Antipsychotic use at adult ambulatory care visits by patients with mental health disorders in the United States, 1996-2003: national estimates and associated factors

Use of Direct-to-Consumer Telemedicine to Access Mental Health Services

BACKGROUND

The coronavirus disease 2019 pandemic has contributed to growing demand for mental health services, but patients face significant barriers to accessing care. Direct-to-consumer(DTC) telemedicine has been proposed as one way to increase access, yet little is known about its pre-pandemic use for mental healthcare.

OBJECTIVE

To characterize patients, providers, and their use of a large nationwide DTC telemedicine platform for mental healthcare.

DESIGN

Retrospective cross-sectional study.

SETTING

Mental health encounters conducted on the American Well DTC telemedicine platform from 2016 to 2018.

PARTICIPANTS

Patients and physicians.

MAIN MEASURES

Patient measures included demographics, insurance report, and number of visits. Provider characteristics included specialty, region, and number of encounters. Encounter measures included wait time, visit length and timing, out-of-pocket payment, coupon use, prescription outcome, referral receipt, where care otherwise would have been sought, and patient satisfaction. Factors associated with five-star physician ratings and prescription receipt were assessed using logistic regression.

KEY RESULTS

We analyzed 19,270 mental health encounters between 6708 patients and 1045 providers. Visits were most frequently for anxiety (39.1%) or depression (32.5%), with high satisfaction (4.9/5) across conditions. Patients had a median 2.0 visits for psychiatry (IQR 1.0-3.0) and therapy (IQR 1.0-5.0), compared to 1.0 visit (IQR 1.0-1.0) for urgent care. High satisfaction was positively correlated with prescription receipt (OR 1.89, 95% CI 1.54-2.32) and after-hours timing (aOR 1.18, 95% CI 1.02-1.36). Prescription rates ranged from 79.6% for depression to 32.2% for substance use disorders. Prescription receipt was associated with increased visit frequency (aOR 1.95, 95% CI 1.57-2.42 for ≥ 3 visits).

CONCLUSIONS

As the burden of psychiatric disease grows, DTC telemedicine offers one solution for extending access to mental healthcare. While most encounters were one-off, evidence of some continuity in psychiatry and therapy visits-as well as overall high patient satisfaction-suggests potential for broader DTC telemental health use.

Potentially Inappropriate Antidepressant Prescriptions Among Older Adults in Office-Based Outpatient Settings: National Trends from 2002 to 2012

Using data from 2002 to 2012 National Ambulatory Medical Care Survey, we estimated that the prevalence of overall antidepressant prescriptions increased almost twofold from 5.2% in 2002 to 10.1% in 2012 in office-based outpatient visits made by older adults. In addition, older adults were exposed to the risk of potentially avoidable adverse drug events in approximately one in ten antidepressant-related visits, or 2.2 million visits annually. Amitriptyline and doxepin were the two most frequent disease-independent potentially inappropriate antidepressants. Racial/ethnic minorities, and Medicaid beneficiaries had higher odds of potentially inappropriate antidepressant prescriptions (P < 0.05). Efforts to minimize potentially inappropriate antidepressant prescriptions are needed.

Effects of depression screening on diagnosing and treating mood disorders among older adults in office-based primary care outpatient settings: An instrumental variable analysis

Existing literature shows mixed findings regarding the efficacy and effectiveness of depression screening, and relatively little is known about the effectiveness of depression screening among older adults in primary care visits in the U.S. This study examines the effects of depression screening on the three following outcomes: mood disorder diagnoses, overall antidepressant prescriptions, and potentially inappropriate antidepressant prescriptions among older adults ages 65 or older in office-based outpatient primary care settings. We used data from 2010-2012 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based primary care outpatient visits among older adults (n=9,313 unweighted). We employed an instrumental variable approach to control for selection bias in our repeated cross-sectional population-based study. Injury prevention and stress management were selected as instrumental variables, as they were considered completely exogenous to outcomes of interests using conceptual and statistical criteria. We conducted multivariate bivariate probit (biprobit) regression analyses to investigate the effect of depression screening on each outcome, when controlled for other covariates. We found that depression screening was negatively associated with potentially inappropriate antidepressant prescriptions (β=-2.17; 95% CI -2.80 to -1.53; p<0.001). However, no significant effect of depression screening on diagnosis of mood disorders and overall antidepressant prescriptions was found. Overall, depression screening had a negative effect on potentially inappropriate antidepressant prescriptions. Primary care physicians and other healthcare providers should actively utilize depression screening to minimize potentially inappropriate antidepressant prescriptions in older adult patients.

