Polypharmacy in psychiatric treatment. Patterns of psychotropic drug use in Austrian psychiatric clinics

Clinical pharmacy services in mental health in Europe: a commentary paper of the European Society of Clinical Pharmacy Special Interest Group on Mental Health

A large proportion of the world's disease burden is attributable to mental illnesses. Although effective interventions are available, many patients still have limited access to evidence-based treatments. Aside from access, treatment gaps, including inappropriate medication selection and monitoring, are also routinely recognised. Mental health clinical pharmacists can help address these gaps and enable patients to receive optimised pharmaceutical care, particularly appropriate medication selection and monitoring. The European Society of Clinical Pharmacy (ESCP) Special Interest Group on Mental Health was established to improve standardised service provision in mental health settings across Europe. The Special Interest Group identified significant barriers (predominantly associated with reimbursement and position within the multidisciplinary team) to effective pharmaceutical care amongst those with mental illnesses. This commentary presents recommendations to address these gaps through improved mental health clinical pharmacy service provision.

Respiratory aspiration during treatment with benzodiazepines, antiepileptic and antidepressant drugs in the pharmacovigilance database from VigiBase

INTRODUCTION

Three psychotropic drug classes, benzodiazepines, antiepileptic drugs (AEDs) and antidepressants (ADs), whether used in treatment or overdose, may be associated with respiratory aspiration. Polypharmacy was defined by counting suspected drugs from these classes or two others, antipsychotics and opioids. The confounding effects of polypharmacy were considered in this study.

AREAS COVERED

VigiBase records of respiratory aspiration associated with benzodiazepines, AEDs, and/or ADs from inception until September 5, 2021, were reviewed. VigiBase, the World Health Organization's global pharmacovigilance database, uses a statistical signal for associations called the information component (IC).

EXPERT OPINION

The ICs (and IC₀₂₅) were benzodiazepines 2.8 (and 2.6), AEDs 1.6 (and 1.5), and ADs 1.4 (and 1.3). The cases of respiratory aspiration associated with at least one drug from these 3 classes included: 1) 553 cases absent any known overdose (2.8±1.7 drugs) and 2) 347 overdose cases (2.9±1.8 drugs). Little support for the association of respiratory aspiration and benzodiazepine, AED or AD monotherapy in therapeutic dosages was found. Studies of the association between benzodiazepine monotherapy and respiration aspiration are needed in geriatric patients. ADs added to other medications increased lethality in all cases of respiratory aspiration including those associated with overdose, polypharmacy and/or major medical problems.

Prevalence and sort of pharmacokinetic drug-drug interactions in hospitalized psychiatric patients

Psychiatric patients are high-risk patients for the development of pharmacokinetic drug-drug interactions (DDIs), leading to highly variable (victim) drug serum concentrations. Avoiding and targeting high-risk drug combinations could reduce preventable adverse drug reactions (ADRs). Pharmacokinetic cytochrome P450 (CYP)-mediated DDIs are often predictable and, therefore, preventable. The retrospective, longitudinal analysis used informations from a large pharmacovigilance study (Optimization of pharmacological treatment in hospitalized psychiatric patients study, study number 01VSF16009, 01/2017), conducted in 10 psychiatric hospitals in Germany. Medication data were examined for the co-prescription of clinically relevant CYP inhibitors or inducers and substrates of these enzymes (victim drugs). In total, data from 27,396 patient cases (45.6% female) with a mean (mean ± standard deviation (SD)) age of 47.3 ± 18.3 years were available for analysis. CYP inhibitors or inducers were at least once prescribed in 14.4% (n = 3946) of the cases. The most frequently prescribed CYP inhibitors were melperone (n = 2504, 28.1%) and duloxetine (n = 1324, 14.9%). Overall, 51.0% of the cases taking melperone were combined with a victim drug (n = 1288). Carbamazepine was the most frequently prescribed CYP inducer (n = 733, 88.8%). Combinations with victim drugs were detected for 58% (n = 427) of cases on medication with carbamazepine. Finally, a DDI was detected in 43.6% of the cases in which a CYP inhibitor or inducer was prescribed. The frequency of CYP-mediated DDI is considerably high in the psychiatric setting. Physicians should be aware of the CYP inhibitory and inducing potential of psychotropic and internistic drugs (especially, melperone).

Sense and non-sense of polypharmacy: increasing efficacy, decreasing compliance?

The objective in managing patients with schizophrenia is to provide effective control of symptoms and enable the patient to reintegrate into society. Pharmacotherapy should, therefore, aim to provide optimum symptom control with minimal side effects using a simple dosage regimen. Ideally, this would be achieved through the use of a single agent. Some patients are successfully managed with a single antipsychotic drug, but it is often necessary or thought to be necessary to use a combination of agents to provide effective treatment. One European survey reported that most patients receive two to three psychotropic agents on average, but at least 5-22% receive five or more agents [53]. Unfortunately, the addition of more agents increases the risk of drug interactions, adverse events and non-compliance. This is amplified by the paucity of evidence-based medicine currently available to guide physicians in the use of combinations of agents, and the tendency of polypharmaceutical practice to be mostly driven by personal preference, clinical experience and marketing. This article therefore briefly looks at the feasibility of using various drug classes as adjunctive therapy in patients with schizophrenia.

Prescribing safely in elderly psychiatric wards: survey of possible drug interactions

Aims and Method

A cross-sectional survey of patient drug prescriptions on two elderly psychiatric wards was carried out to estimate the potential of drug–drug interactions. Two standardised databases, British National Formulary (BNF; British Medical Association & Royal Pharmaceutical Society of Great Britain, 2007) and Upto Date (www.uptodate.com/), were employed.

Results

A majority (96%) of drug prescriptions in our study could potentially cause drug–drug interactions. Most patients were on multiple drugs (on average eight drugs per patient). There was poor concordance between the two databases: BNF picked up fewer cases of potential drug–drug interactions than Upto Date (43 v. 152 instances) and they also estimated the potential for hazardousness differently.

Clinical Implications

Polypharmacy is common in elderly psychiatric patients and this increases the possibility of a drug–drug interaction. Estimating the risk of interactions depends on a sound knowledge in therapeutics and/or referring to a standardised source of information. the results of this study question the concordance of two well-referenced databases.

A cross-sectional comparative study on the assessment of quality of life in psychiatric patients under remission treated with monotherapy and polypharmacy

CONTEXT

The concept of quality of life (QoL) is becoming an important measure of the impact of psychiatric disorders. It is natural that once patient achieves remission, QoL would improve, but very few studies are conducted under this phase. This study compares the differences in QoL in remitted patients with monotherapy and polypharmacy.

AIMS

The aim of this study is to compare the QoL between psychiatric patients in remission treated with monotherapy and polypharmacy.

SETTINGS AND DESIGN

It is a questionnaire based cross-sectional comparative study.

MATERIALS AND METHODS

This study included outpatients under remission who come for follow-up in psychiatric department. Semi-structured data collection form was used. Remission was confirmed using suitable scales, and QoL was assessed using the World Health Organization quality of life-Brief (WHOQOL-BREF) scale. Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) were applied to understand the overall improvement and functioning levels.

