Antipsychotic prescribing trends: a review of pharmaco-epidemiological studies

Metabolic Monitoring for Adults Living with a Serious Mental Illness on a Second-Generation Antipsychotic Agent: A Scoping Review

Premature mortality in people living with a severe mental illness (SMI) is often attributed to multiple factors including the use of medicines such as antipsychotics. Second-generation antipsychotics (SGAs) are known to cause metabolic syndrome which can increase the risk of cardiovascular disease. Practice guidelines have recommended regular physical health monitoring, particularly of metabolic parameters, however, metabolic monitoring for people living with SMI using antipsychotics remains suboptimal. Therefore, highlighting the need for ongoing research. This scoping review aimed to provide an overview of current metabolic monitoring practices. We anticipate that this information will assist clinicians and policymakers and inform future research. The following databases were searched: MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Database of Systemic Reviews (Wiley), APA PsycInfo (Ovid) and Scopus (Elsevier Science Publishers). The target group was adults (aged ≥ 18) diagnosed with SMI (including bipolar disorder, major depressive disorder and psychotic disorders) and taking SGAs. In total, 44 studies from 14 countries were retrieved. Our findings highlighted that most studies conducted in hospitals did not report on metabolic monitoring practices. Additionally, the roles and responsibilities of healthcare professionals in metabolic monitoring for SMI were infrequently described and parameters such as waist circumference and BMI were often poorly monitored. The scoping review highlights that no streamlined approach towards metabolic monitoring currently exists. There is a need to stipulate and define the roles and responsibilities of all health professionals involved in metabolic monitoring in SMI to optimise care for these individuals. Moreover, there is a need for ongoing research, particularly in the community setting, to promote increased accessibility to metabolic monitoring for SMI.

Antipsychotic-Related DRESS Syndrome: Analysis of Individual Case Safety Reports of the WHO Pharmacovigilance Database

INTRODUCTION

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is gaining attention in pharmacovigilance, but its association with antipsychotics, other than clozapine, is still unclear.

METHODS

We conducted a case/non-case study with disproportionality analysis based on the World Health Organization (WHO) global spontaneous reporting database, VigiBase®. We analyzed individual case safety reports of DRESS syndrome related to antipsychotics compared to (1) all other medications in VigiBase®, (2) carbamazepine (a known positive control), and (3) within classes (typical/atypical) of antipsychotics. We calculated reporting odds ratio (ROR) and Bayesian information component (IC), with 95% confidence intervals (CIs). Disproportionate reporting was prioritized based on clinical importance, according to predefined criteria. Additionally, we compared characteristics of patients reporting with serious/non-serious reactions.

RESULTS

A total of 1534 reports describing DRESS syndrome for 19 antipsychotics were identified. The ROR for antipsychotics as a class as compared to all other medications was 1.0 (95% CI 0.9-1.1). We found disproportionate reporting for clozapine (ROR 2.3, 95% CI 2.1-2.5; IC 1.2, 95% CI 1.1-1.3), cyamemazine (ROR 2.3, 95% CI 1.5-3.5; IC 1.2, 95% CI 0.5-1.7), and chlorpromazine (ROR 1.5, 95% CI 1.1-2.1; IC 0.6, 95% CI 0.1-1.0). We found 35.7% of cases with co-reported anticonvulsants, and 25% with multiple concurrent antipsychotics in serious compared to 8.6% in non-serious cases (p = 0.03). Fatal cases were 164 (10.7%).

CONCLUSIONS

Apart from the expected association with clozapine, chlorpromazine and cyamemazine (sharing an aromatic heteropolycyclic molecular structure) emerged with a higher-than-expected reporting of DRESS. Better knowledge of the antipsychotic-related DRESS syndrome should increase clinicians' awareness leading to safer prescribing of antipsychotics.

The atypical antipsychotics and sexual dysfunction: a pharmacovigilance-pharmacodynamic study

Background

Atypical antipsychotics (AAPs)-induced sexual dysfunction (SD) is a frequent issue in clinical practice, often underestimated by clinicians and not extensively researched. The current study aimed to quantify the strength of association between the use of different AAPs and SD using real-world data from the FDA Adverse Event Reporting System (FAERS), as well as investigate the receptor mechanisms that are involved.

Methods

Data from the FAERS database from the first quarter of 2004 to the third quarter of 2023 were queried through OpenVigil 2.1. Disproportionality analysis was estimated using the reporting odds ratio (ROR) and information component (IC) methods, and linear regression was used to investigate the relationship between ROR and receptor occupancy which was estimated using in vitro receptor binding profiles.

