the use of psychopharmacological and other treatments by ... · 2 the use of psychopharmacological...

The use of psychopharmacological and othertreatments by persons with psychosis

Vera MorganDavid Castle

Assen Jablenskyon behalf of the Low Prevalence Disorders Study Group

Low Prevalence Disorder Component of the NationalStudy of Mental Health and Wellbeing

Bulletin 4

October 2002

The use ofpsychopharmacological

and other treatmentsby persons with psychosis

Self-reported data from the NationalStudy of Low Prevalence

(Psychotic) Disorders

Vera MorganSchool of Psychiatry and Clinical Neurosciences,

University of Western Australia

David CastleSchool of Psychiatry and Clinical Neurosciences,


Mental Health Research Institute and University ofMelbourne

Assen JablenskySchool of Psychiatry and Clinical Neurosciences,


on behalf of the Low Prevalence DisordersStudy Group

National Survey of Mental Health and WellbeingBulletin 4

ii The use of psychopharmacological and other treatments by persons with psychosis

© Commonwealth of Australia 2002

ISBN 0 642 50348 6

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no partmay 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 2601.

Publications approval number: 2952

Publications Production Unit (Governance and Business Strategy Branch)Commonwealth Department of Health and AgeingCanberra

Additional copies of the bulletin are available from the Mental Health Branch, CommonwealthDepartment of Health and Ageing, telephone 1800 066 247 or facsimile 1800 634 400.

A copy may also be downloaded from the Mental Health Branch website at:

http://www.mentalhealth.gov.au

Copies of other publications produced under the National Mental Health Strategy are alsoavailable at this site.

The opinions expressed in this report are those of the authors and are not necessarily those of theCommonwealth 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

The use of psychopharmacological and other treatments by persons with psychosis iii

This publication is one of a series of publications produced by the Commonwealth Departmentof Health and Ageing under the National Survey of Mental Health and Wellbeing. Otherpublications include:

Low prevalence component of the survey:

People living with psychotic illness: an Australian study 1997-1998

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 inAustralia (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)

iv The use of psychopharmacological and other treatments by persons with psychosis

Acknowledgement

This bulletin is based on data collected in the framework of the Collaborative Study on Low-prevalence (Psychotic) Disorders, an epidemiological and clinical investigation which is part ofthe National Survey of Mental Health And Wellbeing, Australia 1997-1998. The members of theLow Prevalence (Psychotic) Disorders Study Group are: Professor Assen Jablensky (ProjectDirector and Team Leader, Western Australia); Professor Vaughan Carr (Adviser); Dr DavidCastle (Deputy Team Leader, Western Australia); Dr Mandy Evans (Team Leader, AustralianCapital Territory); Professor Oye Gureje (Deputy Team Leader, Victoria); Dr Carol Harvey(Deputy Team Leader, Victoria); Professor Helen Herrman (Team Leader, Victoria); Mrs AilsaKorten (Statistician); Associate Professor John Mcgrath (Team Leader, Queensland); Ms VeraMorgan (Project Database Manager). Other investigators at the four sites included: ScottHenderson, Stephen Rosenman, Jo Medway (Australian Capital Territory); David Chant, SusetteCardy, Chris Young, Ben Chapple (Queensland); Ian Gordon, Tom Trauer, Helen Evert, TonyPinzone (Victoria); Anna Waterreus (Western Australia). A complete list of the investigators isavailable 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: AnAustralian Study 1997-98. 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. Fulldetails are available on request. The study was funded by the Commonwealth Department ofHealth and Ageing for those components carried out in Brisbane, Melbourne and Perth. Thecomponent carried out in Canberra was funded separately by the Australian Capital TerritoryDepartment of Health and Community Care, and the Psychiatric Epidemiology Research Centre,Australian National University. This report also acknowledges, with thanks, the hundreds ofmental health professionals who assisted in the preparation and conduct of the survey and themany Australians with psychotic disorders who agreed to participate. Without them, this studywould 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 webaddress:

Http://www.health.gov.au/hsdd/mentalhe/resources/reports/plpi_98.htm

The use of psychopharmacological and other treatments by persons with psychosis v

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 10

3. 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

vi The use of psychopharmacological and other treatments by persons with psychosis

Psychosocial treatments 44

Conclusions 44

References 45

Appendix 1. Use and effectiveness of individual psychotropic agents 49

The use of psychopharmacological and other treatments by persons with psychosis 1

1 Introduction

What is a psychotic disorder?Psychotic disorders form a diverse group of illnesses that have their origins in abnormal brainfunction. These disorders include schizophrenia and related disorders, bipolar affective disorder(manic-depressive illness), depression with psychotic features, delusional disorders and othernon-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, hearingvoices) and delusions (incorrect beliefs out of keeping with the shared beliefs and values in theculture). These include the experience of thoughts transferring in or out of one’s mind, forexample, having one’s own thoughts extracted or relayed to others, or having another’sthoughts 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 emotionalresponse); and hypomania (including intense elation, irritability)

• Disorganised thought, speech and non-verbal communication characterised by bizarrebehaviour, inappropriate affect and incoherent speech.

The use of psychotropic medication in the treatmentof psychotic disorders

Background

Treatments for psychotic disorders involve the use of antipsychotic medications and variouspsychosocial interventions. Antipsychotic medications are generally effective in controlling acutesymptoms and can reduce the risk of relapse. Some medications appear to be more effective thanothers with regard to different clusters of symptoms. Regardless of the effectiveness of themedication, the majority of those on antipsychotic medication experience some side effects.

The history of the use of effective psychopharmacological treatments in the management ofpsychotic illness is relatively recent. While phenothiazine derivatives were first synthesised in thenineteenth century – initially for the British dye industry then later in the search for a treatmentfor malaria – it was only in the early 1950s that their effect on reducing positive symptoms inpsychosis was recognised.1 By the late 1950s, the psychopharmacological benefit ofchlorpromazine was established and the development of other drugs of similar effect followedthis first major breakthrough in the treatment of psychotic disorders. Today, these drugs, whichlargely achieve their effect by blocking the dopamine D

2 receptors in the brain2, are variously

known as typical, conventional or first generation antipsychotics.

Within a few years of the introduction of typical antipsychotic medication, it became apparentthat many patients were experiencing serious side effects as a result of their use. While judicioustreatment regimes have been vital in minimising side effects, side effects remain a seriousconcern for users. (A detailed examination of the side effects associated with psychotropicmedications may be found in Section 4.) The next major advance in the development of

2 The use of psychopharmacological and other treatments by persons with psychosis

medications for use in the treatment of psychotic disorders came with the introduction of the so-called atypical drugs (also known as novel, new or second generation drugs). Compared with thetypicals, atypical drugs have fewer extrapyramidal side effects and may be better at reducingnegative symptoms and cognitive deficits in psychotic illness. While there is some debate overthe coverage of the term ‘atypical’3,4, all atypical antipsychotics achieve their effect by selectivelyblocking 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. Atpresent, 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 regardedas an important development in the management of psychotic illness. While both typical andatypical antipsychotics have been effective at reducing the florid (or positive) symptoms ofpsychosis, there has been much interest generated by the potential of atypical antipsychotics toreduce negative symptoms as well as in the reported reduction in extrapyramidal side effects thathas been associated with their use. However, recent comparative trials and systematic reviewsinto the benefits of atypical versus typical medications have been somewhat more equivocal.3 Itwould 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 oftypical agents above what are now the recommended guidelines; where the dosage of typicalagents is within current clinical guidelines, atypical agents do only marginally better with respectto associated side effects.3 In addition, side effects such as weight gain remain to be investigatedmore closely. On balance, there appear to be some additional benefits to the routine use ofatypicals over typicals, but this advantage is not as great as first assumed and needs to beassessed against pragmatic considerations such as cost and availability. Indeed, the 1999 reportof the U.S. Surgeon General into mental health5, while endorsing Recommendation 1 of theSchizophrenia Patient Outcomes Research Team (PORT) project, that ‘Antipsychoticmedications, other than clozapine, should be used as the first-line treatment to reduce psychoticsymptoms for persons experiencing an acute symptom episode of schizophrenia’, did not go sofar as to recommend outright the first-line use of atypicals over typicals, although itacknowledged many of the reported advantages of atypical over typical medications.

The atypical antipsychotic, clozapine, is generally regarded as the medication of choice intreatment-resistant cases.5 However, it is rarely used as a drug of first choice as, in a very smallpercentage of users, it may lead to a potentially fatal complication, agranulocytosis (suppressionof the formation of white blood cells), and therefore necessitates regular monitoring of the bloodcount.2

Several other types of medication may be used in the treatment of persons with psychoticdisorders. Antidepressants are used to treat depression that is a primary feature of the psychosisas well as secondary depression arising in the context of a psychotic illness. Mood stabilisers areused in the treatment of mania. Benzodiazepines are commonly used to treat anxiety andinsomnia as well as the persistent restlessness that may be experienced as a side effect associatedwith 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 theuse of antipsychotic medication.6-8

The judicious use of antidepressants, mood stabilisers and benzodiazepines as adjuncts toantipsychotic drug use is widely endorsed.6,9 However, there are no large-scale studies to providean evidence base for the concomitant use of more than one antipsychotic agent and such use is


considered non-optimal except, perhaps, in treatment-resistant cases.4 Keks et al. reported thatatypicals were used in combination with depot typical medication where non-compliance was anissue or when gradually weaning a person from typical depot to atypical oral forms ofmedication.10 It is likely, therefore, that the simultaneous prescribing of more than oneantipsychotic medication will be reduced somewhat once depot forms of atypical antipsychoticsare introduced onto the market.

Psychosocial interventions and other treatment options

Despite the use of psychopharmacological treatments, many persons with psychoses stillexperience residual symptoms. Furthermore, neither the older typical nor the newer atypicalagents have been shown to have a marked effect on social adjustment or occupationalfunctioning.11 Consequently, a number of adjunctive treatments are available to individuals withpsychotic illness. These treatments specifically address aspects of social and occupationalfunctioning and act synergistically with prescribed medication.

