Audit of antipsychotic prescribing in a private psychiatric hospital

Antipsychotic Medication Risk of Dementia and Death: A Propensity Matched Cohort Study

OBJECTIVE

This study aimed to compare the incidence of dementia and all-cause mortality up to 20 years post-treatment in an index non-demented cohort between antipsychotic (AP) medication treatment and non-AP treatment groups.

METHOD

All patients in Kaiser Permanente Northern California with a major psychiatric diagnosis between 01/01/1996 and 12/31/2000, age ≥ 50 years, and without dementia diagnosis were included. The study cohort was divided into a "user group", patients treated with AP for ≥ 365 days (n = 1,829), and a "non-user group", propensity score matched on age, sex, and race (n = 9,145). The association between AP exposure and dementia or mortality during the follow-up period (01/01/2001-12/31/2015) was evaluated using Cox proportional hazard models adjusted for psychiatric diagnosis, comorbidities, and other medications. The user group had a hazard ratio (HR) of 2.2 (CI 1.8-2.7) for dementia and 1.3 (CI 1.2-1.5) for death. The onset of dementia in the user group was significantly higher in patients aged ≤ 65 years (p < 0.001). The user group was sub-grouped into atypical, typical, and both; HR for dementia was 1.7 (CI 1.2-2.4), 2.5 (CI 1.9-3.1), and 1.8 (CI 1.4-2.4), respectively.

RESULT

Dementia and mortality were significantly higher in patients concurrently treated with benzodiazepine (HR 1.3; CI 1.2-1.5 and HR 1.4; CI 1.3-1.5) or tricyclic antidepressants (HR 1.2; CI 1.1-1.4 and HR 1.1; CI 1.0-1.2), respectively.

CONCLUSION

Our preliminary results reveal an association between AP treatment and increased rates of both dementia and mortality. Future research is needed to substantiate our current findings.

Prevalence of multiple antipsychotic use and associated adverse effects in Australians with mental illness

AIM

This article analyzes the prevalence of use of concurrent multiple antipsychotics and high dosage treatment in people with mental illness, to assess the burden of antipsychotic drug-related side-effects associated with multiple use, and to identify strategies shown to reduce antipsychotic polypharmacy.

METHODS

Literature reviewed was sourced from MEDLINE, Embase, CINAHL, InformIT, PsycINFO, International Pharmaceutical Abstracts, Cochrane Library database and Joanna Briggs Institute databases to identify Australian studies published between January 2000 and February 2015. Studies that reported prevalence of multiple antipsychotic use or addressed the issue of antipsychotic drug-related side-effects were included. Systematic reviews, randomized controlled trials, and observational pre-post studies of Australian and international interventions aiming to reduce multiple antipsychotic use in mental health settings were also identified.

RESULTS

Nineteen studies reporting prevalence of multiple antipsychotic use were identified. The proportion of patients taking more than one antipsychotic ranged from 5 to 61%. Of the studies assessing dosages used, between one-third and one-half of all patients taking multiple antipsychotics received doses higher than recommended. Data from one national study reported that people taking multiple antipsychotics were more likely to experience at least one side-effect in comparison to consumers taking a single antipsychotic (90 verses 80%).International evidence of direct trials of conversion from treatment regimens involving multiple antipsychotics to those based on monotherapy show that between 50 and 75% of people with serious mental illness could be successfully converted to single-agent treatment, with up to 25% obtaining an improvement in health and the remaining 50% staying well managed.

CONCLUSION

Use of multiple antipsychotics is common among Australian people with mental illness, despite guidelines recommending that only one antipsychotic should be used in most cases. People taking more than one antipsychotic at a time are more likely to experience side-effects, and to receive higher than recommended antipsychotic doses. Direct trials that aimed to reduce multiple antipsychotic use suggest it is possible to effectively reduce therapy in the majority of people without worsening outcomes. Simple educational programmes targeting health professionals have not been found to be effective; however, complex multifaceted programmes and quality improvement programmes have demonstrated effect.

Does accreditation improve pro re nata benzodiazepines administration in psychiatric inpatients? Pre-post accreditation medical record comparison

Background

In psychiatric inpatients, administration of pro re nata benzodiazepines is a common practice. Benzodiazepine use is associated with potential complications of risk of abuse, cognitive impairment, and falls. An interest in accreditation is growing rapidly among many countries to enhance the quality of health care services. We aimed to investigate whether hospital accreditation drives improvements for administered pro re nata benzodiazepines in psychiatric inpatients.

Methods

The study reviewed medical records of consecutive hospital admissions for pre- and post-accreditation comparisons of PRN benzodiazepine medications in two acute mental health wards at a teaching general hospital. Data obtained from the 12-month-post-accreditation period (July 2011–June 2012) were compared with those from the 12-month-pre-accreditation period (July 2009–June 2010). The adoption of accreditation standards occurred over a 12-month period in the middle of the study (July 2010–June 2011). Compiled information included demographics, diagnosis, assessment, and LOS. All identified charts were reviewed; there were no exclusion criteria. Patients were not contacted.

Results

There was a statistically significant (P < 0.002) reduction of approximately 22% in the number of administered PRN benzodiazepines. Post-accreditation, the average number of PRN benzodiazepines administrations per patient, was 4.83 ± 2.1 compared to 6.19 ± 3.4 pre-accreditation. There was no significant difference between the two genders. The highest average quantity of PRN benzodiazepines administered was during the time interval of 18–24 h.

Conclusion

Accreditation may have a positive impact on the process of administering PRN benzodiazepine medications in psychiatric inpatients.

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.