Results

Our analysis yielded 4839 reports that co-mentioned AAP and SD events, and the findings revealed statistical associations between 12 AAPs and SD. The highest signal value was identified for iloperidone reporting retrograde ejaculation with iloperidone (ROR = 832.09, ROR025 = 552.77; IC = 9.58, IC025 = 6.36), followed by compulsive sexual behavior with aripiprazole (ROR = 533.02, ROR025 = 435.90; IC = 7.30, IC025 = 5.97), and psychosexual disorder for aripiprazole (ROR = 145.80, ROR025 = 109.57; IC025 = 6.47, IC025 = 4.86). Different characteristics of the SD side effects in each AAPs were discovered after further data mining. Regression analysis revealed potential effects for receptor occupancy of D2, D3, and 5-HT1A receptors on ROR. However, no significant correlation persisted following sensitivity analyses.

Conclusion

This is the first study to investigate the AAP-SD associations by using FAERS. In this study, we report for the first time a significant association between aripiprazole and SD based on real-world data. The study suggests that different AAPs have varying levels of association with SD, and the D2, D3, and 5-HT1A receptor occupancy may contribute to potential mechanisms. The findings of this study warrant further validation of more studies and clinical causality assessment.

Trends and off-label utilization of antipsychotics in children and adolescents from 2016 to 2021 in China: a real-world study

BACKGROUND

Global antipsychotic usage, including off-label prescriptions, has increased in recent decades. However, trends in China, particularly for children and adolescents, remain unclear. This study explored these trends from 2016 to 2021 and identified factors associated with off-label prescriptions.

METHODS

In this retrospective study, we analyzed on-label and off-label prescriptions based on drug information approved by the China National Medical Products Administration. To identify factors associated with off-label prescriptions, we conducted multivariate logistic regression analysis.

RESULTS

Our study included 48,258 antipsychotic prescriptions, 52.4% (25,295) of which were prescriptions for males. Of these, 61.7% (29,813) were off-label. Over time, the number of antipsychotics and the percentage of off-label prescriptions for children and adolescents overall increased from 2016 to 2021. The use of atypical antipsychotics increased, whereas that of typical antipsychotics decreased. For off-label usage, all of the factors in our study were associated with off-label usage, including age, sex, year, region, department, reimbursement, antipsychotic type, drug expense, number of polypharmacy and diagnoses. Additionally, tiapride (15.8%) and aripiprazole (18.6%) were the most common typical and atypical antipsychotics, respectively. For pediatric diseases, common diagnoses included mood or affective disorders (31.7%) and behavioral and emotional disorders, with onset usually occurring in childhood and adolescence (29.1%). Furthermore, a depressive state was the most common diagnosis for which antipsychotic polypharmacy was used for treatment.

CONCLUSION

In this retrospective study, off-label antipsychotic prescriptions were common, with trends generally increasing among children and adolescents from 2016 to 2021. However, there is a lack of evidence supporting off-label usage, thus emphasizing the need for studies on the efficacy and safety of these treatments.

Association of Antipsychotic Polypharmacy and Two-Year All-Cause Mortality: A Population-Based Cohort Study of 33,221 Italian Continuous Users

Background: Differences in survival between patients treated with antipsychotic monotherapy vs. polytherapy are debated. This study aimed to examine the association of antipsychotic polytherapy with 2-year all-cause mortality in a population-based cohort. Methods: Data were retrieved from healthcare databases of four local health units of Lombardy, Italy. Subjects aged 18-79 years who received continuous antipsychotic prescriptions in 2018 were identified. Overall survival among patients with antipsychotic monotherapy vs. polytherapy was compared. A multivariate Cox PH model was used to estimate the association between antipsychotic therapy, or antipsychotic use (continuous vs. non-continuous), and all-cause mortality. Adjustments were made for the presence of metabolic disturbances, total antipsychotic dosage amount (olanzapine equivalent doses), age, and sex. Results: A total of 49,875 subjects receiving at least one prescription of antipsychotics during 2018 were identified. Among the 33,221 patients receiving continuative antipsychotic prescriptions, 1958 (5.9%) experienced death from any cause at two years. Patients with continuous antipsychotic use had a 1.13-point increased mortality risk compared with non-continuous users. Patients treated with antipsychotic polytherapy showed an adjusted mortality risk increased by 17% (95% CI: 2%, 33%) compared to monotherapy. Conclusions: The study highlights the potential risks associated with antipsychotic polypharmacy, emphasizing the importance of optimizing drug prescriptions to improve patient safety and reduce mortality rates in individuals receiving antipsychotic therapy.

