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http://ajp.psychiatryonline.org

8. Bach M, Bach D, de Zwaan M, Serim M, Bhmer F: Validierungder deutschen Version der 20-Item Toronto-Alexithymie-Skalabei Normalpersonen und psychiatrischen Patienten. Psy-chother Psychosom Med Psychol 1996; 46:2328

9. Bagby RM, Taylor GJ, Parker JDA: The twenty-item Toronto Al-exithymia Scale, I: item selection and cross-validation of thefactor structure. J Psychosom Res 1994; 38:2332

10. Bagby RM, Taylor GJ, Parker JDA: The twenty-item Toronto Al-exithymia Scale, II: convergent, discriminant, and concurrentvalidity. J Psychosom Res 1994; 38:3340

11. Cloninger CR, Svrakic DM, Przybeck TR: A psychobiologicalmodel of temperament and character. Arch Gen Psychiatry1993; 50:975990

12. Richter J, Eisenmann M, Richter G, Cloninger CR: Das Tempera-ment und Charakter Inventar (TCI): ein Leitfaden ber seineEntwicklung und Anwendung. Frankfurt am Main, Germany,Swets Test Services, 1999

13. Franke G: Die Symptom-Checkliste von DerogatisdeutscheVersionManual (SCL-90-R). Weinheim, Germany, Beltz, 1994

14. Fukunishi I, Kikuchi M, Takubo M: Changes in scores on al-exithymia over a period of psychiatric treatment. Psychol Rep1997; 80:483489

Brief Report

Medical Decision Making in Antipsychotic Drug Choice for Schizophrenia

Johannes Hamann, M.D.Bernadette Langer, M.D.Stefan Leucht, M.D.Raymonde Busch, Dipl.-Math.Werner Kissling, M.D.

Objective: The influence of patient and physician variables onantipsychotic drug choice for patients with schizophrenia wasassessed.

Method: Interviews with 100 psychiatrists on drug choice for200 patients suffering from schizophrenia were conducted.Data were analyzed by using multiple logistic regression.

Results: Older physicians were up to five times more likely toprescribe first-generation antipsychotics. Patient variables didnot influence treatment decisions significantly.

Conclusions: There is an urgent need for more research onclinical decision making and quality management.

(Am J Psychiatry 2004; 161:13011304)

The research field of medical decision making at-tempts to explore, explain, and alter physician decisionmaking. Despite hundreds of studies on the efficacy ofpsychotropic drugs and in spite of the plethora of marketresearch, surprisingly little has been undertaken to scien-tifically explore decision making of physicians in, for ex-ample, antipsychotic drug choice. Thus, to date there is nosatisfactory explanation of the gap between an increasingnumber of treatment guidelines that recommend second-generation antipsychotics as first-line agents for patientswith schizophrenia (1, 2) and prescription data that show

first-generation antipsychotics are still being prescribedfor a considerable proportion of patients (3).

We therefore undertook a cross-sectional study to clar-ify psychiatrist decision making when choosing antipsy-chotic drugs for patients with schizophrenia.

Method

Semistructured interviews were carried out with 100 psychia-trists in the greater Munich area in Southern Germany. The sampleconsisted of 50 psychiatrists in private practice and 50 psychia-trists working in eight different psychiatric hospitals. To recruit

Phobia Paranoia Psychoticism t t t

0.03 0.49 0.01 0.17 0.005 0.080.33 4.27*** 0.02 0.23 0.17 2.5*

0.06 0.85 0.03 0.42 0.03 0.470.04 0.68 0.15 2.84** 0.09 1.740.04 0.45 0.34 4.5*** 0.25 3.6***

0.15 2.28* 0.24 3.8*** 0.04 0.750.05 0.78 0.18 3.3** 0.16 3.1**

0.35 4.7*** 0.21 3.0** 0.32 5.0***0.03 0.39 0.06 0.82 0.09 1.42

0.14 2.22* 0.03 0.49 0.02 0.390.09 1.59 0.1 1.89 0.03 0.53

0.06 1.1 0.005 0.11 0.01 0.25

R2 F R2 F R2 F

0.35 11.8*** 0.42 15.9*** 0.51 22.1***

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BRIEF REPORTS


physicians in private practice, all psychiatrists in the Munich areatreating patients with schizophrenia were requested to participate(N=83). Of these, 50 physicians took part in the study (60%). Wecontacted nine psychiatric hospitals in the region (two universityhospitals and seven state hospitals), and all but one agreed toparticipate. Physicians working in wards where patients withschizophrenia were treated were then selected for the interviews.Physicians in private practice were older than their hospital-basedcolleagues (mean age=49.8 years [SD=7.9] versus 39.4 years [SD=7.5], respectively) (t=6.86, df=98, p

Am J Psychiatry 161:7, July 2004 1303

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Results

Univariate comparisons (Table 1) showed that older pa-tients, patients with a longer course of illness, and patientswith high CGI ratings for positive symptoms were morelikely to receive first-generation antipsychotics. On thecontrary, patients who expressed a distinct wish for oragainst a certain antipsychotic compound or patients whohad previous bad experiences with first-generation anti-psychotics were more likely to receive second-generationantipsychotics. On the part of the physicians, those whowere older, had more work experience, or estimated theprice of olanzapine as being higher were more likely toprescribe classical compounds. Noteworthy is the fact thatthe actual price of the second-generation antipsychoticwas underestimated by 90% of the physicians.

