Tobacco Smoking Rates in a National Cohort of People with Substance Use Disorder Receiving Treatment.

BACKGROUND AND AIM: The prevalence of tobacco smoking among individuals receiving treatment for substance use disorder (SUD) remains high. Respiratory disease and other harms are of prime concern to health policy-makers, given the contributory role played by tobacco smoking in the excess rates of premature mortality seen in individuals with SUD. The aim was to use SUD treatment data to investigate tobacco smoking prevalence among subgroups of adults over the course of treatment. METHODS: We used the English National Drug Treatment Monitoring System (NDTMS) to examine number of days tobacco had been smoked in the previous month in adults receiving SUD treatment (N = 106,472, median length of treatment 157 days). RESULTS: At baseline (treatment start), 48.7% reported smoking tobacco; the highest rate was observed in opiate users (61%). Overall, the level of smoking at the latest assessment was 48.5%. Reductions (of between 5 and 7%) were observed among those who finished treatment but only within the final stages of treatment. A 5% increase in smoking was observed in those still in treatment within the study timeframe. CONCLUSIONS: This study identifies the potential for a greater emphasis on reducing tobacco consumption within SUD treatment, for example, by offering all smokers within SUD treatment smoking cessation support as part of their SUD treatment programme.

Estimates of the Incidence of Crack Cocaine Use in Those Likely to Attend Treatment in the English Population, 2005-2018.

BACKGROUND: Public health bodies in the UK, and elsewhere, have expressed concern over the wider social and economic impact of crack cocaine use on society. OBJECTIVE: The aim of the study was to use English substance misuse treatment data to estimate the incidence of crack cocaine use in the population who are expected to present to treatment with crack cocaine as the primary substance. METHOD: Known year of first crack-related treatment demand and age of first use of crack were combined to provide the distribution of lag to treatment for each year of onset. The resulting combined lag distribution was used to estimate the proportion of incident crack cocaine users who will have presented in a given year and, from that, the total number who will have started in that year. RESULTS: Our estimates identified an approximate doubling in incidence between 2012 and 2016, following a decrease up to 2012. CONCLUSION: This represents an increase in treatment demand that is likely to continue for a number of years.

Cost-Effectiveness Evaluations of Psychological Therapies for Schizophrenia and Bipolar Disorder: A Systematic Review.

OBJECTIVES: This review aims to assess the cost-effectiveness of psychological interventions for schizophrenia/bipolar disorder (BD), to determine the robustness of current evidence and identify gaps in the available evidence. METHODS: Electronic searches (PsycINFO, MEDLINE, Embase) identified economic evaluations relating incremental cost to outcomes in the form of an incremental cost-effectiveness ratio published in English since 2000. Searches were concluded in November 2018. Inclusion criteria were: adults with schizophrenia/BD; any psychological/psychosocial intervention (e.g., psychological therapy and integrated/collaborative care); probability of cost-effectiveness at explicitly defined thresholds reported. Comparators could be routine practice, no intervention, or alternative psychological therapies. Screening, data extraction, and critical appraisal were performed using pre-specified criteria and forms. Results were summarized qualitatively. The protocol was registered on the PROSPERO database (CRD42017056579). RESULTS: Of 3,864 studies identified, 12 met the criteria for data extraction. All were integrated clinical and economic randomized controlled trials. The most common intervention was cognitive behavioral therapy (CBT, 6/12 studies). The most common measure of health benefit was the quality-adjusted life-year (6/12). Follow-up ranged from 6 months to 5 years. Interventions were found to be cost-effective in most studies (9/12): the probability of cost-effectiveness ranged from 35-99.5 percent. All studies had limitations and demonstrated uncertainty (particularly related to incremental costs). CONCLUSIONS: Most studies concluded psychological interventions for schizophrenia/BD are cost-effective, including CBT, although there was notable uncertainty. Heterogeneity across studies makes it difficult to reach strong conclusions. There is a particular need for more evidence in the population with BD and for longer-term evidence across both populations.