Comprehensive reviews on psychosocial treatments for schizophrenia covering the publishedliterature to 199612, and updated to 200111, have looked at the effectiveness of treatmentsincluding social skills training, family interventions, cognitive behavioural therapy andvocational 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 tomore complex skills such as assertiveness and conversational skills.12

• Family interventions, while usually including some basic educative material about thedisorder, may take one of two approaches: the impact of a pattern of interaction in the familycharacterised by emotional over-involvement coupled with critical remarks (sometimes knownas ‘high expressed emotion’) or the impact on the family of having a family member with asevere mental disorder.12

• Cognitive behavioural therapy generally aims to improve basic information-processing skillsand enhance coping with and/or modifying symptoms such as delusions and hallucinations.12

• Vocational rehabilitation targets an individual’s occupational functioning: competitive, albeitsupported, employment is distinguished from traditional forms of rehabilitation includingprevocational training, transitional and sheltered employment. Results tend to favoursupported employment over traditional forms.11,13

Assessment of these adjunctive treatments is complicated not only by the many forms that theymay 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 ResearchTeam (PORT) project that there is good evidence to justify the inclusion of psychosocialtreatments in the management of psychosis6, particularly if these treatments are long-term.11,12 Itis recommended, however, that these treatments be used in conjunction withpsychopharmacological interventions.5

The management of first incidence cases

The management of patients having their first episode of a psychotic illness is an importantconsideration. It has been argued that active psychosis is ‘biologically toxic’ and that earlyintervention may decrease the morbidity associated with psychotic illness.14,15 There is someevidence of the potential for early intervention to alter the course of the illness by reducing theseverity of the illness16,17 and possibly diminishing the likelihood of treatment resistance.17,18 Firstepisode patients are reportedly more responsive to any antipsychotic treatment regardless of thetype of medication used, but are also more susceptible to side effects.19,20 Consequently, current


guidelines advocate the early treatment of these patients with low doses of typical or atypicalantipsychotics to minimise side effects associated with the use of antipsychotic drugs, as well asadjunctive psychosocial treatments to help them reintegrate into the community as easily and asquickly as possible.20,21


2 Overview of data from the NationalStudy of Low Prevalence(Psychotic) Disorders

Source of dataThe 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 1998. The methodology of thestudy and its findings have been published elsewhere.22-24

Unless otherwise indicated, tables using these data are based on the responses of 1126individuals randomly selected and interviewed as part of the National Study. The majority ofthese (980 individuals) were screened as having a psychotic disorder in the census month: 262were identified in inpatient services, 425 in outpatient services, 173 in private general medical orpsychiatric practices, and 120 (who had not been identified through any of the treatmentservices) were identified through points of contact for persons living in marginalised settings –for example, hostels, shelters, refuges, charity services or other marginal accommodation. Afurther 146 individuals were identified through administrative records as having a psychoticdisorder and in contact with mainstream (inpatient or outpatient) treatment services within threeyears of the census month but not during the census month: they were subsequently contactedand interviewed. The figures in this bulletin will differ from those in other reports and papers thathave focused primarily on the census month sample.22-24

Most of the interviews were conducted between September 1997 and January 1998. Part of theinterview asked participants about their current use (within one month of being interviewed) ofmedication for mental health related problems. A list containing both the generic and tradenames of such medications was used to help participants identify the medication correctly. Onlymedications that had been used for at least one month were included. In addition, the study askedabout the perceived effectiveness of medication, that is, how helpful participants found themedication 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 inTable 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 ofnortriptyline and buspirone has been limited, with no one in the surveyed sample reporting use ofeither of these medications.


Typical antipsychotics Atypical antipsychotics Antidepressants Mood stabilisers - oral other than clozapine other than SSRI, RIMA Carbamazepine

Chlorpromazine Olanzapine Amitryptiline Lithium CarbonateFlupenthixol Risperidone Clomipramine Valproate

Fluphenazine Hydrochloride DesipramineHaloperidol Atypical antipsychotics Dothiepin Benzodiazapines

Perphenazine - clozapine only Doxepin AlprazolamPericyazine Clozapine Imipramine ClorazepatePimozide Mianserin Diazepam

Thioridazine Tranylcypromine LorazepamThiothixene Trimipramine Oxazepam

TrifluoperazineAntidepressants

Typical antipsychotics - SSRI, RIMA only- depot Fluoxetine

Flupenthixol Decanoate MoclobemideFluphenazine Decanoate Nefazodone

Haloperidol Decanoate ParoxetineZuclopenthixol Decanoate Sertraline

Venlafaxine

Table 2.1 Medications covered in survey

Inpatient

N=262

Outpatient

N=425

Private psychiatric practice

N=87

General practice

N=86

Marginal, not using mainstream

treatment services

N=120

Out of contact

N=146

Selected from persons

identified on in-/

outpatient records as

using services within 3

years of census

but not in census

month

Selected from

persons screened

positive for

psychosis

at one of five

recruitment sources

in census month

These data collected on medication use, effectiveness, side effects and related areas consist ofself-reports that are not substantiated by other sources. Nor was it possible to determine from thesurvey data the actual dosages received. Furthermore, the level of compliance with (adhering to apsychopharmacological treatment program) and tolerance of (putting up with the side effectsassociated with medication use) treatment regimes were issues outside of the scope of theNational Survey. Notwithstanding this caveat, the collation and analysis of these data provides aunique opportunity to examine the pharmacological treatment of psychotic disorders from theperspective of the consumers.

Profile of sampleThe majority of the sample was identified in mainstream inpatient or outpatient services in thecensus month (23.3% and 37.7% respectively). A further 15.4% were identified through privatepsychiatric and general medical practices, and 10.7% were identified as both marginalised andnot in contact with services in the census month. Another 13.0% had been in contact withmainstream 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


schizophrenia52%

bipolar affective,mania11%

otherpsychoticillness37%

female41%

male59% VIC

33%

QLD27%

ACT16%

WA24%

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% fromQueensland, 32.7% from Victoria and 23.7% from Western Australia.

Figure 2.2 Sample profile: diagnosis (ICD-10), sex, catchment area

Over half the study participants (52.7%) had a diagnosis of schizophrenia, another 10.7% had adiagnosis of bipolar affective disorder or mania, and 36.6% had some other psychotic illnessincluding schizoaffective disorder and depressive psychosis, as classified by the InternationalClassification of Diseases, 10th revision (ICD-10).

The majority were male (58.9%). The percentage of males varied by diagnostic group and was66.4% for schizophrenia, 51.2% for bipolar affective disorder or mania, and 50.2% for otherpsychoses.

Medication useThere were 998 persons (88.6% of the total sample) who, in the month prior to interview, hadbeen using prescribed medication for the treatment of their disorder for at least four weeks. Thepercentage 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 onmedication who had been identified through inpatient services, outpatient services and privatepractices (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 serviceswithin three years of the census month but not in the census month-suggesting that themaintenance of medication treatment may drop off some time after contact with mainstreamservices has ceased. In marginalised settings, the percentage of participants on medication was alow 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%) andVictoria (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 proportionsof males and females were on prescribed medication.

Most of the interviewed sample (879 persons, 78.1%) was taking antipsychotic medication ofsome kind. Some 54.3% of the total sample was using typical antipsychotic medication with39.6% using the oral form and 24.8% using the depot form. A number were using both forms inthe one-month period prior to interview. The percentage using any atypical antipsychoticmedication was lower (29.7%), with 8.3% using the atypical drug, clozapine. One quarter of thesample (25.4%) had been taking an antidepressant. The percentage using a mood stabiliser was alittle lower at 22.7%, while 10.4% were using a benzodiazepine. See Tables 2.3-2.7.

Medication use varied greatly by diagnosis. Persons with schizophrenia were much more likelyto be using a typical antipsychotic compound (61.4%) compared to those with bipolar affectivedisorder/mania (49.6%) or those with another form of psychotic illness (45.4%). They were alsomore likely to be using atypical antipsychotic medication (34.9% compared with 17.4% and


61

5045

35

17

26

16

27

38

11

65

28

11 710

0

20

40

60

80

schizophrenia bipolar, mania other

DIAGNOSIS

Perc

enta

ge u

sin

g

Any typical antipsychotic

Any atypical antipsychotic

Antidepressant

Mood stabiliser

Benzodiazepine

25.7%, respectively). Lower use of atypical antipsychotics among non-schizophrenia samples isnot surprising in view of pharmaceutical regulatory guidelines restricting their use toschizophrenia10,25; that their use should approach one-in-five for bipolar/mania and one-in-fourfor other psychotic disorders indicates that these regulations do not reflect clinical practice andthe perceived effectiveness of these treatments outside of schizophrenia.

The percentage of patients with schizophrenia using an antidepressant was low (16.4%). Bycomparison, over a quarter of those with bipolar affective disorder/mania (27.3%) and over one-third of those with another psychotic illness (37.9%) were using antidepressants. The differenceswere even more marked in the use of mood stabilisers, with 10.6% of those with schizophreniausing 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 abenzodiazepine ranged from 7.4% for those with bipolar affective disorder/mania to 11.0% forthose with schizophrenia. See Table 2.2 and Figure 2.3.

Figure 2.3 Class of medication currently used by diagnosis

There was also variation in the class of medication used according to the source from which aparticipant had been recruited. Those recruited from private psychiatric and general practiceswere most likely to be using a typical agent (60.7%) with only 21.4% using atypicalantipsychotic medication. More than half those identified in outpatient services (56.5%) wereusing typical antipsychotics and one-third (32.2%) were using atypical antipsychotics. Of thoseidentified through inpatient services, 51.9% were using typical antipsychotics and 45.0% wereusing atypical antipsychotics. By comparison, only 43.3% of those identified through marginalsettings were using typical antipsychotics and only 8.3% were using atypical antipsychotics. Itwould appear that not only are a large minority of those in marginal settings not receivingmedication but, of those who are, very few are likely to be receiving the newer atypicalantipsychotic agents. See Table 2.3 and Figure 2.4.


52 5761

43

53

45

32

21

8

2223 26

41

16 19

29 27

22

9 1210 913

17

8

0

20

40

60

80

in-patient outpatient private

practice

marginal not in

contact

RECRUITMENT SOURCE

Perc

enta

ge u

sin

g



Antidepressant

Mood stabiliser

Benzodiazepine

50

55 55 55

29

38

25 2731

2126 26

22 20 21

29

9 9 13 10

0

20

40

60

80

ACT QLD VIC WA

STATE

Pe

rce

nta

ge

usin

g



Antidepressant

Mood stabiliser

Benzodiazepine

Figure 2.4 Class of medication currently used by recruitment source

The use of medication in the treatment of psychotic disorders was not uniform by State. Use oftypical antipsychotics ranged from 50.0% in the Australian Capital Territory to 55.2% in Victoriawhile 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 moodstabiliser use was highest in Western Australia (28.5%). The use of benzodiazepines ranged from8.7% 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

The use of typical antipsychotics rose in older age groups, from 42.9% of those aged under 25 to61.9% of those aged 55 and over. Conversely, the use of atypical antipsychotics fell in the olderage groups, from 45.2% of those aged under 25 to 20.9% of those aged 55 and over. The patternfor clozapine was similar, though the percentage using this medication was much lower overall.The percentage using antidepressants, mood stabilisers and benzodiazepines generally rose withage. See Table 2.5 and Figure 2.6.


43

50

57 5862

45

33

30

23 2118

26 25 27 282521

31

8 10 12 10 12

1920

0

20

40

60

80

under 25 25-34 35-44 45-54 55 and over

AGE GROUP

Pe

rce

nta

ge

usi

ng



Antidepressant

Mood stabiliser

Benzodiazepine

54 55

31 28

22

31

18

30

11 9

0

20

40

60

80

male female

SEX

Pe

rce

nta

ge

usin

g



Antidepressant

Mood stabiliser

Benzodiazepine

Figure 2.6 Class of medication currently used by age group

The use of antipsychotic medication did not differ greatly between males and females, both fortypical and atypical agents, although the percentages for males using depot medication andclozapine were somewhat higher. The percentages of females using antidepressants and moodstabilisers, however, were markedly higher than the corresponding percentages for males. SeeTable 2.6 and Figure 2.7.

