Low Prevalence Disorder Component of the National Study of Mental Health and Wellbeing Bulletin 4

Transcription

1 Low Prevalence Disorder Component of the National Study of Mental Health and Wellbeing Bulletin 4 The use of psychopharmacological and other treatments by persons with psychosis Vera Morgan David Castle Assen Jablensky on behalf of the Low Prevalence Disorders Study Group October 2002

2 National Survey of Mental Health and Wellbeing Bulletin 4 The use of psychopharmacological and other treatments by persons with psychosis Self-reported data from the National Study of Low Prevalence (Psychotic) Disorders Vera Morgan School of Psychiatry and Clinical Neurosciences, University of Western Australia David Castle School of Psychiatry and Clinical Neurosciences, University of Western Australia Mental Health Research Institute and University of Melbourne Assen Jablensky School of Psychiatry and Clinical Neurosciences, University of Western Australia on behalf of the Low Prevalence Disorders Study Group

3 Commonwealth of Australia 2002 ISBN This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth, available from the Department of Communications, Information Technology and the Arts. Requests and enquiries concerning reproduction and rights should be addressed to the Manager, Copyright Services, Info Access, GPO Box 1920, Canberra ACT Publications approval number: 2952 Additional copies of the bulletin are available from the Mental Health Branch, Commonwealth Department of Health and Ageing, telephone or facsimile A copy may also be downloaded from the Mental Health Branch website at: Copies of other publications produced under the National Mental Health Strategy are also available at this site. The opinions expressed in this report are those of the authors and are not necessarily those of the Commonwealth Department of Health & Ageing. The authors would like to acknowledge the Commonwealth Department of Health and Ageing, Mental Health and Special Programs Branch, for providing the funding to undertake this project Publications Production Unit (Governance and Business Strategy Branch) Commonwealth Department of Health and Ageing Canberra ii The use of psychopharmacological and other treatments by persons with psychosis

4 This publication is one of a series of publications produced by the Commonwealth Department of Health and Ageing under the National Survey of Mental Health and Wellbeing. Other publications include: Low prevalence component of the survey: People living with psychotic illness: an Australian study People living with psychotic illness: an overview (Bulletin 1) Costs of psychosis in urban Australia (Bulletin 2) Employment and psychosis (Bulletin 3) The use of psychopharmacological and other treatments by persons with psychosis (Bulletin 4) Disability, homelessness and social relationships among people living with psychosis in Australia (Bulletin 5) Stigma and discrimination (Bulletin 6) Child and adolescent component of the survey: The mental health of young people in Australia Adolescent depression (Leaflet 1) Conduct disorders (Leaflet 2) Adolescent suicide (Leaflet 3) Attention deficit / hyperactivity disorder (Leaflet 4) The use of psychopharmacological and other treatments by persons with psychosis iii

5 Acknowledgement This bulletin is based on data collected in the framework of the Collaborative Study on Lowprevalence (Psychotic) Disorders, an epidemiological and clinical investigation which is part of the National Survey of Mental Health And Wellbeing, Australia The members of the Low Prevalence (Psychotic) Disorders Study Group are: Professor Assen Jablensky (Project Director and Team Leader, Western Australia); Professor Vaughan Carr (Adviser); Dr David Castle (Deputy Team Leader, Western Australia); Dr Mandy Evans (Team Leader, Australian Capital Territory); Professor Oye Gureje (Deputy Team Leader, Victoria); Dr Carol Harvey (Deputy Team Leader, Victoria); Professor Helen Herrman (Team Leader, Victoria); Mrs Ailsa Korten (Statistician); Associate Professor John Mcgrath (Team Leader, Queensland); Ms Vera Morgan (Project Database Manager). Other investigators at the four sites included: Scott Henderson, Stephen Rosenman, Jo Medway (Australian Capital Territory); David Chant, Susette Cardy, Chris Young, Ben Chapple (Queensland); Ian Gordon, Tom Trauer, Helen Evert, Tony Pinzone (Victoria); Anna Waterreus (Western Australia). A complete list of the investigators is available in: Jablensky, A., Mcgrath, J., Herrman, H., Castle, C., Gureje, O., Morgan, V., & Korten, A. On behalf of the study group (1999) People Living with Psychotic Illness: An Australian Study National Survey of Mental Health and Wellbeing - Report 4. Canberra: Australian Mental Health Branch, Commonwealth Department of Health and Ageing. Ethics approvals for the study were obtained from relevant institutional ethics committees. Full details are available on request. The study was funded by the Commonwealth Department of Health and Ageing for those components carried out in Brisbane, Melbourne and Perth. The component carried out in Canberra was funded separately by the Australian Capital Territory Department of Health and Community Care, and the Psychiatric Epidemiology Research Centre, Australian National University. This report also acknowledges, with thanks, the hundreds of mental health professionals who assisted in the preparation and conduct of the survey and the many Australians with psychotic disorders who agreed to participate. Without them, this study would not have seen the light of the day. The full report of the study [22] is available for downloading as a.pdf file at the following web address: iv The use of psychopharmacological and other treatments by persons with psychosis

