Predictors of antipsychotic medication adherence in patients recovering from a first psychotic episode Adherence to conventional and atypical antipsychotics after hospital discharge. The risks and benefits of switching patients with schizophrenia or schizoaffective disorder from two to one antipsychotic medication: A randomized controlled trial Evidence-based recommendations for monitoring safety of second-generation antipsychotics in children and youth. Longer time to antipsychotic treatment discontinuation for any cause is associated with better functional outcomes for patients with schizophrenia, schizophreniform disorder, or schizoaffective disorder. Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. Maintenance treatment with long-acting injectable risperidone in first-episode schizophrenia: a randomized effectiveness study. Effectiveness and tolerability of oral ziprasidone in psychiatric inpatients with an acute exacerbation of schizophrenia or schizoaffective disorder: a multicenter, prospective, and naturalistic study. Attitude toward antipsychotic medication as a predictor of antipsychotic treatment discontinuation in first-episode early-onset psychosis. First do no harm: promoting an evidence-based approach to atypical antipsychotic use in children and adolescents. Remission in patients with first-episode schizophrenia receiving assured antipsychotic medication: a study with risperidone long-acting injection
BACKGROUND Many patients recovering from a first psychotic episode will discontinue medication against medical advice , even before a 1-year treatment course is completed . Factors associated with treatment adherence in patients with chronic schizophrenia include beliefs about severity of illness and need for treatment , treatment with typical versus atypical antipsychotic and medication side effects . METHOD In this 2-year prospect i ve study of 254 patients recovering from a first episode of schizophrenia , schizophreniform , or schizoaffective disorder we examined the relationship between antipsychotic medication non-adherence and patient beliefs about : need for treatment , antipsychotic medication benefits , and negative aspects of antipsychotic medication treatment . We also examined the relationship between medication non-adherence and treatment with either haloperidol or olanzapine , and objective measures of symptom response and side effects . RESULTS The likelihood of becoming medication non-adherent for 1 week or longer was greater in subjects whose belief in need for treatment was less ( HR=1.75 , 95 % CI 1.16 , 2.65 , p=0.0077 ) or who believed medications were of low benefit ( HR=2.88 , 95 CI 1.79 - 4.65 , p<0.0001 ) . Subjects r and omized to haloperidol were more likely to become medication non-adherent for > or=1 week than subjects r and omized to olanzapine ( HR-1.51 , 95 % CI 1.01 , 2.27 , p=0.045 ) . CONCLUSION Beliefs about need for treatment and the benefits of antipsychotic medication may be intervention targets to improve likelihood of long-term medication adherence in patients recovering from a first episode of schizophrenia , schizoaffective , or schizophreniform disorder BACKGROUND This prospect i ve study measured adherence to conventional and atypical antipsychotics after hospital discharge in patients with a diagnosis of schizophrenia and schizoaffective disorder . We examined the interaction of several predictors such as gender , severity of illness , attitudes toward medications , side effects , and dose frequency . METHOD The sample consisted of consecutive r and omized and nonr and omized patients who were discharged from an inpatient unit with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder between December 1995 and July 1999 . All patients were taking oral antipsychotics  and consented to the use of an electronic adherence monitor at discharge . Medications were prescribed by usual care providers , and medication adherence was followed weekly for 3 months . The outcome measure was the medication adherence rate registered in the electronic monitors . RESULTS We found no significant difference in adherence between the combined groups of atypical and conventional antipsychotics . Individual medication analysis found better medication adherence with olanzapine in comparison with risperidone and conventional antipsychotics , but the difference disappeared in the final model controlling for dose frequency . Dose frequency , gender , and akathisia predicted adherence . CONCLUSIONS Olanzapine initially appeared to be associated with an adherence advantage over risperidone and conventional antipsychotics , but the apparent advantage may