Do Psychiatric Medications Cause More Harm Than Good?

A head-to-head debate published in The BMJ was centered on the question "Does long-term use of psychiatric drugs cause more harm than good?" One of the debaters stated that virtually all psychotropic drug use could be stopped without deleterious effects, claiming that these drugs have minimal benefits, are immensely harmful, and cause more than 500,000 deaths each year. In the current article, this conclusion is disputed by the discussion of the history of psychiatric therapeutics, limitations of research investigations, inherent morbidity and mortality associated with mental disorders, and importance of direct care experience with psychiatric patients and their families.

Persistence of racial disparities in prescription of first-generation antipsychotics in the USA

PURPOSE

The aim of this study was to estimate the prevalence of first-generation antipsychotics (FGA) prescribed for treatment of psychiatric and neurological conditions and use of benztropine to reduce extrapyramidal side effects (EPS) by patient race/ethnicity in a nationally representative sample of adult outpatient visits.

METHODS

The study sample included all outpatient visits (N = 8154) among patients aged 18-69 years where a prescription for one or more antipsychotics was recorded across 6 years of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (2005-2010). Use of FGA was compared by race/ethnicity using multiple logistic regression models accounting for patient and clinical characteristics stratified by neighborhood poverty rate. Frequency of EPS was determined by use of benztropine to reduce or prevent EPS.

RESULTS

Black patients were significantly more likely than White patients to use FGA (odds ratio = 1.48, p = 0.040) accounting for psychiatric and neurological diagnoses, treatment setting, metabolic factors, neighborhood poverty, and payer source. Black patients were more than twice as likely as White patients to receive higher-potency FGA (haloperidol or fluphenazine), particularly in higher-poverty areas (odds ratio = 2.50, p < 0.001). Use of FGA, higher among Black than White patients, was positively associated with use of benztropine to reduce EPS.

CONCLUSIONS

Racial disparities in the pharmacological treatment of severe mental disorders persist 30 years after the introduction of second-generation antipsychotics. The relatively high frequency of FGA of use among Black patients compared with White patients despite more Food and Drug Administration-approved indications and lower EPS risk for second-generation antipsychotics requires additional research.

Cardiovascular and cerebrovascular risk factors and events associated with second-generation antipsychotic compared to antidepressant use in a non-elderly adult sample: results from a claims-based inception cohort study

This is a study of the metabolic and distal cardiovascular/cerebrovascular outcomes associated with the use of second-generation antipsychotics (SGAs) compared to antidepressants (ADs) in adults aged 18-65 years, based on data from Thomson Reuters MarketScan® Research Databases 2006-2010, a commercial U.S. claims database. Interventions included clinicians' choice treatment with SGAs (allowing any comedications) versus ADs (not allowing SGAs). The primary outcomes of interest were time to inpatient or outpatient claims for the following diagnoses within one year of SGA or AD discontinuation: hypertension, ischemic and hypertensive heart disease, cerebrovascular disease, diabetes mellitus, hyperlipidemia, and obesity. Secondary outcomes included the same diagnoses at last follow-up time point, i.e., not censoring observations at 365 days after SGA or AD discontinuation. Cox regression models, adjusted for age, gender, diagnosis of schizophrenia and mood disorders, and number of medical comorbidities, were run. Among 284,234 individuals, those within one year of exposure to SGAs versus ADs showed a higher risk of essential hypertension (adjusted hazard ratio, AHR=1.16, 95% CI: 1.12-1.21, p<0.0001), diabetes mellitus (AHR=1.43, CI: 1.33-1.53, p<0.0001), hypertensive heart disease (AHR=1.34, CI: 1.10-1.63, p<0.01), stroke (AHR=1.46, CI: 1.22-1.75, p<0.0001), coronary artery disease (AHR=1.17, CI: 1.05-1.30, p<0.01), and hyperlipidemia (AHR=1.12, CI: 1.07-1.17, p<0.0001). Unrestricted follow-up results were consistent with within one-year post-exposure results. Increased risk for stroke with SGAs has previously only been demonstrated in elderly patients, usually with dementia. This study documents, for the first time, a significantly increased risk for stroke and coronary artery disease in a non-elderly adult sample with SGA use. We also confirm a significant risk for adverse metabolic outcomes. These findings raise concerns about the longer-term safety of SGAs, given their widespread and chronic use.