RESULTS

Out of the total 100 patients enrolled in the study, fifty patients were on monotherapy and fifty patients on polypharmacy. The cost of medication was comparatively high for polypharmacy (Rs. 3568.92 [±348.54]) than monotherapy (Rs. 1936.56 [±252.07]). The QoL in physical, psychological, and social domains was significantly high in patients on polypharmacy rather than monotherapy when assessed using the WHOQOL-BREF scale. Ninety-six percent of monotherapy patients had CGI scores between 1.5 and 2.4 while 74% of polypharmacy patients had scores between 1.0 and 1.5. Ninety-six percent of monotherapy patients had <80 GAF scores while 92% of polypharmacy patients had >80.

CONCLUSIONS

Patients treated with polypharmacy had better QoL and also clinical improvement and functioning levels were superior.

Prevalence and correlates of antipsychotic polypharmacy among outpatients with schizophrenia attending a tertiary psychiatric facility in Nigeria

BACKGROUND

The study aimed to determine the prevalence, pattern and correlates of antipsychotic polypharmacy (APP) among outpatients with schizophrenia attending a tertiary psychiatric facility in Nigeria.

METHOD

A cross-sectional study of 250 patients with schizophrenia attending the outpatient clinic of a regional tertiary psychiatric facility in Nigeria was undertaken. They were administered a sociodemographic questionnaire, the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning (GAF) scale and the Liverpool University Side Effects Rating Scale (LUNSERS).

RESULTS

Of the 250 subjects interviewed, 176 (70.4%) were on APP. APP was significantly associated with higher prescribed chlorpromazine equivalent doses of antipsychotics (p < 0.001), increased frequency of dosing (p < 0.001), negative symptoms (p < 0.01), poorer functioning (p = 0.04) and greater side-effect burden (p = 0.04).

CONCLUSION

The APP rate reported from this study is high. Clinicians should be mindful of its impact on dosage and side-effect profiles as APP use is associated with negative symptoms and poor psychosocial functioning.

Patterns of antipsychotics' prescription in Portuguese acute psychiatric wards: A cross-sectional study

This study aimed to establish the prescribing patterns of antipsychotics in acute psychiatric wards across Portugal, to determine the prevalence of polypharmacy and "high-doses" treatment, and to identify possible predictors. Twelve acute psychiatric inpatient units and 272 patients were included. The majority (87.5%) was treated with antipsychotics regardless of diagnosis, and 41.6% had at least two antipsychotics prescribed in combination. Age, use of depot antipsychotics, and antipsychotic "high-doses" were significant predictors of antipsychotic polypharmacy. Excluding 'as required' prescriptions, 13.8% of the patients were prescribed "high-doses" of antipsychotics. When antipsychotics 'as required' prescriptions were considered, 49.2% of the patients were on antipsychotic "high-doses". Age, use of depot antipsychotics, previous psychiatric hospitalization and involuntary admission were significant predictors of antipsychotic "high-doses". These results show that in Portugal the antipsychotics prescribing practices in psychiatric inpatient units diverge from those that are universally recommended, entailing important clinical and economic implications. It seems advisable to optimize the prescription of these drugs, in order to prevent adverse effects and improve the quality of the services provided.

Frequency and clinical relevance of potential cytochrome P450 drug interactions in a psychiatric patient population - an analysis based on German insurance claims data

BACKGROUND

Numerous drugs used in the treatment of psychiatric disorders are substrates of cytochrome P450 enzymes and are potential candidates for drug-drug interactions (DDIs).

METHODS

Claims data of a German statutory health insurance company from severely mentally ill patients who registered in an integrated care contract from August 2004 to December 2009 were analysed. We measured time periods of concomitant prescription of drugs that have been reported to interact via cytochrome P450, with a focus on drugs acting as strong inhibitors. Such drug-drug exposure (DDE) is an incontrovertible precursor of DDIs. We assessed whether potential DDIs were considered clinically relevant based on the prescribing information of the respective drugs.

RESULTS

Among all 1221 patients, 186 patients (15.2 %; Clopper-Pearson 95 % confidence interval (CI): 13.3-17.4 %) had at least one DDE prescription, and 58 patients (4.8 %; 95 % CI 3.6-6.1) had at least one DDE prescription involving a strong cytochrome P450 inhibitor. In 59 patients, (4.8 %; 95 % CI: 3.7-6.2 %) five or more DDEs were identified, and five or more DDEs with a strong inhibitor were identified in 18 patients (1.5 %; 95 % CI: 0.9-2.3). The rates of DDEs were 0.27 (Garwood 95%CI: 0.25-0.28) per person-year and 0.07 (95 % CI: 0.07-0.08) for strong-inhibitor DDEs. Four of the ten most frequent DDEs were identified as clinically relevant, and seven of the eight most frequent DDEs involving a strong inhibitor were clinically relevant.

CONCLUSIONS

The number of patients with DDEs was not alarmingly high in our sample. Nevertheless, prescription information showed that some prescribed drug combinations could result in serious adverse consequences that are known to weaken or strengthen the effect of the drugs and should therefore be avoided.

Antipsychotic polypharmacy and augmentation strategies prior to clozapine initiation: a historical cohort study of 310 adults with treatment-resistant schizophrenic disorders

RATIONALE

Antipsychotic polypharmacy (APP) is commonly used in schizophrenia despite a lack of robust evidence for efficacy, as well as evidence of increased rates of adverse drug reactions and mortality.

OBJECTIVES

We sought to examine APP and the use of other adjunctive medications in patients with treatment-resistant schizophrenic disorders (ICD-10 diagnoses F20-F29) immediately prior to clozapine initiation, and to investigate clinical and sociodemographic factors associated with APP use in this setting.

METHODS

Analysis of case notes from 310 patients receiving their first course of clozapine at the South London and Maudsley NHS Trust (SLaM) was undertaken using the Clinical Record Interactive Search (CRIS) case register. Medication taken immediately prior to clozapine initiation was recorded, and global clinical severity was assessed at time points throughout the year prior to medication assessment using the Clinical Global Impression - Severity scale (CGI-S). Logistic regression was used to investigate factors associated with APP.

RESULTS

The point prevalence of APP prior to clozapine initiation was 13.6% (n=42), with 32.6% of subjects prescribed adjuvant psychotropic medications. APP was associated with increasing number of adjuvant medications (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.27-3.06), concurrent depot antipsychotic prescription (OR 2.64, CI 1.24-5.62), concurrent antidepressant prescription (OR 4.40, CI 1.82-10.63) and a CGI-S over the previous year within the two middle quartiles (Quartile 2 vs 1 OR 6.19, CI 1.81-21.10; Quartile 3 vs 1 OR 4.45, CI 1.29-15.37; Quartile 4 vs 1 OR 1.88, CI 0.45-7.13).

CONCLUSIONS

APP and augmentation of antipsychotics with antidepressants, mood stabilizers and benzodiazepines are being employed in treatment-resistant schizophrenia prior to clozapine. The conservative APP rate observed may have been influenced by an initiative within SLaM that reduced APP rates during the study window. Efforts to reduce the use of poorly evidenced prescribing should focus on adjuvant medications as well as APP.