have been due to a usual care dose frequency practice that associated olanzapine more often with once-daily dosing . This study suggests that dose frequency is an important predictor of medication adherence . An important caveat is that these results apply only to short-term adherence BACKGROUND Despite little evidence to support its use and practice guidelines discouraging the practice , antipsychotic polypharmacy is widely prevalent in schizophrenia . This r and omized controlled trial studied the effects of switching patients stable on two antipsychotic medications  to one antipsychotic medication . METHOD 104 adult out patients with schizophrenia from 7 community mental health centers clinical ly stable on concurrent treatment with 2 antipsychotics  were r and omly assigned to stay on polypharmacy or to switch to antipsychotic monotherapy . Participants were followed for 1-year with assessment s of symptoms and side effects occurring every 60days ( 7 total assessment s ) . We examined differences in time trajectories in symptoms ( PANSS , CGI ) and side effects ( EPS , metabolic , other ) as a function of group assignment ( switch vs. stay ) and time , using intention-to-treat analysis . RESULTS Participants who switched to antipsychotic monotherapy experienced greater increases in symptoms than stay patients . These differences emerged in the second 6months of the trial . All-cause discontinuation rates over the 1-year trial were higher in the switch-to-monotherapy group than in the stay-on-polypharmacy group ( 42 % vs. 13 % ; p<0.01 ) . There were no differences in change over time in any of the side effect measures , except that stay patients experienced a greater decrease in Simpson Angus total scores than switch patients . CONCLUSION Clinicians should be cautious in switching patients with chronic schizophrenia who are stable on 2 antipsychotics to one antipsychotic . Given the challenges in discontinuing antipsychotic polypharmacy , adequate trials of evidence -based treatments such as clozapine and long-acting injectable antipsychotics should be undertaken in inadequately responsive schizophrenia patients before moving to antipsychotic polypharmacy BACKGROUND The use of antipsychotics , especially second-generation antipsychotics ( SGAs ) , for children with mental health disorders in Canada has increased dramatically over the past five years . These medications have the potential to cause major metabolic and neurological complications with chronic use . OBJECTIVE To synthesize the evidence for specific metabolic and neurological side effects associated with the use of SGAs in children , and provide evidence -based recommendations for the monitoring of these side effects . METHODS A systematic review of controlled clinical trials of SGAs involving children was performed . Recommendations for monitoring SGA safety were made according to a classification scheme based on the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) system . When there was inadequate evidence , recommendations were based on consensus and expert opinion . A multidisciplinary consensus group review ed all relevant evidence and reached consensus on the recommendations . RESULTS The present guidelines provide evidence -based recommendations for monitoring SGA safety . The strength of recommendations for specific physical examination manoeuvres and laboratory tests are provided for each SGA medication at specific time points . CONCLUSION Multiple r and omized controlled trials evaluated the efficacy of many of the SGAs in paediatric mental health disorders . These benefits , however , are not without risks - both metabolic and neurological side effects occur in children treated with SGAs . The risk of weight gain , increased body mass index and abnormal lipid levels is greatest with olanzapine , followed by clozapine and quetiapine . The risk of neurological side effects of the treatment is greatest with risperidone , olanzapine and aripiprazole . Appropriate monitoring procedures for adverse effects will improve the quality of care of children treated with these medications OBJECTIVE Time to all-cause treatment discontinuation is considered a composite proxy measure of treatment efficacy , safety , and tolerability . Longer time to discontinuation of antipsychotic medication for any cause has been shown to be associated with greater symptom improvements in the treatment of schizophrenia . This study examines whether longer time to all-cause medication discontinuation is also linked to better functional outcomes . METHOD Using pooled data from 4 r and omized , double-blind antipsychotic trials of 24- to 28-weeks ' duration , this study examined the association between time to all-cause treatment discontinuation and functional outcomes , as assessed by a disease-specific , clinician-rated measure ( Quality of Life Scale [ QLS ] ) and a generic , patient-reported measure ( Medical Outcomes Study Short Form 36 [ SF-36 ] ) . Patients in these trials had a DSM-IV diagnosis of schizophrenia , schizophreniform disorder , or schizoaffective disorder . This post hoc analysis used Pearson partial correlations to assess relationships between time to treatment discontinuation and changes in functional scores , adjusting for baseline scores . Repeated measures analyses were also conducted to compare post-baseline functional outcome change over time between completers and noncompleters . RESULTS Longer time to all-cause treatment discontinuation was found to be significantly associated with greater improvements in all assessed functional domains ( p < .05 ) . Patients who completed their respective trials ( 46.8 % , 761/1627 ) experienced significantly greater improvement in functional outcome measures ( in 4 QLS domains and SF-36 mental health component summary score ; all , p < .001 ) compared to patients who discontinued for any cause . In addition , greater symptom improvement was significantly associated with greater functional improvements in assessed domains . CONCLUSIONS Findings from this post hoc analysis illustrate the importance of longer treatment duration with antipsychotics for improving functional outcomes in the treatment of patients with schizophrenia BACKGROUND Relatively little is known about the relationships between medication adherence and long-term functional outcomes in the treatment of schizophrenia . To extend previous research , we prospect ively examined the relationships between adherence with any antipsychotic medication and functional outcomes among schizophrenia patients treated over a 3-year period , assessed the stability of adherence over time , and examined whether adherence in the first year predicts changes in functional outcomes over the following 2 years . METHOD Analyses included 1906 participants with DSM-IV diagnoses of schizophrenia or schizoaffective or schizophreniform disorder in a multi-site , 3-year , prospect i ve , naturalistic study conducted in the United States between July 1997 and September 2003 . Outcome measures were assessed at 6-month intervals using systematic medical record abstract ion and structured interview of patients . Adherence with antipsychotic regimen was assessed using patient-reported adherence and the medication possession ratio ( percent days with prescription for any antipsychotic ) , dichotomized into adherence and non-adherence . Analyses employed generalized estimating equations and mixed models with repeated measures . RESULTS Nonadherence was associated with poorer functional outcomes , including greater risks of psychiatric hospitalizations , use of emergency psychiatric services , arrests , violence , victimizations , poorer mental functioning , poorer life satisfaction , greater substance use , and more alcohol-related problems ( all p < .001 ) . Adherence was relatively stable , with 77.3 % of patients maintaining the same adherence status from the first year to the second year . Nonadherence in the first year predicted significantly poorer outcomes in the following 2 years . CONCLUSIONS Findings highlight the importance of adherence with antipsychotic medication in the long-term treatment of schizophrenia and its potential beneficial impact on the mental health and criminal justice delivery systems BACKGROUND Because long-acting injectable ( LAI ) antipsychotics are largely reserved for persistently ill patients , little is known about the use of LAIs early in the course of illness for first-episode out patients . METHOD A prospect i ve , open-label , r and omized controlled trial was conducted in which out patients with first-episode DSM-IV schizophreniform disorder , schizophrenia , or schizoaffective disorder were enrolled from December 2004 to March 2007 . Participants were r and omly assigned at a 2:1 ratio to a recommendation of changing to LAI risperidone microspheres ( RLAI ) ( n = 26 ) or continuing oral antipsychotic treatment ( n = 11 ) for up to 104 weeks . Primary outcomes were time until initial nonadherence ( medication gap of ≥ 14 days ) and medication attitudes as assessed with the Rating of Medication Influences scale . Patients r and omly assigned to an RLAI recommendation could decline the recommendation , so analysis defined treatment groups by intent-to-treat and as-actually-treated . RESULTS Eighty-one