Evaluation of neuroleptic malignant syndrome induced by antipsychotic drugs using spontaneous reporting system

Adverse events (AEs) of antipsychotic drugs include neuroleptic malignant syndrome (NMS), which presents complex clinical symptoms, resulting in a fatal outcome. In this study, the association between antipsychotic drugs and NMS was comprehensively evaluated by cluster and association analyses using the Japanese Adverse Drug Event Report (JADER) database. The analyses were performed using 20 typical antipsychotics (TAPs) alongside 9 atypical antipsychotics (AAPs). The Standardised MedDRA Queries (SMQ) database was used to analyze NMS (SMQ code: 20000044). Reporting odds ratios (RORs) were used for AE signal detection. The relationship between antipsychotic drugs and AEs for NMS was investigated by performing hierarchical cluster analysis using Ward's method. Between April 2004 and September 2021, the total number of JADER reports was 705,294. RORs (95 % confidence interval) of NMS for haloperidol, chlorpromazine, risperidone, and aripiprazole were 12.1 (11.1-13.3), 6.3 (5.7-7.0), 6.2 (5.8-6.6), and 4.7 (4.4-5.1), respectively. Three clusters were formed, with characteristics as follows: Cluster 1 consisted of only TAPs, such as bromperidol and fluphenazine, whilst having a high reporting rate of hypotension, tachycardia, dyskinesia, and dystonia. Cluster 2 consisted of all AAPs alongside several TAPs, such as haloperidol and chlorpromazine, with higher reporting rates of disturbance of consciousness, extrapyramidal disorders (excluding dyskinesia and dystonia), and serotonin syndrome. Cluster 3 consisted of only perphenazine, whilst having a higher reporting rate of coma, leukocytosis, and Parkinsonism. The results of this study may therefore aid in the management of NMS using antipsychotic drugs.

Association between cumulative exposure periods of flupentixol or any antipsychotics and risk of lung cancer

BACKGROUND

Preclinical evidence suggests that certain antipsychotic medications may inhibit the development of lung cancer. This study aims to investigate the association between incident lung cancer and different cumulative exposure periods of flupentixol or any antipsychotics.

METHODS

Using electronic health records from the Hospital Authority in Hong Kong, this nested case-control study included case participants aged 18 years or older with newly diagnosed lung cancer after initiating antipsychotics between January 1, 2003, and August 31, 2022. Each case was matched to up to ten controls of the same sex and age, who were also antipsychotic users. Multivariable conditional logistic regression models were conducted to quantify the association between lung cancer and different cumulative exposure times of flupentixol (0-365 days [ref]; 366-1825 days; 1826+ days) and any antipsychotics (1-365 days [ref]; 366-1825 days; 1826+ days), separately.

RESULTS

Here we show that among 6435 cases and 64,348 matched controls, 64.06% are males, and 52.98% are aged 65-84 years. Compared to patients with less than 365 days of exposure, those with 366-1825 days of exposure to flupentixol (OR = 0.65 [95% CI, 0.47-0.91]) and any antipsychotics (0.42 [0.38-0.45]) have a lower risk of lung cancer. A decreased risk is observed in patients who have 1826+ days of cumulative use of any antipsychotics (0.54 [0.47-0.60]).

CONCLUSIONS

A reduced risk of lung cancer is observed in patients with more than one year of exposure to flupentixol or any antipsychotics. Further research on the association between lung cancer and other antipsychotic agents is warranted.

Antipsychotic prescribing in GMS paediatric and young adult population in Ireland 2005-2015: repeated cross-sectional study

OBJECTIVES

To examine the rates of antipsychotic prescribing in the Irish paediatric and young adult population enrolled in the Irish General Medical Services Scheme pharmacy claims database from the Health Service Executive Primary Care Reimbursement Services database, with a focus on age and sex differences. To examine concomitant prescribing of certain other related medicines in this population.

METHODS

Data were obtained from the Irish General Medical Services (GMS) scheme pharmacy claims database from the Health Service Executive (HSE) - Primary Care Reimbursement Services (PCRS). Participants included children aged <16 years and youth aged 16-24 years availing of medicines under the HSE-PCRS GMS scheme between January 2005 and December 2015. Outcome measures included prescribing rates of antipsychotics from 2005 to 2015, differences in prescribing rates between different ages and sexes, and percentage of concomitant prescriptions for antidepressants, psychostimulants, anxiolytics and hypnosedatives.

RESULTS

Overall the trend in prescribing rates of antipsychotic medications was stable at 3.94/1000 in 2005 compared with 3.97/1000 in 2015 for children <16 years, and 48.37/1000 eligible population in 2005 compared to 39.64/1000 in 2015 for those aged 16-24. There was a significant decrease in prescribing rates for males in the 16-24 age group.

CONCLUSIONS

While rates of antipsychotic prescribing have decreased or remained stable over the timeframe of the study, we did find a significant proportion of this population were prescribed antipsychotics. This study also shows that co-prescribing of antidepressants increased and highlights the need for guidelines for antipsychotic prescribing in children and youth in terms of clinical indication, monitoring, co-prescribing and treatment duration.

Nuclear receptor 5A2 regulation of Agrp underlies olanzapine-induced hyperphagia

Antipsychotic (AP) drugs are efficacious treatments for various psychiatric disorders, but excessive weight gain and subsequent development of metabolic disease remain serious side effects of their use. Increased food intake leads to AP-induced weight gain, but the underlying molecular mechanisms remain unknown. In previous studies, we identified the neuropeptide Agrp and the transcription factor nuclear receptor subfamily 5 group A member 2 (Nr5a2) as significantly upregulated genes in the hypothalamus following AP-induced hyperphagia. While Agrp is expressed specifically in the arcuate nucleus of the hypothalamus and plays a critical role in appetite stimulation, Nr5a2 is expressed in both the CNS and periphery, but its role in food intake behaviors remains unknown. In this study, we investigated the role of hypothalamic Nr5a2 in AP-induced hyperphagia and weight gain. In hypothalamic cell lines, olanzapine treatment resulted in a dose-dependent increase in gene expression of Nr5a2 and Agrp. In mice, the pharmacological inhibition of NR5A2 decreased olanzapine-induced hyperphagia and weight gain, while the knockdown of Nr5a2 in the arcuate nucleus partially reversed olanzapine-induced hyperphagia. Chromatin-immunoprecipitation studies showed for the first time that NR5A2 directly binds to the Agrp promoter region. Lastly, the analysis of single-cell RNA seq data confirms that Nr5a2 and Agrp are co-expressed in a subset of neurons in the arcuate nucleus. In summary, we identify Nr5a2 as a key mechanistic driver of AP-induced food intake. These findings can inform future clinical development of APs that do not activate hyperphagia and weight gain.

Clinical determinants, patterns and outcomes of antipsychotic medication prescribing in the treatment of schizophrenia and schizoaffective disorder: A naturalistic cohort study

BACKGROUND

Schizophrenia affects individuals, families, and systems, with treatment primarily being antipsychotic medications. Long-acting injectable (LAI) antipsychotics are increasingly being used. This study sought to identify predictors of antipsychotic choice, in terms of formulation (LAI vs oral) and class (FGA vs SGA), and clinical outcomes.

METHODS

123 patients who received LAI antipsychotics were diagnosis-matched to patients who received oral antipsychotics. Sociodemographic and clinical factors were extracted from the medical record, including indicators of illness severity. Groups were compared with Chi-Square and t-tests, and logistic regression models were used to identify independent predictors of antipsychotic choice.

RESULTS

Patients that received LAIs had longer admissions, more complex discharges, and greater illness severity; however, there were no differences in readmission rates. Independent predictors of LAIs included younger age, being single, and longer admission. Patients who received FGA LAIs were more likely to use substances and be undomiciled compared to SGA LAIs, with the only predictor being older age. Oral FGAs were more likely than Oral SGAs to be prescribed to older and female patients, as well as those with co-occurring substance use, complex discharges, and longer admissions.

CONCLUSIONS

Illness severity and duration of illness appear to drive choice of LAI vs. oral antipsychotic medication and FGA vs. SGA. While LAIs were prescribed to patients with greater illness severity, readmission rates were equivalent to those receiving oral medication, supporting the use of LAI in patients with greater illness severity. Rationales for prescribing LAIs to younger patients and FGAs to older patients are discussed.

Characteristics of adverse reactions among antipsychotic drugs using the Korean Adverse Event Reporting System database from 2010 to 2019

BACKGROUND

Retrospective studies using spontaneous reporting system databases have provided a great understanding of adverse drug reactions (ADRs) in the real world, complementing the data obtained from randomized controlled trials. However, there have been few reports on large-scale epidemiological studies on the adverse effects of antipsychotics in Asia.

