Michael J. Sernyak

From clinical trials to real-world practice: use of atypical antipsychotic medication nationally in the Department of Veterans Affairs.

Background.Although clinical trials evaluate pharmacotherapeutic interventions under highly controlled conditions, there remains a need to evaluate medication use in actual practice. Methods.Patients prescribed atypical antipsychotic medications in the VA system during a 4-month period in 1999 (n = 73,981) were classified into 32 groups on the basis of clinical diagnosis and recent level of inpatient use. Variation was e-amined across groups in drug costs, agents, dosages, and duration of use. The potential impact of these medications on VA costs was estimated by calculating medication costs and subtracting estimated inpatient savings. Results.A majority of patients were diagnosed with schizophrenia (57.2%), but substantial off-label use of these medications to treat other psychiatric illnesses was also evident (42.8%). Compared with published trials reporting average annual costs from

Normal neurocognitive performance after extended practice in patients with schizophrenia

3,000 to

Impact of clozapine prescription on inpatient resource utilization.

7,000, average annualized pharmacy costs were only

Benzodiazepine use in posttraumatic stress disorder among veterans with substance abuse.

1,395 per patient because of a 58.5% VA price discount; relatively low dosing, especially for people with diagnoses other than schizophrenia; and medication prescription coverage for only 75% of the days in the study period. The sample averaged only 6.96 inpatient days; as a result, potential inpatient savings were limited. Assuming 0% to 18% inpatient savings, annual net drug costs are estimated to range from

Naltrexone augmentation of neuroleptics in schizophrenia

500 to

Antipsychotic Use in the Treatment of Outpatients With Schizophrenia in the VA From Fiscal Years 1999 to 2006

1,152 per patient. Conclusions.Medication costs in actual practice can be substantially lower than in clinical trials. Atypical antipsychotic medications in actual VA practice incur net costs estimated at

Use of second-generation antipsychotic agents for sleep and sedation: a provider survey.

500 to

Prevalence of concomitant oral antipsychotic drug use among patients treated with long-acting, intramuscular, antipsychotic medications.

1,152 per patient per year with substantial variation across clinical subgroups.

Consistency of atypical antipsychotic superiority to placebo in recent clinical trials

This study evaluated new methods for improving the performance of patients with schizophrenia on specific neurocognitive tasks. Patients (n = 22) practiced sustained perceptual, memory and motor tasks 5 times/week for 10 weeks. Tasks were initially easy enough for patients to do well, but were made gradually more difficult over the 10 weeks. Patients received base pay and performance-based monetary supplements. No coaching or ongoing instruction was provided, and performance gains were assumed to depend upon implicit learning. High functioning healthy controls (n = 5) were given the same tasks at difficulty levels comparable to those achieved by patients after 10 weeks of practice. After 10 weeks of practice, 16 of the 22 patients performed as well or better than the best control on the perceptual and memory tasks, and 11 patients performed within the range of control subjects on the motor task. Half of the patients retested 6 months after training maintained supranormal performance, while the others showed marked performance declines. Patients with schizophrenia appear to have greater potential for neurocognitive improvement, and potentially for employment, than generally appreciated.

Stakeholders’ Perspectives on Community-Based Participatory Research to Enhance Mental Health Services

Although clozapine has been demonstrated to be clinically superior to typical neuroleptics in refractory schizophrenia, it is also more expensive. It had been hoped that the increased costs associated with its use would be offset by decreases in the utilization of other expensive resources, especially inpatient care. All patients who had clozapine initiated during an inpatient hospitalization within the VA for schizophrenia over a 4-year period (N = 1415) were matched with a comparison group (N = 2830) on key service utilization variables and other possible confounding demographic and clinical variables using propensity scoring—an accepted statistical method, although still relatively little used in psychiatry. By using centralized VA databases, subsequent inpatient resource utilization for the 3 years after index discharge was examined. Veterans exposed to clozapine while inpatients recorded 33 (36%) more inpatient days in the subsequent 3 years after discharge than the comparison group (124 ± 190 days vs. 91 ± 181 days, p = .0002). When all patients exposed to clozapine were divided according to whether they had received 1 year of clozapine treatment after discharge, those that received less than 1 year’s treatment recorded significantly more inpatient days than either those maintained on clozapine or controls. These results suggest that in actual practice clozapine treatment may cost substantially more than treatment with conventional neuroleptics.