percent of patients ( 30/37 ) stopped medication within 104 weeks . There was a trend toward an initial adherence benefit favoring RLAI acceptors at 12 weeks ( P = .058 ) , but no significant difference between RLAI and oral antipsychotic treatment in time to initial nonadherence during the overall study ( P = .188 ) . Medication attitudes did not differ between groups . CONCLUSIONS Acceptance of RLAI was associated with an initial adherence benefit that was not sustained over time . Early introduction of LAI therapy did not adversely affect adherence attitudes . The small size of the study and low power limit interpretation , but the few patients who remained adherent into a second year were all receiving RLAI . Nonadherence was almost universal in our first-episode cohort , but nonadherence was more easily detected among first-episode patients treated with LAI therapy than it was with oral antipsychotics . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT00220714 OBJECTIVE This prospect i ve , uncontrolled , and naturalistic study aim ed to evaluate the effectiveness and tolerability of oral ziprasidone in psychiatric in patients with an acute exacerbation of schizophrenia or schizoaffective disorder treated in the clinical practice setting . METHOD Patients had to be at least 18 years old and meet DSM-IV-TR criteria for acute exacerbation of schizophrenia or schizoaffective disorder . Patients were followed until discharge and were evaluated with the Brief Psychiatric Rating Scale ( BPRS ) , Clinical Global Impressions ( CGI ) scale , Drug Attitude Inventory , and the Scale to Assess Unawareness of Mental Disorder .  Ziprasidone dose requirements , dose escalation , discontinuation of treatment , and the use of any concomitant medication including cotreatment with other antipsychotics were established individually according to the clinical judgment of each investigator . The study was conducted from February 2005 to June 2007 . RESULTS We included a total of 196 patients ( intent-to-treat population ) , 9 ( 5 % ) of whom discontinued treatment with ziprasidone ( 3 because of side effects ) . The mean ( SD ) length of stay was 23.4 ( 34.2 ) days . The mean ( SD ) dose at discharge was 186.3 ( 67.6 ) mg/day , and the median dose was 160 mg/day ( interquartile range , 120 - 240 mg/day ) . Response rates at the endpoint , according to BPRS and CGI criteria , were 74 % ( 95 % CI = 68 % to 80 % ) and 67 % ( 95 % CI = 61 % to 74 % ) , respectively . Progressive and statistically significant improvements in all BPRS scores and CGI-Severity of Illness scores were observed from the first week through discharge . All changes from baseline to the study endpoint for BPRS and CGI scores were clinical ly relevant , with effect sizes greater than 0.80 . The insight into illness and the attitude toward medication also improved significantly over the course of the study . Ziprasidone was well tolerated . CONCLUSION Although our results should be interpreted with caution because of the uncontrolled design of our study , they suggest that , in acutely ill in patients with schizophrenia or schizoaffective disorder , the use of ziprasidone under routine clinical conditions is associated with a rapid and progressive improvement in psychopathologic symptoms and a clinical ly relevant improvement in insight into their illness BACKGROUND Antipsychotic drug discontinuation is a key risk factor in psychotic relapses . Clinical relapse is related to poor outcome , especially in the earlier stages of psychotic illness . The attitude toward treatment during the acute phase of a first episode of psychosis has been proposed as one of the main determinants of treatment discontinuation . However , the relationship between attitude toward antipsychotic medication and treatment discontinuation in the adolescent population has not been properly assessed . METHODS Adolescents , aged 12 - 18 years old , consecutively admitted to an adolescent unit with a first lifetime admission for a first episode of psychosis were asked to participate in a r and omized , flexible-dose , 6-month controlled trial of olanzapine vs. quetiapine .  