Figure 2.7 Class of medication currently used by sex

Comparison with other Australian dataThe usage figures reported in this bulletin were collected as part of the survey of Low Prevalence(Psychotic) Disorders, mainly between September 1997 and January 1998. It is expected thatsince then the percentage of those with psychotic illness using atypical antipsychotics hasincreased. Keks et al.10 found, in a community mental health service sample based onprescriptions written in May 1998, that 53 per cent of scripts for antipsychotic medication werefor atypical medication. A year later, in April 1999, Callaly and Trauer examined antipsychoticuse in another community mental health service setting and found that 67 per cent of those usingantipsychotic 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 atypicalagents, although this figure increased to 52.2% for those identified at inpatient settings. Some ofthe differences in usage between the Low Prevalence (Psychotic) Disorders sample and the othertwo samples may be attributed to a smaller percentage of cases diagnosed with schizophrenia inthe current study (59.6% in the present study who were taking any atypical medication had adiagnosis of schizophrenia compared with 68.1% in the Callaly and Trauer sample and 72% inthe sample collected by Keks et al.). At the same time, a trend towards increased use of atypicalmedications over time is clearly indicated in these comparisons.


In-patient Outpatient Privatepractice

Marginal Not incontact

Total %

Typical antipsychotic (oral) 40.5 37.6 46.8 32.5 41.1 39.6 446

Typical antipsychotic (depot) 24.8 29.2 22.5 19.2 19.2 24.8 279

Any typical antipsychotic 51.9 56.5 60.7 43.3 53.4 54.3 611

Atypical antipsychotic (excl. clozapine) 26.7 25.4 17.9 5.8 19.2 21.7 244

Atypical antipsychotic (clozapine) 19.1 7.3 3.5 2.5 2.7 8.3 94

Any atypical antipsychotic 45.0 32.2 21.4 8.3 21.9 29.7 334

Antidepressant 22.5 25.9 41.0 15.8 18.5 25.4 286

Mood stabiliser 28.6 26.8 22.0 9.2 12.3 22.7 256

Benzodiazepine 10.3 8.7 12.7 16.7 7.5 10.4 117

TOTAL % using any medication 96.2 93.2 93.1 63.3 77.4 88.6

TOTAL N using any medication 252 396 161 76 113 998

BASE 262 425 173 120 146 100.0 1126

Total N

Table 2.2 Class of medication* currently used by diagnosis

Schizophrenia Bipolar, mania Other Total % Total N

Typical antipsychotic (oral) 42.0 41.3 35.7 39.6 446

Typical antipsychotic (depot) 34.7 14.0 13.6 24.8 279

Any typical antipsychotic 61.4 49.6 45.4 54.3 611

Atypical antipsychotic (excl. clozapine) 23.9 14.9 20.4 21.7 244

Atypical antipsychotic (clozapine) 11.1 4.1 5.6 8.3 94

Any atypical antipsychotic 34.9 17.4 25.7 29.7 334

Antidepressant 16.4 27.3 37.9 25.4 286

Mood stabiliser 10.6 65.3 27.7 22.7 256

Benzodiazepine 11.0 7.4 10.4 10.4 117

TOTAL % using any medication 91.4 90.9 84.0 88.6

TOTAL N using any medication 542 110 346 998

BASE 593 121 412 100.0 1126

* A number of respondents were using more than one medication either within or across classes of medication. As aresult, 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



ACT QLD VIC WA TOTAL % TOTAL N

Typical antipsychotic (oral) 39.7 40.4 41.6 36.0 39.6 446

Typical antipsychotic (depot) 14.1 26.4 22.8 33.0 24.8 279

Any typical antipsychotic 50.0 55.0 55.2 55.1 54.3 611

Atypical antipsychotic (excl. clozapine) 23.4 24.4 17.9 22.5 21.7 244

Atypical antipsychotic (clozapine) 7.1 14.0 7.1 4.5 8.3 94

Any atypical antipsychotic 28.8 38.4 24.7 27.0 29.7 334

Antidepressant 31.0 20.5 26.1 26.2 25.4 286

Mood stabiliser 22.3 19.9 21.2 28.5 22.7 256

Benzodiazepine 8.7 9.1 12.5 10.1 10.4 117

TOTAL % using any medication 86.4 92.5 84.8 91.0 88.6

TOTAL N using any medication 159 284 312 243 998

BASE 184 307 368 267 100.0 1126

Under 25 25-34 35-44 45-54 55 andover

TOTAL % TOTAL N







Antidepressant 18.3 26.2 25.0 26.9 28.4 25.4 286

Mood stabiliser 19.8 19.3 24.7 21.2 31.3 22.7 256

Benzodiazepine 7.9 9.7 11.5 10.2 11.9 10.4 117



BASE 126 290 312 264 134 100.0 1126

Table 2.4 Class of medication* currently used by catchment area


Table 2.5 Class of medication* currently used by age group



Male Female TOTAL % TOTAL N

Typical antipsychotic (oral) 37.6 42.5 39.6 446

Typical antipsychotic (depot) 27.6 20.5 24.8 279

Any typical antipsychotic 53.5 55.3 54.3 611

Atypical antipsychotic (excl. clozapine) 21.1 22.5 21.7 244

Atypical antipsychotic (clozapine) 9.8 6.3 8.3 94

Any atypical antipsychotic 30.8 28.1 29.7 334

Antidepressant 21.7 30.7 25.4 286

Mood stabiliser 17.9 29.6 22.7 256

Benzodiazepine 11.2 9.3 10.4 117

TOTAL % using any medication 88.1 89.4 88.6

TOTAL N using any medication 584 414 998

BASE 663 463 100.0 1126

Table 2.6 Class of medication* currently used by sex



In Tables 3.1-3.2 and Figure 3.1, the responses regarding the helpfulness of medication arebroken down by class of medication. The main findings for the antipsychotic agents aresummarised below. Appendix 1 includes a full list of specific medications, the percentage of thetotal sample using each one, and the reported effectiveness of the medication.

12 17 10 13 11 7

49

43

42

40

45 4141

33 30

39

47

31

3744

10 9 712 11

8

5

7

0%

20%

40%

60%

80%

100%

Typical

oral

Typical

depot

Atypical

(excl.

clozapine)

Clozapine Anti-

depressant

Mood

stabiliser

Benzo-

diazepine

not helpful helpful very helpful imposs. to assess

3. Did the medication help?

The interviewed sample was asked to identify the medication they were taking and to specifyhow helpful they found the medication. Of those using any of the listed medications, 44.2% saidthe medication was helpful and 35.0% said it was very helpful. Only 11.7% reported that themedication was not helpful. The pattern of reporting on the helpfulness of medication wasrelatively stable across the diagnostic groups. However, there was more variation betweensamples from different recruitment sources as to the perceived effectiveness of prescribedmedication. Overall, persons recruited from private practices were more likely to report that themedication was very helpful (46.7%) compared with 26.6% of the inpatient sample and 23.9% ofthe marginal sample. The figures for the outpatient sample and the sample currently not incontact with services were similar at 36.7% and 38.5% respectively. The private practice and theout of contact samples were least likely to report that medication was not helpful (3.6% and 7.3%respectively). See Tables 3.1-3.2

Figure 3.1 Helpfulness of medication


Depot versus oral typical antipsychoticsIn general, participants considered typical antipsychotics were more effective if taken orallyrather 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 depotform was not helpful was markedly larger than the percentage reporting that oral form was nothelpful. The pattern was similar in the breakdown by recruitment source for all sources exceptfor those from marginal settings. In contrast to the other samples, the marginal sample was lesslikely to report that the depot form was not helpful (8.7% compared with 17.0% for the totalsample) and more likely to report that oral form was not helpful (22.2% compared with 11.5%).

Typical versus atypical antipsychoticsOverall, those using an atypical antipsychotic medication were more likely to report that it wasvery 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 of82.2% 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 andtypicals were more likely to be considered helpful or very helpful; the respective figures are72.2% 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 usingclozapine 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 veryhelpful and another 36.4% found it helpful.

When the benefits of medication were examined by recruitment source, the private practicesample generally reported equally high levels of benefit (helpful and very helpful responsescombined) 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 practicesample were using them. The percentage in the marginal sample using atypical agents was evensmaller (8.3%), however all users reported that they were helpful or very helpful. Thedistribution of responses for the outpatient and the out-of-contact samples was similar to that forthe total sample. When inpatients were compared with outpatients, a slightly higher percentageof inpatients recorded ‘not helpful’ for both typical and atypical agents. They were also lesslikely to record a ‘very helpful’ response for either type of agent. This was particularly so fortypical agents with 19.9% finding them very helpful compared with 35.5% of outpatients. Thefigures for the atypical class of antipsychotics were 35.5% (inpatients) and 38.8% (outpatients).


Schizophrenia Bipolar, mania Other TOTAL

Typical antipsychotic (oral) not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

52.029.57.3100.0249

16.742.633.37.4100.050

Typical antipsychotic (depot) not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

15.444.730.39.6100.0206

27.822.238.911.1100.017

19.644.626.88.9100.056

17.043.330.19.6100.0279

Any typical antipsychotic not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

13.048.929.88.3100.0364

19.437.534.78.3100.060

12.646.335.06.1100.0187

13.547.131.77.7100.0611

Atypical antipsychotic(excl. clozapine)

not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

9.741.440.09.0100.0142

21.142.131.65.3100.018

9.442.437.610.6100.084

10.441.838.69.2100.0244

Atypical antipsychotic(clozapine)


6.136.451.56.1100.066

20.020.020.040.0100.05

0.056.539.14.3100.023

5.340.446.87.4100.094

Any atypical antipsychotic not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

8.539.843.68.1100.0207

20.837.529.212.5100.021

7.445.438.09.3100.0106

9.041.440.88.7100.0334

Antidepressant not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

9.954.524.810.9100.097

12.136.433.318.2100.033

14.240.134.611.1100.0156

12.544.631.111.8100.0286

Mood stabiliser not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

9.439.135.915.6100.063

12.050.032.65.4100.079

11.834.640.213.4100.0114

11.340.636.711.3100.0256

Benzodiazepine not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

7.842.239.110.9100.065

0.044.455.60.0100.09

6.838.650.04.5100.043

6.841.044.47.7100.0117

Any listed medication not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

11.146.333.59.2100.0542

14.842.633.98.7100.0110

11.641.837.49.2100.0346

11.744.235.09.1100.0998

11.3 10.146.838.05.1100.0147

11.549.332.66.6100.0446

Table 3.1 Benefit of class of medication if currently using by diagnosis (percentage)

* Some respondents were using more than one medication either within or across classes of medication, anddescribed the benefits of each.