Prevalence of recent fentanyl use among treated users of illicit opioids in England: based on piloted urine drug screens.

OBJECTIVE: To use a pilot of national fentanyl screening to establish the current prevalence of recent fentanyl use among treated users of illicit opioids in the English treatment system and inform the design of a full study. DESIGN: Cross-sectional fentanyl metabolite urine screening in randomly-selected study sites, stratified to cover all nine geographical regions of England, supplemented with self-report subsequent to a positive fentanyl test. PATIENTS: 468 adult (18 years of age and above) patients receiving treatment for opioid use disorder, screened December 2017 to May 2018. RESULTS: The fentanyl-positive rate in patients receiving treatment for opioid use disorder in the English treatment system was 3% (15/468, 95% CI 1.8% to 5.2%) with a per-site range (for the 10 sites in 9 regions where fentanyl was detected) of between 2% (1/57) and 15% (4/27). Self-report data indicated that the majority of fentanyl-positives (12/15, 80%) was unaware of having purchased fentanyl. CONCLUSIONS: Despite alerts already in place, patients receiving treatment for opioid use disorder, who were fentanyl-positive, were unwittingly purchasing and consuming fentanyl.

Development of a resource allocation formula for substance misuse treatment services.

Background: Funding for substance misuse services comprises one-third of Public Health spend in England. The current allocation formula contains adjustments for actual activity, performance and need, proxied by the Standardized Mortality Ratio for under-75s (SMR < 75). Additional measures, such as deprivation, may better identify differential service need. Methods: We developed an age-standardized and an age-stratified model (over-18s, under-18s), with the outcome of expected/actual cost at postal sector/Local Authority level. A third, person-based model incorporated predictors of costs at the individual level. Each model incorporated both needs and supply variables, with the relative effects of their inclusion assessed. Results: Mean estimated annual cost (2013/14) per English Local Authority area was £5 032 802 (sd: 3 951 158). Costs for drug misuse treatment represented the majority (83%) of costs. Models achieved adjusted R-squared values of 0.522 (age-standardized), 0.533 (age-stratified over-18s), 0.232 (age-stratified under-18s) and 0.470 (person-based). Conclusion: Improvements can be made to the existing resource allocation formulae to better reflect population need. The person-based model permits inclusion of a range of needs variables, in addition to strong predictors of cost based on the receipt of treatment in the previous year. Adoption of this revised person-based formula for substance misuse would shift resources towards more deprived areas.

Levels of Motivation and Readiness for Treatment Aligned With Criminal Justice Referral and Coercion Among Substance Users in England.

OBJECTIVE: Motivation and readiness for substance misuse treatment predict treatment retention and successful treatment outcomes but may be lower among substance users coerced into treatment. We tested for differences associated with legal involvement and with client perceptions of coercion among individuals entering drug misuse treatment in England. METHOD: Data collection involved 342 treatment agencies. Measures of motivation and readiness for treatment were taken from the Circumstances, Motivation, and Readiness (CMR) scale. Referral source was ordered to represent level of legal involvement and conditions. Perceived coercion was defined by a CMR item. Linear regression models, adjusting for client complexity, tested for differences in motivation and readiness by these measures. RESULTS: Levels of motivation and readiness did not differ according to level of legal conditions (coefficient = -0.38, 95% CI [-1.65, 0.88]). Motivation was inversely associated with perceived coercion (coefficient = -0.28, 95% CI [-0.05, -0.50], p = .014). CONCLUSIONS: At the point of treatment entry, criminal justice referral and aligned conditions have no impact on levels of motivation to achieve positive treatment outcomes. Concerns around lower levels of motivation are better focused on those who perceive themselves as coerced rather than on those whose referral carries a level of legal condition.

Insights into the link between drug use and criminality: Lifetime offending of criminally-active opiate users.

