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PAPERS: ROBERT E. McCUE, RUBINA WAHEED, LEONEL URCUYO, GERALDINE ORENDAIN, MICHEL D. JOSEPH, RICHARD CHARLES, and SYED M. HASAN Comparative effectiveness of second-generation antipsychotics and haloperidol in acute schizophrenia The British Journal of Psychiatry 2006; 189: 433-440 [Abstract] [Full text] [PDF]

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A flawed design

Taiwo A Ajayi   (3 November 2006)

A flawed design 3 November 2006
Taiwo A Ajayi, Staff Psychiatrist , Kent & Medway NHS & Social care partnership Send letter to journal: Re: A flawed design taoajayi{at}doctors.org.uk Taiwo A Ajayi	McCue et al's study concluding that haloperidol, olanzapine and risperidone are superior to aripiprazole, quetiapine and ziprasidone for acute treatment of psychosis in hospitalised patients with schizophrenia, schizoaffective disorder or schizophreniform disorder looks convincing until one takes a closer look at the design of the study. One of the two outcome measures for effectiveness in the study was improvement in mental state so that patient no longer required acute in- patient care.This was reportedly determined by the treating psychiatrist's assessment, but no structured scales were mentioned. This choice of outcome measure is highly subjective for several reasons. For starters the threshold for discharge not only varies internationally and locally ,but also between individual psychiatrists depending on experience and attitude towards risk. Secondly, the decision to discharge or not is influenced by factors other than the mental state including social support, anticipated ease of re-admisssion if required and robustness of community mental health services. The Home treatment model is becoming increasingly popular in UK, hence fitness for discharge is no longer a universal entity in the country. Furthermore it is worth remembering that the improvement in mental state of a psychotic in-patient cannot be entirely attributed to effectiveness of antipsychotic medication. The associated psychsocial interventions, ward milleu, role of staff's high expressed emotion, experience and competence all have a part to play.None of these factors were mentioned , considered as confounding factors or conrolled for in this study. Lastly I would like to draw attention to the interpretation of the BPRS results.The authors concluded that Olanzapine,haloperidol and risperidone were superior ,yet the total score in BPRS score from baseline to end point did not differ significantly among the six anti-psychotics. Though the supposedly superior antipsychotics had a greater decrease in their BPRS scores,the time to effective days is longer in the superior anti psychotics(table3).This conclusion of superiority is not justifiable. In my opinion, though this study has a strenght in its pragmatic design and inclusion of subjects with substance misuse disorder; the inappropraite choice of and flawed interpretation of outcome measures makes the conclusion unjustifiable. References McCUe ,R et al(2006) Comparative effectiveness of second generation antipsychotics and haloperidol in acute schizophrenia