Correlates and predictors of antipsychotic drug polypharmacy in real-life settings: Results from a nationwide cohort study

Schizophrenia patients discharged on antipsychotic polypharmacy from a public psychiatric hospital in Taiwan, 2006-2021

The aim of this study was to identify the factors associated with antipsychotic polypharmacy (APP), investigate whether APP could affect the risk of rehospitalization, and explore temporal trends in APP use. Schizophrenia patients discharged from the study hospital between 2006 and 2021 (n = 16,722) were included in the analysis. The logistic regression model was employed to determine the predictors significantly associated with APP use. Survival analysis was used to compare time to rehospitalization between APP and antipsychotic monotherapy (AMT). The temporal trend of APP use was analyzed using the Cochran-Armitage Trend test. In comparison with the patients (n = 10,909) who were discharged on AMT, those (n = 5,813) on APP were significantly more likely to be male gender, to receive LAIs, to take clozapine, to take anticholinergic agents, to have a greater number of previous hospitalizations, and to have a higher CPZ equivalent dose of antipsychotic prescription. The prescription rate of APP significantly increased from 18.4 % in 2006 to 44.9 % in 2021. Compared with AMT, APP was associated with more clozapine use, more LAI use, higher doses of antipsychotics, and an increased risk of rehospitalization. In addition, the prescription of APP continued to increase during the study period.

Exposure to psychotropic medications and mortality in schizophrenia: a 5-year national cohort study

BACKGROUND

Relatively few studies have explored the differential contributions of the accumulative dosage of psychotropic medications on mortality in patients with schizophrenia.

METHODS

We aimed to explore the effects of the exposure dosage of psychotropic medications on mortality during a follow-up period of 5 years with a national cohort of individuals with schizophrenia in 2010. Causes of death were linked through Taiwan's National Mortality Registry. The mean defined daily dose of antipsychotics, antidepressants, mood stabilizers, and sedative-hypnotics, were calculated and survival analyses were conducted.

RESULTS

A total of 102 964 individuals (54 151 men, 52.59%) with schizophrenia were included. Compared to patients with no exposure to antipsychotics, those with antipsychotic exposure had better survival outcomes, regardless of antipsychotic dosage. Antidepressant exposure, in low and moderate dosage, was associated with decreased all-cause mortality; exposure to mood stabilizers appeared to be associated with an increase in all-cause mortality. Although 89.7% of the patients had been prescribed sedative-hypnotics, exposure to sedative-hypnotics was associated with dose-related increased mortality risk [hazard ratio (HR) in low dose group: 1.16, 95% confidence interval (CI) 1.07-1.27; HR in moderate dose: 1.32, 95% CI 1.21-1.44; HR in high dose: 1.83, 95% CI 1.67-2.01)].

CONCLUSIONS

The results indicate that in the treatment of schizophrenia, antipsychotics and antidepressants are associated with lower mortality when using adequate dosages and mood stabilizers and sedative-hypnotics with higher mortality compared with no use. Furthermore, exposure to sedative-hypnotics is associated with a dose-related increased mortality risk which warrants clinical attention and further study.

Pharmacological strategies for the management of the antisocial personality disorder

INTRODUCTION

Antisocial personality disorder (AsPD) is a pervasive pattern of violation of others' rights, related to the concept of psychopathy. AsPD is stable over time from adolescence, with evidence of conduct disorder (CD) before 15 years. DSM-5 included a specifier 'with limited prosocial emotions' (LPE), which characterizes adolescents with higher developmental vulnerability to develop AsPD. Despite being relatively frequent with considerable societal impact, AsPD is a difficult-to-treat condition with high comorbidity rates and poor evidence for effective pharmacological interventions.

AREAS COVERED

We conducted a narrative review and searched PubMed up to September 2022. We included RCTs and naturalistic studies evaluating pharmacological interventions on AsPD in adults, including those with comorbid substance use disorder or psychopathic traits. Evidence in youths with CD, callous-unemotional (CU) traits and aggression were also reviewed, exploring the role of CU traits as moderators of response.

