Neuroleptic dose and schizophrenic symptoms. A survey of prescribing practices

Tackling myths of common prescribing patterns in schizophrenia amongst Egyptian psychiatrists

Background

There is limited data related to how psychiatrists actually choose amongst different medications, especially in Egypt. Our aim was to survey a sample of psychiatrists regarding common patterns of antipsychotic prescribing practices and review how these vary from the evidence-based. We conducted a qualitative, cross-sectional survey of 124 psychiatrists of different grades from hospitals across Cairo, Egypt. Questions were asked to elicit attitudes towards common antipsychotic prescribing practices and the use of treatment guidelines in schizophrenia.

Results

A total 77.4% participants said they would prescribe atypical antipsychotics as first-line treatment if cost were not an issue, 42.7% said they commonly add anticholinergics from the start with antipsychotics, 50% said they would maintain patients on anticholinergics for as long as they were receiving antipsychotics, 93.5% said they commonly or in some situations combine typical depot antipsychotics with oral atypical antipsychotics, 88.7% said they commonly or in some situations use antipsychotics in small doses for sedation, and 55.6% sometimes add a mood stabilizer to enhance the effect of antipsychotic drugs. Using logistic regression, physician grade significantly predicted whether participants commonly add anticholinergic medication from the start with antipsychotics (p = 0.001). Age and gender significantly predicted whether participants sometimes add a mood stabilizer to enhance the effect of antipsychotics (p < 0.05).

Conclusions

We demonstrated that several antipsychotic prescribing practices were not evidence-based, yet appeared to be prevalent in a large proportion of participants. A number of demographic and psychiatrist-related factors predicted certain prescribing patterns.

Sex-based pharmacotherapy in acute care setting, a narrative review for emergency providers

INTRODUCTION

Sex-based medicine, which can be defined as the process of understanding the inherent differences in disease pathophysiology and response to medications that exist between the sexes, seems like a necessary step in the movement towards personalized medicine. While there are strict guidelines for weight-based dosage of pediatric medications, similar guidelines do not exist for the treatment of adults, despite prominent biologic differences between the sexes. The lack of individualization is of particular importance in the treatment of adult patients in the emergency department (ED), because it can determine the trajectory of a patient's stay at the hospital.

OBJECTIVES

This review was conducted to better understand the need for and possible benefits of altering drug dosing guidelines for different categories of medications in the ED. PubMed, SCOPUS, and Google Scholar were queried using a combination of the keywords "gender differences," "sex differences," "treatment," and "emergency". Abstracts, unpublished data, and duplicate articles were excluded.

DISCUSSION

In considering some of the most common causes of ED visits, the majority of diseases demonstrate differences in morbidity and mortality between female and male patients, despite similar treatment regimens. These differences can be attributed to variations in drug pharmacodynamics and pharmacokinetics, which may be affected by sex-based biologic variations in body mass index and body composition, and physiologic variations such as hormonal changes, menstruation, pregnancy, and lactation. Regardless of the mechanism of these differences, there is overwhelming evidence that universal drug dosing results in suboptimal outcomes for both male and female patients.

CONCLUSIONS

Female sex is a risk factor for clinically significant adverse drug reactions, which range from cutaneous reactions to major bleeding, and can have long-standing implications on patient outcomes. However, future studies are needed to understand the exact pathophysiology of these sex differences, after controlling for potential confounding factors such as demographic differences and provider bias in treatment.

High dose neuroleptics – who gives them and why?

Aims and Method

Neuroleptic medication is often used in excess of the BNF maximum. The purpose of this study was to examine the relationship of neuroleptic dose to patient, prescriber and environmental factors, by using a cross sectional ‘snapshot’ study of psychiatric in-patient prescriptions combined with a retrospective case note survey.

Results

It was found that certain consultants prescribe higher doses of neuroleptics than others. Patients with a history of aggression had a nine and a half times higher chance of being prescribed higher doses of neuroleptics. Patients with a greater than 5-year history of neuroleptic prescription received higher doses.

Clinical Implications

High neuroleptic prescription is related more to patients' past reputation and prescriber differences than to patients' current behaviour.

Chlorpromazine equivalents and percentage of British National Formulary maximum recommended dose in patients receiving high-dose antipsychotics

Aims and Methods

The study compared two methods of identifying patients prescribed high doses of antipsychotic medication among in-patients and out-patients in Buckinghamshire. High doses were defined as those in excess of 1000 mg chlorpromazine equivalents (CPZE) per day or more than 100% of the maximum recommended dose in the British National Formulary (BNF).

