Efficacy and effectiveness of first- and second-generation antipsychotics in schizophrenia.

While efficacy as a concept is concerned with whether a treatment works under ideal conditions, effectiveness is concerned with whether a treatment works under the conditions of routine care. Large-scale clinical, pharmacy, and administrative databases can provide naturalistic data for effectiveness studies when appropriate methodology is employed. The Nathan Kline Institute Integrated Research Database includes patient-specific admission, demographic, diagnostic, medication, and discharge information from hospitals operated by the New York State Office of Mental Health. This database was used to study the effectiveness of first- versus second-generation antipsychotics in the treatment of schizophrenia and schizoaffective disorder. Switching off the index medication regimen prior to discharge (negative outcome) was our principal outcome of interest. We concluded that, as a class, second-generation antipsychotics were less likely than first-generation agents to be associated with premature discontinuation of an antipsychotic regimen, both when used as the initial medication regimen following hospitalization and as the second regimen following a prior medication switch.

Relationship of atypical antipsychotics with development of diabetes mellitus.

OBJECTIVE: To review the pharmacoepidemiologic evidence for the link between exposure to atypical antipsychotics and the development of diabetes mellitus. DATA SOURCES: A MEDLINE search (1990-March 2003) was conducted. STUDY SELECTION AND DATA EXTRACTION: The search was limited to articles that described findings from analyses of large databases and used the words diabetes or hyperglycemia, and antipsychotic or clozapine or olanzapine or risperidone or quetiapine or ziprasidone or aripiprazole in the title or abstract. The odds ratio or relative risk, together with their corresponding confidence interval, was extracted. DATA SYNTHESIS: Results are conflicting, and this variability may be due to the different populations studied, different study designs, and the possibility of publication bias related to funding by the pharmaceutical industry. Nevertheless, an increased risk for diabetes mellitus appears to be present for patients receiving atypical antipsychotics. However, differential risk among the atypical antipsychotics is difficult to ascertain. CONCLUSIONS: Clinicians are urged to manage risk by regularly monitoring all patients receiving atypical antipsychotics for the emergence of diabetes mellitus. Future studies should carefully control for confounding variables such as age, diagnosis, change in weight, activity level, family history, and ethnicity.

Antipsychotic medication coprescribing in a large state hospital system.

PURPOSE: To systematically characterize antipsychotic medication coprescribing ('polypharmacy') in a large state hospital system. METHODS: All antipsychotic prescriptions written for all adult in-patients (N = 8212) in New York state-run civil facilities for the year 1999 were identified using the Integrated Research Database (IRDB) created by the Information Systems Division of the Nathan Kline Institute for Psychiatric Research. Antipsychotics were considered to be intentionally coprescribed only when both were prescribed for an overlapping period of 28 days. RESULTS: Coprescribing of typical, atypical, and depot antipsychotics comprised 31% of antipsychotic prescribing episodes. Medications were usually coprescribed with medications from outside their own antipsychotic class. Patient factors, such as age, diagnosis, and history of prior hospitalization, affected coprescribing rates (p < 0.001 for all indicated variables). Atypical antipsychotic medications were less likely to be given with another antipsychotic than were oral or depot typical medications. CONCLUSIONS: Coprescribing of antipsychotic drugs is a common practice in the New York State hospital system. The analysis of large clinical databases can yield valuable information about the kinds of complex pharmacotherapy regimens actually utilized in the treatment of the most severely ill patients.