G. Papageorgiou

Improving treatment adherence in your patients with schizophrenia: the STAY initiative.

Partial and non-adherence to medication is a common problem in schizophrenia, leading to an increased risk of relapse, increased likelihood of hospitalization and poorer long-term outcomes. In contrast, continuous medication in the treatment of schizophrenia is associated with positive outcomes, including improved clinical status, improved quality of life and functioning, and reduced risk of relapse and rehospitalization. Strategies aimed at improving medication adherence are therefore key for patients to achieve their treatment goals. In an attempt to address the issues of partial/non-adherence to antipsychotic medication in schizophrenia, a group of psychiatrists convened to discuss and develop a set of principles aimed at helping patients adhere to their medication. These principles were then refined and developed into the STAY (the Six principles to improve Treatment Adherence in Your patients) initiative following presentation to a wider group of psychiatrists from across Europe. This manuscript summarizes these principles and explains the rationale for their selection. These principles are: (1) recognizing that most patients with schizophrenia are at risk of partial/non-adherence at some time during the course of their illness; (2) the benefits of a good therapeutic alliance for identifying potential adherence issues; (3) tailored treatment plans to meet an individual’s needs, including the most suitable route of delivery of antipsychotic medication; (4) involving family/key persons in care and psychoeducation of the patient, assuming the patient agrees to this; (5) ensuring optimal effectiveness of care; and (6) ensuring continuity in the care of patients with schizophrenia. The application of these six principles should help to raise awareness of and address poor patient adherence, as well as generally improving care of patients with schizophrenia. In turn, this should lead to improved overall clinical outcomes for patients receiving long-term treatment for schizophrenia.

Country differences in patient characteristics and treatment in schizophrenia: data from a physician-based survey in Europe

Schizophrenia is a frequent psychiatric disorder whose prevalence appears to be relatively stable across different patient groups. However, attitudes to care and resources devoted to mental health care may differ between countries. The objective of this analysis was to compare sociodemographic and psychopathological features of patients, antipsychotic treatment and frequency of hospitalisation between four European countries (Germany, Greece, Italy and Spain) collected as part of a large survey of the characteristics of patients with schizophrenia. The survey was conducted by structured interview of 744 randomly-selected psychiatrists in four European countries who recruited 3996 patients. Information on 39 variables was collected. A number of between-country differences were observed which tended to distinguish Germany on the one hand, from the Mediterranean countries, and Greece in particular, on the other. While demographic features and clinical features were essentially similar, more patients in Germany were considered to have severe disease by their psychiatrist (59.0% versus 35.9% in Greece) and to be hospitalised (49.3% versus 15.0%). 46.7% of German patients were living alone compared to less than 20% in the Mediterranean countries and 50.2% were living with their family (versus over 70% elsewhere). Smoking and addictive behaviours were more frequently reported for patients in Spain. With regard to empirically derived patient subgroups, Subgroup 2, corresponding to well-integrated and autonomous patients with mild to moderate disease severity was most highly represented in Greece (23.6% of patients compared to less than 10% elsewhere) elsewhere, Subgroup 6 (poorly-integrated patients with moderately severe disease who require caregiver support) was under-represented in Germany (4.5% versus over 17% elsewhere). Patterns of treatment were essentially similar, although quetiapine was more frequently prescribed and paliperidone less frequently prescribed in Germany than elsewhere. Reasons for treatment choice were comparable between countries, primarily related to good tolerability and control of positive symptoms. The differences observed may be attributed to differences in mental health care resource provision, socio-cultural or educational differences or to resource issues.

