episode of psychosis, and determine associations with neuropsychological function and striatal structure. Never medicated subjects were recruited from consecutive admissions to Early Psychosis Programs with defined catchment areas in Hong Kong, China, and Halifax, Canada. Standardized clinical, neuropsychological and brain imaging assessments were carried out at baseline and following acute and long term treatment with typical or atypical antipsychotic drugs. At the Hong Kong site, we studied 84 subjects with first episode psychosis (n = 10 with EPS). At the Halifax site, we studied 40 subjects with first episode psychosis (n = 17 with EPS), and 23 healthy comparison subjects. Subjects with movement disorders prior to treatment (EPS+) had higher total PANSS scores at baseline (mean elevation 19.9% Hong Kong, P = 0.016; 14.7% Halifax, P = 0.049). In subjects treated with atypical antipsychotics (all Halifax), EPS+ status at baseline predicted more movement disorders at long term follow up (P = 0.0005). In both cohorts, EPS+ subjects had poorer acute symptomatic treatment response assessed with the PANSS (Hong Kong P = 0.005; Halifax P = 0.017). Neuropsychological impairment related to executive dysfunction appeared greater in a small sample of EPS+ subjects (Hong Kong, effect size 0.26-0.27, P < 0.05). Caudate volumes were 4.5% larger in EPS+ compared with EPS-subjects (Halifax P = 0.042), and correlations between striatal volumes and age were different in the EPS+ group. In conclusion, pre-treatment EPS is present in a substantial minority of subjects with first episode psychosis, appears to persist at long term follow up, and is associated with poorer response of symptoms to treatment. Selective impairment of executive function and striatal enlargement provides evidence of abnormalities of brain function and structure associated with this aspect of early psychosis. © 2011 Science China Press and Springer-Verlag Berlin Heidelberg.link_to_subscribed_fulltex

Verbal memory improvement in first-episode psychosis APOE-&epsilon;4 carriers: a pleiotropic effect?

Fidel Vila-Rodriguez,1 Donna J Lang,2 Heather Baitz,3 Kristina Gicas,3 Allen E Thorton,3 Thomas S Ehmann,1 Geoff N Smith,1 Alasdair M Barr,4 Ivan J Torres,1 Lili C Kopala,1 G William MacEwan,1 Daniel J M&uuml;ller,5 James L Kennedy,5 William G Honer11Department of Psychiatry, 2Division of Neuroradiology, Department of Radiology, The University of British Columbia, Vancouver, 3Department of Psychology, Simon Fraser University, Burnaby, 4Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, BC, 5Department of Psychiatry, Centre for Mental Health and Addictions, University of Toronto, Toronto, ON, CanadaBackground: Verbal memory impairment is a core feature in schizophrenia even at early stages of the disease, but its etiopathogenesis is not fully understood. The APOE-&epsilon;4 is the main genetic risk factor for late-onset Alzheimer&rsquo;s disease. Our primary goal was to ascertain whether APOE-&epsilon;4 status had a pleiotropic effect in early stages of the illness.Participants and methods: A total of 86 first-episode psychosis (FEP) outpatients and 39 healthy volunteers were recruited. Demographic and clinical data, APOE genotyping, and a neuropsychological test battery including the California Verbal Learning Test &ndash; second edition (CVLT-II) were administered and assessed at study entry and at 1-year follow-up. Data were analyzed using mixed-model repeated measures, where the dependent variable was verbal memory indexed by California Verbal Learning Test (CVLT) Trials 1&ndash;5 total recall score.Results: FEP-APOE-&epsilon;4 carriers and FEP-APOE-&epsilon;4 noncarriers had similar symptom severity, clinical outcomes, premorbid and current intelligence quotient, and exposure to antipsychotics. There was a main effect of group on CVLT 1&ndash;5 (FEP =43.30 vs control =58.25; F[1, 119.7]=42.97; P&lt;0.001) as well as an APOE-&epsilon;4 by group by time (F[4, 116.2]=2.73, P=0.033) interaction with only FEP-APOE-&epsilon;4 carriers showing improved verbal memory at follow-up.Conclusion: Our study is the first to report improvement in verbal memory in persons afflicted by FEP who are APOE-&epsilon;4 carriers and replicates the prominent verbal memory deficits present in FEP. Our work provides further evidence pointing to an antagonistic pleiotropic effect of APOE-&epsilon;4 in neuropsychiatric disorders. Our results merit further research into antagonistic pleiotropic effects in schizophrenia. Keywords: APOE, verbal memory, antagonistic pleiotropy, first-episode psychosis, schizophreni

Economic evaluation of quetiapine versus risperidone in the treatment of schizophrenia

Objective: To assess and compare the incremental healthcare resource consumption by schizophrenic patients because of Extra Pyramidal Symptoms (EPS) during treatment with two new antipsychotics: quetiapine and risperidone. Design: Cost analysis was performed through a decision tree. Time horizon was one year and the National Health System (NHS) perspective was assumed. A multiple regression model was set up to investigate the incremental healthcare resource consumption because of EPS. Costs for psychiatric interventions were derived from the records of ten community psychiatric services, while inpatient costs were calculated from literature records. NHS charges and market values were used for valuing tests and drug consumption, respectively. Main outcome measures and results: The use of quetiapine saved more than Lit 1,400,000 per patient in one-year period. From the sensitivity analysis it emerged, however, that final results are sensitive to changes in EPS incidence rate: quetiapine remains cost-saving compared with risperidone only if the EPS incidence rate with quetiapine is lower than 5.2% and the EPS incidence rate with risperidone is equal or higher than 9.74%. Conclusions: Based on the hypothesis that the two drugs are therapeutically equivalent in the treatment of schizophrenia, quetiapine is economically advantageous compared with risperidone. However, direct comparisons of the two drugs in clinical trials and longitudinal studies are needed to confirm this hypothesis