6 Contents 1 Introduction 1 What is a psychotic disorder? 1 The use of psychotropic medication in the treatment of psychotic disorders 1 Background 1 Best practice in the management of psychosis 2 Psychosocial interventions and other treatment options 3 The management of first incidence cases 3 2 Overview of data from the National Study of Low Prevalence (Psychotic) Disorders 5 Source of data 5 Medication use 7 Comparison with other Australian data Did the medication help? 15 Depot versus oral typical antipsychotics 16 Typical versus atypical antipsychotics 16 4 Medication side effects 19 Side effects in subsample using one class of medication only 20 Side effects and effectiveness 21 5 Medication use and illness profile 25 Symptom profile 25 Course of disorder and severity of illness 28 Comorbid substance abuse 29 6 Polypharmacy 33 7 Use of psychosocial treatment options 37 Living skills services 37 Rehabilitation programs 38 Psychosocial programs, medication tolerance and treatment compliance 38 8 Discussion 41 Introduction 41 Rates of medication prescribing 41 Reported effectiveness 42 Reported side effects 42 Medication and symptom profile 43 Polypharmacy 43 The use of psychopharmacological and other treatments by persons with psychosis v

7 Psychosocial treatments 44 Conclusions 44 References 45 Appendix 1. Use and effectiveness of individual psychotropic agents 49 vi The use of psychopharmacological and other treatments by persons with psychosis

8 1 Introduction What is a psychotic disorder? Psychotic disorders form a diverse group of illnesses that have their origins in abnormal brain function. These disorders include schizophrenia and related disorders, bipolar affective disorder (manic-depressive illness), depression with psychotic features, delusional disorders and other non-affective psychotic illnesses. They are characterised by fundamental distortions of thinking, perception, and emotional response. Features of these disorders are: Positive symptoms, namely hallucinations (perceptions without external stimuli, eg, hearing voices) and delusions (incorrect beliefs out of keeping with the shared beliefs and values in the culture). These include the experience of thoughts transferring in or out of one s mind, for example, having one s own thoughts extracted or relayed to others, or having another s thoughts inserted into one s own mind Depressive symptoms including dysphoria (pervasive depressed or irritable mood); anhedonia (loss of the ability to enjoy life); emotional blunting (diminished or lacking emotional response); and hypomania (including intense elation, irritability) Disorganised thought, speech and non-verbal communication characterised by bizarre behaviour, inappropriate affect and incoherent speech. The use of psychotropic medication in the treatment of psychotic disorders Background Treatments for psychotic disorders involve the use of antipsychotic medications and various psychosocial interventions. Antipsychotic medications are generally effective in controlling acute symptoms and can reduce the risk of relapse. Some medications appear to be more effective than others with regard to different clusters of symptoms. Regardless of the effectiveness of the medication, the majority of those on antipsychotic medication experience some side effects. The history of the use of effective psychopharmacological treatments in the management of psychotic illness is relatively recent. While phenothiazine derivatives were first synthesised in the nineteenth century initially for the British dye industry then later in the search for a treatment for malaria it was only in the early 1950s that their effect on reducing positive symptoms in psychosis was recognised. 1 By the late 1950s, the psychopharmacological benefit of chlorpromazine was established and the development of other drugs of similar effect followed this first major breakthrough in the treatment of psychotic disorders. Today, these drugs, which largely achieve their effect by blocking the dopamine D 2 receptors in the brain 2, are variously known as typical, conventional or first generation antipsychotics. Within a few years of the introduction of typical antipsychotic medication, it became apparent that many patients were experiencing serious side effects as a result of their use. While judicious treatment regimes have been vital in minimising side effects, side effects remain a serious concern for users. (A detailed examination of the side effects associated with psychotropic medications may be found in Section 4.) The next major advance in the development of The use of psychopharmacological and other treatments by persons with psychosis 1