EXPERT OPINION

Psychosocial interventions are the first option, with possible improvement of CU traits, beyond behavioral and affective symptoms, particularly if implemented early during development. Limited information, based on low-quality studies, supports the pharmacological options. Second-generation antipsychotics, lithium, anti-epileptic drugs, and stimulants are first-line medications, according to different target symptoms. Developmental pathways including ADHD suggest a specific role of psychostimulants.

Antipsychotic drug dose in real-life settings results from a Nationwide Cohort Study

Despite national and international recommendations and while there is no evidence for increased efficacy of higher doses, several studies suggested that the prescribed doses in routine practice are higher than the maximal recommended doses in 20-40% of schizophrenia patients worldwide.

METHODS

the aims of the present study were: (1) to describe the patterns of antipsychotic daily dose prescriptions in routine clinical practice in a large and representative cohort of French schizophrenia patients and, (2) to study the characteristics of patients receiving higher doses.

RESULTS

in all cases, regardless of the antipsychotic treatment used, the average dose was greater than 1.0 defined daily dose (DDDeq), which is the average recommended dose. For SGA, the mean DDDeq ranged from 1.2 for aripiprazole to 1.6 for olanzapine and clozapine, respectively. For a given patient, the mean ± S.D. total daily cumulative dose (TCD) of antipsychotic was 1.9 ± 2.4 DDDeq. A "high dose" was defined as a TCD  ≥ 1.5 DDDeq, 789 (45.2%) patients received a "high dose". Patients in the "high dose" group were more frequently suffering from a more severe paranoid schizophrenia, had more often a comorbid antisocial personality disorder and/or a substance use disorder.

CONCLUSIONS

the present study suggests that in France, antipsychotic drugs doses prescribed by psychiatrists are higher, compared to other countries. All recommendations agree on the fact that the preferential dose should be the "minimum-effective" dose. Optimizing prescribing practices would be important to optimize the benefit/risk ratio and to minimize the risks side effects.

Antipsychotic polypharmacy in adult patients diagnosed with schizophrenia: A retrospective study

Antipsychotic polypharmacy (APP) is a common practice in the treatment of schizophrenia. In this study, we aimed to identify the prevalence of APP in our department, as well as the trends associated with co-prescribing antipsychotics. We collected data from the medical records of all 193 inpatients diagnosed with schizophrenia who were admitted to Prof. Dr. Alexandru Obregia Clinical Psychiatry Hospital (Bucharest, Romania), Department 9, during January 2019-December 2019. Demographic characteristics of the patients, clinical diagnosis, psychiatric admission type and duration of hospitalization were examined. Data regarding the antipsychotic regimen at discharge and other psychotropic drugs used were collected. A total of 69 (35.75%) patients received more than 2 antipsychotics upon discharge. Patients treated with APP did not differ in regards to sex, age, education level, employment status, marital status, living situation, type of admission from those receiving antipsychotic monotherapy (APM). Prolonged hospitalization was found to be an independent predictor of APP (P=0.014). Most of the combinations used in our unit included clozapine (47.8%), and the most frequently used treatment in the APP group was the combination of paliperidone and clozapine (14.5%). In the APP group, 30 (43.5%) patients included in their regimen was a long-acting intramuscular antipsychotic. There was no significant difference in terms of the use of mood stabilizers, antiparkinsonian drugs or anxiolytics between the APP and the APM group; yet, a higher prevalence of antidepressant use, although not statistically significant (P=0.067), in the APP group compared to the APM group, was observed. The use of APP as a long-term regimen is a common practice in our department, as it is worldwide. There is a great need for randomized-control trials and evidence-based studies in order to define the safest and most effective combinations of antipsychotics and also the characteristics of patients that may benefit from these combinations.

