Thursday 14 November 2013

Patient‐held clinical information for people with psychotic illnesses

User‐held information is where the ill person holds personal information about their care. Such records are becoming the norm in many settings and are becoming more popular with patients. This is especially the case where the person concerned is not in hospital and receives care from more than one professional. Providing people with information about their care is thought to increase their feelings of involvement in their treatment and aims to increase people’s satisfaction and participation with services, ensure early treatment and prevent hospital admission.

The value of user‐held personal information for those with severe mental illnesses is not known however and research evaluating the effectiveness is rare. Some research suggests that while many people decline the offer of a user‐held record, the majority of those who carry their records report this to be useful.

Based on a search in 2011, this review includes four trials with a total of 607 people and evaluates the effects of user‐held information for people with severe mental illness. In the main, the number of relevant studies is low, with poor reporting of some outcomes. Based on moderate quality evidence, the review found that user‐held information did not decrease hospital admissions, and did not decrease compulsory admissions or encourage people with severe mental illness to attend appointments (when compared to treatment as usual). Other important outcomes, such as satisfaction with care, costs and effect on mental health, were not available due to the limited quality of the four studies. There is therefore a gap in knowledge and evidence regarding user‐held information for people with severe mental health problems. Further evidence is also required on the different types of user‐held information (for example, if it involves the mental health team and what type of information is included in the record). Large‐scale, well‐conducted and well‐reported studies are required to assess the effects of user‐held information for people with mental illness. Two important randomised studies are currently taking place. For the present, despite a gap in evidence, user‐held information is low cost and acceptable to patients, so its use is likely to grow. However, it cannot be assumed that user‐held information is of benefit to people and is cost‐effective without further large‐scale, well‐conducted and well‐reported trials.

Haloperidol dose for the acute phase of schizophrenia

Schizophrenia is a mental illness where the person often experiences both positive symptoms (such as hearing voices, seeing things and having strange beliefs) and negative symptoms (such as tiredness, apathy and loss of emotion). Antipsychotic drugs are used to treat schizophrenia. The antipsychotic drug, haloperidol, is one of the most frequently used drugs worldwide for people with schizophrenia.

The benefits of antipsychotic drugs, such as haloperidol, need to be weighed against their tendency for causing debilitating side effects (such as movement disorders, weight gain, lack of drive) and in some cases an increased likelihood of physical illnesses such as diabetes and heart disease. These debilitating side effects may mean that people stop taking their medication, which can lead to relapse and going into hospital. It is, therefore, important to find a tolerable and effective dose of haloperidol, which helps control the symptoms of schizophrenia but with fewer side effects.

The main aim of this review was to determine the best range of doses of haloperidol for the treatment of schizophrenia. Nineteen trials were included that compared varying doses of haloperidol. Despite over 30 years of trials, data on the effects of differing doses of haloperidol are sparse and poorly reported. This is especially so for the lower dose ranges generally used for the treatment of schizophrenia today. However, lower doses of haloperidol may be just as effective as higher doses but result in fewer side effects. This review also suggests that an important bias against haloperidol may exist in modern trials comparing new drugs with haloperidol. Results are not conclusive and are based on small, short studies of limited quality.

The authors of the review note that it would be understandable if psychiatrists were cautious about prescribing doses above 7.5 mg a day and if people with schizophrenia did not want to take higher dosages. Further research is needed to assess the tolerability and effectiveness of lower doses. Low doses of haloperidol may be just as good as higher doses, but with fewer side effects.

Atypical antipsychotic medications for adolescents with psychosis

Schizophrenia and other serious mental illnesses often begin in adolescence, and treatment of adolescents with psychosis usually involves use of antipsychotic drugs. Newer drugs (atypical antipsychotics) are more popular than older ones (typical antipsychotics). However, this determination is based on the generalisation of adult treatment to a younger age group, with evidence from studies on adults generally guiding the treatment of adolescents. Adolescents may respond differently to medication compared with adults. This review looks at evidence derived from trials in which the participants are adolescents receiving atypical or typical antipsychotics or a placebo (dummy treatment) and/or high or low doses of medication. A total of 13 trials consisting of 1112 people between 13 and 18 years of age are included. Most studies were short‐term trials (completed within 12 weeks). In the main, no convincing evidence shows that newer drugs (atypical antipsychotics) are better than older ones (typical antipsychotics) in terms of their ability to treat the symptoms of psychosis. However, newer drugs may be more acceptable for young people to take because they produce fewer side effects in the short term. Furthermore, very little evidence is available to support the superiority of one atypical antipsychotic over another atypical antipsychotic. The nature of side effects also differs markedly between medications. For example, treatment with olanzapine, risperidone and clozapine is associated with weight gain, but aripiprazole is not associated with weight gain. Some evidence indicates that adolescents respond better to standard‐dose as opposed to lower‐dose risperidone. However, for aripiprazole and ziprasidone, a lower dose and a standard dose may be equally effective. Longer, clearer and more detailed research trials that use systematic ways of reporting and comparing the side effects of different antipsychotic drugs are much needed. So too is a research focus on other important outcomes such as hospital admission, service use, costs, behaviour change and possible improvements in people’s thinking. Until such research is completed, very little evidence suggests that newer drugs (atypical antipsychotics) are better than older drugs (typical antipsychotics) for the treatment of adolescents with schizophrenia.