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Clozapine, olanzapine, risperidone fare best on more outcomes for schizophrenia

 

Key clinical point: Clozapine appears superior to other second-generation antipsychotics in preventing self-harm.

Major finding: “Olanzapine, risperidone, ziprasidone, and aripiprazole were similar to haloperidol on some outcomes of benefit.”

Data source: One systematic review (SR) of 138 trials (n = 47,189) and 24 trials (n = 6,672) for SGAs vs. SGAs; one SR of 111 trials (n = 118,503) and 5 trials (n = 1,055) for first-generation antipsychotics (FGAs) vs. SGAs; 13 SRs of 271 trials (n = 25,050); and 27 trials (n = 6,404) for psychosocial interventions.

Disclosures: Dr. McDonagh is affiliated with the Pacific Northwest Evidence-based Practice Center, and worked on behalf of the Agency for Healthcare Research and Quality.


 

 

Clozapine, olanzapine, and oral and long-acting injectable formulations of risperidone proved superior on more schizophrenia outcomes that did other second-generation antipsychotics, according to a review of the effectiveness of treatments for adults with the illness. Meanwhile, psychosocial interventions were found to be more effective than “usual care” in “improving two or more outcomes.”

Those were some of the findings of Marian S. McDonagh, PharmD, and her associates in the review of hundreds of studies on the effectiveness of first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), and psychosocial treatments in outpatient adults with schizophrenia. The researchers, who are affiliated with the Pacific Northwest Evidence-based Practice Center and worked on behalf of the Agency for Healthcare Research and Quality, asked two key questions: What did head-to-head comparisons show in terms of SGAs vs. SGAs and FGAs vs. SGAs, and what did trials show for usual care, which they defined as “elements of medication treatment ... rehabilitation services, and psychotherapy.” They reported the findings in a recent Comparative Effectiveness Review.

Dr. McDonagh and her associates conducted a literature search of the evidence on antipsychotics and found one systematic review (SR) of 138 trials (n = 47,189); 24 trials (n = 6,672) for SGAs vs. SGAs; one SR of 111 trials (n = 118,503); and five trials (n = 1,055) for FGAs vs. SGAs. For psychosocial interventions, they found 13 SRs of 271 trials (n = 25,050) and looked at 27 trials that were not included in the reviews (n = 6,404).

They found no evidence showing newer SGAs as superior to older SGAs on any outcomes. When FGAs were compared with SGAs, the reviewers found that olanzapine, risperidone, ziprasidone, and aripiprazole were similar to haloperidol “on some outcomes of benefit, and were superior on overall adverse events and withdrawal due to adverse events.”

Most of the findings were consistent with previous reviews that compared SGAs, and SGAs vs. FGAs. However, a new finding is that risperidone long-acting injectables and olanzapine are associated with significantly lower withdrawals tied to adverse events than are “most other SGAs.” In addition, Dr. McDonagh and her associates found that clozapine proved superior to other SGAs in preventing self-harm and suicides. Two SGAs, olanzapine and risperidone, were more likely to lead to improved scores on the Positive and Negative Syndrome Scale than was quetiapine.

When the reviewers looked at psychosocial interventions and compared them with usual care, the researchers found results that were consistent with some previous findings and different from others. For family interventions, they found the strongest evidence for interventions that last 7 to 12 months. The team also found that “the number of sessions was more predictive of relapse than was duration of treatment.” Their findings also showed that supported employment led to better outcomes for work over 2 years, compared with usual care. “More patients either gained employment (competitive or any job), had more hours worked, were employed longer, or earned more money than those receiving usual care,” the authors wrote. Also, patients who received assertive community treatment “were more likely to be living independently and to be employed, and they were less likely to be homeless or to discontinue treatment, compared with patients assigned to usual care.”

Dr. McDonagh and her associates said future review research should evaluate the comparative effectiveness of psychosocial interventions and compare them with one another. They also said future research should evaluate other nonpharmacologic, deviced-based treatments, such as electroconvulsive therapy and transcranial magnetic stimulation.

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