Individualizing antipsychotic treatment selection in schizophrenia: characteristics of empirically derived patient subgroups

Treatment of schizophrenia with antipsychotic drugs is frequently sub-optimal. One reason for this may be heterogeneity between patients with schizophrenia. The objectives of this study were to identify patient, disease and treatment attributes that are important for physicians in choosing an antipsychotic drug, and to identify empirically subgroups of patients who may respond differentially to antipsychotic drugs. The survey was conducted by structured interview of 744 randomly-selected psychiatrists in four European countries who recruited 3996 patients with schizophrenia. Information on 39 variables was collected. Multiple component analysis was used to identify dimensions that explained the variance between patients. Three axes, accounting for 99% of the variance, were associated with disease severity (64%), socioeconomic status (27%) and patient autonomy (8%). These dimensions discriminated between six discrete patient subgroups, identified using ascending hierarchical classification analysis. The six subgroups differed regarding educational level, illness severity, autonomy, symptom presentation, addictive behaviors, comorbidities and cardiometabolic risk factors. Subgroup 1 patients had moderately severe physician-rated disease and addictive behaviours (23.2%); Subgroup 2 patients were well-integrated and autonomous with mild to moderate disease (6.7%); Subgroup 3 patients were less well-integrated with mild to moderate disease, living alone (11.2%); Subgroup 4 patients were women with low education levels (5.4%), Subgroup 5 patients were young men with severe disease (36.8%); and Subgroup 6 patients were poorly-integrated with moderately severe disease, needing caregiver support (16.7%). The presence of these subgroups, which require confirmation and extension regarding potentially identifiable biological markers, may help individualizing treatment in patients with schizophrenia.

Strategies for successful clinical management of schizophrenia with ziprasidone

Importance of the field: This review addresses practical clinical issues related to the use of ziprasidone in the treatment of schizophrenia using information from clinical trials, unpublished data, manufacturers information, and input from an expert faculty of European psychiatrists with extensive experience of the use of ziprasidone, both in clinical trials and in everyday clinical practice. Areas covered in this review: A Medline search of published data (1998 – 2010) was carried out, together with a review of unpublished data and manufacturers information. In addition, expert opinion was sought from psychiatrists with extensive experience of ziprasidone in the treatment of schizophrenia in clinical settings across Europe. What the reader will gain: This review has been undertaken to determine how the information from clinical trials can be optimally translated into ‘real-life’ practice and to establish how a decade of experience with ziprasidone in clinical practice can inform its optimal use to maximize effectiveness and minimize side effects. Take home message: Effective use of ziprasidone in everyday clinical practice usually requires rapid titration to doses in the range of 120 – 160 mg/day and administration with proper meals, thereby achieving the high levels of schizophrenia symptom control reported in clinical trials. Additional guidance is provided about effective management of side effects, and appropriate coadministration of benzodiazepines and other agents, to achieve desired outcomes.

Switching among antipsychotics in everyday clinical practice: focus on ziprasidone.

Abstract Objectives: This article addresses points to consider when switching patients to the second-generation antipsychotic (SGA), ziprasidone, in everyday clinical practice: 1) the pharmacologic properties of the pre-switch antipsychotic and of ziprasidone; 2) switch and dosing strategies to ensure maintenance or attainment of efficacy; 3) recognition and management of possible rebound effects of the pre-switch medication discontinuation; 4) recognition and management of potential side effects of ziprasidone; and 5) education and support for patients/caregivers concerning correct ziprasidone administration. Methods: A Medline search (up to July 7, 2010) identified studies in which adult patients with schizophrenia were switched to ziprasidone from another antipsychotic. In addition, based on their extensive clinical experience, an expert faculty of European psychiatrists provided advice on identifying patients who may be appropriate candidates for switching to ziprasidone, and on establishing optimal strategies for switching to ziprasidone in everyday clinical practice. Results: Data from 10 studies, in which 1395 patients were switched to ziprasidone, showed that switching from first-generation antipsychotics (FGAs) or SGAs generally resulted in maintenance or improvement of efficacy across all studied symptom domains, improvements in tolerability, and acute and long-term benefits regarding cardiometabolic parameters, including body weight. Maintenance of efficacy is most likely to be achieved using a plateau cross-titration strategy, with a rapid uptitration of ziprasidone to a dose range of 60 to 80 mg administered twice daily with food. Temporary coadministration of benzodiazepines, anticholinergics, or beta-blockers should be considered for the management of potential rebound effects. Conclusion: Optimal switching of patients with schizophrenia from FGAs or SGAs to ziprasidone requires careful attention to differences in the pharmacological profiles of the pre-switch medication and of ziprasidone, which may impact efficacy and tolerability. Good communication between the clinician and patient/caregiver about the goals of switching, the importance of adherence to the chosen switch strategy, and the correct administration of ziprasidone are essential.

