Abstract
Dear Editor,
The Canadian Schizophrenia guidelines have become important references for clinicians and learners in Canada and elsewhere. Thus, we welcome the publication in the Canadian Journal of Psychiatry of new guidelines focusing on special populations in schizophrenia, including well-written recommendations on the choice of antipsychotic pharmacotherapy. 1
Although the evidence and the guidelines clearly state that with the exception of clozapine, there is no difference in efficacy between first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs), 2 –4 this is not reflected in today’s practice, which is dominated by SGAs. 5 –7 Psychiatric practice that is not in keeping with published guidelines or international research findings cannot be considered evidence-based, and the current trend in prescribing risks losing an important tool from our limited therapeutic options. 5 Psychiatry residents, who often adopt the prescribing behaviours of their attending physicians, may be particularly impressionable to these non-evidence-based trends, and a lack of training experience with FGAs may limit their use even further in the future. 5
To identify the training needs and barriers to prescribing for the next generation of psychiatrists, we surveyed Canadian psychiatry residents on their attitudes, experiences, and knowledge regarding FGAs and SGAs, as well as long-acting injectable antipsychotics (LAIs) and clozapine. The survey was approved by the university research ethics board prior to distribution.
In our survey, nearly two-thirds of residents were aware that FGAs and SGAs had similar efficacy. Roughly the same proportion also perceived FGAs to have more or “stronger” side effects than SGAs. A lack of training experience was noted as the second leading concern for prescribing FGAs (23%) after concerns regarding extrapyramidal side effects (35%), with nearly a fifth of trainees never having initiated FGAs themselves. Nearly 90% of trainees felt confident about initiating an oral SGA as a regular medication, while only about 25% felt confident with initiating an FGA (p < 0.001), and only about 50% felt confident with starting a patient on clozapine. Regarding LAIs, nearly 50% of residents reported they were uncomfortable discussing this option with patients.
Our survey has highlighted some worrying gaps in training. FGAs, as well as clozapine and long-acting injectables, can be used effectively with minimal side effects by carefully titrating the dose, providing appropriate psychoeducation to patients, and avoiding antipsychotic polypharmacy. 1,8 As similar training deficits have been identified in two previous studies in Europe, psychiatry trainees may face similar barriers regardless of where they train. 5,9
In conclusion, improving psychiatry resident education and training with antipsychotic pharmacotherapy will reduce the risk that these tools are lost to the future generations of psychiatrists.