AIM

This study aimed to investigate the characteristics of antipsychotic ADRs using a nationwide pharmacovigilance database.

METHODS

Data were collected from the Korea Adverse Event Reporting System database between 2010 and 2019. The study subjects were selected using the International Classification of Disease codes for diseases related to psychosis and Electronic Data Interchange codes for amisulpride, aripiprazole, clozapine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone. The causality assessment of "possible," "probable," or "certain" by the World Health Organization-Uppsala Monitoring Center System causality category was selected. All data were descriptively analyzed.

RESULTS

In total, 5067 adverse events associated with antipsychotic drugs were reported. The antipsychotics that commonly resulted in ADRs were quetiapine (47.7%), olanzapine (11.3%), and clozapine (10.7%). Serious ADRs were most commonly observed with clozapine. Gastrointestinal and central nervous system problems occurred within a month when ADRs were classified according to the time of onset. In contrast, metabolic and bone marrow-related symptoms occurred after long-term use. Sedation and nausea were the most common ADRs in children and adolescents, whereas constipation and dizziness were common in adults and the elderly.

CONCLUSIONS

This study extends our knowledge of antipsychotic ADRs in the Asian population.

Schizophrenia: A Narrative Review of Etiopathogenetic, Diagnostic and Treatment Aspects

Although schizophrenia is currently conceptualized as being characterized as a syndrome that includes a collection of signs and symptoms, there is strong evidence of heterogeneous and complex underpinned etiological, etiopathogenetic, and psychopathological mechanisms, which are still under investigation. Therefore, the present viewpoint review is aimed at providing some insights into the recently investigated schizophrenia research fields in order to discuss the potential future research directions in schizophrenia research. The traditional schizophrenia construct and diagnosis were progressively revised and revisited, based on the recently emerging neurobiological, genetic, and epidemiological research. Moreover, innovative diagnostic and therapeutic approaches are pointed to build a new construct, allowing the development of better clinical and treatment outcomes and characterization for schizophrenic individuals, considering a more patient-centered, personalized, and tailored-based dimensional approach. Further translational studies are needed in order to integrate neurobiological, genetic, and environmental studies into clinical practice and to help clinicians and researchers to understand how to redesign a new schizophrenia construct.

When to Use Amisulpride in Adolescents: A Retrospective Chart Examination of Inpatients

PURPOSE/BACKGROUND

Despite increasing interest in amisulpride, current knowledge about its use in the pediatric population is scarce. This chart review aimed to investigate the use of amisulpride in a naturalistic adolescent population.

METHODS/PROCEDURES

Electronic medical records of a tertiary care adolescent inpatient unit were screened between January 2015 and April 2021. Sociodemographic data and all clinical information were collected via data collection forms, and targeted symptoms were obtained from patients' files. Patients with early-onset psychotic disorders (n = 58), bipolar I disorder (n = 29), major depressive disorder (n = 14), and other psychiatric diagnoses (n = 9) were included. Treatment response was defined as a Clinical Global Impression-Improvement of at least much improvement after treatment.

FINDINGS/RESULTS

Median titration rate of amisulpride was 400 mg/wk, and the maximum administered daily dose ranged between 100 and 1200 mg/d. The maximum daily dose and number of previous antipsychotics were higher in the early-onset psychotic disorder group. Persistent positive symptoms and resistance to previous treatments were leading causes for amisulpride treatment. Other indications were also impulsive/disruptive behaviors, antipsychotic adverse effects, depressive symptoms, somatic complaints, and abnormalities in liver function tests. Finally, patients with lower daily treatment doses and more previous antipsychotic trials are less likely to benefit from the treatment.

IMPLICATIONS/CONCLUSIONS

Persistent psychotic/mood symptoms, impulsive/disruptive behaviors, and abnormalities in liver function tests were reasons for the amisulpride treatment in adolescents. Randomized placebo-controlled trials are needed to evaluate the efficacy and safety of the treatment in adolescents.

[Genotoxicity of psychotropic drugs in experimental and clinical studies]

The analysis of experimental data on the study of the genotoxic activity of psychotropic drugs published over the past 25 years has been carried out. It has been shown that the information describing the genotoxicity of psychotropic drugs is characterized by fragmentation, contradictions, and the conditions for their experimental production often do not meet modern requirements. Conclusions about the presence or absence of genotoxic properties can be made only for 9.6% 94 examined drugs. The need for a large-scale systematic reassessment of the genotoxicity of psychotropic drugs, especially drugs of the first generation, on the basis of modern methodology, including studies of mutagen-modifying activity, has been proven. The expediency of monitoring the genotoxic status of patients receiving psychotropic drugs is emphasized, which should contribute to an adequate assessment of the genotoxic risk of their use and objectification of approaches when choosing a drug for the safe therapy. The urgency of conducting research to determine the role of primary DNA damage in the pathogenesis of mental illnesses has been substantiated.

