Young AS (VA Greater Los Angeles Healthcare System & UCLA), Niv N
(VA Greater LA HCS & UCLA), Cohen AN
(VA Greater LA HCS), Kessler C
(VA Greater LA HCS), McNagny K
(Long Beach VAMC)
In schizophrenia, antipsychotic medications improve outcomes and national treatment guidelines specify strategies for their use. However, many patients receive prescriptions that do not appropriately address their symptoms and side-effects. Most research describing the quality of prescribing for schizophrenia was performed in the 1990s when 1st generation antipsychotic medications were the modal treatment. The newer 2nd generation antipsychotics cause fewer neurologic side-effects, but more weight gain. Weight gain varies markedly between agents, and switching to a medication with less weight gain liability often leads to weight loss. Since most prescriptions are now for 2nd generation antipsychotics, we re-evaluated common clinical problems, quality of treatment, and the effect of provider specialization on treatment quality.
At three VA mental health clinics, we obtained random samples of patients with schizophrenia (n=398). Trained interviewers assessed patients at baseline and one year later using validated instruments that assess symptoms and side-effects. Prescription data were obtained from VistA. We used explicit criteria derived from national guidelines to identify probable inappropriate treatment in patients with significant psychosis, depression, parkinsonism, akathisia, tardive dyskinesia, or elevated weight. Repeated-measures regressions assessed treatment appropriateness over time. The association between the volume of schizophrenia in a psychiatrist's practice and quality of care was examined.
All patients were prescribed antipsychotic medication. At baseline, few patients met criteria for depression (3%), parkinsonism (2%), or akathisia (1%). 44% of patients had psychosis, 11% had tardive dyskinesia, and 46% were substantially overweight. Appropriate treatment was present in 27% of patients with psychosis, 25% of patients with tardive dyskinesia, and 2% of patients with elevated weight. There were no significant differences between clinics. Over the year, there were no changes in appropriateness, except for weight (chi-square = 19.6, p < .0001) which improved modestly from its very low baseline. Psychiatrists treating more than 10 patients with schizophrenia were more likely to improve their treatment over time (in 90% vs. 24% of patients).
When compared with literature from the 1990s, outpatients appear more likely to have significant psychosis. The rate of appropriate treatment of psychosis is unchanged. Weight has become the most important side-effect, yet treatment is rarely changed in response to weight.
Quality improvement research in schizophrenia should attend to management of psychosis and weight, and to the potential implications of low-volume psychiatrists.