Use of psychotropic drugs in Lombardy in time of economic crisis (2007-2011): a population-based study of adult employees

Over years, there has been an increase in the prescription of psychotropic drugs (PDs), particularly antidepressants (ADs). The aim of the study was to evaluate the consumption of PDs in adult employees in a productive area of Italy and the possible changes induced by the "economic crisis". The study is a retrospective survey in all adult employees in Lombardy, Northern Italy, aged >18 years in the period 2007-2011, classified by gender, age class, nationality, education and province. During the 5-year period, there were 3,554,860 employed adults in Lombardy, of whom 277,865 (7.8%) used PDs. The use of PDs (particularly ADs) was associated with being an Italian woman aged >55 years with a basic education, a blue collar job, and an unstable working position. In 39% of cases, the use of PDs was limited to one trimester. The increase in the number of prescriptions of PDs after the economic crisis was the same as before it. The increase in PD use can be attributed more to ADs and anti-epileptic drugs with anxiolytic properties. Although continuously increasing, the use of AD fluctuated and was greater during the fall and winter. The increase involved all the provinces in Lombardy in a similar manner.

Controversies in the use of second generation antipsychotics as sleep agent

A growing number of patients present in clinics with complaints of insomnia. Over the past century, great advances have been made in our knowledge of mechanisms of sleep and wakefulness. Understanding sleep neurochemistry has led to better management of different types of insomnias with a variety of non-pharmacological and pharmacological treatments. Unfortunately, the increasing development and availability of second generation antipsychotics (SGA) have prompted their frequent use exclusively for insomnia. However, to date, no large randomized-controlled or placebo-controlled studies have shown the utility of SGAs in the realm of treating insomnia. Many clinicians use SGAs as "off-label" for sleep induction and maintenance, but this practice needs to be readdressed given their potential risks and the current lack of evidence base. This review will highlight the neurochemistry related to sleep, the mechanisms of action by which SGA may have some benefit in treating insomnia, and the risks associated with their utilization.

Impact of psychotropic drugs on suicide and suicidal behaviors

OBJECTIVE

To examine the impact of psychotropic drugs on suicide and suicidal behaviors in bipolar disorders.

METHODS

A Medline search of articles published from January 1960 to January 2013 was performed using relevant keywords to identify studies examining the relationship of psychotropic drugs to suicidal behaviors. The publications were further reviewed for relevant references and information. Additionally, the US Food and Drug Administration Center for Drug Evaluation Research website was searched.

RESULTS

The available studies used differing methodologies, making interpretation of the findings difficult. Studies suggest that antidepressants may increase suicidal risk in bipolar disorder, this possibly being related to the induction of broadly defined mixed states. There is no evidence that antiepileptic drugs as a class increase suicidal risk in patients with bipolar disorder. Only lithium provides convincing data that it reduces the risk of suicide over the long term. There is little known regarding the effects of antipsychotics, as well as anti-anxiety and hypnotic drugs, on suicidal behavior.

CONCLUSIONS

The available evidence for the impact of psychotropics on suicidal risk in patients with bipolar disorder is largely methodologically flawed and, except for a few instances, clinically not useful at this point. Adequately powered, prospective randomized controlled studies are needed to assess the impact of each class of psychotropic and each psychotropic as well as common combination therapies. Until such studies have been carried out, clinicians are urged to exercise caution in using these drugs and rely on the traditional means of carefully assessing and monitoring patients with bipolar disorder who are at high risk for suicide.

Subtypes of antipsychotics and suicidal behavior in bipolar disorder

OBJECTIVE

Antipsychotics are commonly used in bipolar disorder, with newer (SGA) agents increasingly replacing FGA antipsychotics, particularly in bipolar depression. There are few data on differences between FGA and SGA antipsychotics in terms of their relationship to suicidal behavior in bipolar disorder.

