Attitudes to antipsychotics: a multi-site survey of Canadian psychiatry residents
| Published date | 05 November 2018 |
| DOI | https://doi.org/10.1108/JMHTEP-03-2018-0019 |
| Date | 05 November 2018 |
| Pages | 318-338 |
| Author | Anees Bahji,Neeraj Bajaj |
| Subject Matter | Health & social care,Mental health,Mental health education |
Attitudes to antipsychotics: a multi-site
survey of Canadian psychiatry residents
Anees Bahji and Neeraj Bajaj
Abstract
Purpose –The purpose of this paper is to identify the training needs of the next generation of psychiatrists,
and barriers in prescribing first-generation antipsychotics (FGAs), long-acting injectable (LAIs) antipsychotics
and clozapine.
Design/methodology/approach –An electronic survey was sent to psychiatry residents (N¼75/288,
26 percent) at four Canadian residency programsin late December 2017. The survey was based on an instrument
originally developed at the University of Cambridge and consisted of 31 questions in 10 content domains.
Findings –Nearly 80 percent of residents were aware that FGAs and second-generation antipsychotics
(SGAs) have similar efficacy. However, extra-pyramidal symptoms and lack of training experience were the
leading concerns associated with the prescribing of FGAs. Although over 90 percent of residents felt
confident about initiating an oral SGA as a regular medication, only 40 percent did so with FGAs. Confidence
with initiating LAIs and clozapine was 60 and 61 percent, respectively.
Practical implications –The survey highlights the need for better training in the use of FGAs, clozapine
and LAIs. These medications can be effectively used in providing patients with the most appropriate
evidence-based treatment options to improve treatment outcomes, while ensuring that these resources
are not lost to the future generations of psychiatrists.
Originality/value –The survey may be the first of its kind to assess antipsychotic prescribing attitudes in
Canadian psychiatry residents in multiple sites.
Keywords Training, Education, Schizophrenia, Drug therapy
Paper type Research paper
Introduction
Antipsychotics are the mainstay of treatment for schizophrenia and other psychotic disorders
(Abidi et al., 2017). These include first-generation antipsychotics (FGAs), second-generation
antipsychotics (SGAs), long-acting injection (LAIs) antipsychotics and clozapine (Remington
et al., 2017). In 2005, the Clinical Antipsychotics Trials of Intervention Effectiveness (CATIE) was
published in the New England Journal of Medicine (Lieberman et al., 2005). In this study, which
was a powerful double-blind, randomized controlled trial where patients with chronic
schizophrenia were assigned to treatment with four SGAs (olanzapine, quetiapine, risperidone
or ziprasidone) or perphenazine (an FGA), most patients discontinued their treatment due to
either a lack of efficacy or intolerability. A year later, the Cost Utility of the Latest Antipsychotic
Drugs in Schizophrenia Study (CUtLASS 1), by way of another multicentre, double-blind,
randomized controlled trial, demonstrated that non-clozapine SGAs had no clear advantage of
the FGAs ( Jones et al., 2006).
Although some have criticized the methodology and generalizability of these two major studies
(Lewis and Lieberman, 2008), CATIE and CUtLASS are still the two largest non-commercial
clinical trials comparing FGAs and SGAs directly for the treatment of schizophrenia. However,
despite the research evidence from these two studies, current international psychiatric practices
are dominated by the use of SGAs (Bret et al., 2009; Koranek et al., 2012; Park et al., 2014),
while the use of FGAs, LAIs and clozapine appears to be less popular (Bret et al., 2009; Koranek
et al., 2012; Park et al., 2014; Dibben et al., 2016; Silveira et al., 2015).
Received 31 March 2018
Revised 2 May 2018
Accepted 9 October 2018
The authors have no potential
conflicts of interest and no financial
support to disclose. In summary,
Dr Anees Bahji and Dr Neeraj Bajaj
both report no competing
interests. There are no further
acknowledgments at this time.
Anees Bahji and Neeraj Bajaj
are both based at the
Department of Psychiatry,
Queen’s University, Kingston,
Canada.
