International Journal of Psychiatry in Clinical Practice

ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20

Patient satisfaction and acceptability of long-term treatment with quetiapine J S E Hellewell, A H Kalali, S J Langham, J McKellar & A G Awad To cite this article: J S E Hellewell, A H Kalali, S J Langham, J McKellar & A G Awad (1999) Patient satisfaction and acceptability of long-term treatment with quetiapine, International Journal of Psychiatry in Clinical Practice, 3:2, 105-113 To link to this article: http://dx.doi.org/10.3109/13651509909024770

Published online: 12 Jul 2009.

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International Journal of Psychiatry in Clinical Practice 1999 Volume 3 Pages 105- 113

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Patient satisfaction and acceptability of long-term treatment with quetiapine

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JSE HELLEWELL’, AH KALALI’, SJ LANGHAM’, J MCKELLAR3 and AG AWAD4 ‘Trafford General Hospital, Manchester, M41 5SL UK, 2Department of Psychiatry G Human Behavior, University of Cali/omia Irwine, CA, USA, 3Zeneca Pharmaceuticals, Macclesfield, UK and 4University of Toronto, Ontario, Canada

Correspondence Address Dr Jonathan SE Hellewell, MSc, MRCPsych, Department of Psychiatry, Moorside Unit, Trafford General Hospital, Manchester, UK Tel: +44 (0) 161 746 2680

Received 1 January 1999; accepted for publication 23 April 1999

Satisfaction with, and subjective tolerability of, antipsychotic medication have emerged as important factors in determining treatment compli znce and eventual outcome in the management of psychotic disorders. The acceptability of long-term treatment with quetiapine, an atypical antipsychotic agent with a lower incidence of extrapyramidal effects than standard therapy, was examined in this open-label, multicentre study of patient satisfaction. One hundred and twenty-nine patients with major psychiatric disorders, who had each been receiving quetiapine for at least 6 months in open-label extension studies, were asked to complete a 7-item questionnaire concerning subjective experience and satisfaction with treatment. Over 75% of respondents indicated that they were either “very” or “extremely” satisfied with their antipsychotic medication while 73.7% indicated that, over the last month, they regarded their antipsychotic medication to have been “very” or “extremely” helpful. Subjectively reported side-effects were uncommon, with 74.4% of patients reporting no side-effects, 23.3% mild side-effects and only 2.3% moderate side-effects. There were no unambiguous reports of extrapyramidal symptoms. An overwhelming majority of patients (114/118; 96.6%) reported that they preferred quetiapine to previous antipsychotic medications, the predominant reasons being their perceptions of better tolerability and greater efficacy. Patients also identified improvements in quality of life and their activities of daily living. These positive evaluations appeared to be reflected in the high proportion of respondents who indicated a readiness to continue quetiapine treatment. This study indicates that the combination of efficacy and a favourable tolerability profile shown by quetiapine may result in benefits that are evident to the patient and may be reflected in high levels of patient satisfaction and acceptance of treatment. By improving compliance with treatment, these benefits may also enhunce clinical outcome. (Int J Psych Clin Pract 1999; 3: 105- 113) Keywords patient satisfaction subjective tolerability quetiapine

INTRODUCTION chizophrenia a common and serious mental illness. S The majority patients require long-term treatment with antipsychotic medication, but many, even with is of

treatment, experience enduring positive and negative symptoms. Deficits in social functioning and cognition

acceptability long-term treatment

are commonly seen in established illness, such that many patients require intensive long-term support. Unfortunately, antipsychotic medication is incompletely effective in a substantial proportion of patients, with up to one-third experiencing persistent hallucinations and delusions, despite antipsychotic treatment. In addition, many antipsychotic drugs, particularly the conventional agents, are

