CHU Nantes, Service de Pharmacologie Clinique, Nantes Université, Nantes, France.
CHU Nantes, INSERM, MethodS in Patient-Centered Outcomes and HEalth ResEarch, SPHERE, INSERM, Methods in Patient-Centered Outcomes and Health Research, SPHERE, Nantes Université, Univ Tours, Nantes, France.
Epidemiol Psychiatr Sci. 2023 Sep 19;32:e59. doi: 10.1017/S2045796023000732.
Despite recommendations to initiate clozapine after two unsuccessful trials of antipsychotics, clozapine is underprescribed and initiated too late. The aim of this study was to describe different antipsychotic treatment sequences in the 36 months before the initiation of clozapine and to characterize clusters of treatment trajectories.
Using the French National Health Insurance database, a historical cohort study of the population in an area in western France was performed. The data from all new users of clozapine with a diagnosis of schizophrenia or schizoaffective disorder in the period of 2017-2018 were evaluated. All outpatient reimbursements for antipsychotics during the 36 months before clozapine initiation were analysed. Successive reimbursements for identical treatments were grouped into treatment trials (TTs), and different trajectories were clustered using a state sequence analysis.
The results showed 1191 TTs for 287 individuals. The mean number of TTs per individual was 3.2. Risperidone, aripiprazole and haloperidol were the main treatments delivered. The frequencies of antipsychotics used differed between monotherapies and combination therapies. A three-cluster typology was identified: one cluster ( = 133) of 'less treated' younger individuals with fewer TTs and shorter TT durations; a second cluster ( = 53) of 'more treated' individuals with higher numbers of TTs and combinations of antipsychotics; and a third cluster ( = 103) of 'treatment-stable' older individuals with longer TT durations.
The results indicate that the median number of TTs during the 36 months before clozapine prescription was higher than the two recommended. The different trajectories were associated with individual characteristics and treatment differences, suggesting that additional studies of clinical parameters are needed to understand barriers to clozapine prescription.
尽管有建议在两种抗精神病药物治疗失败后开始氯氮平治疗，但氯氮平的处方不足且启动时间太晚。本研究旨在描述氯氮平治疗前 36 个月的不同抗精神病药物治疗顺序，并描述治疗轨迹的聚类。
使用法国国家健康保险数据库，对法国西部一个地区的人群进行了一项历史队列研究。评估了在 2017-2018 年期间患有精神分裂症或分裂情感障碍的所有新使用氯氮平的患者的数据。分析了氯氮平治疗前 36 个月内所有抗精神病药物的门诊报销情况。将相同治疗的连续报销费用归入治疗试验（TT），并使用状态序列分析对不同轨迹进行聚类。
结果显示，287 名患者进行了 1191 次 TT。每位患者的 TT 平均数量为 3.2 次。利培酮、阿立哌唑和氟哌啶醇是主要的治疗药物。单药治疗和联合治疗的抗精神病药物使用频率不同。确定了一种三聚类类型：一个集群（=133）为“治疗较少”的年轻个体，接受 TT 次数较少，TT 持续时间较短；第二个集群（=53）为“治疗较多”的个体，接受 TT 次数较多，联合使用抗精神病药物；第三个集群（=103）为“治疗稳定”的老年个体，TT 持续时间较长。
结果表明，氯氮平处方前 36 个月的 TT 中位数高于推荐的两次。不同的轨迹与个体特征和治疗差异有关，这表明需要进一步研究临床参数，以了解氯氮平处方的障碍。
