Prescription pattern of antipsychotic drugs for schizophrenic inpatients in Japan: research on East Asia Psychotropic Prescription Pattern-Antipsychotics study

Analysis of the trends of polypharmacy and high-dose prescriptions in Japan

INTRODUCTION

After extensive research, this study explored whether high-dose prescriptions and polypharmacy remain more frequent in Japan than elsewhere. If confirmed, we aimed to identify the factors that contributed to this unique trend.

METHODS

The psychotropic drug prescription patterns for patients with schizophrenia in Japan were reviewed. This was based on a large sample collected from surveys of the Research on Asian Psychotropic Prescription Patterns, an international collaborative research project conducted by Asian psychiatrists to monitor prescriptions of psychotropic drugs for people with mental disorders, in 2001, 2004, 2008, and 2016.

RESULTS

The 2016 Research on Asian Psychotropic Prescription Patterns survey revealed that Japan continued to demonstrate the highest rate of polypharmacy and the highest dosages of psychotropic prescription drugs for patients with schizophrenia among the 15 countries and areas that participated in the survey.

DISCUSSION

The Research on Asian Psychotropic Prescription Patterns surveys demonstrated that science plays a limited role in the decision-making process for prescriptions of psychotropic medications. Such prescriptions are influenced by a wide range of factors, such as the national mental health policy, prescription-financing systems, the history of psychiatry in each country, and the prevailing culture. Hospital-based national mental health policies and mental health financing systems have been the primary obstacles to reducing polypharmacy in Japan.

Patterns of prescription of antipsychotics in Qatar

OBJECTIVE

Even though all guidelines recommend generally against antipsychotic polypharmacy, antipsychotic polypharmacy appears to be a very common practice across the globe. This study aimed to examine the prescription patterns of antipsychotics in Qatar, in comparison with the international guidelines, and to scrutinize the sociodemographic and clinical features associated with antipsychotic polypharmacy.

METHODS

All the medical records of all the inpatients and outpatients treated by antipsychotics at the Department of Psychiatry-Hamad Medical Corporation (HMC) in Doha, Qatar (between October 2012 and April 2014) were retrospectively analyzed. We retrieved the available sociodemographic data, psychiatric features, and details on the medication history.

RESULTS

Our sample consisted of 537 individuals on antipsychotics (2/3 were male; mean age 33.8±10.2 years), prescribed for a psychotic disorder in 57%, a mood disorder in 9.3%, and various other diagnoses in 33.7%. About 55.9% received one antipsychotic, 29.6% received two antipsychotics, and 14.5% received more than two antipsychotics. Polypharmacy was associated with younger age (p = 0.025), being single (p<0.001), the diagnosis of a psychotic disorder (p<0.001), and previous admissions to psychiatry (p<0.001).

CONCLUSIONS

Antipsychotic polypharmacy appears to be quite common in Qatar, as it is the case in many other countries, in contrast with most international recommendations. Studies are needed to explore the reasons behind this disparity.

Perceptions of Psychiatrists Toward the Use of Long-Acting Injectable Antipsychotics: An Online Survey Study From India

PURPOSE/BACKGROUND

Despite proven benefits of long-acting injectables (LAIs), these are frequently underused by the psychiatrists. Accordingly, this study aimed to explore the perceptions of psychiatrists toward the use of LAI antipsychotics in their routine clinical practice.

METHODS/PROCEDURE

An online e-mail survey was conducted by using Survey Monkey platform.