9 medications for use in the treatment of psychotic disorders came with the introduction of the socalled atypical drugs (also known as novel, new or second generation drugs). Compared with the typicals, atypical drugs have fewer extrapyramidal side effects and may be better at reducing negative symptoms and cognitive deficits in psychotic illness. While there is some debate over the coverage of the term atypical 3,4, all atypical antipsychotics achieve their effect by selectively blocking dopamine D 2 and serotonin 2A (5HT-2A) receptors in the brain. 2 Typical antipsychotic medication can be administered either orally, intramuscularly, or as a depot (long-acting) injection. Depots tend to be used where treatment compliance is an issue. At present, atypical antipsychotics can only be administered orally. Best practice in the management of psychosis The introduction of atypical antipsychotics in the treatment of psychosis in the 1990s is regarded as an important development in the management of psychotic illness. While both typical and atypical antipsychotics have been effective at reducing the florid (or positive) symptoms of psychosis, there has been much interest generated by the potential of atypical antipsychotics to reduce negative symptoms as well as in the reported reduction in extrapyramidal side effects that has been associated with their use. However, recent comparative trials and systematic reviews into the benefits of atypical versus typical medications have been somewhat more equivocal. 3 It would appear that the reduction in side effects is not as large an effect as previously believed. Differences observed in the earlier trials have been attributed to the administration of dosages of typical agents above what are now the recommended guidelines; where the dosage of typical agents is within current clinical guidelines, atypical agents do only marginally better with respect to associated side effects. 3 In addition, side effects such as weight gain remain to be investigated more closely. On balance, there appear to be some additional benefits to the routine use of atypicals over typicals, but this advantage is not as great as first assumed and needs to be assessed against pragmatic considerations such as cost and availability. Indeed, the 1999 report of the U.S. Surgeon General into mental health 5, while endorsing Recommendation 1 of the Schizophrenia Patient Outcomes Research Team (PORT) project, that Antipsychotic medications, other than clozapine, should be used as the first-line treatment to reduce psychotic symptoms for persons experiencing an acute symptom episode of schizophrenia, did not go so far as to recommend outright the first-line use of atypicals over typicals, although it acknowledged many of the reported advantages of atypical over typical medications. The atypical antipsychotic, clozapine, is generally regarded as the medication of choice in treatment-resistant cases. 5 However, it is rarely used as a drug of first choice as, in a very small percentage of users, it may lead to a potentially fatal complication, agranulocytosis (suppression of the formation of white blood cells), and therefore necessitates regular monitoring of the blood count. 2 Several other types of medication may be used in the treatment of persons with psychotic disorders. Antidepressants are used to treat depression that is a primary feature of the psychosis as well as secondary depression arising in the context of a psychotic illness. Mood stabilisers are used in the treatment of mania. Benzodiazepines are commonly used to treat anxiety and insomnia as well as the persistent restlessness that may be experienced as a side effect associated with the use of antipsychotics. They may also be used as an adjunct in acute psychosis. Anticholinergic drugs may also be used to reduce Parkinson-like side effects associated with the use of antipsychotic medication. 6-8 The judicious use of antidepressants, mood stabilisers and benzodiazepines as adjuncts to antipsychotic drug use is widely endorsed. 6,9 However, there are no large-scale studies to provide an evidence base for the concomitant use of more than one antipsychotic agent and such use is 2 The use of psychopharmacological and other treatments by persons with psychosis

10 considered non-optimal except, perhaps, in treatment-resistant cases. 4 Keks et al. reported that atypicals were used in combination with depot typical medication where non-compliance was an issue or when gradually weaning a person from typical depot to atypical oral forms of medication. 10 It is likely, therefore, that the simultaneous prescribing of more than one antipsychotic medication will be reduced somewhat once depot forms of atypical antipsychotics are introduced onto the market. Psychosocial interventions and other treatment options Despite the use of psychopharmacological treatments, many persons with psychoses still experience residual symptoms. Furthermore, neither the older typical nor the newer atypical agents have been shown to have a marked effect on social adjustment or occupational functioning. 11 Consequently, a number of adjunctive treatments are available to individuals with psychotic illness. These treatments specifically address aspects of social and occupational functioning and act synergistically with prescribed medication. Comprehensive reviews on psychosocial treatments for schizophrenia covering the published literature to , and updated to , have looked at the effectiveness of treatments including social skills training, family interventions, cognitive behavioural therapy and vocational rehabilitation. The different approaches of these treatments are summarised below: Social skills training may range from training in simple skills such as gazing and meshing to more complex skills such as assertiveness and conversational skills. 12 Family interventions, while usually including some basic educative material about the disorder, may take one of two approaches: the impact of a pattern of interaction in the family characterised by emotional over-involvement coupled with critical remarks (sometimes known as high expressed emotion ) or the impact on the family of having a family member with a severe mental disorder. 12 Cognitive behavioural therapy generally aims to improve basic information-processing skills and enhance coping with and/or modifying symptoms such as delusions and hallucinations. 12 Vocational rehabilitation targets an individual s occupational functioning: competitive, albeit supported, employment is distinguished from traditional forms of rehabilitation including prevocational training, transitional and sheltered employment. Results tend to favour supported employment over traditional forms. 11,13 Assessment of these adjunctive treatments is complicated not only by the many forms that they may take, but also by difficulties inherent in measuring the specificity of various outcomes. 11 Nonetheless, the reviews support the finding of the Schizophrenia Patient Outcomes Research Team (PORT) project that there is good evidence to justify the inclusion of psychosocial treatments in the management of psychosis 6, particularly if these treatments are long-term. 11,12 It is recommended, however, that these treatments be used in conjunction with psychopharmacological interventions. 5 The management of first incidence cases The management of patients having their first episode of a psychotic illness is an important consideration. It has been argued that active psychosis is biologically toxic and that early intervention may decrease the morbidity associated with psychotic illness. 14,15 There is some evidence of the potential for early intervention to alter the course of the illness by reducing the severity of the illness 16,17 and possibly diminishing the likelihood of treatment resistance. 17,18 First episode patients are reportedly more responsive to any antipsychotic treatment regardless of the type of medication used, but are also more susceptible to side effects. 19,20 Consequently, current The use of psychopharmacological and other treatments by persons with psychosis 3