Results

A total of 258 patients were identified as being prescribed antipsychotics, 30 of whom received high doses. There was 93% concordance between the two methods for identifying these patients. Nine of the 12 patients who had been prescribed high potency (> 1000 mg CPZE/day) but low toxicity (> 100% BNF maximum) therapy were receiving flupenthixol decanoate.

A group of six high-risk patients were identified who had been prescribed lower potency drugs at supra-maximal doses.

Clinical Implications

Expressing total antipsychotic dose as a percentage of the BNF maximum is easy to understand and calculate. It helps to ensure patients at risk of antipsychotic toxicity are easily identified to ensure monitoring guidelines can be followed.

Mitochondrial DNA sequence characteristics modulate the size of the genetic bottleneck

With a combined carrier frequency of 1:200, heteroplasmic mitochondrial DNA (mtDNA) mutations cause human disease in ∼1:5000 of the population. Rapid shifts in the level of heteroplasmy seen within a single generation contribute to the wide range in the severity of clinical phenotypes seen in families transmitting mtDNA disease, consistent with a genetic bottleneck during transmission. Although preliminary evidence from human pedigrees points towards a random drift process underlying the shifting heteroplasmy, some reports describe differences in segregation pattern between different mtDNA mutations. However, based on limited observations and with no direct comparisons, it is not clear whether these observations simply reflect pedigree ascertainment and publication bias. To address this issue, we studied 577 mother–child pairs transmitting the m.11778G>A, m.3460G>A, m.8344A>G, m.8993T>G/C and m.3243A>G mtDNA mutations. Our analysis controlled for inter-assay differences, inter-laboratory variation and ascertainment bias. We found no evidence of selection during transmission but show that different mtDNA mutations segregate at different rates in human pedigrees. m.8993T>G/C segregated significantly faster than m.11778G>A, m.8344A>G and m.3243A>G, consistent with a tighter mtDNA genetic bottleneck in m.8993T>G/C pedigrees. Our observations support the existence of different genetic bottlenecks primarily determined by the underlying mtDNA mutation, explaining the different inheritance patterns observed in human pedigrees transmitting pathogenic mtDNA mutations.

Evaluation of Defined Daily Dose, percentage of British National Formulary maximum and chlorpromazine equivalents in antipsychotic drug utilization

OBJECTIVE

The present study was carried out to investigate and compare the three methods for calculating total antipsychotic dose among outpatients with schizophrenia attending primary psychiatric health care centers. The three methods were: Defined Daily Doses (DDDs), chlorpromazine equivalents (CPZeq) and percentages of the British National Formulary (BNF) maximum.

METHODOLOGY

Antipsychotic drug dosing data for 250 patients with schizophrenia were investigated by calculating Spearman's rank correlation coefficients. Factors associated with antipsychotic dose, expressed as DDDs, CPZeq and percentages of the BNF maximum recommended daily dose, were investigated by means of linear regression analysis.

RESULTS

Spearman's correlation showed that there is a significant relationship between all pairs of the three dosing methods. In all three methods, coherence was strongest when dealing with first generation antipsychotics (FGA). Linear regression analyses showed a high degree of coherence between antipsychotic doses expressed as DDDs, CPZeq and percentages of the BNF maximum recommended daily dose.

CONCLUSION

All three tested methods are reliable and coherent for calculating antipsychotic dosing.

Frequency and risk factors of workplace violence on psychiatric nurses and its impact on their quality of life in China

This study examined the frequency of violence on nurses in Chinese psychiatric hospitals and explored its risk factors and impact on nurses' quality of life (QOL). A survey was conducted with 387 frontline psychiatric nurses in China. Information about experience of workplace violence in the past 6 months, type of workplace violence, and demographic characteristics was collected by a questionnaire. Altogether 319 (82.4%) of 387 nurses reported having experienced at least one type of violent event in the past 6 months. The prevalence of sexual assault, physical and verbal harassment was 18.6%, 61.5% and 78.6%, respectively. Compared to those with no exposure to violence, nurses who were exposed to violence had lower QOL in both the physical and mental domains. Significant predictors of violence against nurses are male sex, receiving college level or higher education and working on rotating duty were independently associated with high risk of violence. Workplace violence against psychiatric nurses commonly occurs in China. Considering the deleterious effects of violence, comprehensive strategies from the perspective of nursing education and training, organizational policy, patient care and staff support are recommended to promote occupational safety in psychiatric settings in China.

Sex differences in use of psychotropic drugs and drug-induced side effects in schizophrenia patients: findings of the Research on Asia Psychotropic Prescription (REAP) studies

OBJECTIVE

The aim of this study was to investigate the sex differences in prescribing patterns of psychotropic drugs and drug-induced side effects in schizophrenia patients in Asia using the data of the Research on Asian Psychotropic Prescription Pattern (REAP) surveys.

