Influences on Therapist’s Decisions for Neuroleptic Treatment in Schizophrenia: The Role of Characteristics of the Patient and the Physician

Abstract

Introduction:

We investigated factors influencing physicians’ treatment decisions regarding 4 antipsychotic treatment strategies for schizophrenia (conventional oral/conventional depot/atypical oral/atypical depot). We analysed the influence of the patient’s compliance with medication, socio-economic status (occupational prestige/educational attainment), as well as the influence of gender, age and practice setting (psychiatric/general hospital/private practice) of the prescribing physician.

Methods:

We examined the influence of these factors by means of case vignettes. 4 vignettes were constructed with varying levels for compliance and socio-economic status. For each vignette, physicians had to choose one treatment strategy from the 4 alternatives. Data were collected using a survey (n=1 342) of physicians in Germany and analysed using a weighted least-squares regression model and a random-effect logit model.

Results:

Compliance and status had interactive effects on treatment selection. Low compliance was associated with an increase in selections of depot medication. For high-status, noncompliant patients, physicians selected mainly atypical oral and atypical depot antipsychotics. Low-status, noncompliant patients were mostly given conventional and atypical depot antipsychotics. Noncompliant, low-status patients received conventional depot antipsychotics 4 times as often as noncompliant, high-status patients. The physician’s age and practice setting were also related to the treatment selection.

Discussion:

Therapeutic decisions are influenced by patients’ and the physicians’ characteristics. There might be barriers for patients with low compliance and low socio-economic status that prevent them from being prescribed newer medications. Not all physicians seem to have the same choices of treatment options available to them.

Key words

schizophrenia - schizophrenia treatment - neuroleptic treatment - medical decision making