METHOD

This was a retrospective chart review of 161 bipolar veterans treated naturalistically with antipsychotics at a university-affiliated VA hospital and clinics for up to 8 years. Charts were reviewed to determine monthly antipsychotic use and occurrence of suicidal behavior: completed suicide, attempted suicide or hospitalization to prevent suicide. Suicidal behavior events were compared across patients during treatment with individual antipsychotics and FGAs or SGAs as a class.

RESULTS

Non-lethal suicide events were more common during FGA than SGA monotherapy (9 events/110 months of exposure vs. 6 events/381 months of exposure; χ(2)=9.65, p=0.002). Suicide event rates did not differ between FGAs and SGAs when used in conjunction with mood stabilizers. Event rates were lower with lithium than anticonvulsants when used in conjunction with antipsychotics. No differences were found between olanzapine, risperidone and quetiapine.

LIMITATIONS

The retrospective chart review methodology may have led to confounding by indication and diagnostic inaccuracy. No completed suicides occurred. Study participants were primarily male veterans. Results may not be generalizable to SGAs marketed since 2003.

CONCLUSIONS

FGA antipsychotic monotherapy may be associated with higher suicidal behavior risk than SGA antipsychotic monotherapy. Antipsychotics used in conjunction with mood stabilizers, particularly lithium, are associated with lower rates, independent of antipsychotic subtype.

Coverage of atypical antipsychotics among medicare drug plans in the state of washington: changes between 2007 and 2008

OBJECTIVE

To examine changes in the cost and coverage of atypical antipsychotics among Medicare prescription drug plans and Medicare advantage plans in the state of Washington.

METHOD

Coverage and cost data were obtained in February 2007 and 2008 from the Medicare Prescription Drug Plan Finder, an online database administered by the Centers for Medicare and Medicaid Services. Premiums, deductibles, out-of-pocket costs, and coverage limits were compared for prescription drug plans (PDPs) and for Medicare advantage plans (MAPs).

RESULTS

The number of PDPs in the state of Washington fell slightly from 57 in 2007 to 53 in 2008, while the number of MAPs rose from 43 in 2007 to 52 in 2008. In 2008, the mean monthly drug premium increased by 15% among PDPs and by 20% among MAPs. Mean copayments for the majority of atypical antipsychotics increased from 2007 to 2008. More plans added quantity limits for atypical antipsychotics, but use of other pharmacy management tools varied by type of plan and antipsychotic.

CONCLUSIONS

PDP and MAP participants in the state of Washington paid more for atypical antipsychotics in 2008 than they did in 2007. Affordability of atypical antipsychotics continues to be a concern, particularly for beneficiaries who are not eligible for Medicaid or the low-income subsidy.

Off-label use of atypical antipsychotics: cause for concern?

Licensed indications for medicines were designed to regulate the claims that can be made about a medicine by a pharmaceutical company. Off-label prescribing (i.e. prescribing a drug for an indication outside of that for which it is licensed) is legal and an integral part of medical practice. In psychiatry, off-label prescribing is common and gives clinicians scope to treat patients who are refractory to standard therapy or where there is no licensed medication for an indication. However, efficacy or safety of such off-label use may not be established. There is a growing list of licensed indications for atypical antipsychotics (AAP) beyond schizophrenia and bipolar affective disorder, and also more evidence for other indications where pharmaceutical companies have not obtained a license. Pharmaceutical companies have promoted AAPs for off-label indications to increase sales and consequently have been fined by the US FDA for this. Since the 1990s, AAP use has expanded considerably, for example, the off-label use of quetiapine alone accounted for an estimated 17% of the AAP spend in New Zealand in 2010. There are a number of potential problems with the expanded use of AAPs outside of schizophrenia and related psychoses. A larger population will be exposed to their adverse effects, which include weight gain, type 2 diabetes mellitus, sudden cardiac death and increased mortality rates in the elderly with dementia. There are also concerns with the abuse of these agents, in particular quetiapine. Given that an increasing percentage of the population is being treated with these agents, off-label prescribing of AAPs is a cause for concern; they have a propensity to cause significant side effects and their efficacy and long-term safety for most off-label indications remains largely unknown, and therefore the risks and benefits of their use should be carefully weighed up prior to prescribing these agents off-label.