In-patient Outpatient Private practice Marginal Not in contact TOTAL

Typical antipsychotic (oral) not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

16.553.020.99.6100.0106

12.644.336.86.3100.0160

2.252.739.65.5100.081

22.251.122.24.4100.039

4.850.040.34.8100.060

11.549.332.66.6100.0446

Typical antipsychotic (depot) not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

24.242.418.215.2100.065

19.240.033.67.2100.0124

5.045.037.512.5100.039

8.760.917.413.0100.023

14.342.942.90.0100.028

17.043.330.19.6100.0279

Any typical antipsychotic not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

19.349.219.911.6100.0136

15.442.535.56.7100.0240

3.150.438.97.6100.0105

17.654.420.67.4100.052

7.847.841.13.3100.078

13.547.131.77.7100.0611

Atypical antipsychotic(excl. clozapine)


17.641.929.710.8100.070

10.244.436.19.3100.0108

0.022.671.06.5100.031

0.062.537.50.0100.07

7.146.435.710.7100.028

10.441.838.69.2100.0244

Atypical antipsychotic(clozapine)


6.042.044.08.0100.050

3.245.248.43.2100.031

16.70.066.716.7100.06

0.066.70.033.3100.03

0.025.075.00.0100.04

5.340.446.87.4100.094

Any atypical antipsychotic not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

12.941.935.59.7100.0118

8.644.638.87.9100.0137

2.718.970.38.1100.037

0.063.627.39.1100.010

6.343.840.69.4100.032

9.041.440.88.7100.0334

Antidepressant not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

15.045.028.311.7100.059

12.545.532.19.8100.0110

5.441.941.910.8100.071

30.430.413.026.1100.019

11.159.318.511.1100.027

12.544.631.111.8100.0286

Mood stabiliser not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

17.438.424.419.8100.075

10.247.236.26.3100.0114

2.530.055.012.5100.038

18.236.445.50.0100.011

5.331.652.610.5100.018

11.340.636.711.3100.0256

Benzodiazepine not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

7.738.534.619.2100.027

5.440.554.10.0100.037

4.536.454.54.5100.022

14.338.133.314.3100.020

0.063.636.40.0100.011

6.841.044.47.7100.0117

Any listed medication not helpfulhelpfulvery helpfulimposs. to assessTOTAL %TOTAL N using

16.144.226.613.0100.0252

12.244.136.77.0100.0396

3.640.846.78.9100.0161

17.947.023.911.2100.076

7.348.038.56.1100.0113

11.744.235.09.1100.0998

Table 3.2 Benefit of class of medication if currently using by recruitment source(percentage)

* Some respondents were using more than one medication either within or across classes of medication, anddescribed the benefits of each.


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 upHands, arms or legs shaking or tremblingSlowing down of movementsUnsteadiness when standing or walkingDifficulty starting walking

Shuffling along

Akathisia

a persistent restlessness

Inability to relaxInability to stand stillFeeling 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 normalTrouble with eyesight

OtherDifficulty swallowing

4 Medication side effects

Of the 1126 study participants, 88.6% were on medication for their disorder at the time ofinterview and 74.1% of the total sample were experiencing side effects. The data in Section 6indicate that polypharmacy was common. However, in the interviewed sample, there were 434persons (38.5% of the total sample of 1126) who had been using one class of medication only forat least four weeks in the month prior to interview, although some of these may have used morethan one medication within that class. Unless otherwise stated, the data in this section are forthese 434 individuals using one class of medication only.

Study participants were asked to describe whether they had experienced any of 14 specified sideeffects. 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 thelong-term use of typical antipsychotics), anticholinergic side effects, and other side effects (seeTable 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 askedspecifically about their use of anticholinergic drugs.


As the collection of data on dosage was beyond the objectives of the National Study, it is notpossible to report on the impact of dosage on the level of side effects experienced. However, it iswell-established that dosages over recommended thresholds may lead to a greater number of sideeffects or to side effects of increased severity.3

Side effects in subsample using one class ofmedication onlyOnly 40.0% of those using benzodiazepines reported any medication side effects. The percentagewas 72.7% for those using mood stabilisers and 73.5% for those using antidepressants. Thefigure was higher for those on orally administered typical antipsychotics at 78.7%; this was thesame as the figure for those using atypical antipsychotics excluding clozapine (78.6%), but waslower than the percentage for those on typical antipsychotics administered as a depot (83.0%). Ofthose on clozapine, 92.2% reported side effects. However, both the clozapine group and thoseusing other atypicals were less likely than those on typical antipsychotics to report 6-9 and 10-14side effects. Among users of antipsychotic medication, the mean number of side effects reportedwas higher, but not markedly so, for those on typical antipsychotics (with a mean of 3.9 for oralagents and 3.6 for depot agents) and for those on clozapine (with a mean of 3.8) compared withthose using other atypical medications who recorded a mean number of 3.3 side effects. SeeTable 4.2.

Sedation was reported by almost one half of users of each class of medication except for thoseusing mood stabilisers (where the percentage reporting sedation was 36.4%) andbenzodiazepines (30.0%). Three out of five users of both forms of typical agents (oral, depot)and of clozapine reported at least one extrapyramidal side effect; the figure dropped to one in twofor users of other atypical agents, while the percentages for those using antidepressants or moodstabilisers were slightly lower again. Akathisia was reported by 56.0% of those on typical depotmedication compared with 48.4% of those on typical oral medication, 45.2% of those onatypicals other than clozapine and 45.1% of those using clozapine; percentages for those usingantidepressants, mood stabilisers and benzodiazepines were much lower (29.4%, 27.3% and20.0% respectively). Unwanted tongue movement, while not common, was a reported side effectfor 10.0% of those using typical depots and 9.0% of those using typical oral agents; the figure forthose using atypicals other than clozapine was 11.9%, and for clozapine users was 11.8%. Thepercentage reporting anticholinergic side effects was highest for those using clozapine (78.4%)and lowest for those using other atypical agents (45.2%); for those using typical antipsychotics,the percentage was 58.2% for oral agents and 52.0% for depots. The percentage reportingdifficulty swallowing was similar across the different classes of medication except for depotusers: 7.0% of depot users had difficulty swallowing compared with 12.2% of all users. SeeTable 4.3 and Figure 4.1.


49 50 51

47

36

30

60 58

49

59

44 46

20

48

56

45 45

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9 10 12 12

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Clozapine Anti-

depressant

Mood

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diazepine

% e

xp

erie

ncin

g s

ide

eff

ect

SedationExtrapyramidal side effectsAkathisiaTardive dyskinesiaAnticholinergic side effectsOther

48

Figure 4.1 Side effects of medication

These data on the side effects associated with the usage of particular classes of medication needto be interpreted cautiously. While users in the subsample in this analysis had been using the onemedication for at least four weeks, some of the side effects may have been associated with thelong-term use of other medication prior to this period. Furthermore, the low levels of side effectsreported for benzodiazepines also need to be interpreted with care as the number using abenzodiazepine as a sole form of medication was very small.

Side effects and effectivenessThe reported effectiveness of medication was compared with the type of side effects a personwas experiencing. This analysis was conducted for the total study population of 1126. Table 4.4tabulates the reported helpfulness of medication in the presence of specific side effects, namelysedation, extrapyramidal side effects, akathisia, tardive dyskinesia, anticholinergic side effectsand other side effects. The data suggest there is no consistent relationship between presence of aside effect and the perceived benefit of medication. For sedation, anticholinergic and other sideeffects, there was little difference in the helpfulness reported by those who were experiencingside effects and those who were not. A larger percentage of those experiencing extrapyramidalside effects or akathisia reported that the medication was not helpful compared with those notexperiencing these side effects (13.0% versus 9.5% for extrapyramidal side effects and 14.0%versus 9.0% for akathisia); however, the differences were not striking. The data for tardivedyskinesia are somewhat more intriguing. Overall, there was no marked difference in thepercentage reporting that the medication was beneficial, regardless of the presence of tardivedyskinesia. However, when the beneficial responses are disaggregated into helpful and veryhelpful, 44.1% of the group experiencing tardive dyskinesia reported that medication was veryhelpful compared with 33.4% of the group without symptoms of tardive dyskinesia. Oneexplanation may be that persons with a history of tardive dyskinesia have been placed on atypicalmedication that has alleviated the condition and other side effects without eliminating it. This is


0

10

20

30

40

50

60

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Number of side effects

Pe

rce

nta

ge

not helpful helpful very helpful imposs. to assess

Typicalantipsychotic(oral)

Typicalantipsychotic(depot)

Atypicalantipsychotic(exc. clozapine)

Atypicalantipsychotic(clozapine)

Anti-depressant

Moodstabiliser

Benzo-diazepine

AnymedicationN

Anymedication%

None 21.3 17.0 21.4 7.8 26.5 27.3 60.0 89 20.5

Any side effects

one 9.8 15.0 11.9 13.7 23.5 21.2 20.0 61 14.1

two 14.8 14.0 13.1 19.6 5.9 12.1 0.0 59 13.6

three 10.7 16.0 11.9 17.6 8.8 9.1 0.0 54 12.4

4-5 11.5 11.0 22.6 19.6 14.7 15.2 10.0 65 15.0

6-9 22.1 20.0 13.1 17.6 17.6 9.1 10.0 77 17.7

10-14 9.8 7.0 6.0 3.9 2.9 6.1 0.0 29 6.7

any (1-14) 78.7 83.0 78.6 92.2 73.5 72.7 40.0 345 79.5

TOTAL % 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

TOTAL N using 122 100 84 51 34 33 10 434

Side effects(mean, s.d.)

3.9 (3.6) 3.6 (3.3) 3.3 (3.0) 3.8 (2.8) 2.8 (2.9) 2.7 (3.0) 1.5 (2.9) 3.5 (3.2)

supported by data in Table 4.3, which shows that those using atypicals as their sole medicationwere most likely to report symptoms of tardive dyskinesia.

The reported effectiveness of medication was also compared with the recorded number of sideeffects. From Figure 4.2, it is apparent that there is no simple association between the number ofside effects a person was experiencing at the time of interview and any category of reportedhelpfulness of medication other than the category ‘not helpful’. For this category, there was asmall, albeit insignificant, trend towards increased reporting that medication was not helpful asthe number of side effects increased.

