Drug treatment modalities in psychiatric inpatient practice: a 20-year comparison

Pre- and post-discharge factors influencing early readmission to acute psychiatric wards: implications for quality-of-care indicators in psychiatry

OBJECTIVE

This study aims to describe the association between pre- and post-discharge factors and early readmission to acute psychiatric wards in a well-integrated community-based psychiatric service.

METHODS

The analysis consisted of all the hospital discharge records containing a psychiatric diagnosis in 2011 from four Italian acute inpatient wards. Socio-demographic, clinical, admission and aftercare variables were investigated as possible predictors of readmission at 7, 30 and 90 days after discharge and were analyzed, controlling for dependency among same-patient observations.

RESULTS

Previous psychiatric history was the most important predictor of readmissions. The socio-demographic and clinical characteristics of patients did not clearly influence readmission. Length of stay (LoS) was significant for readmission at 7 days even after controlling for other predictors and for same-patient dependence, in particular, for patients with previous admissions. Results suggest a protective role of a LoS higher than 28 days. In general, having a contact in community services did not turn out as protective from early readmission.

CONCLUSIONS

This paper contributes to increase the knowledge about factors that may predict the risk of early readmission. Implications for quality assessment in psychiatry emerged: readmission seems actionable by LoS and not by community follow-up.

Treatment patterns in inpatient depression care

This study aimed to identify latent patterns of treatment combinations in inpatient depression care. A secondary analysis of routinely collected data on inpatient depression treatment from 2133 patients was conducted. Exploratory latent class modeling was used to identify distinct classes of treatment combinations based on antidepressant medication, psychotherapeutic interventions, and additional treatments. The classes were compared with regard to patient characteristics and treatment outcomes. Eight different classes of inpatient treatment combinations could be identified: 22.8% of the patients were treated with a combination labelled "standard modern antidepressants", 14.6% with "standard tricyclic antidepressants", 12.2% with "high intensity innovative strategies", 12.1% with "standard selective-reuptake-inhibitors", and 11.6% with "low intensity", 9.6% with "somatic", 8.8% with "high intensity traditional", and 8.3% with "high intensity psychosocial" care, respectively. Patients treated with different patterns of interventions differed statistically significantly regarding demographic and clinical characteristics. Responder rates ranged from 68.4% to 86.6% across treatment classes. The presented attempt of empirical modeling of a complex multifactorial intervention by means of latent class analysis proved to be a promising way of capturing the complexity of routine inpatient depression treatment. The identified classes of treatment combinations may provide relevant information for a re-evaluation and improvement of inpatient depression treatment strategies.

Antipsychotic utilisation and polypharmacy in Italian residential facilities: a survey

OBJECTIVE

To evaluate the prescribing practices in psychiatric residential facilities, with particular focus both on the antipsychotic dose and polypharmacy as well as the variation of antipsychotic patterns during a patient's stay within the facilities.

METHODS

Fifteen residential facilities of Liguria region in Italy were included. Data were collected through a chart review during a one-day census. Frequency of psychotropic patterns was estimated. Different non-parametric tests were used to analyse the changes in prescription patterns as well as the relationship among antipsychotic dose, the number of antipsychotics and anticholinergic use.

RESULTS

The study sample includes 362 patients, 61.9% males. On the census day 77.5% of patients received psychotropic polypharmacy and 57.2% antipsychotic polypharmacy. Antipsychotic polypharmacy was related to the total antipsychotic daily dose and to anticholinergic use. A trend towards an increase of antipsychotic and psychotropic polypharmacy and higher doses of antipsychotics over the period of stay within the facilities was noted. This tendency was related to the length of stay in the facility.

CONCLUSIONS

Compared to earlier studies in the same clinical environment a significant increase in the use of psychotropic and antipsychotic polypharmacy was observed. The risk of prescribed polypharmacy seems to be related to time spent in the facility.

Predictors of the discharge dosage of an atypical antipsychotic agent among hospitalized, treatment-naive, first-episode psychosis patients in naturalistic, public-sector settings

OBJECTIVE

Little is known about determinants of second-generation antipsychotic dosages during initial hospitalization of first-episode psychosis. This study examined potential predictors of dosage of an atypical antipsychotic agent, risperidone, at hospital discharge after initial evaluation and treatment of first-episode nonaffective psychosis in 3 naturalistic, public-sector treatment settings.

METHODS

The number of psychotropic agents prescribed and discharge antipsychotic dosage were abstracted from the medical record. Demographic and extensive clinical characteristics were assessed through a clinical research study conducted at the 3 sites. One-way analyses of variance, trend tests using specific linear combinations of estimates, and χ² tests assessed for associations between atypical antipsychotic dosage and 5 hypothesized predictors, as well as 12 exploratory variables.