METHOD

The prescription patterns of 6,441 schizophrenia inpatients in six Asian countries and regions were investigated during the 2001-2009 period. The patients' socio-demographic and clinical characteristics and their prescriptions for psychotropic drugs were recorded using a standardized protocol and data collection procedure.

RESULTS

Univariate analyses found the following factors to be significantly associated with the male sex: a younger age, higher doses of antipsychotics, less prominent delusions and hallucinations, more prominent negative symptoms, less likelihood of a prescription for second-generation antipsychotics (SGAs), greater use of antipsychotic polypharmacy, mood stabilizers and depot antipsychotics, more frequent tardive dyskinesia (TD), and less weight gain. In multivariate analyses, fewer prescriptions for SGAs, greater use of mood stabilizers, anticholinergics, antipsychotic polypharmacy and depot antipsychotics, extrapyramidal side effects (EPS) and TD, and less weight gain were independently associated with the male sex.

CONCLUSIONS

Sex is one of the independent contributors to psychotropic prescription and side effects in Asian schizophrenia patients. Psychopharmacological treatment guidelines for schizophrenia should consider the sexes separately.

Antipsychotic drug use in 503 Chinese inpatients with schizophrenia

Objective. To determine current patterns of antipsychotic medication use and metabolic complications among hospitalized Chinese patients with schizophrenia. Method. A total of 503 inpatients who met ICD-10 diagnostic criteria for schizophrenia were enrolled. Demographic features and records of current treatment (medication, dose, duration of treatment) were collected through cross-sectional chart review along with biophysical parameters (body mass index and laboratory findings). Results. (1) Most patients (457/503, 90.9%) were found to receive antipsychotic monotherapy; (2) clozapine was the most common medication used (152/507, 30.2%); (3) the subset of patients treated within the course of a first episode psychosis, or with less than 5 years of illness, were more likely to be treated with second-generation antipsychotics (SGAs) than with conventional antipsychotic medications or clozapine; (4) patients treated with clozapine or conventional antipsychotics were more likely to manifest metabolism-related physical conditions than those receiving SGAs. Conclusion. Conventional antipsychotics and clozapine constitute the current mainstream of schizophrenia treatment in China where a lower percentage of patients receive SGAs other than clozapine than in developed countries. The high incidence of treatment-related metabolic complications in this population suggests that these issues are under-appreciated based on current patterns of medication use.

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.

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.

Clinical practice variations in prescribing antipsychotics for patients with schizophrenia

Few studies have examined the variations among individual physicians in prescribing antipsychotics for schizophrenia. This study examined clinical practice variations in the route and dosage of antipsychotic medication prescribed for inpatients with schizophrenia by 11 different psychiatrists. The sample consisted of 130 patients with a DSM-III-R diagnosis of schizophrenia who had received inpatient care at a state hospital or Veterans Affairs medical center in the southeastern United States in 1992-1993. Mixed-effects regression models were developed to explore the influence of individual physicians and hospitals on route of antipsychotic administration (oral or depot) and daily antipsychotic dose, controlling for patient case-mix variables (age, race, sex, duration of illness, symptom severity, and substance-abuse diagnosis). The average daily antipsychotic dose was 1092 +/- 892 chlorpromazine mg equivalents. Almost half of the patients (48%) were prescribed doses above or below the range recommended by current practice guidelines. The proportion of patients prescribed depot antipsychotics was significantly different at the 2 hospitals, as was the antipsychotic dose prescribed at discharge. Individual physicians and patient characteristics were not significantly associated with prescribing practices. These data, which were obtained before clinical practice guidelines were widely disseminated, provide a benchmark against which to examine more current practice variations in antipsychotic prescribing. The results raise several questions about deviations from practice guidelines in the pharmacological treatment of schizophrenia. To adequately assess quality and inform and possibly further develop clinical practice guideline recommendations for schizophrenia, well-designed research studies conducted in routine clinical settings are needed.