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associated with unwanted side-effects, notably extrapyramidal symptoms, hyperprolactinaemia and sexual dysfunction. Therefore, it is perhaps not surprising that a substantial proportion of patients with schizophrenia fail to take their medication as prescribed. For example, Naber' estimated that only 30 - 40% of patients with chronic schizophrenia take their medication regularly, while Van Putten' estimated that between one-quarter and two-thirds of patients on antipsychotics take less than the prescribed dose. Although lack of insight into the disease and into the necessity for treatment undoubtedly contribute to these high rates of non-compliance, there is considerable evidence that the side-effects of standard antipsychotics also play a major In particular, extrapyramidal symptoms (especially akathisia) have been found to predict non-compliance,2.6suggesting a causal relationship. Thus, it is probable that a negative subjective response to treatment may lead to non-compliance and thereby to a less favourable clinical outcome, with more frequent relapse, impaired quality of life and additional healthcare expenditure.' At clinically effective doses, conventional antipsychotic drugs show high occupancy of striatal dopamine D2 receptors and thereby give rise to the extrapyramidal symptoms of parkinsonism, dystonia, akathisia and tardive dyskinesia. Extrapyramidal symptoms are commonly seen in patients taking standard antipsychotics, affecting between 20% and 40% of patients: and up to 20% of patients on long-term therapy.' Quetiapine, a dibenzothiazepine derivative, is one of the new atypical antipsychotic agents. Although there is no consistent definition of the term 'atypical', it most commonly refers to an agent that produces a lower incidence of extrapyramidal effects than standard antipsychotics in dosages that provide equivalent therapeutic efficacy."." Quetiapine has been shown to interact at a wide variety of neurotransmitter sites and has considerably higher affinity for 5-HTz receptors than for dopamine D, receptors." In clinical trials, quetiapine has been shown to be an effective antipsychotic in the management of both the positive and negative symptoms of ~chizophrenia,'~ with efficacy equivalent to that of the standard agents chlorpromazine and haloperidol. Remarkably, quetiapine, in the clinical trial programme, was associated with no more extrapyramidal symptoms than placebo, across the full dose range of 150-750 mg/ day.l4,l5 Moreover, it has not been associated with agranulocytosis or with sustained elevations in serum prolactin levels.I6s1 As quetiapine treatment is associated with a much reduced burden of extrapyramidal symptoms than standard antipsychotics, it may prove to be more readily accepted by patients. Results of a preliminary survey of 30 schizophrenic patients who had received quetiapine for at least 4 months confirmed a low rate of subjectively reported side-

effects and indicated that this may be reflected in high levels of satisfaction with treatment." However, this was a small study, involving only 30 patients from a single centre. Therefore the present study was carried out to determine whether the promising results from the preliminary study would be replicated in a larger, international cohort of patients who had each been receiving quetiapine for at least 6 months.

METHODS Patients eligible for the study were those who had been taking quetiapine for a continuous period of 6 months or longer and were currently in the open-label extension phase of clinical trials. As such, these patients had all taken part in a study from the quetiapine clinical trial programme and had been judged by their investigator to be likely to benefit from quetiapine given on an openlabel basis. During one of the scheduled follow-up visits subjects were asked to complete a simple 7-item questionnaire, concerning their attitudes to, and perceptions of, quetiapine treatment. Using a combination of open and directive questions, the questionnaire was designed to assess the patients' perceptions of their experience with quetiapine, the benefits that had become apparent to them and their attitudes to continued treatment. The instrument was designed following a review of published and input from expert opinion. A copy is shown in Table 1. After obtaining the patient's consent, the investigator and patient completed the questionnaire together.

ANALYSES Data from the questionnaires and patient demographic data were managed using an SAS@ data set. To facilitate interpretation, statements given by subjects in response to open questions were apportioned (by the same clinician) to one of the following five categories: Tolerability, Symptom Control, Subjective Benefits, Activities of Daily Living, and Drug Characteristics.

RESULTS DEMOGRAPHY Questionnaires were completed by a total of 129 patients from 12 countries. The majority (55%) of patients were recruited from centres in the United States; other subjects were recruited from centres in Europe (37.2%: Czech Republic, Eire, Finland, Hungary, Norway, Poland, Portugal, Sweden and UK), South Africa (7%) and Israel (0.8%). The mean age of patients was 51.3 years (range 18-91), with 69 men (53.5%) and 60 women (46.5%). The majority of patients (67%) were diagnosed as suffering from

Patient satisfaction with quetiapine

schizophrenia, the paranoid subtype being the most common (41.5% of patients). The remaining subjects

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fulfilled diagnostic criteria for other functional or organic psychoses, as shown in Table 2.