BACKGROUND: We test whether the offending trajectory of those who test positive for opiates is greater than test-negative controls and whether the relationship is constant both prior to, and post, opiate initiation. We consider whether these relationships differ according to gender and offence type. METHODS: The study provides an analysis of historical offending records in adults linked to test results for opiate and cocaine metabolites. Those testing positive for opiates were linked to treatment records to retrieve data on age of opiate initiation. Rate ratios (RR) were calculated to compare opiate positive testers to opiate and cocaine negative controls, separately by gender and adjusting for age and birth cohort. Age of opiate initiation was included in a second model as a time-dependent variable. Within-subject clustering was accounted for using generalised estimating equations. RESULTS: Opiate-positive cases had higher rates of offending than test-negative controls, both prior to, and post, opiate initiation. Initiation of opiate use increased the RR by 16% for males but doubled it for females. The RR increase in non-serious acquisitive crime was greater than that seen in serious crime. For males only, opiate initiation narrowed the difference in violent offending rate between cases and controls. A larger offending increase was associated with opiate initiation in female, compared to male, users. CONCLUSIONS: For most crime categories, the difference between groups is exacerbated by opiate initiation. The findings indicate that opiate prevention initiatives might be effective in reducing offending, particularly among females.

Pathways through opiate use and offending: A systematic review.

BACKGROUND: Although evidence points to a strong link between illicit drug use and crime, robust evidence for temporal order in the relationship is scant. We carried out a systematic review to assess the evidence for pathways through opiate/crack cocaine use and offending to determine temporal order. METHODS: A systematic review sourced five databases, three online sources, bibliographies and citation mapping. Inclusion criteria were: focus on opiate/crack use, and offending; pre-drug use information; longitudinal design; corroborative official crime records. Rate ratios (RR) of post-drug use initiation to pre-drug use initiation were pooled using random effects meta-analysis. RESULTS: 20 studies were included; UK (9) and US (11). All were of opiate use. Mean age at (recorded) offending onset (16.7yrs) preceded mean age at opiate-use onset (19.6yrs). Substantial heterogeneity (over 80%: unexplained by meta-regression) meant that RRs were not pooled. The RR for total (recorded) offending ranged from 0.71 to 25.7 (10 studies; 22 subsamples: positive association, 4: equivocal, 1: negative association). Positive associations were observed in 14/15 independent samples; unlikely to be a chance finding (sign test p=0.001). Individual offence types were examined: theft (RR 0.63-8.3, 13 subsamples: positive, 9: equivocal, 1 negative); burglary (RR 0.74-50.0, 9 subsamples: positive, 13: equivocal); violence (RR 0.39-16.0, 6 subsamples: positive, 15: equivocal); and robbery (RR 0.50-5.0, 5 subsamples: positive, 15: equivocal). CONCLUSIONS: Available evidence suggests that onset-opiate use accelerates already-existing offending, particularly for theft. However, evidence is out of date, with studies characterised by heterogeneity and failure to use a matched non-opiate-user comparison group to better-establish whether onset-opiate use is associated with additional crime.

Short-Term Outcomes for Opiate and Crack Users Accessing Treatment: The Effects of Criminal Justice Referral and Crack Use.

BACKGROUND/AIMS: The English drug treatment population doubled in size between 1998 and 2008, increasingly characterised by crack cocaine use and criminal justice system (CJS) referral. We assessed short-term (median 3.5 month) behaviour changes following participation in drug treatment and the moderating effect of CJS referral/crack use. METHODS: Opiate and/or crack cocaine users (n = 1,267) were recruited from 342 agencies. Outcome effects were assessed via interaction term regression, clustered at participant level, controlling for client characteristics. Treatment retention effects were tested via Cox proportional hazard models. RESULTS: Statistically significant improvements in health, drug use and offensive behaviour were observed (e.g. heroin use from 87 to 51%, acquisitive offending from 47 to 23%). Referral route was not associated with variation in outcomes. Crack use at baseline was associated with a greater chance of non-fatal overdose at follow-up (p = 0.035, 95% CI 1.08-8.20) but a greater reduction in offending income (p = 0.002, 95% CI £104-£419). CONCLUSION: Despite changes in the English drug treatment population, equivalent short-term improvements in client behaviour were observed a decade earlier. Outcomes for CJS-referred clients were comparable to non-CJS. Crack use at treatment entry offered some scope for greater improvements in offending but may be a barrier to cessation of mortality-associated risky behaviour.

