The development of new antipsychotic medications provided the opportunity to enhance the quality of life (QOL) of persons living with schizophrenia, a chronic, disabling brain disorder. The National Institute of Mental Health reports that about 1% of adults living in the United States have schizophrenia [
In clinical studies, atypical antipsychotics are associated with greater improvements in quality of life and subjective well-being than are typical antipsychotics [
Cook et al. [
Aripiprazole plays an inhibitory role as a D2 receptor antagonist when dopamine is released excessively in the brain. On the other hand, it acts as a dopamine agonist when dopamine is insufficient. It is called a dopamine D2 receptor partial agonist [
Abnormal metabolism may increase the risk of coronary heart disease and diabetes [
The purpose of this retrospective study was to evaluate changes in clinical indicators which influence QOL before and after switching antipsychotic medication to aripiprazole.
In this retrospective chart review, the subjects whose antipsychotic was switched to aripiprazole were evaluated. Subsequently, the effects of the switching and quality of life were considered. The subjects were then divided into two groups responsive and nonresponsive.
Changes in the following clinical indicators before and after the switching were analyzed: (1) daily dosage of antipsychotics and antiparkinsonian drugs, (2) the Brief Psychiatric Rating Scale (BPRS), (3) body mass index (BMI), (4) glucose and lipid metabolism, (5) bowel movement pattern, (6) falling risk score, (7) degree of psychiatric nursing needs, and (8) activities of daily living (ADL’s).
The setting for this study was a long-term care unit in a psychiatric hospital in Japan with approximately 500 beds. Approval for the research study was obtained from the Ethical Board of Mifune Hospital. The sample consisted of 27 charts of chronic, long-term hospitalized subjects diagnosed with schizophrenia who had been switched to aripiprazole during the research period of January 2006 to March 2010. The sample consisted of 17 men and 10 women, ages 34–82.
For each of the clinical indicators, the Wilcoxon signed-rank test was used to examine whether or not significant differences occurred after the switching were examined by using. Then, cross-tabulation and the Fisher's exact test were conducted. Data analysis was performed using SPSS11.0J for Windows.
The following eight clinical indicators were used to measure the responsiveness of subjects to aripiprazole. Each clinical indicator was reviewed prior to the switch to aripiprazole, two months after the switch, and when the aripiprazole dose had become constant. Clinical indicator measurements were defined as follows. Daily dose of antipsychotic and antiparkinsonian medication: potency equivalents for antipsychotic drugs are required to guide clinical dosing and for designing and interpreting research studies. The daily dosage of antipsychotic drugs was converted to a chlorpromazine (CP) equivalent, and the daily dosage of antiparkinson drugs was converted to a biperiden (BP) equivalent [ BPRS: the Japanese version of the BPRS is one of the most frequently used instruments for evaluating psychopathology in patients with schizophrenia. Each symptom is rated 1–7 and depending on the version, a total of 18 items are scored. BMI: (20–24 kg/m2). the values in brackets represent the normal range of each item. Glucose and lipid metabolism: the following measurements were evaluated: total protein (TP: 6.4–8.2 g/dL), albumin (ALB: 3.7–5.2 g/dL), albumin-globulin ratio (A/G ratio: 1.1–2.0), total cholesterol (T-cho: 130–240 mg/dL), hemoglobin (Hb: male 13.5–17 g/dL; female 11.5–15 g/dL), and preprandial blood glucose level (60–110 mg/dL). Bowel movement patterns: bowel movements were categorized as “one bowel movement per day,” “one bowel movement in two days,” “one bowel movement in three days,” “one bowel movement in four days,” and “one bowel movement in five days.” Falling risk score: the falling risk score consists of 3 levels: Risk level 1: possibility of falling (score 1–5); Risk level II: likelihood of falling (score of 6–15); Risk level III: frequently falling (score of 16 or more). Age: 60 y/o and greater; hospitalization history: history of falling or fainting during prior hospitalizations; functional disabilities: deterioration of the feet and waist, loss in muscle strength, use of a wheelchair, a stick, or a walker, the need of support for movement, experiencing a wobble or not, and the insertion of any route and/or drains in the body; recognition abilities: disorientation, clouding consciousness, confusion, dementia, abilities to judge and understand, restless behavior, and the difficulty in relearning due to memory decline; medicine: analgesic drugs, narcotic drugs, sleeping tranquilizers, antiparkinsonian drugs, antihypertensive diuretics, enema laxative, and chemotherapy; egestion: urinary or fecal incontinence, frequent micturition, the need of egestion during sleeping, and the distance to the toilet. Degree of psychiatric nursing care: the degree of the need of nursing followup was evaluated by using the following levels: (a: followup is needed all the time); (b: constant followup is needed); and (c: continuous followup is not necessary, or followup after a longer interval than B). Activity of daily living (ADL): life was evaluated using the following definitions: (I: not being able to do any things by him/herself); (II: being able to do some things by him/herself, but having many things s/he cannot do); (III: being able to do most things, but having a problem in his/her independent activities); (IV: being able to do many things independently, but having a problem in social adaptation).