Table 1 Patient Satisfaction Questionnaire

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Section I: Background Information What is your current marital status? Mamed or living with partner Widowed Divorced Separated Never married Who is the main person you rely on for help, support and advice? Husband, wife, boyfriend, girlfriend, partner A member of your family (other than your husbandlwife) Friend Mental health professional Other, please specify .......................................................... During the last six months, where have you been living? At home In specialised accommodation In hospital Other, please specify .......................................................... Section II: Subjective Experience and Satisfaction with Treatment During the last month, how satisfied have you been with your antipsychotic medication? Extremely satisfied Very satisfied Somewhat satisfied Unsatisfied Very unsatisfied During the last month, how helpful do you think your medication has been? Extremely helpful Very helpful Somewhat helpful Unhelpful Very unhelpful During the last month, how would you rate the side effects of your medication? None Mild Moderate Severe Please consider how you feel about the medication you are now on compared to other medications you were on before. 4a. Please list the things about the medication you are now on that you like: 1. 2. 3.

4. 5.

4b. Please list the things about the medication you are now on that you do not like: 1. 2.

.-.

3.

4. 5.

4c. Do you think the medication you are on now is better than other medications you have had in the past? Please say why you think your medication is or is not better. No Yes Why? 5. During the last six months, have you noticed any benefits in the following areas? Yes No Feel better in general Feel happier Feel more confident Feel happier about relationships with friends and family Feel more able to achieve something Have a more positive outlook on life Feel more energetic Feel more relaxed Feel more in control of my thoughts Feel more in control of my actions Feel better able to concentrate Feel more able to cope with stress Experienced an improvement in sex life Feel less depressed Feel less agitated Feel less worried Feel less suspicious of other people Feel less restless Feel less tense

6. During the last six months, do you find it easier: Yes To eat more normally? To sleep more normally? To do things around the house? To prepare and cook meals? To go shopping for food and personal items? To manage your own money?

No

7a. Do you think you need to take medication for your condition? Yes No 7b. Do you always take your medication as prescribed? Yes No 7c. Would you like to continue with your current medication? Yes No

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Table 2 Diagnoses of patients entering the study (n=129)

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DSM-111-R diagnosis

Schizophrenia Paranoid type Undifferentiated type Residual type Disorganized type Catatonic type Other functional psychoses Delusional disorder Shared psychotic disorder Organic psychoses Parkinson’s diseasddementia Alzheimer’s type dementia Vascular dementia Affective disorders Schizo-affective disorder Bipolar disorder

No. of patients (%)

54 (41.9) 18 (14.0) 5 (3.9) 6 (4.7) 4 (3.1)

2 (1.6) 11 (8.5) 11 (8.5) 11 (8.5) 3 (2.3)

Figure 1 Patients’ response to the question ‘’During the last month, how satisfed have you been with your antipsychotic medication!” (n=128).

2 (1.6) 2 (1.6)

DURATION OF TREATMENT The mean duration of treatment with quetiapine was 19.9 months (range 6.1 -47.2). Forty-nine patients (38%) had been receiving quetiapine continuously for between 31 and 42 months, while 59 patients (46%) had been taking the drug for between 6 and 18 months.

PATIENT SATISFACTION Question 1 of the patient satisfaction questionnaire (Table 1) asked how satisfied patients had been with their antipsychotic medication in the last month: 75.8% replied “very satisfied” or “extremely satisfied”; full details are given in Figure 1. Similarly, when patients were asked how helpful they thought their antipsychotic medication had been over the last month (Question 21, almost three-quarters indicated that it had been “very” or “extremely” helpful (34.9% and 38.8%, respectively), while 25.6% rated their treatment as “somewhat helpful”. One patient declined to comment, but none gave a rating of “unhelpful” or “very unhelpful”. The incidence of subjectively reported side-effects during the last month, elicited from Question 3, was very low (Figure 2). The majority of patients (96; 74.4%) reported no side-effects, while 30 (23.3%) had mild sideeffects and only three described moderate side-effects. In Question 4, patients were invited to list “things about your medication” that they liked or did not like. Of the 129 patients in the study, 116 (89.9%) cited aspects of quetiapine treatment that they liked. The average number of comments per patient was 1.95. Table 3 lists the features that were reported by at least three

Patients’ Retlng of Side Effect8

Figure 2 Patients’ response to the question “During the last month, how would you rate the side-eJects of your medication!” (n=129).

