Évaluer les pratiques de prescription et de surveillance d’antipsychotiques (AP) en psychiatrie générale chez les patients schizophrènes âgés et les facteurs susceptibles d’influer sur elles.

Ont été contactés par courrier 190 psychiatres pour participer à une étude observationnelle de leurs pratiques de prescription d’AP chez des patients schizophrènes de 65ans et plus.

Le taux de réponse est de 44,2 % ; 75 % des psychiatres ayant répondu traitent des schizophrènes âgés. Ils utilisent à 87,7 % un AP de seconde génération en première ligne ; 64,9 % prescrivent en monothérapie ; 54,4 % utilisent des AP à action prolongée. La tolérance constitue le critère de choix principal de l’AP pour 3,5 % et secondaire pour 29,8 % des psychiatres. Les surveillances du périmètre abdominal, de la prolactinémie, cardiologique avec électrocardiogramme et ophtalmologique ne sont qu’en partie conformes aux recommandations professionnelles. Lors de la surveillance au long cours, les psychiatres ayant une utilisation courante des recommandations de prise en charge mesurent significativement plus souvent le pouls et la tension artérielle (74,3 % vs 41,2 %, p=0,03) ainsi que le périmètre abdominal (22,9 % vs 0 %, p=0,04) comparés aux psychiatres qui n’utilisent pas couramment des recommandations de prise en charge.

Cette étude démontrant un respect inégal en psychiatrie générale des recommandations de prise en charge concernant la prescription et la surveillance des AP chez les patients schizophrènes âgés, précise les pratiques à améliorer : choix de l’AP d’abord en fonction de la tolérance, surveillances du périmètre abdominal, de la prolactinémie, cardiologique avec électrocardiogramme et ophtalmologique.

Advancing age entails specific treatment modalities for patients with schizophrenia. The choice of appropriate antipsychotic therapy (AP) and the monitoring of treatment is a major challenge. However, little is known about the real-world prescribing practices of psychiatrists for elderly schizophrenia patients. The aim of this study was to assess prescribing practices and treatment monitoring in elderly schizophrenia patients and whether socio-professional psychiatrists’ characteristics are related to their practices.

We contacted by mail 190 psychiatrists to take part in an observational survey of their AP prescribing practices for elderly (aged over 65) schizophrenia patients.

The response rate was 44.2%, and of the psychiatrists who replied 75% were treating elderly schizophrenia patients. A second-generation AP (SGAP) was prescribed as first-line of treatment by 87.7% of the psychiatrists. The most frequently used SGAPs were risperidone and olanzapine (respectively preferred by 54.4% and 19.3% of the psychiatrists taking part). At the beginning of treatment, 91.1% of the psychiatrists prescribed a lower dose than for middle-aged patients. Of the psychiatrists taking part, 64.9% prescribed monotherapy; and among these psychiatrists, 65% cited insufficient control of the disease as the reason for their choice, while 48.7% of those who elected not to prescribe combined AP did so in order to limit the side-effects. Of the psychiatrists taking part, 54.4% prescribed long-acting injectable AP (LAAP); better therapeutic compliance and alliance was the main argument in the choice of LAAP given by the psychiatrists taking part who prescribed the drug, whereas the absence of indications and problems of tolerance were arguments against for those who did not. “Personal experience” emerged as the governing factor in the choice of AP. The AP side-effect profile was the main criterion of choice of the AP agent for 3.5% of the psychiatrists taking part, and the most frequently chosen secondary criterion (29.8%). Monitoring of treatment was partly performed according to professional recommendations: pre-treatment and post-prescription assessments of waist circumference and ophthalmological monitoring were very infrequent (8.8 to 18.5%) as were pre-treatment and early post-prescription assessments of prolactinaemia (14.8 to 20.4%); long-term cardiac monitoring was infrequent (43.9%). The psychiatrists taking part whose first-line drug was SGAP were more familiar with professional recommendations than those who prescribed first generation antipsychotic (FGA) drugs (72% as against 14.3%, P=0.006). Of the psychiatrists taking part in the study, 64.9% reported they commonly use professional recommendations. Psychiatrists who declared they commonly use professional recommendations measured pulse rate and blood pressure significantly more often over the long-term than those who did not (74.3% as against 41.2%, P=0.0315). They also measured waist circumference over the long-term significantly more often than psychiatrists who did not commonly use professional recommendations (22.9% as against 0%, P=0.0420). Psychiatrists treating more than ten of these patients yearly measured significantly more often over the long-term pulse rate and blood pressure than those treating fewer patients (80% as against 50%, P=0.0399). Over the long-term monitoring, psychiatrists with a larger number of elderly schizophrenia patients in their care also performed more often fasting blood glucose test, lipid profile and referral for cardiac consultation with ECG (respectively, 95.5% as against 70.8%, P=0.0489; 90.9% as against 58.3%, P=0.0182; 81.8% as against 29.2%, P<0.0001).

The results of this survey need to be confirmed in a larger population sample. The antipsychotic prescribing practices were broadly in agreement with current recommendations except for the tolerance profile which was not the first element taken into account in the choice of the AP agent. Some clinical and paraclinical medical examinations were carried out infrequently, in particular cardiac monitoring over the long-term, which is essential in this elderly patient population. One important element to emerge from our results was that common use of professional recommendations is associated with better monitoring.