Quantifying crime associated with drug use among a large cohort of sanctioned offenders in England and Wales.

AIM: To assess the relationship between testing positive for opiates and/or cocaine and prior offending. METHODS: 139,925 persons (107,573 men) identified from a saliva test for opiate and cocaine metabolites following arrest in England and Wales, 1 April 2005-31 March 2009, were case-linked with 2-year recorded offending history. The prior offending rate, accounting for estimated incarceration periods, was calculated by: drug-test outcome; gender; four main crime categories (acquisitive, non-acquisitive, serious acquisitive, and non-serious acquisitive) and 16 sub-categories. Rate ratio (RR) compared opiate and/or cocaine positive to dual-negative testers. Adjusted rate ratio (aRR) controlled for age at drug test. RESULTS: The relationship between testing positive for opiates and cocaine and prior 2-year offending was greater for women than men (aRR men 1.77; 95% CI: 1.75-1.79: women 3.51; 3.45-3.58). The association was weaker for those testing positive for opiates only (aRR: men: 1.66, 1.64-1.68; women 2.73, 2.66-2.80). Men testing positive for cocaine only had a lower rate of prior offending (aRR: 0.93, 0.92-0.94), women had a higher rate (aRR: 1.69, 1.64-1.74). The strongest associations were for non-serious acquisitive crimes (e.g. dually-positive: prostitution (women-only): aRR 24.9, 20.9-29.7; shoplifting: aRR men 4.05, 3.95-4.16; women 6.16, 5.92-6.41). Testing positive for opiates and cocaine was associated with violent offences among women (aRR: 1.54, 1.40-1.69) but not men (aRR: 0.98, 0.93-1.02). CONCLUSIONS: Among drug-tested offenders, opiate use is associated with elevated prior offending and the association is stronger for women than men. Cocaine use is associated with prior offending only among women.

Patients' subjective rating of mental health improvement in a randomised controlled trial.

We used UK CUtLASS RCT data to establish that patients' rating of mental health improvement (baseline to week 12) correlated significantly with percentage symptom improvement (PANSS). In a regression analysis predictors of the patient's week 12 mental health rating were percentage change in positive symptoms (PANSS), DAI score and the patient's rating of side effects. Patients in an RCT were able to subjectively rate their mental health status, validated by objective improvement on the PANSS.

The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using class A drugs: a systematic review and economic evaluation.