11 guidelines advocate the early treatment of these patients with low doses of typical or atypical antipsychotics to minimise side effects associated with the use of antipsychotic drugs, as well as adjunctive psychosocial treatments to help them reintegrate into the community as easily and as quickly as possible. 20,21 4 The use of psychopharmacological and other treatments by persons with psychosis

12 2 Overview of data from the National Study of Low Prevalence (Psychotic) Disorders Source of data The primary source of data in this bulletin is the National Study of Low Prevalence (Psychotic) Disorders, conducted in predominantly urban catchment areas in the Australian Capital Territory, Queensland, Victoria and Western Australia between 1997 and The methodology of the study and its findings have been published elsewhere Unless otherwise indicated, tables using these data are based on the responses of 1126 individuals randomly selected and interviewed as part of the National Study. The majority of these (980 individuals) were screened as having a psychotic disorder in the census month: 262 were identified in inpatient services, 425 in outpatient services, 173 in private general medical or psychiatric practices, and 120 (who had not been identified through any of the treatment services) were identified through points of contact for persons living in marginalised settings for example, hostels, shelters, refuges, charity services or other marginal accommodation. A further 146 individuals were identified through administrative records as having a psychotic disorder and in contact with mainstream (inpatient or outpatient) treatment services within three years of the census month but not during the census month: they were subsequently contacted and interviewed. The figures in this bulletin will differ from those in other reports and papers that have focused primarily on the census month sample Most of the interviews were conducted between September 1997 and January Part of the interview asked participants about their current use (within one month of being interviewed) of medication for mental health related problems. A list containing both the generic and trade names of such medications was used to help participants identify the medication correctly. Only medications that had been used for at least one month were included. In addition, the study asked about the perceived effectiveness of medication, that is, how helpful participants found the medication that they were using. The main classes of medication used for reporting data in this bulletin are: typical antipsychotics (oral), typical antipsychotics (depot), atypical antipsychotics and clozapine, antidepressants, mood stabilisers and benzodiazepines. The specific medications within each class are shown in Table 2.1. As quetiapine was not available on the Australian market at the time of the interviews, it could not be included in the survey. Sulpiride has never been used in Australia, and the use of nortriptyline and buspirone has been limited, with no one in the surveyed sample reporting use of either of these medications. The use of psychopharmacological and other treatments by persons with psychosis 5

13 Table 2.1 Medications covered in survey Typical antipsychotics Atypical antipsychotics Antidepressants Mood stabilisers - oral other than clozapine other than SSRI, RIMA Carbamazepine Chlorpromazine Olanzapine Amitryptiline Lithium Carbonate Flupenthixol Risperidone Clomipramine Valproate Fluphenazine Hydrochloride Desipramine Haloperidol Atypical antipsychotics Dothiepin Benzodiazapines Perphenazine - clozapine only Doxepin Alprazolam Pericyazine Clozapine Imipramine Clorazepate Pimozide Mianserin Diazepam Thioridazine Tranylcypromine Lorazepam Thiothixene Trimipramine Oxazepam Trifluoperazine Antidepressants Typical antipsychotics - SSRI, RIMA only - depot Fluoxetine Flupenthixol Decanoate Moclobemide Fluphenazine Decanoate Nefazodone Haloperidol Decanoate Zuclopenthixol Decanoate Paroxetine Sertraline Venlafaxine These data collected on medication use, effectiveness, side effects and related areas consist of self-reports that are not substantiated by other sources. Nor was it possible to determine from the survey data the actual dosages received. Furthermore, the level of compliance with (adhering to a psychopharmacological treatment program) and tolerance of (putting up with the side effects associated with medication use) treatment regimes were issues outside of the scope of the National Survey. Notwithstanding this caveat, the collation and analysis of these data provides a unique opportunity to examine the pharmacological treatment of psychotic disorders from the perspective of the consumers. Profile of sample The majority of the sample was identified in mainstream inpatient or outpatient services in the census month (23.3% and 37.7% respectively). A further 15.4% were identified through private psychiatric and general medical practices, and 10.7% were identified as both marginalised and not in contact with services in the census month. Another 13.0% had been in contact with mainstream services within three years of the census but not in the census month. See Figure 2.1. Figure 2.1 Recruitment sources for interviewed sample Selected from persons screened positive for psychosis at one of five recruitment sources in census month Inpatient N=262 Outpatient N=425 Private psychiatric practice N=87 Selected from persons identified on in-/ outpatient records as using services within 3 years of census but not in census month Out of contact N=146 General practice N=86 Marginal, not using mainstream treatment services N=120 6 The use of psychopharmacological and other treatments by persons with psychosis