Using multiple logistic regression, the physicians age(>50 or 50 years) (odds ratio=4.5, 95% CI=1.310.3; p=0.008), poor compliance (odds ratio=3.4, 95% CI=1.110.8;p

1304 Am J Psychiatry 161:7, July 2004

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7. Watkins C, Moore L, Harvey I, Carthy P, Robinson E, Brawn R:Characteristics of general practitioners who frequently see

drug industry representatives: national cross sectional study.BMJ 2003; 326:11781179

Brief Report

Basal Ganglia High-Energy Phosphate Metabolism in Neuroleptic-Naive Patients With Schizophrenia:

A 31-Phosphorus Magnetic Resonance Spectroscopic Study

B.N. Gangadhar, M.D.P.N. Jayakumar, M.D.D.K. Subbakrishna, Ph.D.N. Janakiramaiah, M.D., Ph.D.M.S. Keshavan, M.D.

Objective: This study used 31-phosphorus magnetic reso-nance spectroscopy (31P MRS) to investigate basal ganglia ab-normalities in neuroleptic-naive patients with schizophrenia.

Method: Nineteen schizophrenia patients and 31 age- and sex-matched healthy comparison subjects underwent 31P MRS.

Results: The phosphocreatine/total phosphorus and phospho-creatine/total ATP ratios in both basal ganglia were significantlylower in patients.

Conclusions: Schizophrenia patients showed features of in-creased metabolism in the basal ganglia consistent with im-paired activity of the frontostriatal pathways.

(Am J Psychiatry 2004; 161:13041306)

Several studies have implicated basal ganglia in thepathophysiology of schizophrenia (13). Decrease in cau-date volumes has been reported in neuroleptic-naive pa-tients with schizophrenia (4). Findings from 31-phospho-rus magnetic resonance spectroscopy (31P MRS) studieshave been inconclusive, perhaps due to differences inMRS methodology and medication status of the patients(5, 6).

We conducted a 31P MRS study of the basal gangliain neuroleptic-naive patients with schizophrenia andmatched healthy comparison subjects. Considering thatdopaminergic activity is increased in schizophrenia insubcortical structures (7), we hypothesized that basalganglia metabolism would be increased in the schizo-phrenia patients.

Method

Subjects

The study group consisted of 19 right-handed inpatients and31 healthy comparison subjects. Patients and comparison sub-jects did not significantly differ in terms of age (patients: mean=27 years [SD=7.6]; healthy subjects: mean=29 years [SD=6.1]) orsex (15 male and four female patients and 21 male and 10 femalehealthy comparison subjects). Diagnosis of DSM-IV schizophre-nia was determined by a psychiatrist with the Structured ClinicalInterview for DSM-IV (paranoid: N=8; catatonic: N=3; disorga-nized: N=2; undifferentiated: N=6). Illness duration ranged be-tween 6 and 120 months (mean=44, SD=35). No patient was everpreviously treated for psychiatric illness. Mean age at onset ofpsychosis was 23.6 years (SD=6.4, range=1539). Their mean Pos-

itive and Negative Syndrome Scale (8) score was 84 (SD=18,range=53119). None had involuntary movements. MRS studieswere conducted before starting antipsychotic treatment. Agita-tion was treated, where necessary, with lorazepam 26 mg/day individed doses.

Healthy comparison subjects were screened using the 12-itemGeneral Health Questionnaire (9). None of the patients or healthycomparison subjects had a history of recent alcohol use (previousweek) or scored positive on the CAGE questionnaire (10), andnone used stimulants or opiate drugs. No subject had a history ofepilepsy or any other neurological or medical disorder. All sub-jects provided written informed consent. The Institutes ethicscommittee approved the study.

Spectroscopy31P MRS was done on a 1.5 T scanner. Two-dimensional chem-

ical shift imaging with image-guided in vivo spectroscopic local-ization and volume-selective adiabatic high-frequency pulseswere used. The volume of interest was placed on representativeslices of the brain in all three orthogonal planes interactively andsimultaneously to avoid the ventricles. The volume of interest waslocalized to the basal ganglia with a mean size of 252550 mm3

(Figure 1). The magnetic field shimming for homogeneity wasdone to achieve a line width less than 0.15 ppm. The technical pa-rameters were repetition time of 1500 msec, free induction decay(FID) sampling rate of 1500 Hz, sampling points of 1024, and 12measurements.

The average FID signal in the spectra was processed using pro-prietary software by the rater (P.N.J.) blind to clinical data, withphosphocreatine as the reference marker. The spectra were quan-tified as integral values by an inbuilt program of fitting curves.The integrated area of phosphocreatine, inorganic phosphate,ATP, ATP, and ATP were measured. Phosphocreatine/totalphosphorus and phosphocreatine/total ATP ratios in right and

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