RESULTS

A total of 622 psychiatrists with a mean age of 41 years who were in psychiatric practice for approximately 14 years participated in the survey. Participants reported using LAI, mainly for patients with schizophrenia, with LAI prescribed to approximately one-tenth (9.30%) of their patients in acute phase of illness and in one-fifth (18.42%) of patients in stabilization/stable phase. Fluphenazine decanoate (32.7%) was the most commonly used LAI followed by flupenthixol decanoate (19.5%), haloperidol decanoate (17.8%), and olanzapine pamoate (11.1%). The most common reasons for starting LAI were history of medication (100%) and treatment (80.5%) nonadherence, followed by having frequent relapses/exacerbations of symptoms (54.8%). Overall, more than half of the participants felt the level of acceptance of LAI among patients offered to be quite reasonable (54.3%), and mostly, LAIs were used as combination therapy with oral antipsychotics (73.6%). Despite all these, approximately three-fifths (59%) of the participants reported that they underuse LAI to a certain extent, with most common reasons that deter them from using LAI being the cost (55.45%), lack of interest of patients in receiving LAI (42.9%), lack of regular availability (41.3%), and patients being scared of receiving injectables (41.2%).

CONCLUSIONS/IMPLICATIONS

The LAI antipsychotics despite having several benefits are still underused by a substantial proportion of practicing psychiatrists.

Remission, response, and relapse rates in patients with acute schizophrenia treated with olanzapine monotherapy or other atypical antipsychotic monotherapy: 12-month prospective observational study

PURPOSE

To compare the rates of antipsychotic response, remission, and relapse in patients with schizophrenia treated with olanzapine or other antipsychotics in usual clinical care in Japan.

PATIENTS AND METHODS

This analysis of a 12-month, prospective, noninterventional study examined outcomes for 1,089 inpatients and outpatients with schizophrenia who initiated antipsychotic monotherapy. All treatment decisions, including medication choice, were left to the discretion of the treating physician. The rates of treatment response, relapse, and 6-month sustained remission were compared between olanzapine monotherapy (OLZ) and other anti-psychotic monotherapy (OAN), and between OLZ and other atypical antipsychotic monotherapy (OAT). Visit-wise comparisons of treatment response and remission were examined using repeated-measures logistic regressions. Propensity scores were used to control for potential baseline differences between groups.

RESULTS

Response rates were higher for OLZ patients and relapse rates were consistently lower for OLZ patients, however the differences were not statistically significant. Rates of 6-month sustained remission were significantly higher for OLZ than OAN patients (P=0.032) and for OLZ than OAT patients (P=0.041). An exploratory analysis of OLZ and OAN comparison found outpatients treated with OLZ or OAN had similar sustained remission rates (OLZ: 22.2%, OAN: 22.8%), while inpatients treated with OLZ had significantly higher sustained remission rates than inpatients treated with OAN (OLZ: 17.1%, OAN: 6.6%, odds ratio [95% confidence interval] =3.54 [2.00-6.25]).

CONCLUSION

In usual care in Japan, treating the acute symptoms of schizophrenia with olanzapine was not found to be significantly different for response and relapse rates; however, treatment with olanzapine was found to have significantly greater sustained remission rates than treatment with other antipsychotics. In the inpatient setting, where patients tend to be more severe and difficult to manage, olanzapine treatment may lead to higher sustained remission rates than other antipsychotics.

Socioeconomic factors influencing antipsychotic prescription for schizophrenia inpatients in China: a cross-sectional study

Medication is critical in schizophrenia therapy, and prescription patterns have changed considerably over the past 20 years in China. This study attempts to evaluate the prescription patterns of antipsychotics for inpatients with schizophrenia in China and to identify factors influencing these patterns. Claims data of inpatients diagnosed with schizophrenia in 2010 were derived from the reimbursement database of Wuhan and Wuxi. A total of 5251 inpatients received antipsychotic medications, of whom 29.0% received second-generation antipsychotics apart from clozapine (SGAs#), 13.7% received clozapine (CLO), 13.5% received first-generation antipsychotics (FGAs), 43.8% received at least both drug classes, and 5.1% used FGAs, CLO as well as SGAs#. Multinomial logistic regression for 2904 identified inpatients showed that factors of drug reimbursement policy, duration of hospitalization, age group, and municipality were statistically significant in antipsychotic medication. Drug list B and the 25-45 age group presented a significant relationship with SGAs# prescription (FGAs vs. SGAs#). Furthermore, the 12-30-day duration of hospitalization and the 25-45 age group showed a significant relationship with SGAs# prescription (CLO vs. SGAs#). Socioeconomic factors such as health insurance policies, especially reimbursement policy of drugs and payment system, as well as mental health resource distribution are important in antipsychotic prescription in China.

Improved outcomes following a switch to olanzapine treatment from risperidone treatment in a 1-year naturalistic study of schizophrenia patients in Japan

AIMS

This study assessed clinical and functional outcomes following a switch from risperidone to olanzapine in a 1-year naturalistic study of schizophrenia patients in Japan.

METHODS

We used data from a large 1-year prospective, multicenter, observational non-interventional study of individuals who were initiated on olanzapine for the treatment of schizophrenia in Japan. Current analyses focused on patients who were switched at study entry from risperidone to olanzapine (n = 258). Repeated measures analysis was employed to assess outcomes on validated measures.

RESULTS

At study entry, 45% were inpatients and 55% outpatients. Participants were in their early 40s with mean illness duration of 14 years. Approximately half were male. Most were switched from risperidone to olanzapine due to poor medication efficacy (67.8%) rather than medication intolerability (29.1%). Most patients (67.8%) completed the 1-year study. Patients experienced clinically and statistically significant (P < 0.05) improvements in global symptom severity, positive, negative, depressive, and cognitive symptoms, health-related quality of life, and paid work rates. Most patients (59.2%) demonstrated treatment response to olanzapine and 43.4% experienced symptom remission. Mean weight gain was 2.19 kg, with one-third of patients (33.3%) experiencing clinically significant weight gain (≥7%).

CONCLUSIONS

In this 1-year naturalistic study, inpatients and outpatients who were switched from risperidone to olanzapine experienced clinically and statistically significant improvements in their clinical and functional outcomes. One-third of all patients experienced clinically significant weight gain. Current findings highlight the favorable benefit-to-risk profile of switching to olanzapine therapy following treatment failure on risperidone among patients with schizophrenia in Japan.

Pharmacotherapy and clinical characteristics of ultra-high-risk for psychosis according to conversion status: a naturalistic observational study

AIM

To explore the differences in pharmacotherapy and clinical characteristics of individuals at ultra-high-risk (UHR) for psychosis according to the conversion status, we analyzed the data for UHR patients seen at the Seoul Youth Clinic.

METHODS

This was a naturalistic observational study. We obtained clinical data, including demographic data, presenting complaint, duration of psychiatric symptoms, diagnosis and scores on clinical rating scales from individual records in the Seoul Youth Clinic. Prescription data were obtained from electronic medical records.

RESULTS

As of April 1, 2010, a total of 78 people were registered as being UHR for psychosis in the Seoul Youth Clinic. Patients commonly presented with paranoid ideas and anxiety. On entry to the Seoul Youth Clinic, 81% of the UHR group were diagnosed as having psychiatric disorders according to DSM-IV criteria. Of the 67 individuals who did not drop out of the Seoul Youth Clinic, 14 converted to psychosis. The mean time to conversion was 412 days post baseline examination. The mean duration of psychiatric symptoms before clinic presentation was shorter in the converter group than in the non-converter group. There were no differences in baseline scores on clinical rating scales between the two groups. Antipsychotics were commonly prescribed for UHR patients in the Seoul Youth Clinic, with the converter group exposed to antipsychotics for a longer period and at higher doses than the non-converter group.

CONCLUSIONS

In a naturalistic setting, the different pattern of exposure to antipsychotics between the converter and non-converter groups calls attention to the effects of antipsychotics on conversion to psychosis.

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.