patients. The reasons most commonly reported by patients for liking the medication were that it had few, or no, side-effects (34 reports), that they had experienced improvements in specific side-effects (32 reports) and that it helped them to relax (26 reports) or to feel better in general (20 reports). The features that patients liked were categorized and these replies are summarized in Table 4. Respondents were asked to list not just the aspects of drug treatment that they liked but also those that they did not. Negative comments were made much less commonly than positive comments, and were made by fewer respondents: 42 patients (32.6%) cited an aspect of quetiapine treatment that they did not like, 87 patients (67.4%) had no negative comments to make. The mean number of negative comments per patient was 0.48, compared with 1.95 positive comments per patient. The most commonly reported reason for dislike was that the treatment “had some side-effects’’ (39 reports). Of these, sedation (15 reports) and dry mouth (six reports) were the most frequently quoted. Other reasons were cited, but much less frequently. These included references to mood states: for example, “it made the patients feel irritable/angry/ anxioudtense” (four reports); the occurrence of mood

Patient satisfaction with quetiapine

Table 3. Features about quetiapine that patients liked (reported by at least three patients)

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Features about quetiapine that patients liked It has noflow side effects Patient experiences improvements in specific side effects It helps patient to reladfeel calmer It makes patient feel better in general Patient can sleep more normally Patient feels more in control of their thoughts It is effectivdmore effective Patient has fewer hallucinationddelusions It enables patient to live normally/feel normal It is effective at controlling mood (less depressed, happy, have fewer suicidal thoughts) Patient has more energylfeels more alert Easy to take Patient feels less paranoid Patient feels more stabldmore in control It enables patient to do mordgo out more Makes patient feel more sociable Patient has a healthy appetite It has improved patient’s sex life It enables patient to work

No. of reports by patients“ 34 32 26 20 19 16 16 15 9 9

7 6 5 5 4 4 3 3 3

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Table 5. Reasons for preferring quetiapine to previous antipsychotic medications (reported by at least three patients)a Reason for preferring quetiapine to previous antipsychotic medication

No. of reports by patientsb

It has noflow side effects It is more effective Patient no longer experiences specific side effects Patient has no more hallucinations It makes patient feel better in general Patient is less paranoifless afraid Patient feels calmer It makes patient feel normaYlive more normally Patients feels more energetidess tired It enables patient to do more It enables patient to work Patient feels more in control of their thoughts Patient feels more stabldin control The medication is mild

42 19 14 10

7 7 6 5 5 4 4 3 3 3

“8 patients had not been on any other antipsychotic medication and could not be included in the sample (n=121) b18 patients did not comment on this section

‘13 patients did not comment on this section

Table 6. Reasons for preferring quetiapine to previous antipsychotic medications (categorized) Table 4. Features about quetiapine that patients liked (categorized) Attribute Attribute

Tolerability Symptom improvement Subjective benefits Activities of daily living Drug characteristics

No. of reports

No. of patients (%I“

66 61 64 48 13

54 (41.9) 50 (38.8) 54 (41.9) 37 (28.7) 12 (9.3)

Tolerability Symptom improvement Subjective benefits Activities of daily living Drug characteristics

No. of reports

No. of patients (%I“

56 41 27

53 (41.1) 37 (28.7) 26 (20.2) 17 (13.2) 9 (7.0)

20 9

“Number of patients reporting a specific attribute (patients could report an attribute more than once)

“Number of patients reporting a specific attribute (patients could report an attribute more than once)

swings (three reports); sleeping problems (three reports); and a preference for taking fewer dosages (three reports). There were no unambiguous reports of extrapyramidal symptoms and few, if any, comments that could have been construed as references to these syndromes. The questionnaire also required patients to state whether they considered quetiapine to be better than other medications they had received in the past. Of the 118 patients who had previous experience of antipsychotic

medication and who expressed a preference, 114 (96.6%) indicated that they preferred quetiapine to previous therapy. Patients answering in the affirmative were then asked to list their reasons, and any responses given by at least three patients are shown in Table 5. The reasons given for preferring quetiapine related both to its perceived tolerability and to its efficacy. The most commonly cited reasons were that “it has noflow side-effects’’ (42 reports), “it is more effective” (19 reports), “patients no longer experience specific side-effects’’ (14 reports) and k o more hallucinations” (10 reports). In total, over 40% of patients

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Figure 3 Benefits noticed in the last 6 months by patients on quetiapine, classed as related to (A) quality of lve, (B) &cac: and (C)activities of daily living.