Nurses’ perceptions of medication adherence in schizophrenia: results of the ADHES cross-sectional questionnaire survey:

Objectives: Poor adherence to antipsychotic treatment is a widespread problem within schizophrenia therapy with serious consequences including increased risks of relapse and rehospitalization. Mounting evidence supports the key roles that nurses play in monitoring patient progress and facilitating long-term treatment adherence. The Adherencia Terapéutica en la Esquizofrenia (ADHES) nurses’ survey was designed to assess the opinions of nurses on the causes and management of partial/nonadherence to antipsychotic medication. Methods: A questionnaire-based cross-sectional survey of 4120 nurses from Europe, the Middle East and Africa. Interpretation of results was based on a descriptive comparison of responses. Results: Nurses perceived 54% of patients seen in the preceding month to be partially/nonadherent to treatment. Most nurses (90%) reported some level of experience with administration of long-acting injectable (LAI) antipsychotics, with 24% of nurses administering >10 injections per month. The majority (85%) of nurses surveyed believed that improving adherence would improve patient outcomes. Nearly half (49%) reported that most of their patients depend on a family member or other nonprofessional carer to remind them to take their medication as prescribed. A similar proportion of nurses (43%) reported that most of their patients relied on a professional to remind them to take medication. Most nurses (92%) felt that ensuring continuous medication with LAI antipsychotics would yield long-term benefits for patients, but their opinion was that over a third of patients were unaware of LAI antipsychotic treatments. In a series of forced options, the strategy used most often by respondents (89%) to promote medication adherence was to build trusting relationships with patients while listening to and interpreting their needs and concerns. Respondents also rated this as the most effective strategy that they used (48%). Conclusion: Nurses are highly aware of adherence issues faced by their patients; further patient education on treatment options is needed.

P-1241 - Nurses' perceptions of assessment, causes and management of partial/non-adherence to medication: results of the EMEA adhes survey in schizophrenia

Introduction Partial/non-adherence to medication is common amongst patients with schizophrenia. Nurses play an important role in assessing and managing mental health problems and are often involved in helping patients manage and adhere to their medication. As such, the perception of nurses regarding the burden and potential causes of non-adherence is vital in addressing the adherence problem. Objectives The ADHES nurses survey collected opinions of nurses across the EMEA (Europe, Middle East and Africa) region. Aim To ascertain nurses perceptions of assessment, potential causes and management of partial/non-adherence to medication in patients with schizophrenia. Methods The survey was conducted from January-March 2010 in 29 countries across EMEA, comprising 14 questions addressing the issue of partial/non-adherence and the use of long-acting injectable (LAI) antipsychotic medication in patients with schizophrenia. Results Results were obtained from 4120 respondents. Nurses estimated high levels of partial/non-adherence (mean 54%) amongst patients with schizophrenia and 85% believed improving medication adherence would have a huge/sizable impact on patient outcomes. 93% believed that continuous medication with an LAI would have long-term benefits for patients with schizophrenia, and that many patients (mean 40%) would prefer LAI medication. Conclusion Nurses recognize the issue of partial/non-adherence to medication in patients with schizophrenia. Most nurses believe patients are well informed about LAI antipsychotics, however, approximately a third of nurses believe patients to be poorly informed. There is a need to address the problem of partial/non-adherence in clinical practice with a multidisciplinary approach to avoid suboptimal treatment outcomes in patients with schizophrenia.