The falling risk score was determined by rating the following 6 items.
The total subjects of this research were 17 men and 10 women. Fourteen subjects (10 men and 4 women) were responsive, and 13 subjects (7 men and 6 women) were nonresponsive. The average age for the responsive group was
The average period of time from the start of switching to switching completion (or discontinuation of switching) was
There was no significant difference in the dosage of antipsychotics (CP equivalent) and antiparkinsonian drugs (BP equivalent) in the two groups before the switching. However, in the nonresponsive group, the daily dosage of antipsychotics tended to be higher after switching (
Changes of clinical indicators of before and after switch to aripiprazole.
Responsive group ( |
Nonresponsive group ( |
|||||||
---|---|---|---|---|---|---|---|---|
Before |
After |
|
|
Before |
After |
|
|
|
Mean daily dosage | ||||||||
Antipsychotics |
|
|
−0.28 | 0.78 |
|
|
−1.73 | 0.08 |
Antiparkinson drug |
|
|
−1.80 | 0.07 |
|
|
−0.94 | 0.35 |
Psychosis | ||||||||
BPRS total score |
|
|
−2.28 | 0.04 |
|
|
−0.57 | 0.58 |
Glucose and lipid metabolism | ||||||||
TP (g/dL) |
|
|
−1.20 | 0.23 |
|
|
−0.79 | 0.43 |
ALB (g/dL) |
|
|
−1.16 | 0.25 |
|
|
−0.05 | 0.96 |
A/G ratio |
|
|
−0.56 | 0.58 |
|
|
−1.30 | 0.20 |
T-cho (mg/dL) |
|
|
−0.80 | 0.42 |
|
|
−2.67 | 0.01 |
Hb (g/dL) |
|
|
−1.04 | 0.30 |
|
|
−0.94 | 0.35 |
Preprandial blood glucose level (mg/dL) |
|
|
−0.73 | 0.46 |
|
|
−0.45 | 0.66 |
BMI |
|
|
−1.85 | 0.06 |
|
|
−1.10 | 0.27 |
CP: chlorpromazine, BP: biperiden, BPRS: brief psychiatric rating scale, TP: total protein, ALB: albumin, A/G ratio: albumin-globulin ratio, T-cho: total cholesterol, Hb: hemoglobin, and BMI: body mass index. *two-tailed asymptotic significance probability (Wilcoxon signed-rank test).
Table
Changes in dosage of antipsychotics per day.
Responsive group ( |
Nonresponsive group |
|
|
|||
---|---|---|---|---|---|---|
Number of subjects | % | Number of subjects | % | |||
Decreased | 10 | 71 | 3 | 23 | 7.08 | 0.03 |
Increased | 4 | 29 | 8 | 62 | ||
No change | 0 | 0 | 2 | 15 |
*Two-tailed asymptotic significance probability (Fisher’s exact test).
The BPRS values were significantly decreased after the switching in the responsive group (
No change was observed in bowel movement frequency, the scores for falling risk, or the ADL scores before and after the switching in either of the groups. In addition, regarding the degree of psychiatric nursing needs, there was no significant difference observed (Table
Changes in clinical evaluation by observation of nursing.
Responsive group ( |
Nonresponsive group ( |
||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Before |
After |
Before |
After |
|
|
||||||||
Number of subjects | % | Number of subjects | % |
|
|
Number of subjects | % | Number of subjects | % | ||||
The bowel movement | One bowel movement per day | 7 | 50 | 5 | 35.7 | 0.88 | 0.20 | 4 | 30.8 | 5 | 38.5 | 2.60 | 0.15 |
One bowel movement in two days | 6 | 42.9 | 8 | 57.1 | 9 | 69.2 | 6 | 46.2 | |||||
One bowel movement in three days | 1 | 7.1 | 1 | 7.1 | 0 | 0 | 1 | 7.7 | |||||
One bowel movement in four days | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||
One bowel movement in five days | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 7.7 | |||||
| |||||||||||||
Falling risk | Risk level I: possibility of falling | 9 | 64.3 | 7 | 50 | 0.58 | 0.45 | 5 | 38.5 | 7 | 53.8 | 2.03 | 0.36 |
Risk level II: likelihood of falling | 5 | 36 | 7 | 50 | 8 | 61.5 | 5 | 38.5 | |||||
Risk level III: frequently falling | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 7.7 | |||||
| |||||||||||||
Degree of psychiatric nursing needs | a: followup is needed all the time | 4 | 28.6 | 1 | 7.1 | 2.19 | 0.14 | 6 | 46.2 | 3 | 23.1 | 1.56 | 0.10 |
b: constant followup is needed | 0 | 0 | 0 | 0 | 3 | 23.1 | 4 | 30.8 | |||||
c: continuous followup is not necessary | 10 | 71.4 | 13 | 92.9 | 4 | 30.8 | 6 | 46.2 | |||||
| |||||||||||||
ADL | I: not being able to do things by him/herself | 1 | 7.1 | 0 | 0 | 1 | 7.7 | 2 | 15.4 | ||||
II: being able to do some things by him/herself, but having many things s/he cannot do | 2 | 14.3 | 5 | 35.7 | 5.41 | 0.17 | 7 | 53.8 | 5 | 38.5 | 1.22 | 0.17 | |
III: being able to do most things, but having a problem in his/her independent activities | 10 | 71.4 | 5 | 35.7 | 4 | 30.8 | 4 | 30.8 | |||||
IV: being able to do quite many things independently, but having a problem in social adaptation | 1 | 7.1 | 4 | 28.6 | 1 | 7.7 | 2 | 15.4 |
ADL: activity of daily living, *asymptotic significance probability (Fisher’s exact test).