Payer types associated with antipsychotic polypharmacy in an ambulatory care setting

Objectives

Antipsychotic polypharmacy is increasingly prescribed despite little documented evidence of a therapeutic benefit. There is also a limited understanding of the role that health insurance plays on the prevalence of antipsychotic polypharmacy. This study was undertaken to investigate the relationship between antipsychotic polypharmacy and individuals' intended source of payment in a US national sample of ambulatory care patients.

Methods

The study combined 2002, 2003 and 2004 data from the National Ambulatory Medical Care Survey (NAMCS) among adults seeking outpatient-based physician medical care services in the USA. We investigated characteristic differences among patients who were prescribed multiple antipsychotics versus individuals receiving only a single antipsychotic medication. Multivariable logistic regression examined the association between antipsychotic polypharmacy and patients' primary payment type classified as private insurance, Medicaid, Medicare or other (primarily out-of-pocket) payment type.

Key findings

Use of more than one antipsychotic agent was recorded in 68 of 830 (8.2%) outpatient physician visits in the 3-year period 2002–2004. Among the payer types studied, Medicaid payment status was correlated with increased risk of antipsychotic polypharmacy (odds ratio 2.7, 95% confidence interval 1.1–6.7).

Conclusions

Insurance status was associated with antipsychotic polypharmacy among non-institutionalized US residents prescribed antipsychotic medications. Patients reporting Medicaid as their primary payer were nearly three times as likely to be prescribed multiple antipsychotic drugs, potentially increasing their risk of adverse side effects as well as greater taxpayer burden. Future research should determine whether these trends continued after 2004 and to determine the costs of treating patients in the public sector with multiple antipsychotic drugs, a common scenario despite financial pressures and uncertain medical benefit.

Genomics and pharmacogenomics of schizophrenia

Schizophrenia (SCZ) is among the most disabling of mental disorders. Several neurobiological hypotheses have been postulated as responsible for SCZ pathogenesis: polygenic/multifactorial genomic defects, intrauterine and perinatal environment-genome interactions, neurodevelopmental defects, dopaminergic, cholinergic, serotonergic, gamma-aminobutiric acid (GABAergic), neuropeptidergic and glutamatergic/N-Methyl-D-Aspartate (NMDA) dysfunctions, seasonal infection, neuroimmune dysfunction, and epigenetic dysregulation. SCZ has a heritability estimated at 60-90%. Genetic studies in SCZ have revealed the presence of chromosome anomalies, copy number variants, multiple single-nucleotide polymorphisms of susceptibility distributed across the human genome, aberrant single nucleotide polymorphisms (SNPs) in microRNA genes, mitochondrial DNA mutations, and epigenetic phenomena. Pharmacogenetic studies of psychotropic drug response have focused on determining the relationship between variation in specific candidate genes and the positive and adverse effects of drug treatment. Approximately, 18% of neuroleptics are major substrates of CYP1A2 enzymes, 40% of CYP2D6, and 23% of CYP3A4; 24% of antidepressants are major substrates of CYP1A2 enzymes, 5% of CYP2B6, 38% of CYP2C19, 85% of CYP2D6, and 38% of CYP3A4; 7% of benzodiazepines are major substrates of CYP2C19 enzymes, 20% of CYP2D6, and 95% of CYP3A4. About 10-20% of Western populations are defective in genes of the CYP superfamily. Only 26% of Southern Europeans are pure extensive metabolizers for the trigenic cluster integrated by the CYP2D6+CYP2C19+CYP2C9 genes. The pharmacogenomic response of SCZ patients to conventional psychotropic drugs also depends on genetic variants associated with SCZ-related genes. Consequently, the incorporation of pharmacogenomic procedures both to drugs in development and drugs on the market would help to optimize therapeutics in SCZ and other central nervous system (CNS) disorders.

Gender differences in psychotic bipolar mania

OBJECTIVE

This study examined gender differences in the prevalence and types of psychotic symptoms in bipolar mania.