Augmentation with antidepressants in schizophrenia treatment: benefit or risk

We focused on the application of antidepressants in schizophrenia treatment in this review. Augmentation of antidepressants with antipsychotics is a common clinical practice to treat resistant symptoms in schizophrenia, including depressive symptoms, negative symptoms, comorbid obsessive-compulsive symptoms, and other psychotic manifestations. However, recent systematic review of the clinical effects of antidepressants is lacking. In this review, we have selected and summarized current literature on the use of antidepressants in patients with schizophrenia; the patterns of use and effectiveness, as well as risks and drug-drug interactions of this clinical practice are discussed in detail, with particular emphasis on the treatment of depressive symptoms in schizophrenia.

Prevalence and correlates of antipsychotic polypharmacy: a systematic review and meta-regression of global and regional trends from the 1970s to 2009

OBJECTIVE

To assess the prevalence and correlates of antipsychotic polypharmacy (APP) across decades and regions.

METHODS

Electronic PubMed/Google Scholar search for studies reporting on APP, published from 1970 to 05/2009. Median rates and interquartile ranges (IQR) were calculated and compared using non-parametric tests. Demographic and clinical variables were tested as correlates of APP in bivariate and meta-regression analyses.

RESULTS

Across 147 studies (1,418,163 participants, 82.9% diagnosed with schizophrenia [IQR=42-100%]), the median APP rate was 19.6% (IQR=12.9-35.0%). Most common combinations included first-generation antipsychotics (FGAs)+second-generation antipsychotics (SGAs) (42.4%, IQR=0.0-71.4%) followed by FGAs+FGAs (19.6%, IQR=0.0-100%) and SGAs+SGAs (1.8%, IQR=0.0-28%). APP rates were not different between decades (1970-1979:28.8%, IQR=7.5-44%; 1980-1989:17.6%, IQR=10.8-38.2; 1990-1999:22.0%, IQR=11-40; 2000-2009:19.2% IQR=14.4-29.9, p=0.78), but between regions, being higher in Asia and Europe than North America, and in Asia than Oceania (p<0.001). APP increased numerically by 34% in North America from the 1980s 12.7%) to 2000s (17.0%) (p=0.94) and decreased significantly by 65% from 1980 (55.5%) to 2000 (19.2%) in Asia (p=0.03), with non-significant changes in Europe. APP was associated with inpatient status (p<0.001), use of FGAs (p<0.0001) and anticholinergics (<0.001), schizophrenia (p=0.01), less antidepressant use (p=0.02), greater LAIs use (p=0.04), shorter follow-up (p=0.001) and cross-sectional vs. longitudinal study design (p=0.03). In a meta-regression, inpatient status (p<0.0001), FGA use (0.046), and schizophrenia diagnosis (p=0.004) independently predicted APP (N=66, R(2)=0.44, p<0.0001).

CONCLUSIONS

APP is common with different rates and time trends by region over the last four decades. APP is associated with greater anticholinergic requirement, shorter observation time, greater illness severity and lower antidepressant use.

Antipsychotic monotherapy among outpatients with schizophrenia treated with olanzapine or risperidone in Japan: a health care database analysis

PURPOSE

Antipsychotic monotherapy is often recommended over antipsychotic polypharmacy because of fewer adverse events, reduced treatment complexity, and lower medication cost. This study compared the rate and the duration of antipsychotic monotherapy following initiation of olanzapine or risperidone in the treatment of outpatients with schizophrenia in Japan.

METHODS

Outpatients diagnosed with schizophrenia in the Japan Medical Data Center database were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision, diagnosis codes. Patients were between 20 and 65 years old, initiated on olanzapine or risperidone therapy between August 2003 and July 2008, and continuously enrolled during the 6 months prior to and the 12 months following the initiation date. Antipsychotic polypharmacy was defined as concurrent use of two or more antipsychotics. The probability of monotherapy during the 12-month follow-up period was assessed using a propensity score-adjusted generalized estimating equation model. Duration of monotherapy was contrasted using a propensity score-adjusted bootstrapping model.

RESULTS

After applying all inclusion and exclusion criteria, the final analytic sample consisted of 332 olanzapine- and 496 risperidone-treated outpatients. At treatment initiation, 61.5% of the olanzapine-treated patients and 45.6% of the risperidone-treated patients received antipsychotic monotherapy (P < 0.001). After correcting for background differences, monotherapy was more common among olanzapine-treated patients (P = 0.001). In addition, olanzapine was used as monotherapy for a longer duration (P = 0.006).

CONCLUSION

Consistent with prior global research, this retrospective naturalistic study of schizophrenia outpatients in Japan found that olanzapine is more likely to be used as monotherapy and to be used as monotherapy for a longer duration than risperidone.

Is antipsychotic polypharmacy associated with metabolic syndrome even after adjustment for lifestyle effects?: a cross-sectional study

BACKGROUND

Although the validity and safety of antipsychotic polypharmacy remains unclear, it is commonplace in the treatment of schizophrenia. This study aimed to investigate the degree that antipsychotic polypharmacy contributed to metabolic syndrome in outpatients with schizophrenia, after adjustment for the effects of lifestyle.

METHODS

A cross-sectional survey was carried out between April 2007 and October 2007 at Yamanashi Prefectural KITA hospital in Japan. 334 patients consented to this cross-sectional study. We measured the components consisting metabolic syndrome, and interviewed the participants about their lifestyle. We classified metabolic syndrome into four groups according to the severity of metabolic disturbance: the metabolic syndrome; the pre-metabolic syndrome; the visceral fat obesity; and the normal group. We used multinomial logistic regression models to assess the association of metabolic syndrome with antipsychotic polypharmacy, adjusting for lifestyle.

RESULTS

Seventy-four (22.2%) patients were in the metabolic syndrome group, 61 (18.3%) patients were in the pre-metabolic syndrome group, and 41 (12.3%) patients were in visceral fat obesity group. Antipsychotic polypharmacy was present in 167 (50.0%) patients. In multinomial logistic regression analyses, antipsychotic polypharmacy was significantly associated with the pre-metabolic syndrome group (adjusted odds ratio [AOR], 2.348; 95% confidence interval [CI], 1.181-4.668), but not with the metabolic syndrome group (AOR, 1.269; 95%CI, 0.679-2.371).

CONCLUSIONS

These results suggest that antipsychotic polypharmacy, compared with monotherapy, may be independently associated with an increased risk of having pre-metabolic syndrome, even after adjusting for patients' lifestyle characteristics. As metabolic syndrome is associated with an increased risk of cardiovascular mortality, further studies are needed to clarify the validity and safety of antipsychotic polypharmacy.

Antipsychotics prescribing patterns of patients with schizophrenia admitted to korean general hospital psychiatric unit: 2001 to 2008

Objective

Although the standard of treatment for schizophrenia is antipsychotic monotherapy, overall psychotropic polypharmacy including antipsychotic polypharmacy is increasingly practiced by clinicians. However, there are very few studies that assess the prescription patterns of psychotropic drugs for patients with schizophrenia in Korea. The objective of this study is to describe changes in prescription patterns with respect to antipsychotic polypharmacy and overall psychotropic polypharmacy.