BACKGROUND: The societal costs of problematic class A drug use in England and Wales exceed £15B; drug-related crime accounts for almost 90% of costs. Diversion plus treatment and/or aftercare programmes may reduce drug-related crime and costs. OBJECTIVES: To assess the effectiveness and cost-effectiveness of diversion and aftercare for class A drug-using offenders, compared with no diversion. POPULATION: Adult class A drug-using offenders diverted to treatment or an aftercare programme for their drug use. INTERVENTIONS: Programmes to identify and divert problematic drug users to treatment (voluntary, court mandated or monitored services) at any point within the criminal justice system (CJS). Aftercare follows diversion and treatment, excluding care following prison or non-diversionary drug treatment. DATA SOURCES: Thirty-three electronic databases and government online resources were searched for studies published between January 1985 and January 2012, including MEDLINE, PsycINFO and ISI Web of Science. Bibliographies of identified studies were screened. The UK Drug Data Warehouse, the UK Drug Treatment Outcomes Research Study and published statistics and reports provided data for the economic evaluation. METHODS: Included studies evaluated diversion in adult class A drug-using offenders, in contact with the CJS. The main outcomes were drug use and offending behaviour, and these were pooled using meta-analysis. The economic review included full economic evaluations for adult opiate and/or crack, or powder, cocaine users. An economic decision analytic model, estimated incremental costs per unit of outcome gained by diversion and aftercare, over a 12-month time horizon. The perspectives included the CJS, NHS, social care providers and offenders. Probabilistic sensitivity analysis and one-way sensitivity analysis explored variance in parameter estimates, longer time horizons and structural uncertainty. RESULTS: Sixteen studies met the effectiveness review inclusion criteria, characterised by poor methodological quality, with modest sample sizes, high attrition rates, retrospective data collection, limited follow-up, no random allocation and publication bias. Most study samples comprised US methamphetamine users. Limited meta-analysis was possible, indicating a potential small impact of diversion interventions on reducing drug use [odds ratio (OR) 1.68, 95% confidence interval (CI) 1.12 to 2.53 for reduced primary drug use, and OR 2.60, 95% CI 1.70 to 3.98 for reduced use of other drugs]. The cost-effectiveness review did not identify any relevant studies. The economic evaluation indicated high uncertainty because of variance in data estimates and limitations in the model design. The primary analysis was unclear whether or not diversion was cost-effective. The sensitivity analyses indicated some scenarios where diversion may be cost-effective. LIMITATIONS: Nearly all participants (99.6%) in the effectiveness review were American (Californian) methamphetamine users, limiting transfer of conclusions to the UK. Data and methodological limitations mean it is unclear whether or not diversion is effective or cost-effective. CONCLUSIONS: High-quality evidence for the effectiveness and cost-effectiveness of diversion schemes is sparse and does not relate to the UK. Importantly this research identified a range of methodological limitations in existing evidence. These highlight the need for research to conceptualise, define and develop models of diversion programmes and identify a core outcome set. A programme of feasibility, pilot and definitive trials, combined with process evaluation and qualitative research is recommended to assess the effectiveness and cost-effectiveness of diversionary interventions in class A drug-using offenders. FUNDING DETAILS: The National Institute for Health Research Health Technology Assessment programme.

Validity of subjective versus objective quality of life assessment in people with schizophrenia.

BACKGROUND: Quality of life (QoL) is considered an important outcome in health research. It can be rated by the patient, or by an external assessor. We wished to identify the predictors of any discrepancies between these two approaches in people with schizophrenia. METHODS: Patients with DSM schizophrenia and related disorders (N = 80) completed both patient-rated (Lancashire Quality of Life Profile; LQOLP) and assessor-rated (Heinrich's Quality of Life Scale; QLS) measures of QoL. RESULTS: Patient-rated (LQOLP) and assessor-rated (QLS) measures showed a modest correlation (r = 0.38). In a regression analysis, independent predictors of subjectively-rated QoL being higher than objectively-assessed QoL in the same patient, were low insight score (BIS), negative symptoms (PANSS), absence of depression (CDSS), and less positive attitude toward prescribed treatment (DAI). CONCLUSIONS: In people with schizophrenia, scores on objectively- and subjectively-rated measures of quality of life can differ markedly. When comparing subjective to objective assessments, patients with depressive symptoms will value their QoL lower, and those with low insight will value their QoL higher. This has important implications for the utility and interpretation of QoL measures in schizophrenia.

Effect of prior treatment with antipsychotic long-acting injection on randomised clinical trial treatment outcomes.