METHODS

Participants were drawn from consecutive admissions to the psychiatric clinic in Chemnitz, Germany, in 2005. The diagnosis of bipolar disorder, manic episode was made within 24 hours of admission, and the severity of mania was assessed using the Young Mania Rating Scale (YMRS) and the German version of the Altman Self-Rating Mania Scale. Data collected for each patient included age at the onset of bipolar illness, number of previous episodes, social functioning between episodes, and duration of hospitalization for the index episode. Based on the Task Force for Methods and Documentation in Psychiatry system, psychotic symptoms were classified as hallucinations (visual, auditory, olfactory, tactile, acousma, somatic); delusions (paranoid, reference, guilt, grandeur, religious, erotomania, hypochondriac, poverty, jealousy); and ego disorder (thought control, thought broadcasting).

RESULTS

One hundred thirty-seven women and 109 men met the criteria for an acute manic episode, of whom 93 women and 62 men had psychotic symptoms. Compared with psychotic men, psychotic women had more delusions and hallucinations, both overall and per patient, and more delusions of reference and paranoid delusions. Psychotic women had more mixed states compared with psychotic men. Psychotic women differed from both psychotic men and nonpsychotic women on a number of clinical and social variables: they had higher YMRS scores and more previous episodes of depression despite an earlier onset of illness.

CONCLUSION

Women with bipolar mania exhibited a specific pattern of psychotic symptoms that appeared to be associated with greater severity of the acute episode, more mixed states, and a more severe course of illness.

The subjective experience of taking antipsychotic medication: a content analysis of Internet data

OBJECTIVE

We explored the subjective effects associated with olanzapine, risperidone and older antipsychotics.

METHOD

We conducted a content analysis of an Internet database of comments about prescribed medications.

RESULTS

We analysed 223 comments on risperidone, 170 on olanzapine and 46 relating to three older antipsychotics. The predominant subjective effects produced by all drugs consisted of sedation, cognitive impairment and emotional flattening or indifference. Connections appeared between these effects and Parkinsonian-like symptoms with the older drugs, sexual impairment with risperidone and metabolic effects with olanzapine. The experience of akathisia was frequently linked to suicidal thoughts. Some respondents described how the drugs' subjective effects helped to reduce symptoms of mania, psychosis and anxiety.

CONCLUSION

The generalisability of Internet data is uncertain. However, the data suggest that adverse subjective effects play a central role in the experience of taking antipsychotic drugs and may be related to the drugs' desired benefits.

Relative contribution of antipsychotics, negative symptoms and executive functions to social functioning in stable schizophrenia

The purpose of this study was to examine the relative contributions of antipsychotic medication, negative symptoms and executive functions to impairment in social functioning in a sample of outpatients with stable schizophrenia. One-hundred and sixty-eight consecutive outpatients with stable schizophrenia were enrolled in a cross-sectional study. We performed a path analysis using multiple regression technique in order to assess the specific effect of antipsychotic type (first-generation antipsychotics versus second-generation antipsychotics) on social functioning and the possible mediating role of executive functions and negative symptoms. Our findings suggested that (i) second generation antipsychotics (SGAs) use predicted better social functioning (Beta=.24, p=.003) and better executive functions (Beta=.25, p=.003); conversely SGAs use was not associated with lesser negative symptoms (Beta=.00, p=.981); (ii) impaired executive functions and severity of negative symptoms were associated with worse social functioning (Beta=.19, p=.016; Beta=.28, p=.001); (iii) when we inserted in the model Positive and Negative Syndrome Scale - Negative Symptom subscale (PANSS-N) and Wisconsin Card Sorting Test - number of achieved sorting categories (WCST-cat), the former failed to show a mediation effect, while the latter seemed to mediate partially the effect of SGAs on social functioning. Taken together, the present results suggest that it is critical to examine individually executive functions and negative symptoms because they seem to relate to social functioning in different and independent ways and thus might represent separable treatment targets. Furthermore, social functioning appears a complex outcome multiply determined with no single predictor variable explaining a sufficient amount of variance.

Antipsychotic prescriptions in a university hospital outpatient population in Turkey: a retrospective database analysis, 2005-2006

OBJECTIVE

The aim of this study is to document the sociodemographic and the clinical profile of patients who are on antipsychotic (AP) medication prescribed in outpatient mental health clinic of a university hospital.