Methods

In this retrospective study, we reviewed all psychotropic drugs prescribed at the time of discharge for patients diagnosed as having schizophrenia (DSM-IV criteria) who entered a psychiatric unit of a Korean general hospital from 2001 to 2008. These included a total of 467 patients.

Results

Of the 467 patients in this study, 205 (43.9%) were discharged with antipsychotic monotherapy and the rest, 262 (56.1%), were discharged with a polypharmacy regimen. A total of 9% of the studied patients received more than two antipsychotic drugs. The most frequent combination of antipsychotics was clozapine and aripiprazole, followed by clozapine and amisulpride, and risperidone and olanzapine. The ratio of patients discharged with a polypharmacy regimen including antipsychotic polypharmacy increased from 2001 to 2008. In relation to the mean dose of all antipsychotic drugs at the time of discharge, mean length of hospital stay and mean initial global assessment of functioning scores on admission statistically significant differences were not detected between both monotherapy and polypharmacy groups.

Conclusion

The main finding of this study is that polypharmacy with antipsychotics and other psychotropic medicines increased in our psychiatric unit from 2001 to 2008. The rates of antipsychotic polypharmacy in our study were less than those described in our literature review.

The course of depressive symptoms and prescribing patterns of antidepressants in schizophrenia in a one-year follow-up study

BACKGROUND

Antidepressants are frequently prescribed in patients with psychotic disorders, but little is known about their effects in routine clinical practice. The objective was to investigate the prescribing patterns of antidepressants in relation to the course of depressive symptoms in patients with psychotic disorders.

METHODS

A cohort of 214 Dutch patients with psychotic disorders received two assessments of somatic and psychiatric health, including a clinician-rated screening for depressive symptoms, as part of annual routine outcome monitoring.

RESULTS

Depressive symptoms were prevalent among 43% (93) of the patients. Antidepressants were prescribed for 40% (86) of the patients and the majority 83% (71) continued this therapy after one year. Multivariable analysis showed that patients with more severe psychopathology had a higher risk to develop depressive symptoms the following year (OR [95% CI]=0.953 [0.912-0.995]). For patients with depressive symptoms at baseline, polypharmacy was a potential risk factor to keep having depressive symptoms (OR [95% CI]=1.593 [1.123-2.261]). Antidepressant use was not an independent predictor in both analyses.

CONCLUSIONS

Routine outcome monitoring in patients with psychotic disorders revealed a high prevalence of depressive symptoms. Antidepressants were frequently prescribed and continued in routine clinical practice.

Prescribing practices in psychiatric hospitals in Eastern Europe

BACKGROUND

There has been no evidence about the prescribing practices in psychiatric care in Eastern Europe.

AIMS

To examine the patterns of psychotropic prescribing in five countries of Eastern Europe.

METHOD

We conducted a one-day census of psychiatric treatments used in eight psychiatric hospitals in Albania, Croatia, Macedonia, Serbia and Romania. We examined clinical records and medication charts of 1304 patients.

RESULTS

The use of polypharmacy was frequent across all diagnostic groups. Only 6.8% of patients were on monotherapy. The mean number of prescribed drugs was 2.8 (SD 0.97) with 26.5% receiving two drugs, 42.1% receiving three drugs and 22.1% being prescribed four or more psychotropic drugs. Typical antipsychotics were prescribed to 63% and atypical antipsychotics to 40% of patients with psychosis. Older generations of antidepressants were prescribed to 29% of patients with depression. Anxiolitic drugs were prescribed to 20.4% and benzodiazepines to 68.5% of patients. One third of patients received an anticholinergic drug on a regular basis.

CONCLUSIONS

Older generation antipsychotics and antidepressants were used more frequently than in the countries of Western Europe. Psychotropic polypharmacy is a common practice. There is a need for adopting more evidence-based practice in psychiatric care in these countries.

[Antipsychotic polypharmacy in a general hospital in-patient psychiatric unit]

INTRODUCTION

The association of antipsychotics is common in clinical practice despite the lack of scientific evidence to support this practice. There are few data on these patterns of use in hospitals in Spain. However, such data are required for the development of indicators of quality of care.

AIMS

To collect information on prescription of antipsychotics in a psychiatric inpatient unit.

METHODS

We performed a retrospective observational study of inpatients under treatment with antipsychotic drugs in 2006.

RESULTS

We reviewed 136 patients with a mean age of 38 years and a mean length of stay of 22 days. Antipsychotics were used primarily in schizophrenic disorder (44.9%). At admission, atypical antipsychotics (second or third generation) were the most frequently used drugs in monotherapy (41.2%), a combination of two or more antipsychotics was used in 43% of the patients and the use of additional medication (not antipsychotics) was very high (84.6%). At discharge, the results were similar, but a notable finding was the increase in the combination of an atypical antipsychotic with extended-release drugs (from 2% to 11%).

CONCLUSIONS

The use of atypical antipsychotics as the first therapeutic option is becoming established, confirming the phenomenon of polypharmacy in the treatment of psychoses. The study design did not allow directional relations to be established but some trends, such as the possibility that polypharmacy is more common in patients with schizophrenia and is associated with the use of depot antipsychotics, were confirmed.

Combined treatment with amisulpride in patients with schizophrenia discharged from a short-term hospitalization unit: a 1-year retrospective study

OBJECTIVE

Antipsychotic monotherapy is considered as the reference standard in the pharmacological treatment of schizophrenia. Nonetheless, there is a large rate of studies showing polypharmacy with antipsychotics as more frequent than would be expected attending experts' recommendations. The objective of this study is to describe polypharmacy with antipsychotic regimen in patients with schizophrenia discharged with amisulpride from the short-term hospitalization unit.

METHODS

We have analyzed the prescription of psychotropic drugs upon discharge of 52 patients with schizophrenia or schizoaffective disorder who were discharged with amisulpride from January to December 2005. Variables were included to describe the following treatments: antipsychotic (drug and dose), benzodiazepine, and anticholinergic drugs. Sociodemographic and clinical variables were also collected.

RESULTS

In the group treated with 2 antipsychotics, the most frequently used common combination was with a classic antipsychotic in depot formulation. Patients (17.5%) were prescribed to another 2 antipsychotics in addition to amisulpride, being the most common combination with a second generation antipsychotic, and a classic or depot antipsychotic.

CONCLUSIONS

The results of our study show that the use of amisulpride as an adjuvant can be a suitable therapeutic strategy for patients with schizophrenia resistant to treatment and for the rapid control of symptoms in schizophrenic patients with acute episodes. However, its clinical use does not have to be reserved exclusively for patients with resistant schizophrenia to clozapine.

Patterns of care in patients discharged from acute psychiatric inpatient facilities: a national survey in Italy

OBJECTIVE

To analyze the characteristics of patients scheduled for discharge from acute psychiatric inpatient facilities in Italy, and their pattern of care.

METHODS

Socio-demographic and clinical characteristics, and patterns of care of 1,330 patients discharged from public and private inpatient facilities in Italy were assessed with a standardized methodology during an index period in the year 2004.

