CLINICAL HANDBOOK OF SCHIZOPHRENIA

620 VIII. SPECIAL TOPICSPHARMACOTHERAPYAlthough psychosocial support is important in managing schizophrenia, pharmacotherapyremains essential for maintenance and recovery. Unfortunately, the treatment of ethnicminorities is often inappropriate. African Americans often receive excessive doses ofmedication, whereas Hispanics and Asians receive lower medication doses, when treatedby ethnic providers. Moreover African Americans are more likely to receive first-generationrather than second-generation or atypical medications, higher doses of medication, andmore depot medication. Table 60.2 summarizes findings about the medicating of AfricanAmericans. Please note that some of the studies involved Medicaid or Veterans Administrationhospital patients, and income presumably should not have affected the difference.Also note that some of the typical agents and high doses may have been a consequence ofthe use of depot medication, for which only one atypical agent is now available, and noatypical form was available at the time of many of the studies. Yet when the use of depotmedication was controlled, the high dosing of typical medication persisted.The biological evidence, if anything, supports lower dosing for ethnic minorities.Ethnic differences have been found in the way many psychotropic agents are metabolizedthrough the cytochrome P450 family of liver isoenzymes. The CYP450 2D6 isoenzyme inparticular shows ethnic variation. Relative to the majority of European Americans,Asians, Hispanics, and African Americans show reduced activity in this enzyme, whereasmany Ethiopians show increased activity. Reduced activity means that a drug is metabolizedmore slowly, therefore having higher plasma levels. Individuals with CYP450 2D6alleles associated with reduced or no activity who are given standard medication dosesare more likely to have extrapyramidal side effects on antipsychotics and to discontinueTABLE 60.2. Reports on Pharmacotherapy for African AmericansReference Setting MedicationOpolka et al. (2004) Texas Medicaid African Americans are less likely thanEuropean Americans to receive risperidone orolanzapine.Daumit et al. (2003) National outpatientdatabaseAfrican Americans are less likely to receiveatypical antipsychotics.Kreyenbuhl et al. (2003)Outpatient study oftwo statesAfrican Americans are less likely to receiveatypical antipsychotics, and more likely toreceive depot medication.Olpolka et al. (2003) Medicaid population African Americans are less likely to receiveolanzapine or risperidone.Mark et al. (2003)Herbeck et al. (2004)Schizophrenia Care andAssessment ProgramAmerican PsychiatricInstitute PracticeResearch NetworkAfrican Americans are more likely to receivedepot medication, and less likely to receivesecond-generation antipsychotics even aftercontrolling for the use of depot medication.African Americans are less likely to receivesecond-generation antipsychotics when clinic,socioeconomic status, and health system arecontrolled.Olpolka et al. (2004) Medicaid population African Americans are less likely to receiveolanzapine or risperidone.Valenstein et al. (2001)Veterans AdministrationhospitalAfrican Americans are more likely to beon depot medication, first-generationantipsychotics, and higher doses.