RESULTS

Among 155 hospitalized first-episode patients, 121 (78.1%) were discharged on risperidone, and subsequent analyses focused on that subset. The mean risperidone dosage among those 121 patients was 4.26 mg; 31 received 1 to 2 mg, 45 received 3 to 4 mg, 37 received 5 to 6 mg, and 8 received more than 6 mg. Analyses suggested that older age at hospitalization, the number of psychotropic agents prescribed, excited symptoms, and premorbid social functioning may be predictors of the discharge dosage.

CONCLUSIONS

Although several factors emerged, in general, predictors of discharge dosages of second-generation agents, here exemplified by risperidone, in real-world practice settings remain to be clarified. Given the importance of antipsychotic initiation during first hospitalization, future research should test an even broader array of potential predictors.

Polypharmacy prevalence rates in the treatment of unipolar depression in an outpatient clinic

OBJECTIVE

Unipolar depression is a complex illness with an ever increasing number of pharmacological treatments available. As the number of available medication options increases, so does the potential for polypharmacy, a practice with possible complications. Such complications include a greater number of side effects with the initiation of additional medications and the consequences of drug-drug interactions. Therefore, it is important to understand the effects of polypharmacy on efficacy of treatment as well as whether polypharmacy is instituted after appropriate initial monotherapy trials. This study attempts to answer these questions.

METHODS

Patient names for this investigation were provided by residents in the UMass Medical School Psychiatry Residency program. The charts of these patients were analyzed to collect data regarding demographics, clinical data about the illness, medication names, types, duration of use and to access efficacy using the Clinical Global Impression (CGI).

RESULTS

Of 160 reviewed charts, 135 subjects were included in the final analyses (others excluded due to incomplete data or no depression diagnosis). Patients were on average on 2.0 medications (SD=0.5) with 2.1 past trials. A greater number of current antidepressant medications did not correlate with a greater improvement in CGI, implying that polypharmacy did not necessarily lead to greater efficacy. The impact of illness severity, as measured by comorbidities, substance abuse, and trauma history, were included in the analysis, and did not significantly change this outcome. Additionally, prescription patterns themselves were examined, including reasons for termination of medication trials, the impact of side-effects, and the number of patients that had complete monotherapy trials before transitioning to polypharmacy.

STUDY LIMITATIONS

Small sample size, retrospective review, one CGI rater.

CONCLUSIONS

First, many patients did not receive an adequate monotherapy trial, as defined by dose and duration, before progressing to polypharmacy. Secondly, the use of two or more medications concurrently did not appear to increase efficacy as measured by CGI. Due to study limitations, direct comparison of the efficacy of one and two medications was not significant; however the study did demonstrate a general correlation between polypharmacy and greater depressive symptomatology. This suggests the need for optimizing monotherapy regimens before initiating polypharmacy that may not lead to improvement in symptoms.

Factors associated with antipsychotic dosing in psychiatric inpatients: a prospective study

The persistent use of doses in excess of recommended levels is associated with increased risks of adverse reactions without evidence of additional benefits. Such treatment modality was evaluated in hospitalized psychiatric patients. During a 6-year recruitment period, a consecutive series of psychiatric inpatients receiving antipsychotic therapy were included. At admission, sociodemographic and clinical data, including antipsychotic drug use, were collected, and the 18-item version of the Brief Psychiatric Rating Scale was administered. At discharge, data on antipsychotic drug therapy were collected. Prescribed daily doses were converted into multiples of the defined daily doses. Using a cut-off score of a prescribed daily dose/defined daily dose as a ratio of more than 1.5 both at admission and at discharge assessments, a total of 62 (15.4%) patients persistently received high antipsychotic dose. With less stringent criteria (prescribed daily dose/defined daily dose as a ratio of more than 2), however, only 4.4% of the entire sample was persistently exposed to high antipsychotic doses. Bootstrapped linear regression analysis revealed that positive symptoms were positively associated with high antipsychotic dose, whereas negative symptoms were negatively associated with high antipsychotic dose. Antipsychotic polypharmacy at admission was the strongest predictor of persistently receiving antipsychotic doses in excess of recommended levels. This study showed that the use of high antipsychotic dosing is not an occasional event. Clinicians should consider that concurrent prescribing of two or more antipsychotic agents increases the probability of administering excessive dosing in the long-term.

Persistence with polypharmacy and excessive dosing in patients with schizophrenia treated in four European countries

The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia.