Psychiatrist decision-making towards prescribing benzodiazepines: the dilemma with substance abusers

A qualitative exploration of factors contributing to non-guideline adherent antipsychotic polypharmacy

BACKGROUND

Antipsychotic polypharmacy ("polypharmacy") involves the concurrent prescribing of two or more antipsychotics for managing schizophrenia. It occurs frequently despite there being limited clinical evidence for this practice and an increased risk of adverse events. Little is understood about why it occurs outside of treatment guidelines, highlighting a current research gap.

OBJECTIVE

To explore the factors contributing to non-evidence based polypharmacy practice and possible strategies for addressing these factors.

METHODS

Three focus groups were conducted between June and August 2018 with doctors and nurses employed at a mental health unit of a Western Australian public hospital. Participants were asked about their perceptions of polypharmacy, why it occurred and what could limit its prevalence. Thematic inductive analysis was mapped to the Theoretical Domains Framework to identify key underlying themes and to establish potential enablers and barriers for practice change.

RESULTS

Participants understood the risks of polypharmacy and perceived it to largely be perpetuated by external factors, out of which two key themes emerged: system-related issues (e.g.: communication failures whereby de-prescribing plans are not actioned); and patient-related issues (e.g.: misinformed views translating to medication-seeking behaviour). This led to the third theme: a disconnect between clinicians' knowledge and their practices (i.e.: being aware of Australian evidence-based guideline recommendations yet acknowledging polypharmacy still occurred due to the aforementioned issues). Strategies suggested to address these issues included developing medication management plans to bridge communication gaps and managing patients' medication expectations with education.

CONCLUSIONS

Management of schizophrenia is complex, requiring consideration of many patient-related and systemic factors. Polypharmacy has a place in certain contexts, however, must be well considered and closely monitored to allow for early identification of opportunities to rationalise (i.e.: de-prescribe) therapy, where appropriate. Future research objectives will centre on implementing strategies identified from these focus groups to optimise patient outcomes.

Dilemma of prescribing aripiprazole under the Taiwan health insurance program: a descriptive study

OBJECTIVES

Refractory major depressive disorder (MDD) is a serious problem leading to a heavy economic burden. Antipsychotic augmentation treatment with aripiprazole and quetiapine is approved for MDD patients and can achieve a high remission rate. This study aimed to examine how psychiatrists in Taiwan choose medications and how that choice is influenced by health insurance payments and administrative policy.

DESIGN

Descriptive study.

OUTCOME MEASURES

Eight questions about the choice of treatment strategy and atypical antipsychotics, and the reason to choose aripiprazole.

INTERVENTION

We designed an augmentation strategy questionnaire for psychiatrists whose patients had a poor response to antidepressants, and handed it out during the annual meeting of the Taiwanese Society of Psychiatry in October 2012. It included eight questions addressing the choice of treatment strategy and atypical antipsychotics, and the reason whether or not to choose aripiprazole as the augmentation antipsychotic.

RESULTS

Choosing antipsychotic augmentation therapy or switching to other antidepressant strategies for MDD patients with an inadequate response to antidepressants was common with a similar probability (76.1% vs 76.4%). The most frequently used antipsychotics were aripiprazole and quetiapine, however a substantial number of psychiatrists chose olanzapine, risperidone, and sulpiride. The major reason for not choosing aripiprazole was cost (52.1%), followed by insurance official policy audit and deletion in the claims review system (30.1%).

CONCLUSION

The prescribing behavior of Taiwanese psychiatrists for augmentation antipsy-chotics is affected by health insurance policy.