Practical guidance for prescribing ziprasidone in acute manic or mixed episodes of bipolar I disorder

Introduction: Limited information is available on the clinical issues and strategies for optimal clinical usage of ziprasidone in the treatment of adult patients with acute manic or mixed episodes of bipolar disorder. Areas covered: To address those issues, information from clinical trials addressing the efficacy and tolerability of ziprasidone in acute bipolar mania was reviewed and supplemented with the input from an expert faculty of European psychiatrists with extensive experience in treating patients with bipolar mania, both in clinical trials and in everyday clinical practice. Expert opinion: Effective use of oral ziprasidone in the treatment of acute bipolar mania requires rapid titration to doses in the range 120 – 160 mg/day and administration with meals of ≥ 500 kcal. As in the clinical trials, temporary short-term use of benzodiazepines (in particular lorazepam for agitation or temazepam for insomnia) could be advisable. Available evidence from randomized clinical trials in combination with clinical experience supports the use of ziprasidone as one of the first-line effective and safe treatments for acute manic or mixed episodes associated with bipolar I disorder.

P03-276 - The EMEA ADHES survey in schizophrenia, an initiative to raise awareness of non-adherence to medication. demographics and methodology

Introduction Rates of non-adherence of up to 72% have being reported, in schizophrenia, depending on the method used and the patient population. Rates of approximately 59% over 1 year have been reported for individuals with a first episode. Patients who stop medication are almost five times more likely to experience relapse than adherent patients. Failure to adhere to medication can have a major impact on the course of illness and treatment outcomes. Objectives The EMEA (Europe, Middle East and Africa) ADHES schizophrenia survey was a survey of psychiatrists across the region, treating patients with schizophrenia, designed to canvas their perceptions of assessment, potential reasons and management for partial or non-adherence to medication amongst their patients. Aims To present methodology and demographics of the EMEA ADHES survey in schizophrenia. Methods The EMEA ADHES survey comprised 20 questions and was conducted in 36 countries across EMEA. In addition to recording the gender, age and practice setting of the respondents, questions related directly to the issue of partial-/non-adherence in patients with schizophrenia. Results The survey was conducted amongst psychiatrists (including neurologists with psychiatric background in Germany) from January - March 2010. Results were obtained from 4722 respondents. Psychiatrists perceived that during the previous month more than half of their patients (53%) were partially or non-adherent across all EMEA regions Discussion The EMEA ADHES schizophrenia survey is a large and geographically broad survey providing insight on psychiatrists’ perceptions of the assessment, causes and management of partial and non-adherence to medication.

P03-277 - The EMEA ADHES survey in schizophrenia: psychiatrists’ perceptions of the extent of assessment and management of partial and non-adherence to medication

Introduction Partial or non-adherence to medication is high amongst patients with schizophrenia. Rates of non-adherence of up to 72% have being reported depending on the method used and the patient population. Adherence is essential for optimal long-term patient outcomes in schizophrenia and failure to adhere to medication can have a major impact on the course of illness and treatment outcomes. Objectives The objective of the EMEA (Europe, Middle east and Africa) ADHES survey was to collect psychiatrists perceptions of the assessment, reasons and management of partial and non-adherence to medication. Aims The aim of this poster is to present psychiatrists perceptions collected in the EMEA ADHES survey. Methods The survey was devised to ascertain psychiatrists’ preferred methods of assessing adherence, their perceptions of the level of adherence, reasons for non-adherence and on strategies to improve adherence. Results Psychiatrists estimated that during the previous month more than half of their patients (53%) were partially or non-adherent. They estimated that as few as a third of patients who deteriorated after stopping medication was able to attribute this to their non-adherence. 76% of psychiatrists assessed adherence most frequently by asking their patient explicitly. Use of long-acting treatment was the preferred choice to address adherence problems for 62% of respondents. Discussion This EMEA-wide survey illustrates that while respondents recognised the relevance and importance of partial and non-adherence to medication, there remains a need for more proactive management of treatment adherence of patients with schizophrenia to reduce the frequency and consequences of relapse.