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Patient satisfaction with quetiapine

cited reasons relating to tolerability, 28% described benefits relating to symptom control, while 20% identified benefits of a more subjective nature. When all the reasons for prefemng quetiapine to previous medications were categorized, the main categories were tolerability, symptom improvement, and subjective benefits, reported by 41.1%, 28.7% and 20.2% of patients, respectively (Table 6). In contrast, only three reasons were given for quetiapine not being better than previous medications. In Questions 5 and 6, respondents were asked to state whether or not they had observed benefits during the previous 6 months in a number of distinct and specific areas. A wide variety of items were listed, covering quality of life, symptomatic improvement, and activities of daily living. Subjects’responses are shown in Figure 3. Over 90% of subjects reported “feeling better in general”, and improvements in other aspects of quality of life were reported by between 33% and 84%. Clearly, the majority had noticed benefits in all of these areas, suggesting a perceived general improvement in quality of life; notably, one-third of patients considered that there had been benefits in sexual function. There was a uniform improvement in efficacy-related benefits, ranging from “feeling more in control of their actions”, reported by 87% of patients, to “feeling less suspicious of other people”, reported by 77% of patients. Similarly, there was an overall improvement in activities of daily living, with “sleeping more normally” being the area of improvement reported most commonly (by over 80% of patients). Other activities of daily living were also reported to have improved, the least commonly reported improvement being in “preparing and cooking meals”, which nonetheless was reported by 55% of the sample. When asked directly about their attitudes to longerterm treatment, 94.4% of patients acknowledged they needed to take medication for their condition, while almost all (97.7%) indicated that they took their medication as prescribed and all except two (98.4%) expressed a readiness to continue taking quetiapine.

DISCUSSION These findings indicate that patient satisfaction and acceptability of long-term treatment with quetiapine were excellent. A total of 75.8% of study patients, who had been treated with quetiapine for a mean duration of 20 months, rated themselves as “very” or “extremely” satisifed with their antipsychotic medication and almost three-quarters (73.7%) regarded their medication, during the preceding month, to have been “very” or “extremely” helpful. These high levels of satisfaction and acceptability suggest that the efficacy and tolerability benefits of quetiapine are indeed evident to patients. However, these results must be put into context. The population selected for the study consisted of patients who had received quetiapine for more than 6 months as part of an initial

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comparative trial, and who had been judged by their doctor to be likely to benefit from entry into an open-label trial of quetiapine; that is, the study population was selected from patients who had already shown a good response to quetiapine. Nevertheless, despite the generally good response to quetiapine and the majority reporting high levels of satisfaction (ratings of “very” and “extremely” satisfied), about 24% rated themselves only “satisfied. This observation is in line with other reports suggesting that symptomatic improvement, though important for patients’ satisfaction, is not the sole determinant, and that other issues, such as values and attitudes towards health and illness, stigma, or previous experiences with medication, A particular strength of this study is its can play a naturalistic design, reflecting clinical management in reallife situations outside the controlled conditions of the double-blind study. One possible explanation for the high levels of patient satisfaction in this study is that this may simply be a reflection of quetiapine’s very good side-effect profile. Certainly, the burden of side-effects reported by patients was very low, with 74.4% of patients reporting no sideeffects, 23.3% reporting mild side-effects and only 2.3% moderate side-effects. The main reason given by patients for liking quetiapine was its perceived freedom from sideeffects. Of those patients who did complain of some sideeffects, the most commonly quoted were sedation and dry mouth; remarkably, there were no reports suggestive of extrapyramidal symptoms. In addition to extrapyramidal symptoms, standard antipsychotics are associated with the development of dysphoria, a particularly unpleasant subjective feeling. The development of ‘neuroleptic dysphoria’ has an obvious impact on patients’ satisfaction with medication and consequently upon compliance and clinical o ~ t c o m e . ~ ~ ~ ~ ’ ~ Notably, reports of negative emotional change were uncommon in this study and there were few, if any, reports that could be construed as representing this phenomenon. Therefore, it seems probable that the low prevalence of side-effects is reflected in the patients’ positive subjective response to antipsychotic medication. Certainly, acceptability of treatment has been shown to be closely related to patient sati~faction.’~ In this study, the satisfaction of patients with quetiapine was demonstrated by the finding that almost all of those who had received previous antipsychotic medication reported that they preferred quetiapine (96.6%). Another important factor in determining the satisfaction of patients with their medication is likely to be their perception of the quality of life they experience when on medication, and this may be particularly relevant for the long-term treatment of chronic diseases such as schizoph~enia.’~ In general, the patients in this study were aware of wide-ranging improvements in their quality of life and their activities of daily living. There was a uniform improvement in efficacy-related benefits, ranging from

