Assessing the Levels of Adherence to Antipsychotic Treatment Guidelines For First Episode Schizophrenia by Prescibers at Chainama Hills College Hospital in Lusaka

Abstract

Mental health disorders pose an increasing burden on societies all over the world .Notable one is schizophrenia, a debilitating conditions that presents as marked distortion in thinking and perception, whose first presentation of symptoms in a newly diagnosed patient requires accurate and effective management. Patients with first episode schizophrenia may present in a variety of clinical settings to providers who have a range of knowledge and skills. Clinical case vignettes with free-form responses can be used to carefully assess whether front line practitioners provide guideline-adherent management of first episode psychosis. This study aimed to assess the levels of adherence to first episode schizophrenia antipsychotic treatment guidelines by mental health prescribers at Chainama Hills Mental hospital because, Disease-specific clinical practice guidelines serve as a useful tool for effective clinical management. This was a cross sectional study to assess adherence by prescribers at Chainama Hills Mental hospital. Out of the current establishment of 35 prescribers, 31 were sampled for the study. A clinical case vignette, presenting a patient with first episode schizophrenia, was created with algorithmically scored open ended responses to assess adherence. Free-form responses to 4 questions with question 1 asking about differential diagnosis, question 2 inquiring about the next steps in evaluation of the patient, question 3 asking to provide answers regarding first-line medication treatment (including type, name, initial dose and target dose of treatment), and question 4 asking for the proposed duration of treatment once the patient’s symptoms had remitted, were scored based on published practice guidelines. A total of four points were possible for each question giving a maximum possible of 16 points. Response frequencies were tabulated and performance was compared among professional disciplines. There were a total 31 prescribers assessed for this study, 12/31 (38.7%) psychiatrists and 19/31 (61.3%) clinical officer psychiatrists. The proportional difference of the two groups of prescribers assessed was not statistically significant, P-value = 0.21. Overall, major depression was the most commonly listed diagnosis, with 29/31 (93.5%) naming this diagnosis; 26/31 (83.9%) respondents listed schizophrenia; 16/31 (51.6%) respondents listed substance induced psychosis (e.g. cannabis-induced). Regarding diagnostic workup, 13/31 (41.9%) of the respondents obtained a toxicology. Risperidone was the most frequently chosen antipsychotic with 18/31 (58.1%) of the respondents. There were only 9/31 (29%) respondents who recommended treatment for 1 year or more, which is in line with published recommendations. The overall mean treatment duration was 0.7 years ± 0.30. The mean total score on the vignette questions was 8.4 points ± 4.86 out of a possible 16 points. The respondents scored best (mean score 2.8 ± 1.02 out of 4 points) on the differential diagnosis question (1) and lowest (mean score of 1.2 ± 1.85) on the treatment duration question (4). The mean score on the assessment questions (questions 1 and 2) was slightly greater than the treatment questions (question 3 and 4) but not significantly different; mean score on the assessment questions was 4.5 ± 2.87 vs. 3.9 ± 2.42 on the treatment questions; t = 0.77; P-value = 0.45. Comparing vignette performance between psychiatrists and clinical officer psychiatrists (COP), there were suggestive group differences favoring psychiatrists but however, the differences were not statistically significant. If urine toxicology investigation was not requested, there was on average 2.6 times increased odds for the prescriber to be a COP (OR = 2.60, CI = 0.93 – 7.29, P-value = 0.069). Overall, there were 23/31 (74.2%) prescribers with less than 85% compliance 7/31 (22.6%) between 85 – 95% compliance, and 1/31 (3.2%) with above 95% compliance. The front line clinicians who encounter patients with first episode schizophrenia may have significant gaps in the initial and follow-up care of these patients. Given the preliminary nature of this study and the debate about the optimal care for first episode psychosis, further study with larger sample size is needed. If such gaps are confirmed additional educational interventions are required to align clinical management with published practice guidelines.