The More, the Merrier…? Antipsychotic Polypharmacy Treatment Strategies in Schizophrenia From a Pharmacology Perspective

Antipsychotic polypharmacy/drug combination treatment (APP) is a remarkably common practice in the schizophrenia context, given the lack of general support in treatment Guidelines. There is also a vast literature on APP outcomes, but a paucity of high-quality evidence-based data to guide and optimize adequate use of APP. This seems particularly true regarding many pharmacology-based considerations involved in APP treatment strategies. This paper first briefly summarizes clinical literature related to the use of APP. Against this backdrop, the pharmacological target profile features are then described of frequently used antipsychotic agents, in relation to estimated free plasma exposure levels at clinically efficacious dosing. APP strategies based on the properties of these drugs are then scrutinized and gauged within the background literature framework. The anticipated usefulness of APP from the pharmacological standpoint is detailed regarding efficacy, adverse effect (AE)/tolerability, and safety perspective, including why, when, and how it may be used to its advantage. For the purpose, a number of theoretically beneficial combinations as well as instances with suboptimal-and even futile-APP approaches are exemplified and discussed from the rational pharmacodynamic and pharmacokinetic pros and cons point-of-view. In this exposé, particular attention is paid to the utility and features of 3rd Generation Antipsychotic dopamine (DA) D2-D3 agonists within an APP setting.

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study

Background

Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.

Objectives

We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.

Design and setting

We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.

Participants

Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.

Interventions

Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).

Main outcome measures

Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.

Results

Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.

Limitations

There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.

Conclusions

Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.

Future work

Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Antipsychotic Polypharmacy: A Dirty Little Secret or a Fashion?

The term polypharmacy was originally coined to refer to problems related to multiple drug consumption and excessive drug use during the treatment of a disease or disorder. In the treatment of schizophrenia, polypharmacy usually refers to the simultaneous use of 2 or more antipsychotic medications or combined (adjunct) medications such as mood stabilizers, antidepressants, anxiolytics, or hypnotics in addition to single or multiple antipsychotics. Two decades ago, antipsychotic polypharmacy was criticized as being more expensive, having unproven efficacy, and causing more side effects. However, in recent years, antipsychotic polypharmacy has become more or less acceptable in the views of clinical practitioners and academic researchers. Results from recent reviews have suggested that the common practice of antipsychotic polypharmacy lacks double-blind or high-quality evidence of efficacy, except for negative symptom reduction with aripiprazole augmentation. We reviewed some representative studies that enrolled large numbers of patients and compared antipsychotic polypharmacy and monotherapy during the past decade. The results revealed that a certain proportion of select patients can benefit from antipsychotic polypharmacy without further negative consequences. Because most of the current treatment guidelines from different countries and organizations prefer monotherapy and discourage all antipsychotic polypharmacy, guidelines regarding the use of antipsychotic polypharmacy in clinical practice should be revised. On the basis of the findings of 2 large-scale studies from Asia and Europe, we also suggest ideal rates of various maintenance treatments of schizophrenia, which are as follows: antipsychotic polypharmacy, 30%; combined mood stabilizer, 15%; combined antidepressant, 10%; combined anxiolytics, 30%; and combined hypnotic, 10%.

Association Between Antipsychotic Polypharmacy and Outcomes for People With Serious Mental Illness in England

OBJECTIVE

Although U.K. and international guidelines recommend monotherapy, antipsychotic polypharmacy among patients with serious mental illness is common in clinical practice. However, empirical evidence on its effectiveness is scarce. Therefore, the authors estimated the effectiveness of antipsychotic polypharmacy relative to monotherapy in terms of health care utilization and mortality.

METHODS

Primary care data from Clinical Practice Research Datalink, hospital data from Hospital Episode Statistics, and mortality data from the Office of National Statistics were linked to compile a cohort of patients with serious mental illness in England from 2000 to 2014. The antipsychotic prescribing profile of 17,255 adults who had at least one antipsychotic drug record during the period of observation was constructed from primary care medication records. Survival analysis models were estimated to identify the effect of antipsychotic polypharmacy on the time to first occurrence of each of three outcomes: unplanned hospital admissions (all cause), emergency department (ED) visits, and mortality.

