The Pharmaceutical Journal
Vol 269 No 7228 p860
14 December 2002

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College of Mental Health Pharmacists/Industrial Pharmacists Group summary

Discrepancy exists between guidance and practice

Although there is general consensus among many as to the best way forward in the treatment of schizophrenia, there remain large gaps between such guidance (as suggested by the National Institute for Clinical Excellence) and current practice, said Shameem Mir, chief pharmacist, East London and the City Mental Health Trust.

NICE recommends that atypicals are considered first-line in the treatment of schizophrenia and should be used for patients experiencing unacceptable side effects with typical antipsychotics. If a patient experiences treatment failure with two different antipsychotics, treatment with clozapine should be considered. NICE also recommends that the patient and carer are involved in the choice of antipsychotic as well as in any advance directives made. There should be no polypharmacy, according to NICE, except during cross tapering. NICE recognises that typical antipsychotics still have a place in therapy, as long as treatment with them provides adequate symptom control and the drug is tolerable to the patient.

Ms Mir said that despite a lack of evidence to support the use of more than one antipsychotic, polypharmacy appears to be commonplace. In a national atypical antipsychotic survey conducted by the Maudsley Hospital in London, only 30 per cent of patients received an atypical drug as a single agent. Most patients were co-prescribed a typical antipsychotic either regularly or prn, which led to an increased rate of anticholinergic drug use thus further increasing the potential for adverse effects. To confirm these findings, another study at the Maudsley (investigating co-prescription) found that this practice was not evidence-based, worsened the adverse effect burden and rarely resulted in any clear clinical benefit.

Ms Mir went on to say that it is well known that clozapine is the drug of choice for treatment of refractory schizophrenia and that early treatment with clozapine results in better clinical outcome. Despite this, there seems to be a general delay in starting people on clozapine. Results from a study at the Maudsley hospital suggest an average delay of five years. NICE recommends this lag-period to be no more than 16 weeks. Although Ms Mir believed that in practice this may be too short, she said that a delay of five years is unacceptable considering the time taken for a person with schizophrenia to reach psychiatric services in the first place. Ms Mir pointed out the difference in side effect profiles between the atypicals, stressing the importance of knowing these if patients are to be switched to an atypical antipsychotic as a result of "intolerable side effects". For example, for someone experiencing galactorrhoea with a typical antipsychotic, although a change in treatment may be appropriate, the choice of atypical is important as some, such as amisulpride, may increase prolactin levels and so a switch to this drug would not be appropriate.

Ms Mir also highlighted the fact that atypicals are not without side effects and in particular, some of them are associated with greater weight gain and a higher incidence of hyperglycaemia than are typical antipsychotics.