By switching the antipsychotics to aripiprazole, there were some significant improvements in psychiatric condition in the responsive group, showing the effectiveness of switching to aripiprazole. As the dosage of antiparkinsonian drugs in the responsive group tended to decline after the switching, it is suggested that extrapyramidal side effects were reduced by switching to aripiprazole [
On the other hand, there was no significant change in the dosage of antipsychotics in the nonresponsive group who were switched to other antipsychotics. However a tendency toward a higher dose of antipsychotics after the switching may indicate a temporarily worsening psychosis.
A significant increase in lipid levels was observed after the switching in the nonresponsive group. Eight of 13 subjects in the nonresponsive group were switched to other drugs, such as olanzapine and quetiapine, which were likely to affect glucose and lipid metabolic abnormality.
It is reported that aripiprazole is less likely to cause various side effects including glucose and lipid metabolic abnormality [
According to Kolotkin’s research [
Nursing evaluations indicated the bowel movement frequency, falling risk scores, the degree of psychiatric nursing needed, and the ADL score remained unchanged. This might be because the assessment was carried out only two months after switching from the previous medications; thus, it will be necessary to observe this factor in the long term. However, there was a tendency toward increased proportion and degree of psychiatric nursing needs in the responsive group. The increase in proportion of continuous followup despite no change in the life dependence levels suggests the effectiveness of the switch to aripiprazole, indicating that patients with aripiprazole could live independently.
Before the switching, 4 subjects in the responsive group were in the category, “continuous followup is needed all the time,” but this declined to one subject after the switching. This suggests that the patients needed less nursing assistance. This result suggests that switching to aripiprazole might contribute to reducing the burden on nurse as well as to the transition of patients to community living status.
It is reported that patients with schizophrenia who have been chronically treated with high-dose antipsychotic polypharmacy are more dependent on psychiatrists and nurses [
To improve quality of life and decrease metabolic syndrome in patients with schizophrenia, it is essential for caregivers to support patients’ drug administration with a minimal effective dose, and aripiprazole is considered to be one of the most effective options available. In order to make the treatment with aripiprazole more effective, physical exercise and nutritional instruction based on the evaluation of glucose and lipid metabolism are also necessary. Also, for patients to move toward a healthy lifestyle, a comprehensive support system is required. Such a system should include collaboration between the patient’s various specialists and should take into account the patient’s level of subjective side effects and discomfort in daily life.
The limitations of the present study include the small sample size and the retrospective design using secondary data. Also, the different switching methods might affect the degree of switching success, and switching protocols were dependent on several physicians, which might also affect outcomes.
The results of this research suggest that switching to aripiprazole improves psychiatric symptoms and leads to fewer side effects for persons diagnosed with schizophrenia. This could improve a person’s quality of life, medication adherence, and perhaps lead to living in the community. It is important to improve patients' medication adherence through patient education of side effects and drug advantages in order to make full use of aripiprazole. In addition to drug administration, it is also important that doctors, pharmacists, nutritionists, and nurses collaborate to support patients’ movement toward a healthy lifestyle.
The authors declare that there is no conflict of interests.
T. Tanioka, S. Fuji, and M. Kataoka participated in the design of this study, assisted with interpretation of the data, and drafted the paper; B. King and R. Locsin participated in the study, assisted with interpretation of the data, and were involved in critically reviewing the paper; M. Tomotake and K. Mifune were responsible for data analysis, assisted with the interpretation of the results, and were involved in critically reviewing the paper; Y. Yasuhara and K. Sekido participated in the design of the full study and the substudy, assisted with interpretation of the data, and were involved in critically reviewing the paper. All authors have read and approved the final paper.