BACKGROUND: It is uncertain whether antipsychotic long-acting injection (LAI) medication in schizophrenia is associated with better clinical outcomes than oral preparations. AIMS: To examine the impact of prior treatment delivery route on treatment outcomes and whether any differences are moderated by adherence. METHOD: Analysis of data from two pragmatic 1-year clinical trials in which patients with schizophrenia were randomised to either an oral first-generation antipsychotic (FGA), or a non-clozapine second-generation antipsychotic (SGA, CUtLASS 1 study), or a non-clozapine SGA or clozapine (CUtLASS 2 study). RESULTS: Across both trials, 43% (n = 155) of participants were prescribed an FGA-LAI before randomisation. At 1-year follow-up they showed less improvement in quality of life, symptoms and global functioning than those randomised from oral medication. This difference was confined to patients rated as less than consistently adherent pre-randomisation. The relatively poor improvement in the patients prescribed an LAI pre-randomisation was ameliorated if they had been randomised to clozapine rather than another SGA. There was no advantage to being randomly assigned from an LAI at baseline to a non-clozapine oral SGA rather than an oral FGA. CONCLUSIONS: A switch at randomisation from an LAI to an oral antipsychotic was associated with poorer clinical and functional outcomes at 1-year follow-up compared with switching from one oral antipsychotic to another. This effect appears to be moderated by adherence, and may not extend to switching to clozapine. This has implications for clinical trial design: the drug from which a participant is randomised may have a greater effect than the drug to which they are randomised.

Drug spend and acquisitive offending by substance misusers.

AIM: The need to generate income to fund drug misuse is assumed to be a driver of involvement in acquisitive crime. We examined the influence of drug misuse expenditure, and other factors, on acquisitive offending. METHODS: Clients (N=1380) seeking drug treatment within 94 of 149 Drug Action Teams (DATs) across England completed a comprehensive survey, incorporating validated scales and self-report measures, such as levels of drug and alcohol use and offending. RESULTS: Forty per cent (N=554) had committed acquisitive crime in the previous month. Regression analysis showed that acquisitive offending was associated with the presence of problematic use of crack cocaine, poly-drug use, sharing injecting equipment, unsafe sex, overdose risk, higher drug spend, unemployment, reduced mental wellbeing, and younger age. CONCLUSIONS: Rates of acquisitive crime among drug users are high. Drug using offenders can be distinguished from drug using non-offenders by problematic crack cocaine use, younger age, income-related factors, and indicators of a chaotic life style and complex needs. Behavioural and demographic factors were associated more strongly with acquisitive crime than drug use expenditure, suggesting that the need to finance drug use is not necessarily the main factor driving acquisitive offending by drug users.

Sexual function of patients with schizophrenia receiving first-generation (FGA) or second-generation antipsychotic (SGA) treatment.

OBJECTIVES: The aim of the study was to investigate sexual function in patients with schizophrenia receiving treatment with a first-generation antipsychotic (FGA) or a second-generation antipsychotic (SGA) drug. Sexual function is an important aspect of human experience, which can be affected by antipsychotic drug treatment. Sexual dysfunction in patients with schizophrenia may be less prevalent with SGA than with FGA drug treatment. METHODS: A cross-sectional prevalence study assessed sexual function in a sample of 144 patients with DSM-IV schizophrenia aged between 18 and 65, using the Derogatis Interview for Sexual Functioning (self-report version: DISF-SR). Two equal-sized groups (N = 72) received treatment with an FGA or an SGA drug for at least 12 weeks. RESULTS: No significant differences were seen on DISF-SR total score or subscale score between the two treatment groups. CONCLUSIONS: There are no differences in measured sexual function of non-randomised patients with schizophrenia treated with an FGA compared with SGA-treated patients.

Second generation antipsychotics improve sexual dysfunction in schizophrenia: a randomised controlled trial.

The impact of antipsychotic drug treatment on sexual function was investigated during a randomised trial comparing first generation antipsychotics (FGAs) to (nonclozapine) second generation antipsychotics (SGAs). Sexual function and quality of life were (rater-blind) assessed in 42 patients with DSM-IV schizophrenia (aged 18-65) using the self-report version of the Derogatis Interview for Sexual Function (DISF-SR) and the Heinrichs Quality of Life Scale (QLS), prior to, and 12 weeks following, a change in medication from an FGA drug to either an FGA or SGA drug. SGAs significantly improved sexual function compared to FGAs. Change in sexual function was associated with change in quality of life. Where impaired sexual functioning is a distressing adverse effect of treatment with an FGA agent, consideration should be given to switching to an SGA.

The ANNSERS (Antipsychotic Non-Neurological Side Effects Rating Scale): Validation of Sexual Side-Effect Measurement.

