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Treatments for Schizophrenia in Adults: A Systematic Review
Comparative Effectiveness Reviews, No. 198
Investigators: Marian S McDonagh, PharmD, Tracy Dana, MLS, Shelley Selph, MD, MPH, Emily B Devine, PharmD, PhD, MBA, Amy Cantor, MD, MPH, Christina Bougatsos, MPH, Ian Blazina, MPH, Sara Grusing, BA, Rochelle Fu, PhD, Sarah L Kopelovich, PhD, Maria Monroe-DeVita, PhD, and Daniel W Haupt, MD.
Author Information and AffiliationsStructured Abstract
Objectives:
This systematic review (SR) provides evidence on pharmacological and psychosocial treatments for schizophrenia.
Data sources:
MEDLINE®, the Cochrane Library databases, PsycINFO®, and included studies through February 2017.
Study selection:
We included studies comparing second-generation antipsychotics (SGA) with each other or with a first-generation antipsychotic (FGA) and studies comparing psychosocial interventions with usual care in adults with schizophrenia.
Data extraction:
We extracted study design, year, setting, country, sample size, eligibility criteria, population, clinical and intervention characteristics, results, and funding source.
Results:
We included 1 SR of 138 trials (N=47,189) and 24 trials (N=6,672) for SGAs versus SGAs, 1 SR of 111 trials (N=118,503) and 5 trials (N=1,055) for FGAs versus SGAs, and 13 SRs of 271 trials (N=25,050) and 27 trials (n=6,404) for psychosocial interventions. Trials were mostly fair quality and strength of evidence was low or moderate. For drug therapy, the majority of the head-to-head evidence was on older SGAs, with sparse data on SGAs approved in the last 10 years (asenapine, lurasidone, iloperidone, cariprazine, brexpiprazole) and recent long-acting injection (LAI) formulations of aripiprazole and paliperidone. Older SGAs were similar in measures of function, quality of life, mortality, and overall adverse events, except that risperidone LAI had better social function than quetiapine. Core illness symptoms were improved more with olanzapine and risperidone than asenapine, quetiapine, and ziprasidone, and more with paliperidone than lurasidone and iloperidone; all were superior to placebo. Risperidone LAI and olanzapine had less withdrawal due to adverse events. Compared with olanzapine and risperidone, haloperidol, the most studied FGA, had similar improvement in core illness symptoms, negative symptoms, symptom response, and remission but greater incidence of adverse event outcomes. In comparison with usual care, most psychosocial interventions reviewed were more effective in improving intervention-targeted outcomes, including core illness symptoms. Various functional outcomes were improved more with assertive community treatment, cognitive behavioral therapy, family interventions, psychoeducation, social skills training, supported employment, and early interventions for first episode psychosis (FEP) than with usual care. Quality of life was improved more with cognitive behavioral therapy and early interventions for FEP than usual care. Relapse was reduced with family interventions, psychoeducation, illness self-management, family interventions, and early interventions for FEP.
Conclusions:
Most comparative evidence on pharmacotherapy relates to the older drugs, with clozapine, olanzapine, and risperidone superior on more outcomes than other SGAs. Older SGAs were similar to haloperidol on benefit outcomes but had fewer adverse event outcomes. Most psychosocial interventions improved functional outcomes, quality of life, and core illness symptoms, and several reduced relapse compared with usual care.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Evidence Summary
- Introduction
- Methods
- Results
- Results of Literature Searches
- Key Question 1a. Comparative Benefits and Harms of Pharmacological Treatments for Adults With Schizophrenia
- Key Question 1b. Variation of Benefits and Harms of Pharmacological Treatments for Adults With Schizophrenia by Patient Characteristics
- Key Question 2a. Benefits and Harms of Psychosocial and Other Nonpharmacological Treatments for Adults With Schizophrenia Compared With Usual Care
- Key Question 2b. Variation of Benefits and Harms of Psychosocial and Other Nonpharmacological Treatments Versus Usual Care for Adults With Schizophrenia by Patient Characteristics
- Discussion
- Conclusions
- References
- Abbreviations
- Appendix A. Search Strategies
- Appendix B. Included Studies
- Appendix C. Excluded Studies With Reasons
- Appendix D. Scale Abbreviations and Scoring
- Appendix E. Data Abstraction
- Appendix F. Quality Assessment
- Appendix G. Forest Plots for Pooled Analyses and Matrixes of Results for Network Meta-Analyses
- Appendix H. Strength of Evidence
- Appendix I. Strength of Evidence—Drug Comparisons
Suggested citation:
McDonagh MS, Dana T, Selph S, Devine EB, Cantor A, Bougatsos C, Blazina I, Grusing S, Fu R, Kopelovich SL, Monroe-DeVita M, Haupt DW. Treatments for Schizophrenia in Adults: A Systematic Review. Comparative Effectiveness Review No. 198. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 17(18)-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; October 2017. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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