Figure 4.2 Number of side effects and reported helpfulness of medication (total sample)

Table 4.2 Number of side effects by class of medication (persons using one class ofmedication only)


Table 4.3 Type of side effects by class of medication (persons using one class ofmedication only)

Typicalanti-psychotic(oral)

Typicalanti-psychotic(depot)

Atypicalanti-psychotic(excl.clozapine)

Atypicalanti-psychotic(clozapine)

Anti-depressant

Moodstabiliser

Benzo-diazepine

AnymedicationN

Anymedication%

Sedation

Drowsiness, sleepiness during the day 48.4 49.0 50.0 51.0 47.1 36.4 30.0 207 47.7

Extrapyramidal side effects

Muscles feeling stiff or tensed up 35.2 25.0 27.4 31.4 20.6 9.1 10.0 118 27.2

Hands/arms/legs shaking or trembling 35.2 36.0 25.0 25.5 17.6 36.4 20.0 133 30.6

Slowing down of movements 27.0 23.0 22.6 21.6 14.7 21.2 10.0 99 22.8

Unsteadiness when standing, walking 17.2 18.0 14.3 23.5 23.5 15.2 20.0 78 18.0

Difficulty starting walking 13.1 6.0 8.3 13.7 5.9 6.1 0.0 40 9.2

Shuffling along 10.7 10.0 9.5 9.8 2.9 6.1 0.0 39 9.0

Any extrapyramidal side effects 59.8 58.0 48.8 58.8 44.1 45.5 20.0 234 53.9

Akathisia

Inability to relax 34.4 33.0 27.4 25.5 23.5 15.2 10.0 125 28.8

Inability to stand still 32.8 35.0 27.4 23.5 8.8 15.2 10.0 119 27.4

Feeling of inner restlessness 30.3 42.0 33.3 27.5 20.6 18.2 10.0 135 31.1

Any akathisia 48.4 56.0 45.2 45.1 29.4 27.3 20.0 197 45.4

Tardive dyskinesia

Unwanted tongue movement 9.0 10.0 11.9 11.8 2.9 3.0 0.0 39 9.0

Anticholinergic side effects

Mouth dry/ more watery than normal 51.6 45.0 34.5 72.5 44.1 45.5 10.0 205 47.2

Trouble with eyesight 28.7 23.0 23.8 21.6 32.4 24.2 20.0 110 25.3

Any anticholinergic side effects 58.2 52.0 45.2 78.4 55.9 45.5 20.0 237 54.6

Other

Difficulty swallowing 12.3 7.0 15.5 15.7 14.7 15.2 0.0 53 12.2

TOTAL % experiencing side effects 78.7 83.0 78.6 92.2 73.5 72.7 40.0 79.5

TOTAL N experiencing side effects 96 83 66 47 25 24 4 345

BASE 122 100 84 51 34 33 10 434

Sedation Extrapyramidalside effects

Akathisia Tardivedyskinesia

Anticholinergicside effects

Other

no yes no yes no yes no yes no yes no yes

Not helpful 11.3 12.1 9.5 13.0 9.0 14.0 11.9 10.7 11.6 11.8 11.7 11.6Helpful 43.3 44.9 42.9 45.0 45.6 43.0 45.3 38.1 42.4 45.3 44.3 43.8Very helpful 34.6 35.3 37.0 33.8 35.4 34.6 33.4 44.1 35.5 34.6 34.8 36.1Imposs. to assess 10.8 7.7 10.7 8.2 10.0 8.4 9.5 7.0 10.5 8.3 9.2 8.4

TOTAL 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Table 4.4 Type of side effects by class of medication (total sample)


Table 5.1 Survey items used to screen for the presence of selected symptom clusters

Hallucinations

any hallucinations

Delusions

any delusions

Depressive symptoms

pervasive depressed mood or loss of the ability to enjoy life

Mania

intense elation or irritability

Negative symptoms

any poverty of speech or restricted/blunted affect

Disorganisation

any bizarre behaviour, inappropriate affect or incoherent speech

5 Medication use and illness profile

Differences in symptom profiles, course and severity of illness, and substance abuse withpsychopathology were reflected, for the most part, in different patterns of medication use. Thesedifferences are recorded in the tables in this section. When interpreting the data in these tables, itis important to note that a person may have been using more than one class of medication in thereference period for medication use.

Symptom profileSymptom clusters used in this analysis include hallucinations, delusions, depressive symptoms,mania, negative symptoms, and disorganisation. Table 5.1 outlines the survey items used toscreen for the presence of these selected symptom clusters. These symptom clusters are notmutually exclusive and a person may experience symptoms from more than one cluster within agiven timeframe.

Table 5.2 examines the class of medication by present state symptom clusters, that is, the type ofsymptoms that a person was experiencing at the time of assessment, or within one month ofinterview. Persons with symptoms of mania and persons experiencing negative symptoms had thehighest rates of use of any medication, at 93.9% and 94.6% respectively; the lowest figure wasfor persons with depressive symptoms (87.9%).

The use of medication varied by the type of symptoms experienced. The percentage takingtypical agents ranged from 53.8% for those with depressive symptoms to 64.0% for those withsymptoms of mania. The figures for persons currently experiencing hallucinations, delusions,negative symptoms and disorganisation were similar (at, or just below, 60%). Just over 30% ofthose with hallucinations, delusions, negative symptoms and disorganisation were using the


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depot form of typical medication; the figure dropped to one in four for persons with mania andone in five for persons with depressive symptoms. The use of any atypical agent was highestamong persons with negative symptoms (40.6%) followed by persons experiencinghallucinations (37.0%), dropping to 34.0% for persons experiencing delusions and 32.3% forthose with symptoms of disorganisation; only one in four of those with depressive symptoms(24.2%) or mania (24.7%) were using atypical antipsychotics. A similar percentage of those withhallucinations (14.4%), negative symptoms (14.0%) and disorganisation (13.9%) were usingclozapine. The use of clozapine dropped to 10.7% for persons with delusions, 4.8% for thosewith depressive symptoms and 5.6% for those with mania. While, overall, one-quarter of thesample was using antidepressants, the highest use was in the group with depressive symptoms(42.5%). Mood stabilisers were used most frequently by the mania group (49.4%); this groupalso had the highest percentage using benzodiazepines – at 20.2%, this figure was twice as highas the figure for the total sample. See also Figure 5.1

Figure 5.1 Current medication use by present state symptom profile

Table 5.3 compares current medication use by persons experiencing hallucinations and delusionsin the present state (that is, in the four week period prior to interview) with current medicationuse by those experiencing hallucinations and delusions at any stage during their lifetime. Whilecurrent use of both typical and atypical antipsychotic medication was lower for those who hadever experienced hallucinations and delusions (lifetime) compared with those currentlyexperiencing hallucinations and delusions (present state), the difference is not as marked asmight be expected from the difference in base numbers. It appears that, while the use ofantipsychotics drops somewhat as positive symptoms recede, antipsychotic medication regimesare retained in a large proportion of cases.


Figure 5.2 Current medication use by present state and lifetime hallucinations, delusions

Table 5.4 examines medication use according to the balance between the psychotic and anyaffective symptoms (depression and/or mania) that a person may be experiencing. During thecourse of interview, clinically trained interviewers assessed whether there was any co-occurrenceof psychotic and affective symptoms and, if there was, whether one or other symptompredominated. The percentage using typical or atypical antipsychotics was highest wherepsychotic symptoms predominated (60.5% and 37.3% respectively) and lowest where affectivesymptoms predominated (43.3% and 23.6%). The use of clozapine was similar for all groupsexcept the group for whom affective symptoms predominated, where it fell from around the 10per cent mark to 4.1%. The use of antidepressants was highest in the groups where affectivesymptoms predominated (38.9%) or there was balanced co-occurrence of both psychotic andaffective symptoms (33.6%). The proportion using mood stabilisers approached one in two forthe group where affective symptoms predominated (45.9%); the next highest percentage of userswas the group with balanced co-occurrence of psychotic and affective symptoms (26.3). Onlyone in ten of the other two groups (no co-occurrence of symptoms, or predominantly psychoticsymptoms) were using mood stabilisers (11.0% and 11.4% respectively).

Course of disorder and severity of illnessTable 5.5 and Figure 5.3 look at medication use in relation to severity of illness as assessed bythe lifetime course of the illness. The percentages using any medication increased with chronicityand severity: two-thirds of the first onset cases were using any medication (64.2%) comparedwith 94.5% of the persons with a chronic, deteriorating illness. The use of typical antipsychoticsranged from 31.1% for single episode cases to 58.8% for those with a chronic deterioratingillness and 62.4% for those with a chronic non-deteriorating course of illness. Furthermore,while only 22.6% of single episode cases and 19.5% of those with multiple episodes but goodrecovery between episodes were using atypical agents, this rose to 40.8% for those with achronic deteriorating course of illness. Likewise, clozapine use increased with the severity ofillness, ranging from 3.8% for single episode cases to 16.4% for those with a chronicdeteriorating illness. By contrast, the use of antidepressants and mood stabilisers was highestamongst those with multiple episodes and at least some recovery between episodes.

0

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Figure 5.3 Current medication use by course of disorder

Comorbid substance abuseLevels of comorbid substance abuse were high in the sampled population: 37.7% of males and17.5% of females recorded a lifetime history of alcohol abuse/dependence, and 32.1% of malesand 13.4% of females recorded a lifetime history of cannabis abuse/dependence. By comparison,the general population figures for an alcohol use disorder (past 12 months) were 9.4% for malesand 3.7% for females, while the figures for illicit drug use disorders (past 12 months) were 3.1%for males and 1.3% for females.23 Although the percentages for comorbid abuse/dependence with

Almost half (47.8%) of the total sample had had at least one inpatient hospitalisation in theprevious year. Table 5.6 calculates the mean and median number of inpatient weeks in the 12months prior to interview, according to the class of medication used. The mean number ofinpatient weeks for those using atypical antipsychotics (10.5 weeks) was double the sampleaverage of 5.9 weeks, with the figure rising to 18.7 weeks for those on clozapine; these datasuggest that atypicals in general, and clozapine in particular, were used for the most refractorycases of psychotic illness. By contrast, the mean number of weeks of hospitalisation for those onno medication was 1.3 weeks. See Figure 5.4.

Figure 5.4 Current medication use by mean number of inpatient weeks in past 12months


psychopathology among the interviewed sample – 29.6% for males and 14.5% for females foralcohol; 27.9% for males and 12.3% for females for cannabis – were lower than lifetime figuresfor abuse/dependence, they remained nevertheless very high.

Table 5.7 compares persons with substance abuse/dependence and psychopathology to thosewithout substance abuse/dependence and psychopathology. In this table, substance abuse/dependence data are reported separately for alcohol and cannabis abuse/dependence. While thereis some evidence in the literature that atypical agents, notably clozapine, have definiteadvantages over typical agents in the treatment of persons with psychosis and comorbidsubstance abuse disorders27, there is no strong confirmation in our data that this is the preferredoption in actual practice. A slightly smaller percentage of alcohol abusers were using atypicalscompared with persons with psychosis who were not alcohol abusers; on the other hand, asomewhat higher percentage of cannabis abusers were using atypical medications compared withnon-abusers. Overall, lower percentages of persons in the abuser groups were using typicalantipsychotics compared with persons who were not abusers, and this difference was verymarked for the alcohol group. Among both alcohol and cannabis abusers, the use of moodstabilisers was lower and the use of benzodiazepines was higher when compared with non-abusers.

