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Articles   |    
Psychiatrists’ Judgments About Antipsychotic Benefit and Risk Outcomes and Formulation in Schizophrenia Treatment
Michael A. Markowitz, M.D., M.S.P.H.; Bennett S. Levitan, M.D., Ph.D.; Ateesha F. Mohamed, M.A.; F. R. Johnson, Ph.D.; John F. P. Bridges, Ph.D.; Larry Alphs, M.D., Ph.D.; Leslie Citrome, M.D., M.P.H.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300290
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When this work was done, Dr. Markowitz was with Janssen Scientific Affairs, LLC, Titusville, New Jersey, where Dr. Alphs is affiliated. Dr. Markowitz is now with the CNS Practice Division, UCB Biosciences, Inc., Raleigh, North Carolina (e-mail: mmarko8@yahoo.com). Dr. Levitan is with Janssen Research and Development, Titusville, New Jersey. When this work was done, Ms. Mohamed was with the Division of Health Preference Assessment, RTI Health Solutions, Research Triangle Park, North Carolina. Ms. Mohamed is now with Bayer Healthcare Pharmaceuticals, Inc., Whippany, New Jersey. Dr. Johnson is with the Center for Clinical and Genetic Economics, Duke University, Durham, North Carolina. Dr. Bridges is with the Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Citrome is with the Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objective  The objectives were to quantify psychiatrists’ judgments of the benefits and risks of antipsychotic treatments of patients with schizophrenia and to evaluate how patient adherence history affects these judgments.

Methods  Weights assigned by respondents to risks, benefits, and alternative drug formulations in the treatment of schizophrenia were assessed via a Web-based survey by using a discrete-choice experiment. Respondents in the United States and the United Kingdom chose among alternative scenarios characterized by various levels of improvement in positive symptoms, negative symptoms, social functioning, weight gain, extrapyramidal symptoms (EPS), hyperprolactinemia, and hyperglycemia and by formulation. The effect of patient adherence history on respondents’ judgments was also assessed. Random-parameters logit and bivariate probit models were estimated.

Results  The sample included 394 psychiatrists. Improvement in positive symptoms from “no improvement” to “very much improved” was the most preferred outcome over the range of improvements included and was assigned a relative importance score of 10. Other outcomes, in decreasing order of importance, were improvement in negative symptoms from “no improvement” to “very much improved” (5.2; 95% confidence interval [CI]=4.2–6.2), social functioning from “severe problems” to “mild problems” (4.6, CI=3.8–5.4), no hyperglycemia (1.9, CI=1.5–2.4), <15% weight gain (1.5, CI=.9–2.0), no hyperprolactinemia (1.3, CI=.8–1.6), and no EPS (1.1, CI=.7–1.5). As adherence decreased, formulation became more important than modest efficacy changes and injections were preferred to daily pills (p<.05).

Conclusions  Psychiatrists favored treatments that primarily improve positive symptoms. Choice of formulation became more important as likely adherence declined.

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Figure 1 Relative importance assigned to schizophrenia treatment attributes by 394 psychiatrists

a Extrapyramidal symptoms

Figure 2 Relative importance assigned by 394 psychiatrists to attributes of treatment for adherent and nonadherent patients with schizophrenia

a Extrapyramidal symptoms

b In a typical week compared with initial presentation

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Table 1Attributes and levels of improvement for the choice questions used in a survey of U.S. and U.K. psychiatrists
Table Footer Note

a Levels developed with use of the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression scale, both of which are used in clinical trials to measure improvements in schizophrenia symptoms. Although changes in PANSS positive and negative subscores are well understood by clinical trial experts, these numeric changes are likely to be less familiar to most practicing clinicians. To accommodate psychiatrists’ differing knowledge of the PANSS, these attribute definitions included textual labels (“very much improved”), PANSS subscore changes, and short examples.

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