Antipsychotic nonneurological side effects, such as sexual dysfunction, can adversely affect the quality of patients' relationships, their treatment adherence and their quality of life. In the UK CUtLASS (Cost Utility of the Latest Antipsychotics in Severe Schizophrenia) study, nonneurological side effects were assessed using the ANNSERSv1 (Antipsychotic Non-Neurological Side Effects Rating Scale version 1), a new scale to assess the side effects associated with both first- and second-generation antipsychotic drugs. A total of 26 participants also completed the Derogatis Interview for Sexual Functioning (self-report version, DISF-SR). A statistically significant, and specific, correlation was found between scores on the DISF-SR and the sexual side-effect section of the ANNSERS at baseline. The sexual side-effects subscale of the ANNSERS is a valid measure of sexual dysfunction in the treatment of schizophrenia.

A randomized controlled trial of the cost-utility of second-generation antipsychotics in people with psychosis and eligible for clozapine.

OBJECTIVE: To assess whether clozapine is likely to be more cost-effective than other second-generation antipsychotics (SGAs) in people with schizophrenia. METHODS: An integrated clinical and economic multicenter, rater-blind, randomized controlled trial (RCT) compared clozapine to the class of other SGAs, using the perspectives of the National Health Service, social support services, and patients. The practice setting was secondary and primary care in the United Kingdom; patients were followed for 1 year. Incremental cost-effectiveness ratios (ICERs), net benefit statistics, and cost acceptability curves were estimated. RESULTS: The ICER for clozapine was 33,240 pound per quality-adjusted life-year (QALY) (range 23,000-70,000 pound for the sensitivity analyses). The proportion of simulations when clozapine was more cost-effective than other SGAs reached 50% if decision-makers are prepared to pay 30,000 pound to 35,000 pound per QALY. This is at the top of the range of acceptable willingness-to-pay values per QALY implied by decisions taken by the National Institute for Health and Clinical Excellence (NICE). CONCLUSIONS: This study adds to a limited body of evidence comparing clozapine to other SGAs and is the first economic and clinical RCT to compare clozapine to the class of other SGAs using the lower cost of generic clozapine and a pragmatic trial design. Policy decisions by the NICE suggest that additional reasons would be needed to accept clozapine as effective and efficient if it had a high probability of having ICERs more than 35,000 pound per QALY. The results and limitations of the analysis suggest that there is still a need for further economic evaluation of clozapine.

A controlled, mirror-image study of second-generation antipsychotics in the treatment of schizophrenia.

Second-generation antipsychotics are now treatments of choice in many countries. In this study, we aimed to compare hospital stay and admissions to hospital in patients switching from first-generation (conventional) to second-generation (atypical) antipsychotics with patients switching from one first-generation drug to another. This was a retrospective, 6-year, controlled mirror-image study conducted in an acute general psychiatry services in an inner-city area. Subjects were consisted of patients diagnosed with schizophrenia or schizoaffective disorder receiving continuous prescription of antipsychotics over at least a 6-year period between 1994 and 2002. The main outcome measures were number of days spent in hospital and number of admissions to hospital. In 36 patients switched from first to second-generation antipsychotics, total number of days spent in hospital increased, from a mean of 90 days in the 3 years before switching, to a mean of 200 days in the 3 years after (P<0.001). Mean number of admissions did not change significantly (1.61 before vs. 1.44 after, P=0.360). In 36 matched control patients, switching between first-generation antipsychotic drugs, mean number of days in hospital fell from 64 to 50 (P=0.189) and number of admissions was virtually unchanged (1.42 before vs. 1.03 after, P=0.202). Mean days in hospital were significantly increased in the second-generation antipsychotic group compared with the first-generation antipsychotic (control) group (P<0.001). Switching from first to second-generation antipsychotics resulted in an important increase in number of days spent in hospital. Switching from one first-generation antipsychotic drug to another did not significantly affect number of days in hospital.