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“feeling more in control of their actions”, reported by 87% of patients, to “feeling less suspicious of other people”, reported by 77% of patients. In addition, improvements in quality of life and in a number of activities of daily living were also reported by large numbers of patients, suggesting that the efficacy and tolerability benefits may be leading to improvements in personal and social functioning. These findings are consistent with the conclusions of Awad and who showed that a positive subjective response to medication and patients’ perception of improved quality of life are linked both with good compliance and with favourable therapeutic outcome. It is tempting to speculate that the subjective benefits of quetiapine treatment, particularly in activities of daily living, may be a reflection, in part, of improvements in cognition, as evidence is emerging that the atypical agents may be effective in alleviating the motor executive dysfunction in schizophrenia.26 It could be argued that the data gathered using the patient satisfaction questionnaire in this study are essentially qualitative rather than quantitative. It is difficult to design a quantitative survey which would encompass all the subjective components involved in ‘patient satisfaction’, and to which descriptive statistics could be readily applied.27*28 Nevertheless, while the precise measurement of patient satisfaction may pose challenges, compliance with treatment can be a~certained.~~ Regarding the question of compliance in this study, over 90% of patients, when asked directly about their views on continued treatment, acknowledged they needed to take medication for their condition, while almost all described taking medication as prescribed and expressed a readiness to continue treatment with quetiapine. Thus, the new generation of atypical antipsychotic agents may offer real possibilities for improving compliance with treatment among patients with schizophrenia who are dissatisfied with existing antipsychotic~.~~ Although many factors contribute to compliance, or the lack of it, subjective tolerability and satisfaction have been consistently identified as major contributors. As such, the level of adherence to prescribed medications largely reflects overall satisfaction with the medication and can be

regarded as evidence of good subjective tolerability. The endorsement of quetiapine by the vast majority of patients in this study is significant for its relevance to compliance and eventual outcome. There may also be considerable pharmaco-economic implications, in terms of relapse prevention and reducing the need for rehospitalization. These results regarding long-term treatment with quetiapine add to recent reports in pointing to the superiority of new atypical antipsychotics over standard antipsychotics in terms of lower side-effects, better subjective tolerability and improved quality of life.30.31 Thus, the present study, although having some limitations, indicates strongly that the efficacy and tolerability of quetiapine are both evident to patients and reflected in superior acceptability and satisfaction with treatment.

ACKNOWLEDGEMENT This study was sponsored by Zeneca Pharmaceuticals.

KEY POINTS 0

0

0 0

0

Subjective tolerability and satisfaction with treatment are important determinants of compliance and eventual outcome in psychotic illnesses This is a survey of the opinions of 129 patients receiving long-term treatment with the atypical antipsychotic quetiapine Patient satisfaction with quetiapine was excellent Quetiapine treatment was well regarded, wideranging subjective benefits were identified and side effects were few These positive perceptions may be reflected in enhanced acceptability of treatment, and thereby improved long-term outcome

REFERENCES Naber D (1995) A self-rating to measure subjective effects of neuroleptic drugs, relationship to objective psychopathology, quality of life, compliance and other clinical variables. Int Clin Psychopharmacol 10 (suppl3): 133-8. Van Putten T (1974) Why do schizophrenic patients refuse to take their drugs? Arch Gen Psychiatry 31: 67 - 72. Falloon I, Watt DC, Shepherd M (1978) A comparative controlled trial of pimozide and fluphenasine decanoate in the continuation therapy of schizophrenia. Psychof Med 8: 59- 70. Hogan TP, Awad AG, Eastwood R (1983) A self report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity. Psychol Med 13: 177-83.

Nelson A (1975) Drug default among schizophrenic patients. AmJ Hosp Pharm 32: 1237-42. Buchanan A (1992) A two-year prospective study of treatment compliance in patients with schizophrenia. Psychol Med 22: 787-97. Awad AG, Hogan TP, Voruganti LN, Heslegrave RJ (1995) Patients’ subjective experiences on antipsychotic medications: implications for outcome and quality of lie. Int Clin Psychophamacol 10 (suppl3): 123-32. Tarsey D (1983) Neuroleptic-induced extrapyramidal reactions: classification, description and diagnosis. Clin Neuropharmacol6 (suppl 1): S9-S26.