Table 5.2 Class of medication by present state symptom profile

Hallucinations Delusions Depressivesymptoms

Mania Negativesymptoms

Disorganisation TOTAL % TOTAL N

Typical antipsychotic (oral) 45.3 42.6 42.5 50.6 40.6 46.2 39.6 446

Typical antipsychotic (depot) 32.4 30.3 19.0 25.8 32.4 30.3 24.8 279

Any typical antipsychotic 59.9 58.9 53.8 64.0 58.4 60.6 54.3 611

Atypical antipsychotic (excl. clozapine) 23.1 23.8 19.4 20.2 26.7 19.1 21.7 244

Atypical antipsychotic (clozapine) 14.4 10.7 4.8 5.6 14.0 13.9 8.3 94

Any atypical antipsychotic 37.0 34.0 24.2 24.7 40.6 32.3 29.7 334

Antidepressant 19.2 21.4 42.5 20.2 24.1 16.7 25.4 286

Mood stabiliser 13.9 19.6 20.9 49.4 14.6 22.7 22.7 256

Benzodiazepine 13.4 13.3 13.6 20.2 11.1 10.0 10.4 117

TOTAL % using any medication 91.5 90.3 87.9 93.9 94.6 92.0 88.6

TOTAL N using any medication 376 558 240 83 298 231 998

BASE 411 618 273 89 315 251 1126

* Respondents may have been experiencing more than one symptom or using more than one class of medication. Asa result, the sum of the totals may be greater then the total number of persons.


Table 5.3 Class of medication by present state, lifetime profiles of hallucinations anddelusions

Hallucinations Delusions TOTAL % TOTAL NPresent state Lifetime Present state Lifetime







Antidepressant 19.2 22.4 21.4 24.6 25.4 286

Mood stabiliser 13.9 18.1 19.6 22.7 22.7 256

Benzodiazepine 13.4 11.6 13.3 10.6 10.4 117



BASE 411 835 618 1043 1126

* Respondents may have been experiencing more than one symptom or using more than one class of medication. Asa result, the sum of the totals may be greater then the total number of persons.

Table 5.4 Class of medication by balance between psychotic and affective symptoms

No co-occurrenceof psychotic,affectivesymptoms

Psychoticsymptomspredominate

Balanced co-occurrence ofpsychotic, affectivesymptoms

Affectivesymptomspredominate

TOTAL % TOTAL N







Antidepressant 15.3 19.3 33.6 38.9 25.4 286

Mood stabiliser 11.0 11.4 26.3 45.9 22.7 256

Benzodiazepine 8.8 12.3 7.3 11.1 10.4 117



BASE 308 367 137 314 1126


Table 5.5 Class of medication by course of disorder

Table 5.6 Mean, median number of inpatient weeks in past 12 months by class ofmedication

Singleepisode

Multipleepisodes,goodrecovery

Multipleepisodes,partialrecovery

Chronic, littledeterioration

Chronic,cleardeterioration

TOTAL % TOTAL N







Antidepressant 21.7 29.2 34.1 20.4 16.4 25.4 286

Mood stabiliser 10.4 29.7 25.3 21.7 18.9 22.7 256

Benzodiazepine 3.8 9.3 12.2 10.2 12.2 10.4 117



BASE 106 236 320 226 238 1126

Mean (standard deviation) Median

Typical antipsychotic (oral) 5.6 (12.3) 0.0

Typical antipsychotic (depot) 6.1 (12.5) 0.0

Any typical antipsychotic 5.4 (11.8) 0.0

Atypical antipsychotic (excl. clozapine) 7.3 (13.5) 1.5

Atypical antipsychotic (clozapine) 18.7 (20.0) 10.5

Any atypical antipsychotic 10.5 (16.4) 2.0

Antidepressant 4.3 (9.4) 0.0

Mood stabiliser 6.2 (11.2) 2.0

Benzodiazepine 4.8 (9.5) 1.0

TOTAL any medication (N=998) 6.5 (13.0) 0.0

TOTAL no medication (N=128) 1.3 (2.8) 0.0

TOTAL sample (N=1126) 5.9 (12.3) 0.0


Table 5.7 Class of medication by comorbid alcohol, cannabis abuse/dependence withpsychopathology

Alcohol abuse/dependencewith psychopathology

Cannabis abuse/dependencewith psychopathology

TOTAL % TOTAL N

Present Not present Present Not present







Antidepressant 27.4 24.8 22.3 26.2 25.4 286

Mood stabiliser 17.1 24.4 18.2 24.0 22.7 256

Benzodiazepine 15.2 8.9 14.9 9.2 10.4 117



BASE 263 863 242 884 1126


ACT QLD VIC WA TOTAL % using Total N using

None 13.6 7.5 15.2 9.0 11.4 128

One 39.7 52.8 41.0 44.9 44.9 506

Two 39.7 30.9 33.2 36.3 34.4 387

Three 6.5 6.8 10.1 9.7 8.5 96

Four 0.5 2.0 0.5 0.0 0.8 9

TOTAL % 100.0 100.0 100.0 100.0 100.0

TOTAL persons 184 307 368 267 1126

6 Polypharmacy

Of those surveyed, 43.7% (or 49.3% of those on medication) had used more than one class ofmedication in the month prior to interview, if classes of medication are broadly defined as typicalantipsychotics, atypical antipsychotics, antidepressants, mood stabilisers, and benzodiazepines.(As some had used several medications within the one class, the proportion using more than onemedication of any kind was 52.0% of the total sample - or 58.6% of those on medication.) One-third of the total (34.3%) had used medication from two classes; almost one in ten (9.3%)reported using medication from more than two. In these self-reported data, it is not possible todetermine conclusively whether the use of these medications was indeed concurrent. However,given the narrow reporting window of one month, and the requirement that the medication hadbeen used for a period of at least four weeks before it was included in the survey, it is likely thatthe proportion of cases in the process of changing medication in this period was small, and thatthe majority were using several classes of medication concurrently.

Polypharmacy varied by State, with 52.8% of those from the Queensland catchment areas usingone class of medication only compared with an overall figure of 44.9% (Table 6.1). Thepercentage from Western Australia using one medication only was the same as the overallpercentage (44.9%); the figures for Victoria and the Australian Capital Territory were lower at41.0% and 39.7% respectively.

Tables 6.2-6.4 indicate that, for the majority of those using more than one class of medication,antidepressants, mood stabilisers and benzodiazepines were being taken as an adjunct to the useof typical or atypical antipsychotic medication. The proportion using adjunct medication wassimilar, regardless of whether a person was on typical or atypical antipsychotic medication. Thepercentage of those using any typical antipsychotics who reported concomitant use ofantidepressants, mood stabilisers and/or benzodiazepines was 41.4% compared with 38.1% forthose using atypical antipsychotics.

Some 66 persons (5.9%) reported using both typical and atypical agents in the reference month(see Tables 6.2-6.4). At the same time, a sizeable minority were using more than one medicationwithin a class of medications: one-quarter (22.3%) of those using typical antipsychotics hadtaken one or more typical antipsychotics in the month prior to interview while 10.5% of those onmood stabilisers were using two different mood stabilisers (see Table 6.5).

Table 6.1 Number of classes of medication* currently used by catchment area

* Classes were typical antipsychotic, atypical antipsychotic, antidepressant, mood stabiliser, benzodiazepine. Thenumber using one class only (506) is higher than the number in tables in Section 4 (434) as Table 6.1 does notseparate oral from depot typical antipsychotics, or clozapine from other atypical antipsychotics.


% of total sample using N

Typical + atypical 3.3 37

Typical + antidepressant 7.1 80

Typical + mood stabiliser 7.5 85

Typical + benzodiazepine 3.1 35

Atypical + antidepressant 4.6 52

Atypical + mood stabiliser 3.9 44

Atypical + benzodiazepine 1.2 14

Antidepressant + mood stabiliser 2.8 32

Antidepressant + benzodiazepine 0.6 7

Mood stabiliser + benzodiazepine 0.1 1

TOTAL using two classes of medication 34.4 387

BASE 1126


Typical + atypical + antidepressant 1.2 13

Typical + atypical + mood stabiliser 0.8 9

Typical + atypical + benzodiazepine 0.2 2

Typical + antidepressant + mood stabiliser 2.0 22

Typical + antidepressant + benzodiazepine 1.7 19

Typical + mood stabiliser + benzodiazepine 0.9 10

Atypical + antidepressant + mood stabiliser 0.7 8

Atypical + antidepressant + benzodiazepine 0.9 10

Atypical + mood stabiliser + benzodiazepine 0.1 1

Antidepressant + mood stabiliser + benzodiazepine 0.2 2

TOTAL using three classes of medication 8.5 96

BASE 1126


Typical + atypical + antidepressant + mood stabiliser 0.3 3

Typical + atypical + mood stabiliser + benzodiazepine 0.2 2

Typical + antidepressant + mood stabiliser + benzodiazepine 0.2 2

Atypical + antidepressant + mood stabiliser + benzodiazepine 0.2 2

TOTAL using four classes of medication 0.8 9

BASE 1126

Table 6.2 Classes of medication if using two classes of medication in month prior tointerview

Table 6.3 Classes of medication if using three classes of medication in month prior tointerview

Table 6.4 Classes of medication if using four classes of medication in month prior tointerview


Table 6.5 Number of separate medications used within a class of medication(percentage)

Typicalantipsychotic

Atypicalantipsychotic


one 75.9 97.6 96.9 89.5 98.3

two 22.3 2.1 2.8 10.5 1.7

three or more 1.8 0.3 0.3 0.0 0.0

TOTAL % 100.0 100.0 100.0 100.0 100.0

TOTAL N 611 334 286 256 117


40 48 36 40 41 48 64 84

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did not use living skills services used living skills services

Social and occupational functioning

N=5 N=25 N=75 N=189 N=198 N=200 N=316 N=92 N=25 N=1

persistent inabilty

to maintain minimal

personal hygiene

superior function

in wide range of

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7 Use of psychosocial treatmentoptions

Living skills servicesStudy participants were asked about their use of seven specific treatment services in the 12months prior to interview. Overall, 93.9% had received at least one of the specified services, withjust over half (55.2%) having received at least one living skills service. Table 7.1 gives both thepercentage that had received each of the named services, and the percentage of those receivingthe service who reported that the service met their needs. The vast majority had had medicationprescribed in the past year and felt the prescription service (as distinct from the medication itself)had met their needs. Far fewer, however, had received therapy or counselling, or had receivedassistance with living skills including work and time management skills, help with housing orfinances, social support, or advice on self or home management. At the same time, for eachcategory of service, three-quarters of those receiving services reported that the service met theirneeds.

Figure 7.1 Use of living skills services by level of disability as measured on the social andoccupational functioning scale

This poor level of access to living skills services is in sharp contrast to the psychosocial profileof the survey sample. While over one in five were managing exceptionally well when assessed ona number of items relating to social and occupational functioning (21.2%), over a quarter(28.7%) were markedly impaired in their ability to care for themselves, and well over one-half(57.6%) were clearly dysfunctional in their ability to socialise, even though 44.8% reported thatthey needed or wanted more friends. Only 30.4% were in current employment (broadly definedto include studies and home duties), while 66.5% were receiving a disability or invalid pension.The percentage living in accommodation such as an institution, hostel, group home, crisis shelter,rooming house, supported housing, hotel or rented room, or who had no fixed address was41.5%. Of those living in a household, 46.8% were assessed as obviously or severely impaired intheir ability to participate in normal household activities. When the use of living skills services


was examined by level of disability as measured on the Social and Occupational FunctioningScale (SOFAS), there was no clear pattern of increased use as the level of disability rose. SeeFigure 7.1.