METHODS

A retrospective chart review was conducted for all outpatient files between 2005 and 2006 at the Zonguldak Karaelmas University, Medical Faculty Hospital, Department of Psychiatry in Turkey. All patients prescribed AP with regular follow up were recruited for the study. The type of AP and the route of administration were recorded. The diagnosis, age and gender of the patients were also evaluated.

RESULTS

We reviewed 1606 patients' files. APs were prescribed in 27.6% of the patients. Atypical antipsychotics (AAPs) represented 75.1% and typical antipsychotics (TAPs) represented 24.9% of all antipsychotic prescriptions in our study. The main psychiatric diagnoses associated with a TAP prescription were: psychotic disorders (6.5%), major affective disorders (49.5%), anxiety disorders (36.4%), and other psychiatric diseases (7.4%). The main psychiatric diagnoses associated with an AAP prescription were: psychotic disorders (35.1%), major affective disorders (31.1%), anxiety disorders (27.8%), somatoform disorders (2.4%) and other psychiatric diseases (6.4%). Twenty-eight of these patients (6.3%) were prescribed more than one AP, 45 patients were prescribed mood stabilizer (10.2%) and 272 patients were prescribed antidepressant agents (61.2%) in addition to AP.

CONCLUSIONS

The results reflect the particular use of AAPs in present study population. In line with the published data, the results of this study show that AAPs and TAPs are widely used in those with major affective disorders and psychotic disorders. These findings also underline the widespread off-label use of APs in the treatment of other psychiatric disorders.

Epidemiology and characteristics of emergency departments visits by US adults with psychiatric disorder and antipsychotic mention from 2000 to 2004

BACKGROUND AND OBJECTIVE

There is limited research to acquaint clinicians and payers about antipsychotic use in psychiatric patients visiting United States (US) emergency departments (EDs). The study objective is to describe the epidemiology and compare characteristics of ED visits by adults > or = 18 years with psychiatric diagnoses and different types of antipsychotic.

METHODS

Data for 2000-2004 adult ED visits were obtained from the National Hospital Ambulatory Medical Care Survey. Sample-weighted national estimates of (1) typical, (2) atypical, or (3) typical-atypical combination antipsychotic-associated psychiatric ED visits with 95% confidence intervals (CIs) were produced. Characteristics of the three psychiatric ED visit groups with antipsychotic mention, (prescribed, supplied, administered, ordered or continued) were analyzed retrospectively. Significant characteristics for atypical versus typical antipsychotic mention at visits were determined using multivariate logistic regression.

RESULTS

Adults made an estimated 26 million ED visits over the 5-year study period that resulted in a psychiatric diagnosis. Of 2 million (or 8%) of these psychiatric ED visits, 38, 55, and 8% mentioned typical, atypical, and combination antipsychotics respectively. From 2000 to 2004 there was an 8-, 3.5-, and 1.5-fold increase in ED visits with combination, atypical, and typical antipsychotics, respectively. The majority of antipsychotic-associated psychiatric ED visits were made by young adults less than 40 years old, Caucasians, needing urgent treatment, and reimbursed by public insurance. More combination-, and typical versus atypical antipsychotic-associated ED visits included a mention of medications for extrapyramidal symptoms (40%, 14% vs. 4%; p < 0.0001) and antianxiety medications (50%, 48% vs. 27%; p < 0.0001). More combination and atypical than typical antipsychotic-related ED visits had anticonvulsant (42%, 35% vs. 12%; p < 0.0001) and antidepressant mentions (31%, 42% vs. 11%; p < 0.0001). A diagnosis of depression (OR 3.2, 95% CI: 1.9-5.3; p < 0.001) or bipolar-disorder (OR 2.5, 95% CI: 1.3-5.0; p = 0.008), and the number of medications received (OR 1.4, 95% CI: 1.0-1.8; p = 0.034) significantly increased the likelihood of atypical versus typical antipsychotic mention at psychiatric ED visits.

CONCLUSIONS

Despite limitations of analyses with cross-sectional visit data, an increasing number of combination- and atypical antipsychotic-associated US adult ED visits depict the burden on the healthcare system. The associated characteristics of these visits deserve the attention of providers, and payers for cost-effective patient management.