Attitude toward antipsychotic medication  was assessed using the 10-item Drug Attitude Inventory ( DAI ) . The outcome variable was all-cause treatment discontinuation over the 6-month follow- up . The study sample was composed of 42 patients [ 34 boys ( 82.9 % ) , eight girls ( 17.1 % ) , mean age ± SD : 16.1±1.3 ] . RESULTS Of the 42 patients , only 29 ( 69 % ) continued the medication throughout the entire 6-month follow-up , while 13 ( 31 % ) discontinued the medication . DAI scores were greater than zero at all assessment s , indicating that the general attitude of the patients toward medication was positive . Higher DAI scores at baseline were related to lower all-cause treatment discontinuation [ adjusted hazard ratio ( HR ) = 0.81 ( 95 % CI : 0.68 - 0.96 ) , P=0.016 ] , while DAI scores at 15 days were unrelated to treatment discontinuation [ adjusted HR=1.0 ( 95 % CI : 0.82 - 1.23 ) , P=0.998 ] . CONCLUSIONS A better attitude toward antipsychotic medication at a first lifetime psychiatric admission for a first early-onset psychotic episode was significantly related to lower all-cause antipsychotic treatment discontinuation OBJECTIVES To review the evidence for efficacy and metabolic effects of atypical antipsychotics ( AAPs ) , and to propose a metabolic monitoring protocol for AAP use in children and adolescents . METHODS A PubMed search was performed to obtain all studies related to efficacy , metabolic side-effects , and monitoring in those less than 18 years of age . RESULTS There are no approved indications for AAP use in children and adolescents in Canada . Based on US Food and Drug Administration approvals and a review of r and omized controlled trials , we identified 7 indications for AAP use that target specific symptoms in youth including schizophrenia , bipolar I disorder , autism , pervasive developmental disorder , disruptive behaviour disorders ( including conduct disorder and ADHD ) , developmental disabilities and Tourette Syndrome . A wide range of metabolic effects including weight gain , increased waist circumference , dysglycemia , dyslipidemia , hypertension , elevated hepatic transaminases and prolactin levels have been reported . We have developed a proposal for metabolic monitoring that includes anthropometric measurements and laboratory testing at baseline and appropriate intervals thereafter . CONCLUSION There is an urgent need for national clinical practice guidelines that provide , not only appropriate treatment algorithms for AAP-use based on evidence , but also address metabolic monitoring and subsequent management of complications in this vulnerable population Recently proposed criteria for remission by a ‘ Remission in Schizophrenia Working Group ’ have generated considerable interest . We assessed rates , predictors , and correlates of remission in a sample of patients with first-episode schizophrenia treated with injectable , long-acting risperidone .  This allowed us to examine remission among patients known to be receiving medication . This was a single-site open-label study in which 50 newly diagnosed cases of schizophreniform disorder or schizophrenia aged 16 to 43 years were treated with injectable , long-acting risperidone 25–50 mg every 2 weeks for 2 years . Remission , according to Remission in Schizophrenia Working Group criteria , was achieved in 64 % of the patients . Of those achieving remission , 97 % maintained this status until study completion . Remission was associated with greater improvements in other symptom domains , insight , and social and occupational functioning . Patients in remission received lower doses of antipsychotic medication , had fewer extrapyramidal symptoms , and a more favorable attitude toward medication . The results of this open-label study suggest that a majority of first-episode patients who receive long-acting injectable  antipsychotic medication may achieve sustained remission . Double-blind-controlled studies using long-acting injectable antipsychotics in early psychosis are warranted to further test this
CONCLUSIONS This review provides some support to the notion that patients experiencing antipsychotic side-effects are at risk of developing more negative attitudes toward medication .
BACKGROUND Antipsychotics are associated with a wide range of side-effects .
Many patients experience antipsychotics as unpleasant and something they would rather avoid , leading some of them to discontinue taking their medication .
The importance of evaluating the patients ' perspective , especially their attitudes toward medication in the presence of side-effects , has long been emphasized .
However , no definite conclusion has been made to date on the relationship between antipsychotic side-effects and attitudes toward medication .
OBJECTIVES The objective of this systematic review was to determine the best available evidence regarding the impact of antipsychotic side-effects on attitudes toward medication in patients with schizophrenia and related disorders , which include schizoaffective and schizophreniform disorders .
SEARCH STRATEGY The search aim ed to find published studies using a range of data bases .