Atypical antipsychotics in ordinary clinical practice: a pharmaco-epidemiologic survey in a south London service

The introduction of atypical antipsychotics has triggered a reevaluation of treatment strategies in schizophrenia. Although research findings inform about the efficacy and safety of drugs, it is the decisions made daily in ordinary practice that affect the vast majority of patients. The aim of this paper was to examine the use of atypical antipsychotics in clinical care, by means of a survey of prescribing practices for clozapine, risperidone, olanzapine, sertindole and quetiapine for all patients treated for DSM-IV schizophrenia within a psychiatric service. Seventy-five (26%) of the 286 patients identified were on atypical antipsychotics. Patients on clozapine were mostly male, had more than 15 years of contact with psychiatric services and were poor responders. Patients prescribed other atypicals had responded to prior treatment with typical neuroleptics and had less than five years of contact with psychiatric services. Gender distribution was equal in this group. The use of research criteria for treatment resistance identified only one patient, as prolonged use of high-dose neuroleptics was uncommon. The new atypical antipsychotics appear to be replacing older neuroleptics as the first-line treatment of schizophrenia while clozapine is mostly reserved for poor responders. Clinicians' definition of treatment resistance was variable and below the threshold used in research.

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

There are great variations in the way psychotropic drugs are prescribed. Most experts are in favour of psychopharmacological monotherapy, but little is known about the extent to which it is actually practised. A survey of the psychopharmacological medication of all patients under treatment was carried out in three Austrian psychiatric clinics of various types on two separate days. A psychiatric university clinic, the psychiatric department of a general hospital and a regional mental hospital were selected for the survey. It was established that only 8% to 22% of the patients underwent psycho-pharmacological monotherapy and that the patients received 2.2 to 3.3 psychotropics on average. Five to 22% of the patients received five or more psychotropic agents. The results are presented in more detail in relation to the diagnoses of schizophrenia and depression. The rare occurence of monotherapy might be due to unsound treatment regimens in some instances, but much more to a general trend in psychiatry fostering polydrug use.

Modifying psychotropic drug prescription patterns: a follow-up survey

Cross-sectional surveys of prescription patterns of psychotropic drugs provide a quick, global estimation of the appropriateness of psychopharmacotherapy. Recurrent inadequacies in prescribing for psychiatric patients include polypharmacy, high doses of antipsychotics (APS), the use of multiple APS simultaneously, and the administration of these drugs in multiple divided doses. Faulty prescribing patterns are difficult to amend. Following a survey in a rehabilitation facility for chronic psychiatric patients, a systematic education program and other measures were introduced to improve prescribing habits. Two years later the survey was repeated. Significant improvements were detected in the following areas: reductions in the doses of APS and antiparkinsonian (AP) drugs, reductions in the number of patients placed on these drugs, and reductions in the percentage of patients receiving multiple antipsychotics simultaneously. Despite these reductions in doses of psychotropic agents, patients' rehabilitative potential was not compromised.

Paranoid/belligerence and neuroleptic dosage in newly admitted schizophrenic patients

The aim of this study was to determine if the severity of paranoid/belligerence was a major determinant of neuroleptic dosage in newly admitted patients with acute or exacerbated schizophrenia. Two clinical psychiatrists, who had no clinical responsibility for drug treatment and were blind to neuroleptic dosage regimens, jointly interviewed 155 patients who were cooperative enough to be carefully interviewed with the Structured Clinical Interview for the DSM-III-R, Positive and Negative Syndrome Scale (PANSS) Edition. The large majority of the patients were receiving moderate dosages of neuroleptics (mean peak dosage: 500 mg/day of chlorpromazine equivalents). There was a positive correlation between the score on the PANSS paranoid/belligerence cluster and the daily dosage of neuroleptic treatment. Splitting the sample by gender, the correlations remained highly significant. In a multivariate analysis controlling for the effects of other clinical variables, paranoid/belligerence and gender emerged as significant predictors of neuroleptic dosage. Clinicians prescribed lower doses of neuroleptics for female patients and higher doses for patients with higher ratings on the PANSS paranoid/belligerence cluster. These findings suggest that clinicians' strategy of increasing neuroleptic dosage at the manifestation of hostility is not limited to assaultive or uncooperative schizophrenic patients who are on very high dosages of neuroleptics.

Recurrent mandibular dislocation under neuroleptic drug therapy, treated by bilateral eminectomy

Acute mandibular dislocations caused by extrapyramidal syndromes under neuroleptic therapy have often been reported in the literature. However, the success of surgical therapy for recurrent mandibular dislocation in patients under long-term neuroleptic therapy has been discussed controversially. In our opinion, modifications in drug therapy--including the administration of so-called atypical neuroleptics--should be considered before advocating surgery. If the revised therapeutic approach proves to be unsuccessful because of psychotic relapse or persistence of extrapyramidal symptoms, good operative results may be achieved by bilateral eminectomy as reported on three psychiatric patients in this paper. In order to avoid postoperative subluxation and internal derangement due to increased muscular tension under chronic neuroleptic therapy, as much bone as possible should be removed when performing eminectomy.