RESULTS

About one half of the sample had schizophrenia or bipolar disorder. However, the case-mix differed between public and private facilities, where in-patients had more frequently mood and anxiety disorders. The use of two or more drugs was very common, involving more than 90% of patients and including typically benzodiazepines and antipsychotics. Structured psychosocial treatments were rarely initiated during the hospital stay. Increasing age, male gender, long stay in the facility (>60 days), personality disorder and type of facility were associated with a higher likelihood of being discharged to a community residential facility. Predictors of discharge to another psychiatric facility were increasing age, being single, schizophrenia, personality disorder and organic mental disorder. Families were not involved in decisions about patients' discharge in a significant proportion of cases. University psychiatric clinics and private facilities were less coordinated with the community system of care than General Hospital Psychiatric Units. Referral of patients with substance use disorder to drug addiction services occurred in just 30% of subjects.

CONCLUSIONS

This study provides information on the characteristics and the pattern of care of patients discharged from inpatient facilities in a country that has closed down all its mental hospitals. This information may be relevant for those countries that are affording now the downsizing of MHs, and the expansion of community-based models of care.

Advantages and disadvantages of combination treatment with antipsychotics ECNP Consensus Meeting, March 2008, Nice

TERMINOLOGY AND PRINCIPLES OF COMBINING ANTIPSYCHOTICS WITH A SECOND MEDICATION: The term "combination" includes virtually all the ways in which one medication may be added to another. The other commonly used terms are "augmentation" which implies an additive effect from adding a second medicine to that obtained from prescribing a first, an "add on" which implies adding on to existing, possibly effective treatment which, for one reason or another, cannot or should not be stopped. The issues that arise in all potential indications are: a) how long it is reasonable to wait to prove insufficiency of response to monotherapy; b) by what criteria that response should be defined; c) how optimal is the dose of the first monotherapy and, therefore, how confident can one be that its lack of effect is due to a truly inadequate response? Before one considers combination treatment, one or more of the following criteria should be met; a) monotherapy has been only partially effective on core symptoms; b) monotherapy has been effective on some concurrent symptoms but not others, for which a further medicine is believed to be required; c) a particular combination might be indicated de novo in some indications; d) The combination could improve tolerability because two compounds may be employed below their individual dose thresholds for side effects. Regulators have been concerned primarily with a and, in principle at least, c above. In clinical practice, the use of combination treatment reflects the often unsatisfactory outcome of treatment with single agents. ANTIPSYCHOTICS IN MANIA: There is good evidence that most antipsychotics tested show efficacy in acute mania when added to lithium or valproate for patients showing no or a partial response to lithium or valproate alone. Conventional 2-armed trial designs could benefit from a third antipsychotic monotherapy arm. In the long term treatment of bipolar disorder, in patients responding acutely to the addition of quetiapine to lithium or valproate, this combination reduces the subsequent risk of relapse to depression, mania or mixed states compared to monotherapy with lithium or valproate. Comparable data is not available for combination with other antipsychotics. ANTIPSYCHOTICS IN MAJOR DEPRESSION: Some atypical antipsychotics have been shown to induce remission when added to an antidepressant (usually a SSRI or SNRI) in unipolar patients in a major depressive episode unresponsive to the antidepressant monotherapy. Refractoriness is defined as at least 6 weeks without meeting an adequate pre-defined treatment response. Long term data is not yet available to support continuing efficacy. SCHIZOPHRENIA: There is only limited evidence to support the combination of two or more antipsychotics in schizophrenia. Any monotherapy should be given at the maximal tolerated dose and at least two antipsychotics of different action/tolerability and clozapine should be given as a monotherapy before a combination is considered. The addition of a high potency D2/3 antagonist to a low potency antagonist like clozapine or quetiapine is the logical combination to treat positive symptoms, although further evidence from well conducted clinical trials is needed. Other mechanisms of action than D2/3 blockade, and hence other combinations might be more relevant for negative, cognitive or affective symptoms. OBSESSIVE-COMPULSIVE DISORDER: SSRI monotherapy has moderate overall average benefit in OCD and can take as long as 3 months for benefit to be decided. Antipsychotic addition may be considered in OCD with tic disorder and in refractory OCD. For OCD with poor insight (OCD with "psychotic features"), treatment of choice should be medium to high dose of SSRI, and only in refractory cases, augmentation with antipsychotics might be considered. Augmentation with haloperidol and risperidone was found to be effective (symptom reduction of more than 35%) for patients with tics. For refractory OCD, there is data suggesting a specific role for haloperidol and risperidone as well, and some data with regard to potential therapeutic benefit with olanzapine and quetiapine. ANTIPSYCHOTICS AND ADVERSE EFFECTS IN SEVERE MENTAL ILLNESS: Cardio-metabolic risk in patients with severe mental illness and especially when treated with antipsychotic agents are now much better recognized and efforts to ensure improved physical health screening and prevention are becoming established.

Antipsychotic polypharmacy in patients with schizophrenia in a brief hospitalization unit

INTRODUCTION

Antipsychotic monotherapy is considered the gold standard in pharmacological treatment of schizophrenia and other psychotic disorders. Only 2 of the main clinical guides recommend the use of antipsychotic polypharmacy (AP) for those patients refractory to monotherapy. Nonetheless, there is a large rate of studies, conducted in many different settings, showing that AP is more frequent as would be expected attending experts' recommendations.

METHODS

In this retrospective study, we review all the psychotropic drugs dispensed to inpatients of a brief hospitalization psychiatric unit diagnosed as having schizophrenia or schizoaffective disorder (International Statistical Classification of Diseases, 10th Revision) at time of discharge in the year 2005. These included a total of 209 patients older than 18 years.

RESULTS

Of the 209 studied patients, 55.5% were discharged under AP treatment. Inpatients were given a mean of 3.06 psychotropic drugs and a mean of 1.61 antipsychotics at the time of hospital discharge. A total of 33.2% of the studied patients got anticholinergic drugs, and 66.2% were given benzodiazepines. The most prevalent combination of drugs was intramuscular long-acting risperidone plus an atypical antipsychotic. Amisulpride was the most used antipsychotic as adjuvant treatment.

CONCLUSIONS

Despite different clinical guidelines, AP is a common pharmacological strategy as it is shown in our study and in the reviewed literature. Data in our study indicate that the observed rates of AP cannot exclusively be attributed to the treatment of patients with clozapine-resistant schizophrenia.

Off-label utilization of antidepressants

While antidepressant prescription rules are established for approved indications by large-scale studies, off-label utilization naturally often lacks the validation by large scientific databases, and is at its best based on expert consensus. The aim of the present survey was to study the prescription habits of hospital psychiatrists with regard to antidepressants, comparing patients treated for depressions and anxiety disorder with patients receiving off-label antidepressant treatment.

METHODS

Data on drug use for this study were based on 6 reference days from April 1999 to November 2001 in the 98-bed psychiatric hospital of the University of Lausanne, Switzerland. The drug prescriptions of 174 patients were assessed.