Antipsychotic polypharmacy in schizophrenia: benefits and risks

Antipsychotic polypharmacy refers to the co-prescription of more than one antipsychotic drug for an individual patient. Surveys of prescribing in psychiatric services internationally have identified the relatively frequent and consistent use of combined antipsychotics, usually for people with established schizophrenia, with a prevalence of up to 50% in some clinical settings. A common reason for prescribing more than one antipsychotic is to gain a greater or more rapid therapeutic response than has been achieved with antipsychotic monotherapy. However, the evidence on the risks and benefits for such a strategy is equivocal, and not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry. Combined antipsychotics are a major contributor to high-dose prescribing, associated with an increased adverse effect burden, and of limited value in helping to establish the optimum maintenance regimen for a patient. The relatively widespread use of antipsychotic polypharmacy identified in cross-sectional surveys reflects not only the addition of a second antipsychotic to boost therapeutic response, but also the use of as-required antipsychotic medication (mainly to treat disturbed behaviour), gradual cross-titration while switching from one antipsychotic to another, and augmentation of clozapine with a second antipsychotic where the illness has failed to respond adequately to an optimized trial of clozapine. This review addresses the clinical trial data and other evidence for each of these pharmacological approaches. Also reviewed are examples of systematic, practice-based interventions designed to reduce the prevalence of antipsychotic polypharmacy, most of which have met with only modest success. Guidelines generally agree that if combined antipsychotics are prescribed to treat refractory psychotic illness, this should be after other, evidence-based, pharmacological treatments such as clozapine have been exhausted. Further, their prescription for each patient should be in the context of an individual trial, with monitoring of the clinical response and adverse effects, and appropriate physical health monitoring.

Differences in the preferred antipsychotics for acute schizophrenia among young psychiatrists in two regions of Japan

BACKGROUND

Effective emergency intervention for acute schizophrenia is of great concern to psychiatrists. To investigate whether differences in attitudes toward pharmacotherapy exist in the emergency setting, we surveyed two regions of Japan.

METHODS

The subjects were 100 psychiatrists. The clinical experience of all subjects was not more than 15 years. A questionnaire with a case vignette was sent to them and returned anonymously. Thirty-five out of 42 subjects in Hokkaido and 30 out of 58 subjects in Fukuoka responded.

RESULTS

We found a difference in the preferred route of administration of haloperidol, the agent chosen by 46.2% of the respondents. Most psychiatrists in Hokkaido preferred intravenous administration, but none of the Fukuoka psychiatrists chose this route preferring intramuscular administration. The mean dose of haloperidol was significantly higher in Hokkaido (7.29±2.5mg) compared to that in Fukuoka (5.56±1.7mg).

CONCLUSION

The difference in preferred route of administration and dose of haloperidol probably reflects the content of training at each hospital and suggests that early training determines the subsequent clinical custom of each psychiatrist.

Pharmacotherapy for schizophrenic inpatients in East Asia--changes and challenges

OBJECTIVES

(1) to review characteristics of prescription patterns of antipsychotic medication in China, Hong Kong, Japan, Korea, Singapore and Taiwan, (2) to examine the changes of prescriptions brought about by the introduction of second generation psychotropic drugs (SGA) in East Asia, (3) to analyse factors contributing to the characteristic use of antipsychotics, and (4) to suggest ways and means to improve the prescription practice of antipsychotics in East Asia.

METHODS

Authors of this study collaborated with psychiatrists in East Asia to undertake an international survey reviewing prescription patterns of psychotropic medications in East Asia. The REAP (Research on Asian psychotropic prescription patterns) study reviewed the prescription of a large number of schizophrenic inpatients in China, Hong Kong, Japan, Korea, Singapore and Taiwan in 2001 and 2004 using a unified research protocol and questionnaire.

RESULTS

Prescription patterns of antipsychotic drugs differ greatly country by country and have recently experienced rapid changes. Our survey shows second generation antipsychotics are frequently used in East Asia. The introduction of SGA resulted in the combined use of first generation psychotropic drugs (FGA) and SGA in East Asia. These changing prescription patterns have created many challenges for psychiatrists in East Asia.