• References

• 1 McEvoy J, Scheifler P, Frances A. The expert consensus guideline series: Treatment of schizophrenia 1999. J Clin Psychiatry. 1999 60. 9-34
• 2 Kane JM, Leucht S, Carpenter D et al. The expert consensus guideline series. Optimizing pharmacologic treatment of psychotic disorders. Introduction: methods, commentary, and summary. J Clin Psychiatry 2003; 64: 5-19
• 3 American Psychiatric Association . Practice guideline for the treatment of patients with schizophrenia. Washington: American Psychiatric Publishing; 2004
• 4 Leucht S, Heres S, Kissling W et al. Evidence-based pharmacotherapy of schizophrenia. Int J Neuropsychopharmacol 2011; 14: 269-284
• 5 Leslie DL, Rosenheck R. The effect of institutional fiscal stress on the use of atypical antipsychotic medications in the treatment of schizophrenia. J Nervous Mental Dis 2001; 189: 377-383
• 6 Mamdani M, Tu K, Austin P et al. Influence of socioeconomic status on drug Selection for the elderly in Canada. Ann Pharmacother 2002; 36: 804-808
• 7 Ren XS, Kazis LE, Lee AF et al. Patient characteristics and prescription patterns of atypical antipsychotics among patients with schizophrenia. J Clin Pharm Therap 2002; 27: 441-451
• 8 Copeland L, Zeber J, Valenstein M et al. Racial disparity in the use of atypical antipsychotic medications among veterans. Am J Psychiatry 2003; 160: 1817-1822
• 9 Hamann J, Ruppert A, Auby P et al. Antipsychotic prescribing patterns in Germany: a retrospective analysis using a large outpatient prescription database. Int Clin Psychopharmacol 2003; 18: 237-242
• 10 Chong MY, Tan CH, Fujii S et al. Antipsychotic drug prescription for schizophrenia in East Asia: rationale for change. Psychiatry Clin Neurosci 2004; 58: 61-67
• 11 Gaebel W, Riesbeck M, Janssen B et al. Atypical and typical neuroleptics in acute schizophrenia and related delusional disorders. Drug choice, switching and outcome under naturalistic treatment conditions. Eur Arch Psychiatry Clin Neurosc 2004; 253: 175-184
• 12 Magliano L, Fiorillo A, Guarneri M et al. Prescription of psychotropic drugs to patients with schizophrenia: an Italian national survey. Eur J Clin Pharmacol 2004; 60: 513-522
• 13 Hoblyn J, Noda A, Yesavage JA et al. Factors in choosing atypical antipsychotics: toward understanding the bases of physicians’ prescribing decisions. J Psychiatric Res 2006; 40: 160-166
• 14 Valenstein M, Copeland L, Owen R et al. Adherence assessments and the use of depot antipsychotics in patients with schizophrenia. J Clin Psychiatry 2001; 62: 545-551
• 15 Sim K, Su A, Ungvari G et al. Depot antipsychotic use in schizophrenia: an East Asian perspective. Human Psychopharmacol 2004; 19: 103-109
• 16 Shi L, Ascher-Svanum H, Zhu B et al. Characteristics and use patterns of patients taking first-generation depot antipsychotics or oral antipsychotics for schizophrenia. Psychiatric Services 2007; 58: 482-488
• 17 Mahadun P, Marshall M. Insight and treatment attitude in schizophrenia: comparison of patients on depot and atypical antipsychotics. Psychiatrist 2008; 32: 53-56
• 18 Vehof J, Postma MJ, Bruggeman R et al. Predictors for starting depot administration of risperidone in chronic users of antipsychotics. J Clin Psychopharmacol 2008; 28: 625-630
• 19 West JC, Marcus SC, Wilk J et al. Use of depot antipsychotic medications for medication nonadherence in schizophrenia. Schizophr Bull 2008; 34: 995-1001
• 20 Ascher-Svanum H, Peng X, Faries D et al. Treatment patterns and clinical characteristics prior to initiating depot typical antipsychotics for nonadherent schizophrenia patients. BMC Psychiatry 2009; 9: 46-54
• 21 Barnes T, Shingleton-Smith A, Paton C. Antipsychotic long-acting injections: prescribing practice in the UK. Br J Psychiatry 2009; 195: 37-42
• 22 Citrome L, Jaffe A, Levine J. Treatment of schizophrenia with depot preparations of fluphenazine, haloperidol, and risperidone among inpatients at state-operated psychiatric facilities. Schizophr Res 2010; 119: 153-159
• 23 Kelin K, Brnabic A, Newton R et al. Baseline characteristics and initial treatment decisions for patients with schizophrenia at risk of treatment nonadherence. Patient Preference Adherence 2010; 4: 301-311
• 24 Eisenberg JM. Sociological influences on decison-making by clinicians. Ann Intern Med 1979; 90: 957-964
• 25 Denig P, Haaijer-Ruskamp FM. Therapeutic decision making of physicians. Pharmacy World & Science 1992; 14: 9-15
• 26 Bradley CP. Decision making and prescribing patterns – a literature review. Family Practice 1991; 8: 276-287
• 27 Figueras A. The use of drugs is not as rational as we believe, but it can’t be! The emotional roots of prescribing. Eur J Clin Pharmacol 2011; 67: 433-435
• 28 American Psychological Association Task Force on Socioeconomic Status . Report of the APA task force on socioeconomic status. Washington: American Psychological Association; 2007
• 29 Scott A, Shiell A, King M. Is general practitioner decision making associated with patient socioeconomic status?. Soc Sci Med 1996; 42: 35-46
• 30 Wang PS, West JC, Tanielian T et al. Recent patterns and predictors of antipsychotic medication regimens used to treat schizophrenia and other psychotic disorders. Schizophr Bull 2000; 26: 451-457
• 31 Clark JA, Potter DA, McKinlay JB. Bringing social structure back into clinical decision making. Soc Sci Med 1991; 32: 853-866
• 32 DGPPN. Praxisleitlinien in Psychiatrie und Psychotherapie. Band 1: Behandlungsleitlinien Schizophrenie. Darmstadt: Steinkopff; 1998
• 33 Waddell L, Taylor M. Attitudes of patients and mental health staff to antipsychotic long-acting injections: systematic review. Br J Psychiatry 2009; 52: S43-S50
• 34 Koch G, Landis J, Freeman J et al. A general methodology for the analysis of experiments with repeated measurement of categorical data. Biometrics 1977; 33: 133-158
• 35 SAS Institute Inc . SAS/STAT User’s Guide, Version 8. Cary, NC: SAS Institute Inc; 1999
• 36 Agresti A, Booth JG, Hobert JP et al. Random-effects modeling of categorical response data. Sociolog Methodol 2000; 30: 27-80
• 37 Train K. Discrete choice methods with simulation. Cambridge: University Press. 2003
• 38 Raudenbush SW, Bryk AS, Congdon R. HLM 6 for Windows [Computer software]. Lincolnwood, IL: Scientific Software International;
• 39 Thompson K, Kulkarni J, Sergejew A. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophr Res 2000; 42: 241-247
• 40 Tavacar R, Dernovsek MZ, Zvan V. Choosing antipsychotic maintenance therapy: a naturalistic study. Pharmacopsychiatry 2000; 33: 66-71
• 41 Kuno E, Rothbard A. Racial disparities in antipsychotic prescription patterns for patients with schizophrenia. Am J Psychiatry 2002; 159: 567-572
• 42 Barbui C, Danese A, Guaiana G et al. Prescribing second-generation antipsychotics and the evolving standard of care in Italy. Pharmacopsychiatry 2002; 35: 239-243
• 43 Jones TV, Gerrity MS, Earp J. Written case simulations: do they predict physicians behavior?. J Clin Epidemiol 1990; 43: 805-815
• 44 Morell DC, Roland MO. Analysis of referral behaviour: responses to simulated case histories may not reflect real clinical behaviour. Br J Gen Pract 1990; 40: 182-185
• 45 Tamayo-Sarver JH, Dawson NV, Hinze SW et al. The effect of race ethnicity and desirable social characteristics on physicians’ decision to prescribe opioide analgesics. Academic Emerg Med 2003; 10: 1239-1248