14 Enumeration of cases took place within predominantly urban catchment areas across four States, with 16.3% of the interviewed sample from the Australian Capital Territory, 27.3% from Queensland, 32.7% from Victoria and 23.7% from Western Australia. Figure 2.2 Sample profile: diagnosis (ICD-10), sex, catchment area other psychotic illness 37% bipolar affective, mania 11% schizophrenia 52% female 41% WA 24% male 59% VIC 33% ACT 16% QLD 27% Over half the study participants (52.7%) had a diagnosis of schizophrenia, another 10.7% had a diagnosis of bipolar affective disorder or mania, and 36.6% had some other psychotic illness including schizoaffective disorder and depressive psychosis, as classified by the International Classification of Diseases, 10th revision (ICD-10). The majority were male (58.9%). The percentage of males varied by diagnostic group and was 66.4% for schizophrenia, 51.2% for bipolar affective disorder or mania, and 50.2% for other psychoses. Medication use There were 998 persons (88.6% of the total sample) who, in the month prior to interview, had been using prescribed medication for the treatment of their disorder for at least four weeks. The percentage was higher for those with schizophrenia (91.4%) or bipolar affective disorder/mania (90.9%) compared to those with other psychotic disorders (84.0%). The proportion of patients on medication who had been identified through inpatient services, outpatient services and private practices (psychiatric or general medical) was quite similar at 96.2%, 93.2% and 93.1% respectively. However, the figure fell to 77.4% for those who had been in contact with services within three years of the census month but not in the census month-suggesting that the maintenance of medication treatment may drop off some time after contact with mainstream services has ceased. In marginalised settings, the percentage of participants on medication was a low 63.3%. Relatively more people in Queensland and Western Australia were on medication (92.5% and 91.0% respectively) compared with the Australian Capital Territory (86.4%) and Victoria (84.8%). Medication use ranged from 85.7% for those under 25 years of age to 92.5% for those aged 55 and over, with use tending to increase in older age groups. Similar proportions of males and females were on prescribed medication. Most of the interviewed sample (879 persons, 78.1%) was taking antipsychotic medication of some kind. Some 54.3% of the total sample was using typical antipsychotic medication with 39.6% using the oral form and 24.8% using the depot form. A number were using both forms in the one-month period prior to interview. The percentage using any atypical antipsychotic medication was lower (29.7%), with 8.3% using the atypical drug, clozapine. One quarter of the sample (25.4%) had been taking an antidepressant. The percentage using a mood stabiliser was a little lower at 22.7%, while 10.4% were using a benzodiazepine. See Tables Medication use varied greatly by diagnosis. Persons with schizophrenia were much more likely to be using a typical antipsychotic compound (61.4%) compared to those with bipolar affective disorder/mania (49.6%) or those with another form of psychotic illness (45.4%). They were also more likely to be using atypical antipsychotic medication (34.9% compared with 17.4% and The use of psychopharmacological and other treatments by persons with psychosis 7