RESULTS

Whereas the diagnosis did not influence the choice between newer or older antidepressants, patients presenting an anxiety disorder were 4.5 times more likely (p<0.05) and patients with other diagnoses 8 times more likely (p<0.001) to receive an antipsychotic comedication compared to patients whose primary diagnosis was a depressive disorder. Also, patients receiving concomitantly a nonbenzodiazepine hypnotic were less likely to be prescribed an older antidepressant (p<0.05). While patients with anxiety disorder and those with major depression received their antidepressants at comparable doses, patients with an off-label indication were treated preferentially with lower doses.

CONCLUSIONS

The results of this survey suggest, that the prescribing hospital psychiatrists developed preferences with regard to the choice of the antidepressant class, which they then used for both registered and off-label indications. They then seemed to adapt the dose and the comedication according to the diagnosis, confirming the initial study hypothesis.

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.

Cost of antipsychotic polypharmacy in the treatment of schizophrenia

BACKGROUND

This study compared the costs of antipsychotic polypharmacy for patients who initiated on 1 of the 3 most commonly prescribed atypical antipsychotics - olanzapine, quetiapine, or risperidone.

METHODS

Data were drawn from a large, prospective, naturalistic, multi-site, nonrandomized study of treatment for schizophrenia in the United States conducted between July 1997 and September 2003. Participants who were initiated on olanzapine (N = 405), quetiapine (N = 115), or risperidone (N = 276) were followed for 1 year post initiation and compared on: (a) average daily cost of the index antipsychotic while on the index antipsychotic, (b) average daily cost of the coprescribed antipsychotics while on the index antipsychotic, (c) average daily cost of the index antipsychotic and the coprescribed antipsychotics while on the index antipsychotic, (d) total annual cost of antipsychotic medications prescribed in the year following initiation on the index antipsychotic, using propensity score-adjusted bootstrap resampling method. Average daily antipsychotic costs and total annual antipsychotic costs were also estimated using more recent (2004) antipsychotic drug prices.

RESULTS

During the 1 year following initiation on the index antipsychotic, the total average daily cost of the index antipsychotic was higher for quetiapine ($15.33) than olanzapine ($13.90, p < .05) and risperidone ($11.04, p < .01), although the average daily cost of the index antipsychotic was higher for olanzapine ($10.08) than risperidone ($6.74, p < .01) or quetiapine ($6.63, p < .01). Lower total average daily costs were observed in risperidone than olanzapine or quetiapine. Significantly lower average daily cost of concomitant antipsychotic medications for olanzapine ($3.82) compared to quetiapine ($8.70, p < .01) or risperidone-initiated patients ($4.30, p < .01) contributed to the lower average daily cost of all antipsychotic medication for olanzapine-initiated patients. Each dollar spent on the index antipsychotic was accompanied by spending an additional $1.31 on concomitant antipsychotics for quetiapine compared to $0.64 for risperidone and $0.38 for olanzapine-initiated patients. A separate intent-to-treat analysis of the total annual antipsychotic cost found a significantly higher total annual antipsychotic cost for quetiapine-initiated patients ($5320) compared to olanzapine ($4536, p < .01) or risperidone ($3813, p < .01).

CONCLUSION

Prevalent antipsychotic polypharmacy adds substantial cost to the treatment of schizophrenia. Comparison of medication costs need to address the costs of all antipsychotics. A better understanding of concomitant antipsychotic costs provides a more accurate portrayal of antipsychotic medication costs in the treatment of schizophrenia.

Gene expression on liver toxicity induced by administration of haloperidol in rats with severe fatty liver

Sudden deaths are often encountered in schizophrenic patients prescribed with antipsychotic drugs, and fatty liver may be more prevalent among patients with schizophrenia. The aim of this study is to investigate the adverse effects of antipsychotic drugs on fatty liver. We administered haloperidol intraperitoneally to fatty liver rats and examined the mRNA expression in the liver. Basic expressions of cytochrome P450 (CYP)1A2, CYP2C11 and CYP3A2 decreased, and response of these CYPs to haloperidol was reduced in the fatty liver. Metabolism of haloperidol was also suppressed in the fatty liver rats. Moreover, hepatic injury by administration of haloperidol was shown pathohistologically and molecular-biologically in severe fatty liver. These results suggest that fatty liver increases susceptibility to adverse effects of haloperidol, possibly leading to life-threatening events. It should be noted by clinicians that excessive dose of antipsychotic drugs may be more harmful in patients with fatty liver.

Real-world antipsychotic treatment practices

This article examines real-world antipsychotic use in the treatment of schizophrenia by comparing real-world prescribing with medication algorithms and guidelines, by evaluating the evidence underlying recommendations and guidelines, and by examining the roles of side effects and medication adherence in real-world prescribing decisions.

Changes in the treatment of acute psychosis in a German public hospital from 1998 to 2004

INTRODUCTION

The aim of our study was to investigate antipsychotic treatment strategies in acute schizophrenic episodes in a German university hospital.

METHODS

Documented pharmacological procedures in the first six weeks of acute episodes of schizophrenia in the years 1998 (n = 108), 2001 (n = 92), and 2004 (n = 94) were analyzed. Inclusion criteria were: admission voluntary and involuntary as inpatient to our acute ward with a diagnosis of F20x according to ICD 10.

RESULTS

Atypical antipsychotics (AAP) were significant more frequently used in the first week of treatment in 2001 and 2004 compared to the year 1998. Switching to AAP occurred significantly earlier in 2001 and 2004 (after 7.6 +/- 7 days in 1998, 3.5 +/- 5 days in 2001 and 2.3 +/- 5 days in 2004; P < 0.002). In all three years prescription of high potent typical antipsychotics decreased during the first six weeks of treatment. Involuntary treatment (P < 0.001) and age (P = 0.001) were significantly correlated to initial prescription of AAP. Involuntary admitted patients received more often a combination of high-potent conventional high potent typical neuroleptics and AAP (48% vs. 24%, P = 0.007).

CONCLUSION

Second generation atypicals are used more frequently according to current guidelines and switching from conventional medications occurs earlier.

[Prevalence and characteristics of neuroleptic association in a patient cohort with psychotic disorders]

OBJECTIVES

Combined antipsychotic drugs are often prescribed, despite a lack of objective supporting data. Therefore, it is especially important to determine the scope of this practice and to better understand the characteristics of affected patients to identify which associations to study first.

METHOD

We studied patients with psychotic disorders followed for at least 1 year at an outpatient psychiatric clinic in Geneva (n = 253). We collected data on prescriptions given at baseline and during that period, as well as sociodemographic and clinical data.

RESULTS

During the follow-up period, 36% of patients were prescribed a neuroleptic. These patients differ by negative changing characteristics: less activity, financial assistance, nursing home placement, and numerous admissions with earlier onset of disorder. Three-quarters of patients did not change treatment during that period. Treatment stability is associated with treatment compliance and lack of hospital admission during the follow-up period.

CONCLUSION

Without any scientific substantiation, patients with negative changing characteristics are often prescribed neuroleptics. Such treatment options are likely relatively inefficient strategies. Moreover, this practice risks further complicating patients who are already characterized by negative elements.

