Comparison of risperidone and olanzapine as used under ‘‘real-world’’ conditions in a state psychiatric hospital Claire Advokat a, * , Dennis Dixon a , Jeffrey Schneider a , Joseph E. Comaty Jr. a,b a Department of Psychology, Louisiana State University, 236 Audubon Hall, Baton Rouge, LA 70803, USA b Louisiana Office of Mental Health, Department of Health and Hospitals, Baton Rouge, LA, USA Accepted 14 November 2003 Abstract As a follow-up to our previous study of clozapine, medical records of a state psychiatric hospital were reviewed for patients who were prescribed an atypical antipsychotic. From that sample, demographic and clinical data were obtained for individuals with an initial score of 35 or greater on the Brief Psychiatric Rating Scale (BPRS), and at least two additional successive monthly BPRS ratings. A total of 100 patients met the criteria. Most received either olanzapine (46%) or risperidone (36%), with few administered quetiapine (11%) or clozapine (7%). Most also received adjunctive medications, including conventional antipsychotics, anticonvulsants/mood stabilizers, antidepressants, and antiparkinsonian agents. The number of patients whose BPRS total scores decreased by 20% or more from baseline was significantly greater for those who received olanzapine than those who received risperidone. However, there was no difference between the two antipsychotics in the number of patients who maintained that degree of improvement, in the average latency to achieve that decrease (1.67 and 1.47 months, respectively), or the average length of stay (LOS; 332 and 376 days, respectively). These results indicate a modest therapeutic advantage of olanzapine compared to risperidone, and a substantial degree of polypharmacy in the use of atypical antipsychotics. This uncontrolled ‘‘real- world’’ evaluation supports data from controlled clinical trials, showing that either risperidone or olanzapine would be a reasonable first choice in patients with treatment-resistant schizophrenia, with the decision based on the least adverse side effect profile and economic constraints. When compared to our previous clozapine study, we confirm a slight advantage for the effectiveness of clozapine in the treatment of this refractory population. D 2003 Elsevier Inc. All rights reserved. Keywords: Atypical antipsychotics; Olanzapine; Risperidone; Schizophrenia 1. Introduction The clinical advantages and adverse effects of the first ‘‘atypical’’ antipsychotic, clozapine, are now well estab- lished. The advantages include clozapine’s efficacy, com- pared to first-generation antipsychotics (FGAs) and other second-generation antipsychotics (SGAs), for individuals who are resistant or refractory to conventional treatment for schizophrenia (Kane et al., 1988; Wahlbeck et al., 1999), and the fact that it produces minimal extrapyramidal side effects (Tarsey et al., 2002). Clozapine’s adverse side effect profile includes the requirement of frequent blood tests (to monitor for the occurrence of agranulocytosis), weight gain, the fact that it lowers the seizure threshold, and other less serious but nevertheless disturbing side effects (Miller, 2000). Efforts to develop similar antipsychotics, without cloza- pine’s drawbacks, have been moderately successful. There are now five other SGAs approved for general use: risper- idone, olanzapine, quetiapine, ziprasidone, and, most re- cently, aripiprazole. Under appropriate circumstances, all produce fewer extrapyramidal side effects than FGAs (McGavin and Goa, 2002; Tarsey et al., 2002). Several reviews and investigations comparing the newer antipsy- chotics with clozapine have been published (Fleischhacker, 1999; Azorin et al., 2001; Chakos et al., 2001; Davis et al., 2003; Tandon and Jibson, 2003), with mixed results. Some (but not all; Geddes et al., 2000) suggest that risperidone or olanzapine is not inferior to clozapine (Davis et al., 2003; 0278-5846/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/j.pnpbp.2003.11.015 Abbreviations: BPRS, Brief Psychiatric Rating Scale; ELMHS, Eastern Louisiana Mental Health System; FGA, first-generation antipsychotic; LOS, length of stay; SGA, second-generation antipsychotic. * Corresponding author. Tel.: +1-225-578-8500; fax: +1-225-578- 4125. E-mail address: cadvoka@lsu.edu (C. Advokat). www.elsevier.com/locate/pnpbp Progress in Neuro-Psychopharmacology & Biological Psychiatry 28 (2004) 487 – 495