15 25.7%, respectively). Lower use of atypical antipsychotics among non-schizophrenia samples is not surprising in view of pharmaceutical regulatory guidelines restricting their use to schizophrenia 10,25 ; that their use should approach one-in-five for bipolar/mania and one-in-four for other psychotic disorders indicates that these regulations do not reflect clinical practice and the perceived effectiveness of these treatments outside of schizophrenia. The percentage of patients with schizophrenia using an antidepressant was low (16.4%). By comparison, over a quarter of those with bipolar affective disorder/mania (27.3%) and over onethird of those with another psychotic illness (37.9%) were using antidepressants. The differences were even more marked in the use of mood stabilisers, with 10.6% of those with schizophrenia using this class of medication, compared with 65.3% of those with bipolar affective disorder/ mania and 27.7% of those with another form of psychotic illness. The percentage using a benzodiazepine ranged from 7.4% for those with bipolar affective disorder/mania to 11.0% for those with schizophrenia. See Table 2.2 and Figure 2.3. Figure 2.3 Class of medication currently used by diagnosis 80 Percentage using Any typical antipsychotic Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine schizophrenia bipolar, mania other DIAGNOSIS There was also variation in the class of medication used according to the source from which a participant had been recruited. Those recruited from private psychiatric and general practices were most likely to be using a typical agent (60.7%) with only 21.4% using atypical antipsychotic medication. More than half those identified in outpatient services (56.5%) were using typical antipsychotics and one-third (32.2%) were using atypical antipsychotics. Of those identified through inpatient services, 51.9% were using typical antipsychotics and 45.0% were using atypical antipsychotics. By comparison, only 43.3% of those identified through marginal settings were using typical antipsychotics and only 8.3% were using atypical antipsychotics. It would appear that not only are a large minority of those in marginal settings not receiving medication but, of those who are, very few are likely to be receiving the newer atypical antipsychotic agents. See Table 2.3 and Figure The use of psychopharmacological and other treatments by persons with psychosis

16 Figure 2.4 Class of medication currently used by recruitment source 80 Percentage using in-patient outpatient private practice marginal not in contact Any typical antipsychotic Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine RECRUITMENT SOURCE The use of medication in the treatment of psychotic disorders was not uniform by State. Use of typical antipsychotics ranged from 50.0% in the Australian Capital Territory to 55.2% in Victoria while the use of atypical antipsychotics ranged from 24.7% in Victoria to 38.4% in Queensland. Queensland had the lowest percentages using antidepressants (20.5%) and mood stabilisers (19.9%). Antidepressant use was highest in the Australian Capital Territory (31.0%) and mood stabiliser use was highest in Western Australia (28.5%). The use of benzodiazepines ranged from 8.7% in the Australian Capital Territory to 12.5% in Victoria. See Table 2.4 and Figure 2.5. Figure 2.5 Class of medication currently used by State 80 Percentage using ACT QLD VIC WA Any typical antipsychotic Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine STATE The use of typical antipsychotics rose in older age groups, from 42.9% of those aged under 25 to 61.9% of those aged 55 and over. Conversely, the use of atypical antipsychotics fell in the older age groups, from 45.2% of those aged under 25 to 20.9% of those aged 55 and over. The pattern for clozapine was similar, though the percentage using this medication was much lower overall. The percentage using antidepressants, mood stabilisers and benzodiazepines generally rose with age. See Table 2.5 and Figure 2.6. The use of psychopharmacological and other treatments by persons with psychosis 9

17 Figure 2.6 Class of medication currently used by age group Percentage using under and over AGE GROUP Any typical antipsychotic Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine The use of antipsychotic medication did not differ greatly between males and females, both for typical and atypical agents, although the percentages for males using depot medication and clozapine were somewhat higher. The percentages of females using antidepressants and mood stabilisers, however, were markedly higher than the corresponding percentages for males. See Table 2.6 and Figure 2.7. Figure 2.7 Class of medication currently used by sex 80 Percentage using Any typical antipsychotic Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine 0 male SEX female Comparison with other Australian data The usage figures reported in this bulletin were collected as part of the survey of Low Prevalence (Psychotic) Disorders, mainly between September 1997 and January It is expected that since then the percentage of those with psychotic illness using atypical antipsychotics has increased. Keks et al. 10 found, in a community mental health service sample based on prescriptions written in May 1998, that 53 per cent of scripts for antipsychotic medication were for atypical medication. A year later, in April 1999, Callaly and Trauer examined antipsychotic use in another community mental health service setting and found that 67 per cent of those using antipsychotic agents were taking atypical medication. 25 By comparison, in the present study, 38.9% of the outpatient sample who were on antipsychotic medication were using atypical agents, although this figure increased to 52.2% for those identified at inpatient settings. Some of the differences in usage between the Low Prevalence (Psychotic) Disorders sample and the other two samples may be attributed to a smaller percentage of cases diagnosed with schizophrenia in the current study (59.6% in the present study who were taking any atypical medication had a diagnosis of schizophrenia compared with 68.1% in the Callaly and Trauer sample and 72% in the sample collected by Keks et al.). At the same time, a trend towards increased use of atypical medications over time is clearly indicated in these comparisons. 10 The use of psychopharmacological and other treatments by persons with psychosis

