Elsevier

Psychiatry Research

Volume 200, Issues 2–3, 30 December 2012, Pages 835-842
Psychiatry Research

Validation of a clinician questionnaire to assess reasons for antipsychotic discontinuation and continuation among patients with schizophrenia

https://doi.org/10.1016/j.psychres.2012.05.005Get rights and content

Abstract

The Reasons for Antipsychotic Discontinuation Questionnaire (RAD-Q) was designed to assess clinicians' perceptions of reasons for antipsychotic discontinuation or continuation. The current study examined psychometric properties of this instrument and patterns of antipsychotic discontinuation. The sample of 121 patients (81 discontinuation, 40 continuation) with schizophrenia or schizoaffective disorder was 66.9% male, with a mean age of 41.6 years. Treating clinicians reported a mean of 4.1 reasons for discontinuation and 7.5 reasons for continuation. RAD-Q domain scores were derived to quantify the impact of three factors on the decision to discontinue or continue: treatment benefits, adverse events, and distal reasons other than direct effects of the medication. Analysis of inter-rater reliability indicated an acceptable degree of agreement between clinicians (weighted Kappa for discontinuation scores=0.70–0.78). Correlations with symptom measures (Clinical Global Impression-Schizophrenia Scale (CGI-SCH), Positive and Negative Syndrome Scale (PANSS)) supported convergent validity of the benefits domain score (r=0.28–0.47; all p<0.05). Domain scores discriminated among groups of patients differing in clinician and patient-reported clinical variables. Results suggest that the RAD-Q is a useful detailed measure of reasons for antipsychotic discontinuation and continuation. Findings indicate that clinicians usually report multiple reasons for discontinuation, rather than a single reason for each patient.

Introduction

When evaluating antipsychotic medication, treatment discontinuation is often considered to be an indicator of overall effectiveness because it incorporates patients' and clinicians' judgments of efficacy and tolerability (Ascher-Svanum et al., 2006, Davis et al., 2003, Dunayevich et al., 2007, Lieberman et al., 2005). Discontinuation is usually quantified as time to treatment discontinuation or rates of discontinuation. These discontinuation variables have been the primary outcomes in key antipsychotic trials (Kahn et al., 2008, Lieberman et al., 2005). Like poor treatment adherence, antipsychotic discontinuation is an important area of research because it is associated with negative outcomes such as relapse, exacerbation of symptoms, and decreased functional status (Dunayevich et al., 2007, Gitlin et al., 2001, Liu-Seifert et al., 2005).

Despite the frequent use of antipsychotic discontinuation as an outcome measure, little is known about specific reasons for discontinuation. Clinical trials usually assess only a single general reason for discontinuation, without capturing the complex interaction among multiple factors leading to the decision to discontinue treatment. Reasons for discontinuation may include insufficient improvement in positive, negative, depressive, or cognitive symptoms; failure to improve functional status; adverse events; financial cost; and psychosocial factors such as lack of social support (Weiden and Ross, 2002). Furthermore, trials do not assess reasons why patients continue medication.

Although measures are available for assessing subjective effects of antipsychotics and influences on treatment compliance (Hogan et al., 1983, Naber, 1995, Weiden et al., 1994), these measures do not identify specific reasons for the decision to continue or discontinue antipsychotic treatment. Specific data on reasons for discontinuation and continuation could improve our understanding of patients' experiences with antipsychotics, while providing guidance for treatment decisions in clinical settings. Consequently, the Reasons for Antipsychotic Discontinuation Questionnaire (RAD-Q) was designed to assess the clinician's perceptions of why treatment with a specific antipsychotic is discontinued or continued. The RAD-Q was developed based on literature review, patient interviews, expert panel input, and cognitive debriefing interviews with clinicians (Matza et al., 2011). The purpose of the current study was to validate the RAD-Q by examining individual item responses, deriving domain scores, and examining reliability and validity of these scores. The RAD-Q includes items assessing reasons for discontinuation or continuation within three domains: treatment benefits, adverse events, and distal reasons other than direct effects of the medication.

Section snippets

Study design and sample selection

Data were collected in the United States at 17 clinical sites including three Veterans Administration hospitals; seven university hospitals or medical centers; three private healthcare organizations; two private medical research organizations; and two private psychiatric inpatient/outpatient services. Patients diagnosed with schizophrenia or schizoaffective disorder attended one study visit. Patients were categorized as either discontinuation patients or continuation patients. Discontinuation

Patient and clinician characteristics

Data are from 121 patients and their treating clinicians. Patient demographic and clinical characteristics are presented in Table 1. All patients had a diagnosis in their medical chart beginning with the DSM-IV code 295, representing schizophrenia (58.7%) or schizoaffective disorder (41.3%). Of the 121 patients, 81 were discontinuation patients, and 40 were continuation patients. The continuation patients were significantly older than the discontinuation patients (p<0.01). Compared with

Discussion

Current findings provide encouraging initial support for reliability and validity of the RAD-Q. Although analyses of inter-rater reliability should be interpreted with caution due to the small sample of available clinician pairs, results suggest an acceptable degree of agreement between clinicians. Findings also support the validity of the RAD-Q, as indicated by associations with measures of clinician-rated symptoms, interviewer-rated symptoms, and patient-reported adverse events. In addition,

Acknowledgments

The authors thank Jodi Shorr, Julie Meilak, and Aria Gray for production assistance; Meghan Werner and Kimberly Walter for assistance with data collection; and Chris Thompson for statistical programming.

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    This study was funded by Eli Lilly and Company.

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