Some Prescribing Practices for First-Episode Psychosis Not Concordant With Guidelines, Study Shows

Antipsychotic prescribing for nearly 40% of patients with first-episode psychosis was not concordant with practice guidelines, according to a report, “Prescription Practices in the Treatment of First-Episode Schizophrenia Spectrum Disorders: Data From the National RAISE-ETP Study,” published today in AJP in Advance.

Delbert Robinson, M.D., of Hofstra North Shore-LIJ School of Medicine and colleagues found prescribing patterns were outside guidelines for 159 of 404 first-episode patients at community treatment centers in 21 states. The most common practices that were not concordant with guidelines were use of more than one antipsychotic drug, a higher-than-recommended antipsychotic dosage, using a psychotropic medication other than an antipsychotic, using an antidepressant without justification, and/or use of olanzapine, an antipsychotic that is especially likely to cause significant weight gain but was often prescribed at high dosages nonetheless.

“Although each questionable medication practice we identified affected only 1.2% to 4.4% of patients, cumulatively 39.4% of patients might have benefited from changes in their psychotropic medication prescriptions,” Robinson and colleagues said. “Primary immediate targets for improving first-episode community treatment include discouraging the use of two or more antipsychotics and the prescription of olanzapine, especially at high dosages.”

But many studies have shown that aggressive treatment of first-episode psychosis is crucial to long-term trajectory of illness and outcome, and American Journal of Psychiatry Editor Robert Freedman, M.D., (pictured above) pointed out that some of the prescribing practices identified in the study may not necessarily be clinically inappropriate.

"The prescription acutely of higher doses of antipsychotics, and specifically olanzapine, to first-episode patients is outside guidelines, but whether or not it is misinformed clinical practice has yet to be determined,” he told Psychiatric News. “First-episode patients are often identified by their families and clinicians because they have suddenly become acutely psychotic, and it is often necessary, for both clinical and financial reasons, to decrease their symptoms as quickly as possible." He added that future analyses of the data "may help clarify the reason for these prescription strategies and their utility and thus will ultimately inform guidelines."

For more on this subject, see the Psychiatric News article, "Maryland Undertakes Ambitious Effort at Early ID of Psychosis."