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‘Striking’ Changes in Psychiatrists’ Antipsychotic Prescribing Practices
Preferences for specific antipsychotics among psychiatrists and other physicians changed significantly between 2002 and 2007, new research shows.
Although some physicians remained heavily concentrated in their antipsychotic prescribing, sticking with a few agents, others diversified their choice of agent, with “striking” differences by specialty.
Psychiatrists were most likely to diversify, and their average annual volume of antipsychotic prescriptions was more than 7 times that of the other physicians, the study showed.
Led by Julie Donohue, PhD, from the Graduate School of Public Health, University of Pittsburgh, Pennsylvania, the study was published online December 16 in Psychiatric Services.
Decline in First-Generation Drugs
The investigators used the IMS Health Xponent database to assess changes in antipsychotic prescribing practices from 2002 to 2007 among 7399 physicians, including 2437 psychiatrists, 4398 generalists, and 564 neurologists or pediatricians.
“We measured changes in the concentration of prescribing in the wake of high-profile FDA safety warnings, consensus statements issued from professional societies, a landmark comparative effectiveness study, expanded approval of new indications and off-label use, highly publicized litigation against second-generation antipsychotic manufacturers, and policy changes regarding coverage of these drugs,” the investigators write.
“We hypothesized that evidence of substantial heterogeneity in risk profiles might have induced physicians to diversify their choice of agent, and we found evidence of this effect, particularly among psychiatrists,” they add.
The rise in antipsychotic polypharmacy during the study period may have increased the diversity of agents prescribed and contributed to this finding.
Overall, physicians’ reliance on a preferred antipsychotic agent, as measured by the concentration of their prescribing, declined between 2002 and 2007, particularly among psychiatrists, according to the data.
The investigators uncovered “dramatic” changes in physicians’ preferred antipsychotics between 2002 and 2007. In 2002, few physicians favored a first-generation antipsychotic, with only 3.7% preferring haloperidol, 0.6% perphenazine, and 23.8% one of the other first-generation antipsychotics.
Among second-generation antipsychotics, in 2002, more than two thirds of physicians favored 3 drugs ― risperidone (30.2%), olanzapine (29.9%), and quetiapine (9.5%) ― whereas only 1.8% preferred clozapine, and 0.5% ziprasidone.
By 2007, a vast majority of physicians had shifted their preference to a different agent, the investigators found.
Among the first-generation antipsychotics, even a smaller proportion of physicians favored haloperidol (2%) or perphenazine (0.5%) in 2007 than in 2002.
As for the second-generation agents, the share of physicians preferring olanzapine dropped from 29.9% in 2002 to 10.3% in 2007 (P < .001). A decline in preference for risperidone was also noted, from 30.2% of physicians in 2002 to 23.1% in 2007.
Biggest Jump in Quetiapine
The largest increase in the share of physicians preferring a drug was for quetiapine, which jumped from 9.4% in 2002 to 44.5% in 2007 (P < .001). Increases in the share of physicians preferring ziprasidone and aripiprazole were also noted, although the absolute share was low.
In a subset of 2215 physicians who favored olanzapine over other antipsychotics in 2002, the investigators noticed a “particularly dramatic shift” in preferences. More than half (52.8%) of all prescriptions filled by patients of these physicians were for olanzapine in 2002.
However, beginning in the second quarter of 2003, these physicians cut their use of olanzapine, so that by 2007, it accounted for only 17.8% of prescriptions. Most of the shift was to prescriptions for quetiapine and risperidone.
Dr. Donohue and colleagues note that although they deliberately selected the study period to coincide with key events, such as FDA warnings on atypical antipsychotics, other underlying factors may have had an effect on prescribing behavior, and they cannot infer a causal relationship between the release of studies or warnings and prescribing decisions.
And because all physicians were equally “exposed,” and because they lacked a comparison group, the investigators were unable to tease out the effects on prescribing behavior of any single event.
They also lacked patient-level information, which means they could not determine the reason for antipsychotic use or the severity of illness or distinguish between new treatment starts and ongoing treatment episodes.
The study was supported by the National Institute of Mental Health, the Agency for Healthcare Research and Quality, and the Robert Wood Johnson Foundation. Dr. Donohue has disclosed no relevant financial relationships. One author has received research grants from Pfizer and Sanofi. Two authors serve on the Academic Advisory Committee for the Health Services Research Network at IMS Health Inc (uncompensated).
Psychiatr Serv. Published online December 16, 2013. Abstract