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9. Baldessarini RJ, Cole JO, Davis JM (1980) Tardive dyskinesia: a summary of a task force report of the American Psychiatric Association. Am J Psychiatry 137: 1163 - 72. 10. Kerwin R, Taylor D (1996) New antipsychotics: a review of their current status and clinical potential. CNS Drugs 6: 71 -82. 11. Meltzer HY (1996) Pre-clinical pharmacology of atypical antipsychotic drugs: a selective review. Br J Psychiatry 168 (suppl 29): 23-31. 12. Saller CF, Salama AL (1993) Seroquel: biochemical profile of a potential atypical antipsychotic. Psychopharmacol 112: 285 -92. 13. Peuskens J, Link CGG (1997) A comparison of quetiapine and chlorpromazine in the treatment of schizophrenia. Acta Psychiatr Scand 96: 265-73. 14. Arvanitis LA, Miller BG, and the Seroquel Trial 13 Study Group (1997) Multiple fixed doses of 'Seroquel' (quetiapine) in patients with acute exacerbation of schizophrenia: a comparison with haloperidol and placebo. Biol Psychiatry 42: 233-46. 15. Small JG, Hirsch SR, Arvanitis LA et a1 (1997) Quetiapine in patients with schizophrenia: a high- and low-dose double-blind comparison with placebo. Arch Gen Psychiatry 54: 549- 57. 16. Meats P (1997) Quetiapine ('Seroquel'): an effective and welltolerated atypical antipsychotic. IntJ Psych Clin Pract 1: 231-9. 17. Hamner MB, Arvanitis LA, Miller BG (1996) Plasma prolactin in schizophrenia patients treated with Seroquel (1Cl 204,636). Psychopharmacol Bull 32: 107- 110. 18. Kalali A (1999) Patient satisfaction with, and acceptability of, atypical antipsychotics. Curr Med Res Opin 15: 135-7. 19. Hogan TP, Awad AG (1992) Subjective response to neuroleptics and outcome in schizophrenia: a re-examination comparing two measures. Psycho1 Med 22: 347-52. 20. Awad AG (1993) Subjective response to neuroleptics in schizophrenia. Schizophr Bull 19: 609- 18.

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21. Weiden PJ, Shaw E, Mann JJ (1986) Causes of neuroleptic noncompliance. psychiatry Ann 16: 571 -5. 22. Awad AG, Hogan TP (1994) Subjective response to neuroleptics and the quality of life: implications for treatment outcome. Acta Psychiatr Scand 89 (suppl 380): 27-32. 23. Van Putten T, May PR, Marder SR, Wittmann LA (1981) Subjective response to antipsychotic drugs. Arch Gm Psychiatry 38: 187-90. 24. Kalman TP (1983) An overview of patient satisfaction with psychiatric treatment. Hosp Commun Psychiatry 34: 48 - 54. 25. Awad AG (1995) Quality of life issues in medicated schizophrenics: therapeutic and research implications. In Contemporary issues in the treatment of schizophrenia (eds C Shriqui, H Nasrallah) 735 - 47. American Psychiatric Press, Washington, DC. 26. Fleming K, Kalali A, Yeh C et a1 (1996) Neurocognitive effects of 'Seroquel' (ICI 204,636). World Congress of Psychiatry 2: 305. 27. Williams B (1994) Patient satisfaction: a valid concept? Soc Sci Med 38: 509- 16. 28. Williams B, Wilkinson G (1995) Patient satisfaction in mental health care. Evaluating an evaluative method. Br J Psychiatry 166: 559-62. 29. Keks NA (1997) Impact of newer antipsychotics on outcomes in schizophrenia. Clin Therapeut 19: 148- 52. 30. Awad AG, Voruganti LNP (in press) Neuroleptics and quality of life in schizophrenia. In Quality of life and mental health care (ed S Priebe). Wrightson Biomedical Publishing, London, UK. 31. Franz M, Lis 5, Pluddemann K, Galhofer B (1997) Conventional versus atypical neuroleptics: subjective quality of life in schizophrenic patients. Br J Psychiatry 170: 422-5.

Patient satisfaction and acceptability of long-term treatment with quetiapine.

Satisfaction with, and subjective tolerability of, antipsychotic medication have emerged as important factors in determining treatment compliance and ...
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