Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study
EDITOR – The naturalistic follow-up study by Tiihonen et al1
indicates that antipsychotics are not equally effective in the treatment
of schizophrenia. Following a first admission with schizophrenia patients
treated with clozapine, olanzapine or perphenazine depot had substantially
lower risks of rehospitalisation, and discontinuation of treatment for any
reason, than patients treated with oral haloperidol.
The increased effectiveness of clozapine is understandable in terms
of its superior efficacy in treatment resistant schizophrenia2. The
increased effectiveness of perphenazine depot presumably derives from it
ability to reduce non-compliance, a common problem in schizophrenia that
can be overt or covert3. In Tiihonen et al’s study the less favorable
outcome for oral perphenazine, in contrast to the depot preparation,
supports this hypothesis. The effectiveness of clozapine and perphenazine
depot may also partly reflect the regular clinical contact and supervision
which is integral to both treatments; with a depot this relates to its
administration and with clozapine to regular haematological monitoring.
The results are unlikely to reflect a prescribing bias as depots are
largely used in patients who comply poorly with oral medication and
clozapine is restricted to use in treatment resistant schizophrenia.
Despite its effectiveness perphenazine depot was not commonly used.
This may reflect negative perceptions about depots4. In a Cochrane review
a greater proportion of patients treated with depot than with oral
medication showed global improvement, perhaps reflecting depots reducing
partial compliance5. Tiihonen et al’s work adds to the view that depot
antipsychotics are effective for some patients. Like all antipsychotics,
depots should be prescribed on an individual basis following full
discussion with the patient and considering a range of factors.
In summary, at a pharmacological level clinical outcomes in
schizophrenia can be improved by employing drugs that are either more
efficacious or by improving medication compliance, one way of which is to
use a depot preparation.
Peter M. Haddad, Consultant Psychiatrist,
Cromwell House, Bolton, Salford and Trafford Mental Health NHS Trust,
Salford, M30 0GT Peter.Haddad@bstmht.nhs.uk
Omair Niaz, Specialist, Registrar in Psychiatry,
Sheffield Care Trust
Competing interests: PMH has received honoraria for lecturing and/or
attending advisory boards from Eli Lilly, Janssen-Cilag and Novartis.
1. Tiihonen J, Walhbeck K, Lonnqvist J, Klaukka T, Ioannidis JP,
Volavka J, Haukka J. Effectiveness of antipsychotic treatments in a
nationwide cohort of patients in community care after first
hospitalisation due to schizophrenia and schizoaffective disorder:
observational follow-up study. BMJ 2006; 333:224-7.
2. Chakos M, Lieberman J, Hoffman E, Bradford D, Sheitman B.
Effectiveness of second-generation antipsychotics in patients with
treatment-resistant schizophrenia: a review and meta-analysis of
randomized trials. Am J Psychiatry 2001:158;518-26.
3. Lindstrom E, Bingefors K. Patient compliance with drug therapy in
schizophrenia. Economic and clinical issues. Pharmacoeconomics 2000;18:106
-24.
4. Patel MX, Nikolaou V, David AS. Psychiatrists' attitudes to maintenance
medication for patients with schizophrenia. Psychol Med. 2003;33:83-9.
5. Adams CE, Fenton MK, Quraishi S, David AS. Systematic meta-review of
depot antipsychotic drugs for people with schizophrenia. Br J Psychiatry
2001;179:290-9
Competing interests:
PMH has received honoraria for lecturing and/or attending advisory boards from Eli Lilly, Janssen-Cilag and Novartis.
Competing interests:
No competing interests
29 July 2006
Peter M Haddad
Consultant Psychiatrist
Omair Niaz
Cromwell House, Bolton, Salford and Trafford Mental Health NHS Trust, Salford, M30 0GT
Rapid Response:
Antipsychotics are not equally effective
EDITOR – The naturalistic follow-up study by Tiihonen et al1
indicates that antipsychotics are not equally effective in the treatment
of schizophrenia. Following a first admission with schizophrenia patients
treated with clozapine, olanzapine or perphenazine depot had substantially
lower risks of rehospitalisation, and discontinuation of treatment for any
reason, than patients treated with oral haloperidol.
The increased effectiveness of clozapine is understandable in terms
of its superior efficacy in treatment resistant schizophrenia2. The
increased effectiveness of perphenazine depot presumably derives from it
ability to reduce non-compliance, a common problem in schizophrenia that
can be overt or covert3. In Tiihonen et al’s study the less favorable
outcome for oral perphenazine, in contrast to the depot preparation,
supports this hypothesis. The effectiveness of clozapine and perphenazine
depot may also partly reflect the regular clinical contact and supervision
which is integral to both treatments; with a depot this relates to its
administration and with clozapine to regular haematological monitoring.
The results are unlikely to reflect a prescribing bias as depots are
largely used in patients who comply poorly with oral medication and
clozapine is restricted to use in treatment resistant schizophrenia.
Despite its effectiveness perphenazine depot was not commonly used.
This may reflect negative perceptions about depots4. In a Cochrane review
a greater proportion of patients treated with depot than with oral
medication showed global improvement, perhaps reflecting depots reducing
partial compliance5. Tiihonen et al’s work adds to the view that depot
antipsychotics are effective for some patients. Like all antipsychotics,
depots should be prescribed on an individual basis following full
discussion with the patient and considering a range of factors.
In summary, at a pharmacological level clinical outcomes in
schizophrenia can be improved by employing drugs that are either more
efficacious or by improving medication compliance, one way of which is to
use a depot preparation.
Peter M. Haddad, Consultant Psychiatrist,
Cromwell House, Bolton, Salford and Trafford Mental Health NHS Trust,
Salford, M30 0GT
Peter.Haddad@bstmht.nhs.uk
Omair Niaz, Specialist, Registrar in Psychiatry,
Sheffield Care Trust
Competing interests: PMH has received honoraria for lecturing and/or
attending advisory boards from Eli Lilly, Janssen-Cilag and Novartis.
1. Tiihonen J, Walhbeck K, Lonnqvist J, Klaukka T, Ioannidis JP,
Volavka J, Haukka J. Effectiveness of antipsychotic treatments in a
nationwide cohort of patients in community care after first
hospitalisation due to schizophrenia and schizoaffective disorder:
observational follow-up study. BMJ 2006; 333:224-7.
2. Chakos M, Lieberman J, Hoffman E, Bradford D, Sheitman B.
Effectiveness of second-generation antipsychotics in patients with
treatment-resistant schizophrenia: a review and meta-analysis of
randomized trials. Am J Psychiatry 2001:158;518-26.
3. Lindstrom E, Bingefors K. Patient compliance with drug therapy in
schizophrenia. Economic and clinical issues. Pharmacoeconomics 2000;18:106
-24.
4. Patel MX, Nikolaou V, David AS. Psychiatrists' attitudes to maintenance
medication for patients with schizophrenia. Psychol Med. 2003;33:83-9.
5. Adams CE, Fenton MK, Quraishi S, David AS. Systematic meta-review of
depot antipsychotic drugs for people with schizophrenia. Br J Psychiatry
2001;179:290-9
Competing interests:
PMH has received honoraria for lecturing and/or attending advisory boards from Eli Lilly, Janssen-Cilag and Novartis.
Competing interests: No competing interests