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Comparison of Outcomes for African Americans, Hispanics, and Non-Hispanic Whites in the CATIE Study
Jodi Gonzalez Arnold, Ph.D.; Alexander L. Miller, M.D.; José M. Cañive, M.D.; Robert A. Rosenheck, M.D.; Marvin S. Swartz, M.D.; Jim Mintz, Ph.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.002412012
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Dr. Arnold, Dr. Miller, and Dr. Mintz are affiliated with the Department of Psychiatry and Dr. Mintz is also with the Department of Epidemiology and Biostatistics, University of Texas Health Science Center, 7703 Floyd Curl Dr., Med, Room 730 E-2, San Antonio, TX 78209 (e-mail: arnoldjg@uthscsa.edu). Dr. Cañive is with Psychiatry Research at the New Mexico Veterans Affairs Healthcare System, Albuquerque, and the Departments of Psychiatry and Neurosciences, University of New Mexico, Albuquerque. Dr. Rosenheck is with the Department of Psychiatry, Yale Medical School, West Haven, Connecticut. Dr. Swartz is with the Department of Psychiatry, Duke University Medical Center, Durham, North Carolina.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  Medication outcome literature in schizophrenia across racial-ethnic groups is sparse, with inconsistent findings. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study provided an opportunity for exploratory analyses of racial-ethnic outcomes. The study objective was to examine race-ethnicity outcomes for CATIE's main outcome (study discontinuation) and secondary outcomes.

Methods  CATIE participants included whites (non-Hispanic) (N=722), African Americans (N=506), and Hispanics (N=170). Survival analyses and mixed-effects regression modeling were conducted, with adjustment for baseline sociodemographic differences and baseline scores of the secondary outcomes.

Results  Racial-ethnic groups had unique patterns of outcomes. Hispanics were much more likely to discontinue for lack of efficacy from perphenazine (64% versus 42% non-Hispanic whites and 24% African Americans) and ziprasidone (71% versus 40% non-Hispanic whites and 24% African Americans); Hispanics' quality of life also declined on these medications. Non-Hispanic whites were more likely to discontinue for lack of efficacy in general (averaging olanzapine, quetiapine, and risperidone discontinuation rates). African Americans were less likely to continue after the first phase (32% continuing versus 40% for non-Hispanic whites and 41% Hispanics). Discontinuations were driven by research burden, personal issues, and unspecified loss to follow-up. Non-Hispanic whites had higher depression scores during the follow-up period. African Americans had fewer side effects.

Conclusions  CATIE results did not show disparities favoring non-Hispanic whites. CATIE may have provided state-of-the-art treatment and thus reduced disparate treatments observed in community clinics. African Americans discontinued even after consideration of socioeconomic differences. Why perphenazine and ziprasidone may be less effective with Hispanics should be explored.

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Table 1Demographic characteristics of non-Hispanic whites, African Americans, and Hispanics in CATIEa
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a Clinical Antipsychotic Trials of Intervention Effectiveness

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b Percentages adjusted for missing data

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Table 2Baseline illness characteristics for non-Hispanic whites, African Americans, and Hispanics in CATIEa
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a Clinical Antipsychotic Trials of Intervention Effectiveness

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b Clinical Global Impression scale. Possible scores range from 1 to 7, and higher scores indicate greater illness severity.

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c Positive and Negative Syndrome Scale. Possible scores range from 30 to 210, and a higher score indicates more severe psychopathology.

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d Calgary Depression Rating Scale. Possible scores range from 0 to 27, and a higher score indicates greater depression.

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e Possible scores range from 0 to 100, with higher scores indicating better emotional health.

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f Possible scores range from 1 to 7, with higher scores indicating better functioning.

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g Structured Clinical Interview for DSM-IV, a clinician-administered semistructured interview for DSM-IV axis I diagnoses.

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h Does not include obsessive-compulsive disorder

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Table 3Kaplan-Meier estimates of proportion discontinuing antipsychotic medication for lack of efficacya
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a Evaluations of racial-ethnic groups' responses to medication were done by strata to maximize the N in each analysis. The proportions are the final estimates of failure rates based on separate Kaplan-Meier survival analyses for each stratum.

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b Accelerated failure time analysis comparisons for all randomly assigned participants. Total N=977: 500 non-Hispanic whites, 349 African Americans, and 128 Hispanics. Medication χ2=24.1, df=2, p≤.001; race-ethnicity χ2=6.6, df=2, p=.037; medication × ethnicity interaction, χ2=6.9, df=4, p=.142

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c Accelerated failure time analysis comparisons versus perphenazine (excluding patients with tardive dyskinesia). Total N=1,031: 522 non-Hispanic whites, 377 African Americans, and 132 Hispanics. Medication χ2=22.1, df=3, p≤.001; race-ethnicity χ2=6.0, df=2, p=.051; medication × ethnicity interaction, χ2=15.3, df=6, p=.018

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d Accelerated failure time analysis comparisons versus ziprasidone (excluding patients receiving antipsychotics before CATIE added ziprasidone). Total N=708: 365 whites, 261 African Americans, and 82 Hispanics. Medication χ2=9.3, df=3, p=.025; race-ethnicity χ2=6.9, df=2, p=.032; medication × ethnicity interaction, χ2=13.2, df=6, p=.039

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e Accelerated failure time analysis comparisons of perphenazine versus ziprasidone (excluding patients with tardive dyskinesia and patients receiving antipsychotics before CATIE added ziprasidone). Total N=288: 156 non-Hispanic whites, 107 African Americans, and 25 Hispanics. Medication χ2=.05, df=1, p=.83; race-ethnicity χ2=13.8, df=2, p=.001; medication × ethnicity interaction, χ2=1.7, df=2, p=.42

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Table 4Secondary outcomes for non-Hispanic whites, African Americans, and Hispanics in CATIEa
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a Means of average scores during the 18-month follow-up period of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). Means are adjusted by baseline scores and visit type (scheduled versus unscheduled).

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b Positive and Negative Syndrome Scale (PANSS). Possible scores range from 30 to 210, and a higher score indicates more severe psychopathology.

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c Calgary Depression Rating Scale. Possible scores range from 0 to 27, and a higher score indicates greater depression.

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d Possible scores range from 0 to 100, with higher scores indicating better emotional health.

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e Possible scores range from 1 to 7, with higher scores indicating better functioning.

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f Abnormal Involuntary Movement Scale. Possible scores range from 0 to 28, with higher scores indicating more severe side effects. Just the first seven items on the scale were used for CATIE outcome analyses.

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g Possible scores range from 0 to 9, with higher scores indicating more severe side effects. Just the first three items were used for CATIE outcome analyses.

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h Simpson-Angus Extrapyramidal Side Effect Scale. Possible scores range from 0 to 24, with higher scores indicating more severe side effects. For CATIE outcome analyses the mean of items 1–6 was calculated.

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i Based on predicted scores from Tobit regression adjusting for pre-CATIE hospitalization days.

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