Rehabilitation programsOf this sample of persons with psychosis, only 17.9% had accessed a formal rehabilitationprogram in the previous 12 months. Use of rehabilitation programs was highest among thoseidentified as using outpatient services at the time of the census (25.2%), and was lowest for theprivate practice (9.2%), marginal (11.7%) and not-in-contact (10.3%) samples. See Table 7.2.

Of those who had used rehabilitation services, only one-third (32.7%) had spent 6 months ormore in a rehabilitation program. While few in the private practice sample had accessedrehabilitation services (9.2%), those who had were most likely to continue in a rehabilitationprogram for 6 months or more (43.8%), closely followed by the outpatient sample (41.1%). It isof some interest that over one-in-four (26.7%) of the not-in-contact sample who had accessedthese services had used them for 6 months or more. See Table 7.3.

Of even greater concern is the very small percentage (2.0%) who had been in contact with adrug/alcohol clinic or who had seen a mental health professional specialising in drug/alcoholrehabilitation over the past year, especially in view of very high rates of substance abuse (seeSection 5). While well-managed, comprehensive, integrated mental health and substance abusetreatment programs are, on the balance, more effective than separate parallel or sequentialprograms28, there is no indication that the survey population was accessing such programs,although a number of individuals may have received support from individual case managers andother mental health professionals with respect to substance abuse disorders. Anecdotal evidencefrom mental health professionals suggests that persons with comorbid diagnoses were falling in agap between drug and alcohol services that did not have the expertise to treat severe mentaldisorders and mental health services that did not have the resources to deal with comorbidsubstance abuse. Whatever the reason, this poor level of response from a potential clientpopulation to services targeting substance abuse requires careful investigation.

Psychosocial programs, medication tolerance andtreatment complianceLow levels of participation in psychosocial programs augur poorly for persons with psychosis.These interventions, in conjunction with good psychopharmacological management, are widelyendorsed as a means of reducing relapse rates, improving social and occupational functioningand generally leading to a better quality of life.13 However, there is some evidence that neithercompliance with treatment regimes nor participation in psychosocial treatment programs will behigh while persons with psychotic illness lack a meaningful social role to underpin their dailyactivities.13,29 Thus, when the study findings were presented back to a group of men withpsychosis living at an inner city hostel within the study’s catchment area, their response to thepoor use of rehabilitation services, particularly drug/alcohol services, was: ‘What is there to stopfor? When you wake up in the morning, what else is there?’ and ‘We smoke marijuana becausethere is nothing else to do’. 30

Similarly, medication side effects may be better tolerated by those who have valued roles tomotivate them. There is some support for this in the survey data. For survey participants,satisfaction with life was elevated in persons who were employed full-time or part-time at thetime of the survey compared with those not employed at that time, even when matched on the


0

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number of side effects they were experiencing. Although Figure 7.2 shows a trend forsatisfaction to decrease as the number of side effects increased for both groups, those who wereemployed expressed higher levels of satisfaction at each category of number of side effects thanthose who were unemployed.

Figure 7.2 Relationship between number of side effects and satisfaction with life in thepast year by employment status.

Medication prescription 89.3 88.4

Provision of mental health information 44.8 77.0

Therapy, counselling 38.1 77.9

Help improving work skills, time management skills 32.6 76.6

Guidance in management of housing, financial matters 31.5 76.9

Social support 28.6 77.0

Advice on managing self and taking care of home 23.1 74.6

% received service % with needs metif service received



TOTAL % TOTAL N

TOTAL % using any rehab. service 19.1 25.2 9.2 11.7 10.3 17.9

TOTAL N using any rehab. service 50 107 16 14 15 202

BASE 262 425 173 120 146 100.0 1126

Table 7.2 Use of rehabilitation services by recruitment source

Table 7.1 Specific treatment and living skills services received and adequacy of serviceprovided


Table 7.3 Months in rehabilitation by recruitment source



TOTAL % TOTAL N

2 months or less 56.0 33.6 37.5 50.0 46.7 41.6 84

Between 2 - 6 months 26.0 25.2 18.8 35.7 26.7 25.7 52

6 months or more 18.0 41.1 43.8 14.3 26.7 32.7 66

TOTAL % 100.0 100.0 100.0 100.0 100.0 100.0

BASE (N using any rehab. service) 50 107 16 14 15 202


8 Discussion

IntroductionInevitably, self report of medication use might be inaccurate in some cases, but there is no reasonto suspect systematic bias in this regard. We were also unable to ascertain doses of drugs used,nor duration of treatment, though respondents were asked to record only those medications theyhad been receiving for at least the prior four weeks. In those patients on more than one agent,some confusion was bound to occur in determining which particular agent was responsible forwhich side effects.

Despite these caveats, we believe that the data give a good insight into clinical correlates,reported side effects and perceived benefits of antipsychotic agents, as experienced by thepatients themselves. The sampling frame was epidemiologically sound, and allowed acomparison of rates of use of various agents across treatment settings.

Rates of medication prescribingThe current study was conducted in 1997 and the data are already dated in terms of theproportion of patients on atypical antipsychotics. In another Australian study, conducted in May1998, Keks and colleagues (1999) described prescribing patterns for antipsychotic agents in aninner-city Melbourne catchment.10 Of 859 patients, 77% received antipsychotic medication, 53%of these being atypical agents (42% risperidone, 37% olanzapine, and 21% clozapine). The latestpublished survey of antipsychotic use in an Australian mental health service (Geelong, Victoria)revealed that of antipsychotics prescribed, 30.8% were for clozapine, 22.9% olanzapine, and14.3% risperidone (total 68%).25

Thus, over the last few years, there has been a marked increase in the proportion of patients withpsychosis who are being prescribed atypical antipsychotics. In some respects this reflects atriumph for marketing, but more charitably suggests that clinicians are increasingly compelled bystudies showing a lower side effect burden associated with the atypicals31,4, and are choosingthem for their patients. Indeed, Australian National guidelines for the treatment of first psychosispatients advocate the first-line use of atypical agents, and this practice is now commonplace.

Not all commentators are convinced of the superiority of the atypical antipsychotics. Indeed, arecent meta-regression analysis concluded that typical agents were, at doses below 12mg/day ofhaloperidol (or equivalent), equal to atypicals in efficacy and tolerability3. The major drawbackof the atypical agents is their cost, which increasingly places a burden on pharmacy budgets andwhich makes these medications almost inaccessible in countries less affluent than Australia. It isthus of interest that in the current study, atypical antipsychotics tended to be viewed as morehelpful by patients, than were typical agents.

The current study revealed that atypical antipsychotics were not prescribed exclusively forpatients with schizophrenia. This is similar to the Keks et al. study which found that, of patientson atypical antipsychotics, 74% met Diagnostic and Statistical Manual of Mental Disorders IVthedition (DSM-IV) criteria for schizophrenia; thus, these agents were also used for patients withother diagnoses.10 Similarly, in the Geelong survey, use of atypical agents was not restricted topatients with a diagnosis of schizophrenia.25 Indeed, whilst 68.1% of prescribed atypicals werefor patients with schizophrenia, 11.9% were used for those with a schizoaffective disorder


diagnosis, 10% for bipolar disorder patients, and 2.5% for patients with major depression. Theseresults show that Australian psychiatrists are not restricted in their prescribing practice, either onthe basis of the dictates of the Therapeutic Goods Administration, nor the results of the double-blind placebo controlled trials which the companies are required to conduct to have drugsapproved for use. This ‘off label’ use of atypicals is a worldwide phenomenon, and arguablymakes a mockery of governmental regulatory controls.

Rates of depot antipsychotic use held fairly stable across the three studies reviewed here. Somecriticism has been levelled at the extent of depot use in Australia10,32, and this has been broughtinto sharper focus by the fact that no atypical antipsychotic is yet available in depot form. Ratesof non-compliance in schizophrenia are high (median 55%, range 24%-88%, in the review byFenton et al.33), and most clinicians acknowledge that some such individuals require depotmedication to maintain wellness. However, it is recognised that one of the main reasons for non-compliance is side effect burden33, and arguably the use of atypicals, with fewer side effects,should enhance compliance and reduce the need for depot use. Whether this is borne out in factremains to be seen. Certainly, the data to hand show that despite increasing use of atypicals,depot usage has changed but little.

Reported effectivenessWe are not aware of other studies that have asked patients to rate whether they believe theirmedication is beneficial for them. We did not specify which particular symptoms we were askingabout, and results thus reflect a global satisfaction rating. It is not unreasonable to assume thatthe overall ‘helpfulness’ rating by patients is a composite of perceived effectiveness weighedagainst side effect burden. Thus, the reported higher satisfaction with atypicals is consonant withthe findings of lower symptom ratings and (overall) reduced side effects of the atypicalscompared with typicals.

It is depot antipsychotics that fare worst in terms of patient perception of effectiveness. Thismight in part reflect the fact that depots tend to be used with patients who would otherwise benon-compliant, and who would thus be expected to lack insight into their illness and the need fortreatment, and resent the fact that they are on medication at all. On the other hand, depotantipsychotics are notorious for the high doses used34 and, being typical agents, would beexpected to carry a high side effect burden (as borne out in the current study).

Reported side effectsOne of the major problems with the current study relates to the lack of any objective measure ofside effects. Furthermore, the grouping of side effects presented here was performed post-hocand, though it makes clinical sense, does not necessarily reflect statistical groupings.Unfortunately we did not collect data on sexual side effects and weight gain, noted to beparticularly problematic for risperidone and olanzapine, respectively.4 Also, the attribution ofcertain side effect symptoms to medications by the patient is open to error, and no definitetemporal sequence was established. Finally, the fact that we excluded from these analyses anypatient on more than one medication could have resulted in bias.

These caveats aside, individuals’ perceptions of the side effects they attribute to medications theyare receiving are useful in the clinical setting not least because side effect burden is a predictor ofnon-compliance with medication.33 The profile of side effects reported here is somewhat at oddswith data from clinical trials.


Some form of extrapyramidal side effect was described by the majority of respondents, with aslightly lower rate being found solely in those on risperidone/olanzapine. These agents have beenshown in clinical trials to cause fewer extrapyramidal side effects than typical antipsychotics,though the meta-analysis of Geddes et al. concluded that overall tolerability is similar betweenatypicals and typicals when the dose of the typical agent is below 12mg/day haloperidol (orequivalent).3 We cannot comment on dose effects in the current study, as we did not collectdosage data. The high rates of reported extrapyramidal side effects in clozapine patients areunexpected, as this agent reportedly causes few or no extrapyramidal side effects.4 Again one isleft querying whether patient report is really accurate in terms of extrapyramidal side effects.