Psychotropic drug prescription in a psychiatric university hospital in Germany

A retrospective survey on drug prescription over a 5-year period (1998 to 2003) in 1,540 inpatients in a psychiatric university hospital in Germany was carried out. The aim was to establish a basis for a monitoring of prescription habits and for pharmacoeconomic considerations. It was established that there was only a slight increase in polyvalent drug use between 1998 and 2003. The results are presented in more detail in relation to the diagnosis of organic mental disorders, drug abuse disorders, schizophrenia, mood disorders and personality disorders. Newer atypical antipsychotics, SSRIs and mood stabilizers were increased across diagnoses while lithium and clozapine were prescribed less frequently. The rare occurrence of monotherapy in general might reflect a common trend in psychiatry fostering polydrug use. Studies of this type are biased by the fact that local habits of prescription do not allow generalisation of the findings. Such surveys should be carried out more frequently and simultaneously in different centers. Critical comparisons could help to optimize treatment.

Predictive factors of the number and the dose of anti-psychotics in a cohort of schizophrenic patients

BACKGROUND

Anti-psychotic prescription in schizophrenia is characterised in Europe by frequent associations and high doses. Nevertheless, few longitudinal epidemiological studies have explored anti-psychotic prescriptions.

AIM

(1) To describe the evolution of prescription patterns across time; (2) to determine risk factors for prescription of high doses of anti-psychotics and for anti-psychotic combinations.

MATERIALS AND METHODS

Three thousand four hundred seventy three subjects were included in 1993. Data collected in 1993 and subsequently in 1996 and 1999, provided information on demographics, clinical status and prescription. In 1996, the response rate was 68.5% and 56.7% in 1999.

RESULTS

The number of anti-psychotics prescribed slightly decreased across time, while doses remained high for one-third of the patients. The factors predicting dose were: dose at previous evaluation, class of anti-psychotic and clinical severity. The factors predicting the number of anti-psychotics were: previous number and class of anti-psychotic and clinical severity.

CONCLUSION

Higher dosage and combinations were related more to physicians' habits than to patient characteristics, as is frequently observed in chronic disease.

Patterns of clinical use of antipsychotics in hospitalized psychiatric patients

The ways of using antipsychotic drugs have greatly changed over the last 10 years. The aim of this study was to evaluate such changes in psychiatric patients admitted to the Psychiatric Department of Milan's Ospedale Maggiore in 1989 (n=350), 1999 (n=718) and 2002 (n=628). The medical records of the hospitalized patients were evaluated by analyzing the anamnestic and clinical data with particular reference to age, gender, diagnosis and medication use. In 2002, atypical antipsychotics were more frequently prescribed as monotherapy upon discharge than typical antipsychotics (32.64% vs. 30.10%). Combinations of two or more antipsychotic drugs were prescribed upon discharge for 20.63% of the patients in 1989, 31.24% in 1999 and 23.09% in 2002. The combinations of one typical and one atypical drug increased from 4.04% in 1999 to 13.06% in 2002. The mean (+/-S.D.) daily antipsychotic drug dose (expressed in chlorpromazine equivalents) was significantly higher in 2002 than in 1999 and 1989. The results of this study confirm the trend to use combinations of one typical and one atypical antipsychotic, and higher doses.

Polypharmacy in psychiatric practice in the Canary Islands

BACKGROUND

Polypharmacy with psychoactive drugs is an increasingly common and debatable contemporary practice in clinical psychiatry based more upon experience than evidence. The objective of this study was to evaluate the prevalence and conditioners of polypharmacy in psychiatric patients.

METHOD

A cross-sectional survey was carried out using the Canary Islands Health Service Clinical Records Database. A representative sample (n = 2,647) of patients with mental disorders receiving psychotropic medication was studied.

RESULTS

The mean number of psychoactive drugs prescribed was 1.63 +/- 0.93 (range 1-7). The rate of polypharmacy was 41.9%, with 27.8% of patients receiving two drugs, 9.1% receiving three, 3.2% receiving four, and 1.8% of the patients receiving five or more psychotropic drugs. Multiple regression analysis shows that variables sex and diagnosis have a predictive value with regard to the number of psychotropic drug used, being men and schizophrenic patients the most predisposed. Benzodiazepines were the more prevalent drugs in monotherapy, while anticonvulsants and antipsychotics were the more used in combination with other treatment. A questionable very high degree of same-class polypharmacy was evidenced, while multi-class, adjunctive and augmentation polypharmacy seem to be more appropriate.

CONCLUSIONS

Almost half of the psychiatric patients are treated with several psychotropics. Polypharmacy is common and seems to be problematic, especially when same class of drugs are prescribed together. Some diagnoses, such as schizophrenia, are associated with an increase risk of Polypharmacy but there is a lack of evidence based indicators that allows for quality evaluation on this practice.

Clinical correlates of antipsychotic polytherapy in patients with schizophrenia in Singapore

The purpose of the present study wa to determine the prevalence of antipsychotic polytherapy (use of more than one antipsychotic drug at one time) and its clinical correlates among 300 hospitalized psychotic Asian patients diagnosed with schizophrenia. It was hypothesized that such treatment would be associated with more severe illness than in comparable monotherapy patients, and with higher chlorpromazine-equivalent (CPZ) total daily doses. Clinical and demographic details were obtained from the medical records and direct clinical examinations. Polytherapy was encountered in 215 of the 300 patients (71.7%), with an average number of 1.8 antipsychotics (range 1-4) prescribed at a mean CPZ daily dose of 612 +/- 528 mg (median: 464 mg, range: 25-2500 mg). The 215 patients prescribed more than one antipsychotic agents were younger, ill longer, more likely to be taking at least one high-potency agent, in receipt of higher average daily CPZ doses, and more likely to be prescribed anticholinergic agents but with similar admission illness severity rating (Brief Psychiatric Rating Scale) scores compared to the 85 patients given only one antipsychotic drug at one time. The high rate of antipsychotic polytherapy that appeared to be unrelated to current illness severity suggests that this practice may not consistently be based on rational therapeutic principles.

Potential for drug interactions involving cytochromes P450 2D6 and 3A4 on general adult psychiatric and functional elderly psychiatric wards

AIMS

To assess the potential for interactions involving cytochromes P450 2D6 (CYP2D6) and 3A4 (CYP3A4) between drugs prescribed in a city in-patient psychiatric service.

METHODS

Prescription information was obtained from all 236 patients in general adult wards and all 87 patients in functional elderly wards under a city psychiatric service. The frequencies with which combinations of drugs expected to interact via CYP2D6 or CYP3A4 were documented and compared between these two settings.

RESULTS

All 2089 drug prescriptions, of which 1237 (59%) were administered, were analyzed. One hundred and seventy-two patients (73%) on adult wards and 59 (68%) on functional elderly wards were prescribed at least one drug metabolized by and/or inhibiting CYP2D6, the difference being nonsignificant (95% confidence interval on the difference -6.3%, 16.4%). Anticipated interactions from 62/82 CYP2D6-related combinations prescribed on adult wards (27/100 patients) and 19/30 prescribed to elderly patients (22/100 patients) were judged to be clinically important or potentially clinically important. The proportion of patients on functional elderly wards prescribed at least one drug interacting with CYP3A4 (87%) was significantly greater than that for patients on adult wards (57%, P < 0.001). The frequency of interactions involving CYP3A4 was significantly greater on functional elderly than adult wards (43/100 vs 22/100 patients, P < 0.025, 95% confidence interval on the difference 4, 38/100).

