by Elisa Cascade; Amir H. Kalali, MD; and Peter Buckley, MD
Ms. Cascade is Vice President, Quintiles Inc./iGuard, Falls Church, Virginia; Dr. Kalali is Vice President, Global Therapeutic Group Leader CNS, Quintiles Inc., San Diego, California, and Professor of Psychiatry, University of California, San Diego; and Dr. Buckley is Professor and Chairman, Department of Psychiatry, Medical College of Georgia, Augusta, Georgia.
Psychiatry (Edgemont) 2009;6(3):15–17
Abstract
In this article, we investigate the range of treatments prescribed for schizoaffective disorder. The data show that the majority of those treated, 87 percent, receive two or more pharmaceutical classes. From a therapeutic class perspective, 93 percent of schizoaffective disorder patients receive an antipsychotic, 48 percent receive a mood disorder treatment, and 42 percent receive an antidepressant. An expert commentary is also included.
Key words
schizoaffective disorder, antipsychotic, antidepressant
Introduction
In this article, we investigate the range of treatments prescribed to patients with schizoaffective disorder.
Methods
We obtained data on product treatment regimens from SDI/Verispan’s Prescription Drug & Diagnosis Audit (PDDA) database from January 2008 to December 2008 for patients with schizoaffective disorder as defined by ICD-9 diagnosis code 295.7. PDDA captures data on disease states and associated therapy from 3,100 office-based physicians representing 29 specialties across the United States.
Results
According to practice data from SDI/Verispan, about one-half of patients presenting with schizoaffective disorder are women and two-thirds are under the age of 50. Figure 1 displays the number of classes of central nervous system (CNS) agents typically prescribed to treat schizoaffective disorder. As seen in Figure 2 , only 13 percent are prescribed one class of treatment. The majority receive two classes (48%) or three different classes (39%) of CNS treatment.
The most common regimen for the treatment of schizoaffective disorder is antipsychotic only (22%), followed closely by antipsychotic + mood agent (20%); antipsychotic + antidepressant (19%); and antipsychotic + mood + antidepressant (18%). All other regimens have a prevalence of three percent or lower.
From a therapeutic class perspective, 93 percent of schizoaffective disorder patients receive an antipsychotic. Mood disorder treatments and antidepressants are the next most commonly used CNS agents (48% and 42%, respectively). Prevalence of sleep agent and antianxiety treatment is six percent.
Expert Commentary
by Peter Buckley, MD
These are interesting data and should be considered in the context of our current-day understanding of schizoaffective disorder, a conditiion originally described in the 1940s. Schizoaffective disorder is a contentious nosological entity. It was originally conceived as a third, independent entity alongside schizophrenia and bipolar disorder. Its course is intermediary and considered to be more favorable than schizophrenia. Some have suggested that schizoaffective disorder, depressive subtype, resembles more schizophrenia in course and treatment while schizoaffective disorder, manic subtype, is more like a bipolar disorder over time. However, beyond some early, classic genetics studies and some long-term outcome studies, the aspects that would set it apart as an independent illness—namely biology, risk, course, and treatment—have rarely been studied with any methodological rigor. In addition, pharmacological studies do not focus on schizoaffective disorder alone, and what we know about the drug treatment of schizoaffective disorder comes from analyses of large trials in patients with schizophrenia that have included a subset of patients with schizoaffective disorder.
Another complicating factor is that, in the absence of clearly delineated features and course of this condition, schizoaffective disorder is apt to be mis/overdiagnosed. For example, it is well known—and entirely logical—that people with schizophrenia become depressed over the course of their illness. This comorbidity, common in schizophrenia,[1] is ripe to be misconstrued and then ‘labelled’ as schizoaffective disorder. This can easily happen as doctors often do not have the time to go back over years of course of illness so as to meticulously chart the pattern of mood symptoms in a patient with chronic schizophrenia. Additionally, in our mental health system, patients are more likely to be followed over time by several doctors sequentially rather than to have the same doctor for many years. It is also observed that when a diagnosis is made by one doctor, it tends to be retained over time. So if one doctor calls the patient’s illness schizoaffective disorder, this diagnosis will likely be carried forward in care. When diagnostic boundaries are complex and blurred, this is another source of variability on ascribing this diagnosis.
Keeping the above comments in mind, there are a number of interesting observations from these data. Firstly, the overwhelming majority of patients are being treated with antipsychotics. This resonates well with the notion that schizaffective disorder is related to schizophrenia and falls within the family of psychotic disorders. We also note that only about 20 percent of patients are receiving antipsychotics alone. While this polypharmacy is not a surprise, the extent is a little higher than in most studies of schizophrenia alone.[2,3] Also, the pattern of polypharmacy appears similar overall to that seen in schizophrenia. There are no “ah-ha’s” when you see these data, and I would contend that these pharmacovigilance data offer little support for the idea that schizoaffective disorder is really a different condition from schizophrenia.
So what does this all mean? The status of schizoaffective disorder is “up for grabs” in the review process for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). It is not clear how to position this condition, especially since there is such a paucity of biological and treatment studies to inform evidence-based decisions about the status of schizoaffective disorder. I vote for abandoning the concept altogether!
I think the field will be better served by simplifying things. The process for DSM-V will better serve clinicians if it produces a DSM-V that does not just “lump” or “split” but also “takes out.” If schizoaffective disorder was removed, I believe there would be little impact on treatment but better diagnostic agreement among clinicians.
People with schizophrenia who experience depression would be treated for their depression and would not get “reclassified” to a different diagnosis, as part of their care. Many people with schizophrenia get depressed. Becoming depressed should not be, by itself, a reason to change a diagnosis of schizoaffective disorder. There is some support for removing schizoaffective disorder from DSM nosology.[4,5] Although the data above are just that—data about how clinicians prescribe medications—they are interesting and provide their own statement about whether schizoaffective disorder is really any different from schizophrenia.
References
1. Buckley PF, Miller B, Lehrer D, Castle D. Comorbidities and schizophrenia. Schizophr Bull. 2009 (in press).
2. Correll CU. Antipsychotic polypharmacy, part 1: shotgun approach or targeted cotreatment? J Clin Psychiatry. 2008;69(4):674–675.
3. Bora E, Yucel M, Fornito A, et al. Major psychoses with mixed psychotic and mood symptoms: Are mixed psychoses associated with different neurobiological markers? Acta Psychiatr Scand. 2008;118(3):172–187.
4. Pierre J. Deconstructing schizophrenia for DSM-V: challenges for clinical and research agenda. Clin Schizophr Related Psychoses. 2008;2:166–174.
5. Lake CR, Hurwitz N. Schizoaffective disorder: its rise and fall: Perspectives for DSM-V. Clinical Schizophrenia & Related Psychoses. 2008;2(1):91–97.