PAGE318
j
THE JOURNAL OF MENTALHEALTH TRAINING, EDUCATION AND PRACTICE
j
VOL. 13 NO. 6 2018, pp.318-338, © Emerald Publishing Limited, ISSN 1755-6228 DOI 10.1108/JMHTEP-03-2018-0019
There are several potential explanations for this trend toward SGAs. The influence of
pharmaceutical industry sponsorship appears to play a role, as industry-funded drug studies
have been linked with the selective reporting of favorable outcomes with SGAs (Lexchin et al.,
2003; Schott et al., 2010). As well, although the magnitude of publication bias for antipsychotic
trials may be smaller than that observed for antidepressant trials (Woods et al., 2001), it continues
to blur distinctions between effective and ineffective antipsychotics in the absence of access to
regulatory agency data (Turner et al., 2018).
Regarding clozapine, despite research demonstrating its superior efficacy (Jones et al., 2006;
Lewis and Lieberman, 2008; Kane et al., 1988), the fear of clozapine’s adverse effects (so called
“clozaphobia”) is linked with its significant underutilization (Silveira et al., 2015; Agarwal et al.,
2011; Cetin, 2014; Cetin and Kose, 2016; Joober and Boksa, 2010). As well, recent studies
suggest that the attitudes and experience of practicing psychiatrists toward clozapine are a major
contributing factor (Dibben et al., 2016; Kane et al., 1988; Cetin, 2014).
Likewise, despite the evidence of effectiveness, LAIs are also significantly underused, and are
received by fewer than 20 percent of patients with schizophrenia (Kirschner et al., 2013; Jaeger
and Rossler, 2010; Subotnik et al., 2015; Bosanac and Castle, 2015; Manchanda et al., 2013).
As with clozapine, discontinuation of or failure to initiate an LAI are often due to the attitudes of the
treating psychiatrist ( Jaeger and Rossler, 2010).
In line with this evidence, the recently published Canadian guidelines for the treatment of
schizophrenia do not recommend one group of antipsychotics over the other, and advocate for
the use of LAIs and clozapine (Canadian Psychiatric Association –Clinical Practice Guidelines,
2005). However, despite our best efforts, current trends in prescribing may lead to the loss of
FGAs, LAIs and clozapine, which are three of the most important tools in our limited therapeutic
armamentarium (Dibben et al., 2016). Can anything be done?
The answer to this question may lie in addressing the training needs of the next generation of
psychiatrists –residents and trainees. Some European studies have posited that a lack of training
experience with FGAs, LAIs and clozapine limits their use ( Jauhar et al., 2012). However, such
studies have yet to be replicated in North American samples. In this study, we electronically
surveyed Canadian psychiatry trainees on their experience, knowledge and attitudes regarding
antipsychotics for individuals with schizophrenia. Our primary study aims are to identify the
current prescribing behaviors of the next generation of psychiatrists, and to identify some of the
barriers in prescribing FGAs, LAIs and clozapine.
Methods
We surveyed Canadian psychiatry residents in four different psychiatry residency training
programs using an electronic questionnaire that was distributed in December 2017. Psychiatry
residents were recruited after obtaining written permission from the respective program directors
and chief residents of each program. The survey asked residents questions about their
knowledge, confidence and prescribing behaviors regarding the use of FGAs, SGAs, LAIs and
clozapine for patients with schizophrenia (see Appendix). Subjects were only allowed to
participate in the survey if they provided explicit electronic informed consent after reviewing the
complete study description and protocol, which was built into the survey tool itself. Subjects were
also allowed to exit the survey at any point in time and were informed that they would not be
identified in any way based on their responses to the survey.
The survey itself was based on an instrument originally developed at the University of Cambridge,
consisting of 31 questions in ten content domains, with 4 demographic questions (Dibben et al.,
2016). The survey was set up electronically via the Qualtrics Survey Tool Database (Qualtrics,
2017) and distributed to all psychiatry residents in the four residency programs. An electronic link
was shared with the main contact for each program, who later distributed the link to the resident
pool. The survey tool can be found in the Online Supplement.
The surveyed sample did excluded residents in other specialties who were undertaking
psychiatry rotations, or psychiatry fellows. Following the initial survey distribution, we sent two
e-mail reminders to the residents, and then closed the survey after three months. Data analysis
VOL. 13 NO. 6 2018
j
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATIONAND PRACTICE
j
PAGE319
To continue reading
Request your trial