CONCLUSIONS

Our findings confirm extensive polypharmacy on general adult psychiatric and functional elderly psychiatric wards. A substantial proportion of patients were receiving combinations of drugs that interact with CYP2D6 and/or CYP3A4, many of which are known to produce clinically important interactions. Doctors practising in old age psychiatry should be aware that patients on functional elderly wards are at increased risk of clinically important CYP3A4 interactions. Psychiatrists should consider the pharmacokinetic implications of drugs prescribed for use 'as needed', because of the potential for unpredictable interactions.

Combination of "atypical" antipsychotic medication in the management of treatment-resistant schizophrenia and schizoaffective disorder

BACKGROUND

This article reviews the published clinical data on treatment-resistant schizophrenic and schizoaffective patients managed with combinations of "atypical" antipsychotic medication.

METHOD

A computerized MEDLINE literature search covering an 18-year period (1985-2003) was conducted. All pertinent papers on the subject of the use of combination "atypical" antipsychotic medication in the management of treatment-resistant schizophrenia and schizoaffective disorder were obtained with subsequent analysis and discussion of the retrieved data.

RESULTS

The search identified 29 case reports and case series reports (172 patients) and one double-blind placebo-controlled trial (28 patients) describing the use of combination "atypical" antipsychotic medication (clozapine-risperidone; clozapine-sulpiride; clozapine-olanzapine; clozapine-quetiapine; olanzapine-sulpiride; olanzapine-quetiapine; risperidone-olanzapine; risperidone-quetiapine) in the treatment of resistant schizophrenic and schizoaffective patients. An overview of results suggests that the combinations were beneficial in the described patients with reduction of positive symptoms and occasionally negative symptoms. Significant adverse effects, while rare, were reported in a few cases and did not appear to different in nature from those managed on monotherapeutic regimens.

CONCLUSION

Combinations of "atypical" antipsychotic medications are well tolerated and may be effective in the management of treatment refractory schizophrenia and schizoaffective disorder. However, further double-blind placebo-controlled trials are required in order to test and confirm these observations.

New developments in the pharmacotherapy of schizophrenia

This review summarizes current key research strategies and the most prominently pursued new potential treatments for schizophrenia. First, new routes of administration for second generation antipsychotics are presented. These include rapidly dissolving tablets, drops and sirups as well as new intramuscular formulations. Newly available short acting and long acting (depot) antipsychotics complement oral antipsychotics so that the full spectrum of routes of administration is now available for second generation antipsychotics. Next to antipsychotic polypharmacy, in which two or more antipsychotics are combined, pharmacological add-on treatments, mainly with benzodiazepines, antidepressants and mood stabilizers enjoy increasing popularity. Most of this practice is driven by personal preferences, clinical experience and marketing rather than evidence based medicine. New pharmacological mechanisms currently utilized in advanced states of development include partial dopamine D2-receptor agonism, supplementation with glutamatergic agents, estrogen and omega-3-fatty acids. While the concept of partial D1-agonism has already led to the successful launch of a new antipsychotic, aripiprazole, the other attempts to improve therapeutic response in schizophrenia patients have so far provided equivocal results. It is argued that they may be helpful for certain subgroups or specific symptoms of schizophrenia patients. In conclusion, many exciting new pharmacological leads are currently pursued and this will very likely augment the options for treating patients with schizophrenia.

Combination treatment in bipolar disorder: a review of controlled trials

OBJECTIVES

Monotherapy is often inadequate and combination drug regimens have become the norm for the treatment of bipolar disorder. Virtually all classes of psychotropic drugs have been used in bipolar disorder in combination for a variety of indications. This article reviews the available published data from controlled, blinded studies regarding combination treatments in the different treatment phases of bipolar disorder.

METHODS

Articles for this review were obtained from a search of the Medline database (1966-2002), using the following keywords and phrases: add-on, antipsychotic, anticonvulsant, antidepressant, combination treatment, lithium, neuroleptic, and polypharmacy. The search was augmented by data presented at scientific meetings. Data included in this article were only from controlled studies that evaluated combinations of two or more agents.

RESULTS

For acute mania, the most useful combination treatments as determined by controlled studies, appear to be an antipsychotic drug with a mood-stabilizer. The combination of lithium and valproate, even though widely used for acute mania, is lacking in controlled data. For acute bipolar depression, the controlled combination studies reviewed fail to show clear advantages in efficacy of an antidepressant with a mood-stabilizer versus two stabilizers or a mood-stabilizer alone. Large, controlled, randomized, long-term studies with modern antidepressants are not available. Controlled combination studies of mood-stabilizers suggest gains in efficacy over monotherapy in the long-term treatment of bipolar disorder.

CONCLUSIONS

Controlled combination studies in bipolar disorder are uncommon. Increased attention should be given to study combination treatments in all phases of bipolar illness to determine the most efficacious and safest combinations.

The use of drug monotherapy in psychiatric inpatient treatment

OBJECTIVE

Monotherapy has always been the goal in psychiatric drug treatment, but it does not seem to be very common in everyday practice.

METHOD

The available literature on the frequency of monotherapy or polytherapy with psychotropic agents in psychiatric inpatient treatment is reviewed.

FINDINGS

Taken all together (28 studies on 42 treatment facilities), the mean number of psychotropics prescribed was 2.47, the rate of monotherapy was 36.2% and 37.9% of inpatients received > or = 3 different drugs. Comparing the last three decades, a significant decline of the rate of monotherapy was found, topping at 47.8% in the 70s and falling to 19.6% in the 90s. The mean number of psychotropic drugs prescribed rose from 2.2 to 2.9 and the number of patients receiving > or = 3 psychotropics rose from 27.5 to 49.7%.

CONCLUSION

Though it is still mandatory to avoid unsound polypharmacy, we must assume that the occasions for polypharmacy are increasing. New psychotropic drugs, increasing comorbidity and augmentation strategies may be incentives for polydrug use. Since in most countries the number of psychiatric beds declines, inpatient treatment has to deal with the most severe, often treatment-resistant patients requiring special therapies.

The therapeutic transnosological use of psychotropic drugs

The current clinical use of psychotropic drugs is transnosologically oriented. This is facilitated by the current classification of mental disorders (International Classification of Diseases, 10th Revision [ICD-10]) and is perhaps justified if depression and psychosis (taken here as examples) are considered as being complex syndromes with heterogeneous etiologies, but common pathogenesis, more than specific entities. However, this approach does not identify possible differences between specific psychiatric entities, which could in turn mask differences in therapeutic responses and, therefore, therapeutic outcome. This is compounded by the current disharmony between the nosological classification of diseases, drug development, clinical research, and therapeutic uses of psychotropic drugs. Functional pharmacology targeting abnormal behavioral traits could represent an avenue for future research and treatment.