RESULTS

Relative to monotherapy, antipsychotic polypharmacy was not associated with increased risk of unplanned hospital admission (hazard ratio [HR]=1.14; 95% confidence interval [CI]=0.98-1.32), ED visit (HR=0.95; 95% CI=0.80-1.14), or death (HR=1.02; 95% CI=0.76-1.37). Relative to not receiving antipsychotic medication, monotherapy was associated with a reduced hazard of unplanned admissions to the hospital and ED visits, but it had no effect on mortality.

CONCLUSIONS

The study results support current guidelines for antipsychotic monotherapy in routine clinical practice. However, they also suggest that when clinicians have deemed antipsychotic polypharmacy necessary, health care utilization and mortality are not affected.

Switching to antipsychotic monotherapy vs. staying on antipsychotic polypharmacy in schizophrenia: A systematic review and meta-analysis

BACKGROUND

While recent meta-analyses have reported the superiority of antipsychotic polypharmacy (APP) over antipsychotic monotherapy (APM) in schizophrenia, switching to APM can be beneficial in terms of side effects. To determine whether patients receiving APP should switch to APM or stay on APP, we conducted a systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) examining a switch from APP to APM vs. staying on APP were systematically selected from a previous meta-analysis comparing APP with APM in patients with schizophrenia. In addition, we conducted an updated systematic literature search using MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Data on study discontinuation, relapse, psychopathology, neurocognition, extrapyramidal symptoms, and body weight/body mass index (BMI) were extracted and synthesized.

RESULTS

A total of 6 RCTs involving 341 patients were included. All studies examined a switch from 2 antipsychotic agents to a single agent. Clozapine-treated patients were included in 3 studies. There was a significant difference in study discontinuation due to all causes in favor of staying on APP (N = 6, n = 341, RR = 2.28, 95% CI = 1.50-3.46, P < 0.001). There were no significant differences in relapse, any psychopathology, neurocognition, extrapyramidal symptoms, or body weight/BMI between the 2 groups. The quality of evidence was low to very low.

CONCLUSIONS

The findings suggest that clinicians should closely monitor patient condition when switching to APM after receiving 2 antipsychotics. Given the low to very low overall quality of the evidence, the findings should be considered preliminary and inconclusive.

Prevalence of suicide attempts in individuals with schizophrenia: a meta-analysis of observational studies

AIMS

Suicide attempt is an important indicator of suicide and potential future mortality. However, the prevalence of suicide attempts has been inconsistent across studies. This meta-analysis aimed to examine the prevalence of suicide attempts in individuals with schizophrenia and associated correlates.

METHODS

Relevant publications in Embase, PsycINFO, PubMed, Web of science and Cochrane were systematically searched. Data on the prevalence of suicide attempts in individuals with schizophrenia were pooled using a random-effects model.

RESULTS

Thirty-five studies with 16 747 individuals with schizophrenia were included. The pooled lifetime prevalence of suicide attempts was 26.8% (95% CI 22.1-31.9%; I2 = 97.0%), while the 1-year prevalence, 1-month prevalence and the prevalence of suicide attempts from illness onset were 3.0% (95% CI 2.3-3.7%; I2 = 95.6%), 2.7% (95% CI 2.1-3.4%; I2 = 78.5%) and 45.9% (95% CI 42.1-49.9%; I2 = 0), respectively. Earlier age of onset (Q = 4.38, p = 0.04), high-income countries (Q = 53.29, p < 0.001), North America and Europe and Central Asia (Q = 32.83, p < 0.001) were significantly associated with a higher prevalence of suicide attempts.

CONCLUSIONS

Suicide attempts are common in individuals with schizophrenia, especially those with an early age of onset and living in high-income countries and regions. Regular screening and effective preventive measures should be implemented as part of the clinical care.