18 Table 2.2 Class of medication* currently used by diagnosis Schizophrenia Bipolar, mania Other Total % Total N Typical antipsychotic (oral) Typical antipsychotic (depot) Any typical antipsychotic Atypical antipsychotic (excl. clozapine) Atypical antipsychotic (clozapine) Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine TOTAL % using any medication TOTAL N using any medication BASE * A number of respondents were using more than one medication either within or across classes of medication. As a result, the sum of the totals is greater than the total number using any medication. Table 2.3 Class of medication* currently used by recruitment source In-patient Outpatient Private practice Marginal Not in contact Total % Total N Typical antipsychotic (oral) Typical antipsychotic (depot) Any typical antipsychotic Atypical antipsychotic (excl. clozapine) Atypical antipsychotic (clozapine) Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine TOTAL % using any medication TOTAL N using any medication BASE * A number of respondents were using more than one medication either within or across classes of medication. As a result, the sum of the totals is greater than the total number using any medication. The use of psychopharmacological and other treatments by persons with psychosis 11

19 Table 2.4 Class of medication* currently used by catchment area ACT QLD VIC WA TOTAL % TOTAL N Typical antipsychotic (oral) Typical antipsychotic (depot) Any typical antipsychotic Atypical antipsychotic (excl. clozapine) Atypical antipsychotic (clozapine) Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine TOTAL % using any medication TOTAL N using any medication BASE * A number of respondents were using more than one medication either within or across classes of medication. As a result, the sum of the totals is greater than the total number using any medication. Table 2.5 Class of medication* currently used by age group Under and over TOTAL % TOTAL N Typical antipsychotic (oral) Typical antipsychotic (depot) Any typical antipsychotic Atypical antipsychotic (excl. clozapine) Atypical antipsychotic (clozapine) Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine TOTAL % using any medication TOTAL N using any medication BASE * A number of respondents were using more than one medication either within or across classes of medication. As a result, the sum of the totals is greater than the total number using any medication. 12 The use of psychopharmacological and other treatments by persons with psychosis

20 Table 2.6 Class of medication* currently used by sex Male Female TOTAL % TOTAL N Typical antipsychotic (oral) Typical antipsychotic (depot) Any typical antipsychotic Atypical antipsychotic (excl. clozapine) Atypical antipsychotic (clozapine) Any atypical antipsychotic Antidepressant Mood stabiliser Benzodiazepine TOTAL % using any medication TOTAL N using any medication BASE * A number of respondents were using more than one medication either within or across classes of medication. As a result, the sum of the totals is greater than the total number using any medication. The use of psychopharmacological and other treatments by persons with psychosis 13

21 14 The use of psychopharmacological and other treatments by persons with psychosis

22 3. Did the medication help? The interviewed sample was asked to identify the medication they were taking and to specify how helpful they found the medication. Of those using any of the listed medications, 44.2% said the medication was helpful and 35.0% said it was very helpful. Only 11.7% reported that the medication was not helpful. The pattern of reporting on the helpfulness of medication was relatively stable across the diagnostic groups. However, there was more variation between samples from different recruitment sources as to the perceived effectiveness of prescribed medication. Overall, persons recruited from private practices were more likely to report that the medication was very helpful (46.7%) compared with 26.6% of the inpatient sample and 23.9% of the marginal sample. The figures for the outpatient sample and the sample currently not in contact with services were similar at 36.7% and 38.5% respectively. The private practice and the out of contact samples were least likely to report that medication was not helpful (3.6% and 7.3% respectively). See Tables Figure 3.1 Helpfulness of medication not helpful helpful very helpful imposs. to assess 100% % 60% % 20% 0% Typical oral Typical depot Atypical (excl. clozapine) Clozapine Mood stabiliser Antidepressant Benzodiazepine In Tables and Figure 3.1, the responses regarding the helpfulness of medication are broken down by class of medication. The main findings for the antipsychotic agents are summarised below. Appendix 1 includes a full list of specific medications, the percentage of the total sample using each one, and the reported effectiveness of the medication. The use of psychopharmacological and other treatments by persons with psychosis 15

