BMJ  2006;333:353 (12 August), doi:10.1136/bmj.333.7563.353

Letter

What works in schizophrenia

Depot preparations may improve outcomes

EDITOR—The study by Tiihonen et al indicates that antipsychotics are not equally effective in treating schizophrenia.¹ After a first admission with schizophrenia, patients treated with clozapine, olanzapine, or perphenazine depot had substantially lower risks of readmission, and discontinuation of treatment for any reason, than patients treated with oral haloperidol.

Credit: BSIP, PIKO/SPL

 

The increased effectiveness of clozapine is understandable in terms of its superior efficacy in treatment resistant schizophrenia.² The increased effectiveness of perphenazine depot presumably derives from its ability to reduce non-compliance, a common problem in schizophrenia that can be overt or covert.³ In the study reported by Tiihonen et al, the less favourable 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 that are 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 drugs 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 depots.⁴ In a Cochrane review a greater proportion of patients treated with depot than with oral drugs showed global improvement, perhaps reflecting depots reducing partial compliance.⁵ The work of Tiihonen et al adds to the view that depot antipsychotic drugs are effective for some patients. Like all antipsychotic drugs, they should be prescribed on an individual basis after full discussion with the patient and considering a range of factors.

Pharmacologically, clinical outcomes in schizophrenia can be improved by using drugs that are either more efficacious or improve compliance, and one way to do this is to use a depot preparation.

Bolton, Salford and Trafford Mental Health NHS Trust, Salford M30 0GT Peter.Haddad{at}bstmht.nhs.uk

Sheffield Care Trust, Fulwood House, Sheffield S10 3TG

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Competing interests: PMH has received honorariums for lecturing or attending advisory boards from Eli Lilly, Janssen-Cilag, and Novartis.

References

1. Tiihonen J, Wahlbeck K, Lonnqvist J, Klaukka T, Ioannidis JP, Volavka J, et al. 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. (29 July.)[Abstract/Free Full Text]
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.[Abstract/Free Full Text]
3. Lindstrom E, Bingefors K. Patient compliance with drug therapy in schizophrenia. Economic and clinical issues. Pharmacoeconomics 2000;18: 106-24.[Medline]
4. Patel MX, Nikolaou V, David AS. Psychiatrists' attitudes to maintenance medication for patients with schizophrenia. Psychol Med 2003;33: 83-9.[CrossRef][ISI][Medline]
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.[Abstract/Free Full Text]

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Relevant Article

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

Jari Tiihonen, Kristian Walhbeck, Jouko Lönnqvist, Timo Klaukka, John P A Ioannidis, Jan Volavka, and Jari Haukka
BMJ 2006 333: 224. [Abstract] [Full Text] [PDF]

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