Akathisia is one of the most distressing side effects associated with antipsychotic medication.Patients on typical depot agents reported the highest rates of putative akathisia, but the fact thatnearly half of those on any of the atypical agents also reported this symptom is contrary to bothclinical practice and trial data, which show much lower rates of akathisia with the newerantipsychotics.4 It is possible, though, that respondents were interpreting restlessness due to othercauses (for example, anxiety) as due to medication, and thus labelling it as ‘akathisia’.

Rates of putative tardive dyskinesia are not inconsistent with expectation of rates in a relativelyseverely affected sample such as this.35 The finding that there was little difference between theagents with respect to rates of tardive dyskinesia might well be a reflection of prior medicationexposure, rather than being directly consequent upon current use. For example, clozapine, whilstgenerally considered not to cause tardive dyskinesia4 is reserved for ‘treatment resistant’ cases,who would have previously been prescribed typical antipsychotics over long periods of time.

Medication and symptom profileThe data on correlations between medications and symptoms is difficult to interpret in terms ofclinical practice. On the one hand, clinicians should have been alerted to the occurrence ofdepressive and other symptoms amongst their patients, and have prescribed appropriatemedications for these symptoms. On the other hand, such symptoms might persist despite suchtherapeutic interventions, and point to a failure of the medications used.

It is of interest that atypical antipsychotics were associated with lower scores on all psychoticand mood symptoms, relative to typical agents. In particular, atypical agents were associatedwith low rates of affective symptomatology, possibly reflecting the putative antidepressant andmood stabilising properties of these drugs.36 It is reassuring that depressive symptoms were mostcommonly targeted with antidepressants, and mania with mood stabilising medication.

PolypharmacyWhilst polypharmacy is usually considered poor psychiatric practice, it is not unusual in theclinical settings, notably during change-over from typical to atypical agents, or if using anatypical to supplement a depot. In the study of Keks et al., 13% of patients were being prescribedcombinations of antipsychotics, with 8% of patients being on a combination of a typical and anatypical, (5% on an atypical and a depot typical, and 3% an oral typical); less than 1% were ontwo typicals or two atypicals. Mood stabilisers were prescribed to over half of patients onhaloperidol and a quarter of those on olanzapine/risperidone.10 Antidepressant prescription wasof the order of one-fifth of patients, though only 6% for those on clozapine.10 In the Callaly andTrauer survey, mood stabilisers were prescribed to 18.0% of patients on atypical agents, 25.6%of those on oral typicals, and 8.9% of those on depot typicals.25 Rates of antidepressant useacross these groups were 22.1%, 35.4%, and 7.4%, respectively.25


Data from the US also show polypharmacy to be not unusual. For example, the AmericanPsychiatric Association Practice Research Network (PRN) surveyed prescribing habits amongstUS psychiatrists and found that, for patients with schizophrenia and related psychoses (n=155),78% were on a single antipsychotic agent, 15% on two antipsychotics, and 2% on three or moresuch agents.37

These data again suggest that clinical judgement often overrides pharmacological purism, even inthe absence of firm data to support benefit from combinations of antipsychotic agents. The ratesof use of mood stabilisers and antidepressants in the current survey reflect in part the diagnosticheterogeneity of the sample, but also underline the clinical reality of extensive depressivecomorbidity in schizophrenia and related disorders.36

Psychosocial treatmentsIn comparison with medications, psychosocial treatments have received scant attention fromresearchers. A recent review concluded that, of the established psychosocial treatments forschizophrenia, only family therapy and intensive case management have a reasonably robustevidence base.11 Furthermore, services tend not to prioritise psychosocial treatments. Forexample, in the treatment guidelines produced by the Schizophrenia Patient Outcomes ResearchTeam (PORT) in the US6, only nine of the 30 recommendations related to psychosocialtreatments, and a review of US services in two States showed that conformance with theseguidelines was low, expressly for those patients who were not inpatients.38 This led onecommentator39 to conclude that:

‘The PORT Client Survey documents the abysmally poor care that the majority of patients receive.Simply stated, most mental health care providers “just don’t get it”!...Usual care for persons withschizophrenia is clearly unacceptable.’ (p. 30)

Regrettably, much the same conclusion can be drawn with respect to psychosocial treatments forpsychosis in Australia. Much work needs to be done to enhance the provision of such services, toevaluate and refine them, and to disseminate them so that they are widely available to peoplewith psychosis and their families.

ConclusionsWe report here findings from a representative Australian sample of psychosis patients, withrespect to pharmacological treatment. The vast majority of patients were receiving antipsychoticmedication, and a substantial proportion was also on antidepressant and mood stabilising agents.Atypical antipsychotics tended to be associated with lower levels of psychotic and affectivesymptomatology, and a generally lower side effect burden. However, even the newerantipsychotics are neither free of side effects nor associated with a full resolution ofsymptomatology. More work needs to be done in determining the optimal medication regime foreach individual patient, and in exploring psychosocial treatments which can augmentmedications in the holistic care of people living with psychosis.


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N % of total sampleof 1126 using*

Benefit if using* (%)

Typical antipsychotics - oral

Chlorpromazine 96 8.5 not helpful 15.6helpful 43.8very helpful 35.4impossible to assess 5.2TOTAL 100.0

Flupenthixol 20 1.8 not helpful 10.0helpful 45.0very helpful 35.0impossible to assess 10.0TOTAL 100.0

Fluphenazine Hydrochloride 17 1.5 not helpful 11.8helpful 58.8very helpful 23.5impossible to assess 5.9TOTAL 100.0

Haloperidol 88 7.8 not helpful 13.6helpful 51.1very helpful 22.7impossible to assess 12.5TOTAL 100.0

Perphenazine 1 0.1 not helpful 100.0helpful 0.0very helpful 0.0impossible to assess 0.0TOTAL 100.0

Pericyazine 16 1.4 not helpful 0.0helpful 68.8very helpful 31.3impossible to assess 0.0TOTAL 100.0

Pimozide 5 0.4 not helpful 0.0helpful 0.0very helpful 100.0impossible to assess 0.0TOTAL 100.0

Thioridazine 118 10.5 not helpful 9.3helpful 50.0very helpful 36.4impossible to assess 4.2TOTAL 100.0

Thiothixene 11 1.0 not helpful 18.2helpful 27.3very helpful 36.4impossible to assess 18.2TOTAL 100.0

Trifluoperazine 115 10.2 not helpful 9.6helpful 53.0very helpful 32.2impossible to assess 5.2TOTAL 100.0

Appendix 1. Use and effectiveness ofindividual psychotropic agents

Table A1 Specific medication currently used, and benefit if currently using


Typical antipsychotics - depot

Flupenthixol Decanoate 72 6.4 not helpful 18.1helpful 45.8very helpful 23.6impossible to assess 12.5TOTAL 100.0

Fluphenazine Decanoate 130 11.5 not helpful 13.8helpful 42.3very helpful 35.4impossible to assess 8.5TOTAL 100.0

Haloperidol Decanoate 60 5.3 not helpful 18.3helpful 40.0very helpful 35.0impossible to assess 6.7TOTAL 100.0

Zuclopenthixol Decanoate 21 1.9 not helpful 28.6helpful 47.6very helpful 4.8impossible to assess 19.0TOTAL 100.0

Atypical antipsychotics

Clozapine 94 8.3 not helpful 5.3helpful 40.4very helpful 46.8impossible to assess 7.4TOTAL 100.0

Olanzapine 99 8.8 not helpful 8.1helpful 39.4very helpful 43.4impossible to assess 9.1TOTAL 100.0

Risperidone 150 13.3 not helpful 12.0helpful 43.3very helpful 35.3impossible to assess 9.3TOTAL 100.0

Antidepressants other than SSRI, RIMA

Amitryptiline 14 1.2 not helpful 7.1helpful 35.7very helpful 35.7impossible to assess 21.4TOTAL 100.0

Clomipramine 7 0.6 not helpful 0.0helpful 57.1very helpful 42.9impossible to assess 0.0TOTAL 100.0

Desipramine 4 0.4 not helpful 25.0helpful 50.0very helpful 25.0impossible to assess 0.0TOTAL 100.0

Dothiepin 36 3.2 not helpful 19.4helpful 38.9very helpful 27.8impossible to assess 13.9TOTAL 100.0

Doxepin 13 1.2 not helpful 0.0helpful 61.5very helpful 15.4impossible to assess 23.1TOTAL 100.0




Imipramine 6 0.5 not helpful 33.3helpful 33.3very helpful 33.3impossible to assess 0.0TOTAL 100.0

Mianserin 2 0.2 not helpful 0.0helpful 50.0very helpful 50.0impossible to assess 0.0TOTAL 100.0

Tranylcypromine 3 0.3 not helpful 33.3helpful 0.0very helpful 66.7impossible to assess 0.0TOTAL 100.0

Trimipramine 3 0.3 not helpful 0.0helpful 0.0very helpful 100.0impossible to assess 0.0TOTAL 100.0

Antidepressants - SSRI, RIMA

Fluoxetine 39 3.5 not helpful 7.7helpful 64.1very helpful 17.9impossible to assess 10.3TOTAL 100.0

Moclobemide 13 1.2 not helpful 15.4helpful 30.8very helpful 53.8impossible to assess 0.0TOTAL 100.0

Nefazodone 12 1.1 not helpful 8.3helpful 58.3very helpful 25.0impossible to assess 8.3TOTAL 100.0

Paroxetine 41 3.6 not helpful 12.2helpful 39.0very helpful 36.6impossible to assess 12.2TOTAL 100.0

Sertraline 80 7.1 not helpful 15.0helpful 43.8very helpful 28.8impossible to assess 12.5TOTAL 100.0

Venlafaxine 23 2.0 not helpful 8.7helpful 39.1very helpful 34.8impossible to assess 17.4TOTAL 100.0

Mood stabilisers

Carbamazepine 59 5.2 not helpful 8.5helpful 44.1very helpful 33.9impossible to assess 13.6TOTAL 100.0

Lithium carbonate 150 13.3 not helpful 12.0helpful 38.7very helpful 42.0impossible to assess 7.3TOTAL 100.0




Valproate 74 6.6 not helpful 12.2helpful 41.9very helpful 28.4impossible to assess 17.6TOTAL 100.0

Benzodiazapines

Alprazolam 2 0.2 not helpful 0.0helpful 100.0very helpful 0.0impossible to assess 0.0TOTAL 100.0

Clorazepate 1 0.1 not helpful 0.0helpful 0.0very helpful 100.0impossible to assess 0.0TOTAL 100.0

Diazepam 95 8.4 not helpful 7.4helpful 38.9very helpful 44.2impossible to assess 9.5TOTAL 100.0

Lorazepam 14 1.2 not helpful 7.1helpful 42.9very helpful 35.7impossible to assess 14.3TOTAL 100.0

Oxazepam 7 0.6 not helpful 0.0helpful 42.9very helpful 57.1impossible to assess 0.0TOTAL 100.0



* A number of respondents were using more than one medication and described the benefits of each one.

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