23 Depot versus oral typical antipsychotics In general, participants considered typical antipsychotics were more effective if taken orally rather than by injection. Of those using depot medication, 17.0% said it was not helpful, compared with 11.5% of those using the oral form. It was also the case for all three diagnostic groups that the percentage reporting that the depot form was not helpful was markedly larger than the percentage reporting that oral form was not helpful. The pattern was similar in the breakdown by recruitment source for all sources except for those from marginal settings. In contrast to the other samples, the marginal sample was less likely to report that the depot form was not helpful (8.7% compared with 17.0% for the total sample) and more likely to report that oral form was not helpful (22.2% compared with 11.5%). Typical versus atypical antipsychotics Overall, those using an atypical antipsychotic medication were more likely to report that it was very helpful (40.8%) compared with those using a typical antipsychotic (31.7%). When helpful and very helpful responses are combined, the differential reduces somewhat with a figure of 82.2% for atypicals and 78.8% for typicals. The percentages were similar for persons with schizophrenia or in the other psychoses group. However, for persons with bipolar affective disorder/mania, the percentages were lower and typicals were more likely to be considered helpful or very helpful; the respective figures are 72.2% for typical agents and 66.7% for atypical agents. While the use of clozapine was not widespread (94 users in all), only 5.3% of those using clozapine reported that it was not helpful, while 46.8% found it very helpful. Not surprisingly, clozapine was used most commonly by the schizophrenia sample where 51.5% found it very helpful and another 36.4% found it helpful. When the benefits of medication were examined by recruitment source, the private practice sample generally reported equally high levels of benefit (helpful and very helpful responses combined) from the use of both typical and atypical medication. The figures for this subgroup (89.3% for typicals and 89.2% for atypicals) were well above the total sample figures. However, while 38.9% of this group assessed typicals as very helpful, an extraordinarily high 70.3% assessed atypicals as very helpful even though relatively few (21.4%) in the private practice sample were using them. The percentage in the marginal sample using atypical agents was even smaller (8.3%), however all users reported that they were helpful or very helpful. The distribution of responses for the outpatient and the out-of-contact samples was similar to that for the total sample. When inpatients were compared with outpatients, a slightly higher percentage of inpatients recorded not helpful for both typical and atypical agents. They were also less likely to record a very helpful response for either type of agent. This was particularly so for typical agents with 19.9% finding them very helpful compared with 35.5% of outpatients. The figures for the atypical class of antipsychotics were 35.5% (inpatients) and 38.8% (outpatients). 16 The use of psychopharmacological and other treatments by persons with psychosis

24 Table 3.1 Benefit of class of medication if currently using by diagnosis (percentage) Schizophrenia Bipolar, mania Other TOTAL Typical antipsychotic (oral) not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Typical antipsychotic (depot) Any typical antipsychotic not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Atypical antipsychotic (excl. clozapine) not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Atypical antipsychotic (clozapine) not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Any atypical antipsychotic not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Antidepressant not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Mood stabiliser not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Benzodiazepine not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Any listed medication not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using * Some respondents were using more than one medication either within or across classes of medication, and described the benefits of each. The use of psychopharmacological and other treatments by persons with psychosis 17

25 Table 3.2 Benefit of class of medication if currently using by recruitment source (percentage) In-patient Outpatient Private practice Marginal Not in contact TOTAL Typical antipsychotic (oral) not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Typical antipsychotic (depot) not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Any typical antipsychotic not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Atypical antipsychotic (excl. clozapine) not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Atypical antipsychotic (clozapine) not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Any atypical antipsychotic not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Antidepressant not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Mood stabiliser not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Benzodiazepine not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using Any listed medication not helpful helpful very helpful imposs. to assess TOTAL % TOTAL N using * Some respondents were using more than one medication either within or across classes of medication, and described the benefits of each. 18 The use of psychopharmacological and other treatments by persons with psychosis

26 4 Medication side effects Of the 1126 study participants, 88.6% were on medication for their disorder at the time of interview and 74.1% of the total sample were experiencing side effects. The data in Section 6 indicate that polypharmacy was common. However, in the interviewed sample, there were 434 persons (38.5% of the total sample of 1126) who had been using one class of medication only for at least four weeks in the month prior to interview, although some of these may have used more than one medication within that class. Unless otherwise stated, the data in this section are for these 434 individuals using one class of medication only. Study participants were asked to describe whether they had experienced any of 14 specified side effects. In this discussion, side effects have been grouped into six main categories: sedation, extrapyramidal side effects (side effects that resemble the symptoms of Parkinson s disease), akathisia (a persistent restlessness), tardive dyskinesia (a movement disorder resulting from the long-term use of typical antipsychotics), anticholinergic side effects, and other side effects (see Table 4.1). Information on weight gain as a side effect of medication use was not collected, however, appreciable weight gain is associated with the use of both typical and atypical agents. 26 While anticholinergic side effects are distinguished in the data, participants were not asked specifically about their use of anticholinergic drugs. Table 4.1 Specific side effects Sedation Drowsiness or sleepiness during the day Extrapyramidal side effects side effects that resemble the symptoms of Parkinson s disease Muscles feeling stiff or tensed up Hands, arms or legs shaking or trembling Slowing down of movements Unsteadiness when standing or walking Difficulty starting walking Shuffling along Akathisia a persistent restlessness Inability to relax Inability to stand still Feeling of inner restlessness Tardive dyskinesia a movement disorder resulting from the long-term use of typical antipsychotics Unwanted tongue movement Anticholinergic side effects side effects associated with peripheral anticholinergic blockade Dry mouth; mouth more watery than normal Trouble with eyesight Other Difficulty swallowing The use of psychopharmacological and other treatments by persons with psychosis 19