We Should Improve Personalization of Management in Patients with a Diagnosis of Schizophrenia

The current management of patients with schizophrenia is marked by a lack of personalization. After the diagnosis is made, a second-generation antipsychotic is usually prescribed based on the current clinician's preferences, sometimes accompanied by a psychosocial intervention which is typically not evidence-based and not targeted to the specific needs of the individual patient. In this opinion paper, some steps are outlined that could be taken in order to address this lack of personalization. A special emphasis is laid on the clinical characterization of the patient who has received a diagnosis of schizophrenia. Considerations are put forward concerning the assessment of the negative dimension in ordinary clinical practice, which is often neglected; the evaluation of cognitive functioning using a simple test battery which requires limited professional training and takes no more than 15 min to administer; the evaluation of social functioning using a validated instrument focusing on personal care skills, interpersonal relationships, social acceptability, activities, and work skills; and the assessment of the unmet needs of the person (including practical, social, and emotional needs, and existential or personal recovery). The implications of the assessment of these domains for the formulation of the management plan are discussed.

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD)

Background

Most patients with mental illness are managed in primary care, yet there is a lack of data exploring potential prescribing safety issues in this setting for this population.

Objectives

Examine the prevalence of, between-practice variation in, and patient and practice-level risk factors for, 18 mental health-related potentially hazardous prescribing indicators and four inadequate medication monitoring indicators in UK primary care.

Method

Cross-sectional analyses of routinely collected electronic health records from 361 practices contributing to Clinical Practice Research Datalink GOLD database. The proportion of patients ‘at risk’ (based on an existing diagnosis, medication, age and/or sex) triggering each indicator and composite indicator was calculated. To examine between-practice variation, intraclass correlation coefficient (ICC) and median OR (MOR) were estimated using two-level logistic regression models. The relationship between patient and practice characteristics and risk of triggering composites including 16 of the 18 prescribing indicators and four monitoring indicators were assessed using multilevel logistic regression.

Results

9.4% of patients ‘at risk’ (151 469 of 1 611 129) triggered at least one potentially hazardous prescribing indicator; between practices this ranged from 3.2% to 24.1% (ICC 0.03, MOR 1.22). For inadequate monitoring, 90.2% of patients ‘at risk’ (38 671 of 42 879) triggered at least one indicator; between practices this ranged from 33.3% to 100% (ICC 0.26, MOR 2.86). Patients aged 35–44, females and those receiving more than 10 repeat prescriptions were at greatest risk of triggering a prescribing indicator. Patients aged less than 25, females and those with one or no repeat prescription were at greatest risk of triggering a monitoring indicator.

Conclusion

Potentially hazardous prescribing and inadequate medication monitoring commonly affect patients with mental illness in primary care, with marked between-practice variation for some indicators. These findings support health providers to identify improvement targets and inform development of improvement efforts to reduce medication-related harm.

Interacting effects of the MAM model of schizophrenia and antipsychotic treatment: Untargeted proteomics approach in adipose tissue

Schizophrenia is a severe neuropsychiatric disease associated with substantially higher mortality. Reduced life expectancy in schizophrenia relates to an increased prevalence of metabolic disturbance, and antipsychotic medication is a major contributor. Molecular mechanisms underlying adverse metabolic effects of antipsychotics are not fully understood; however, adipose tissue homeostasis deregulation appears to be a critical factor. We employed mass spectrometry-based untargeted proteomics to assess the effect of chronic olanzapine, risperidone, and haloperidol treatment in visceral adipose tissue of prenatally methylazoxymethanol (MAM) acetate exposed rats, a well-validated neurodevelopmental animal model of schizophrenia. Bioinformatics analysis of differentially expressed proteins was performed to highlight the pathways affected by MAM and the antipsychotics treatment. MAM model was associated with the deregulation of the TOR (target of rapamycin) signalling pathway. Notably, alterations in protein expression triggered by antipsychotics were observed only in schizophrenia-like MAM animals where we revealed hundreds of affected proteins according to our two-fold threshold, but not in control animals. Treatments with all antipsychotics in MAM rats resulted in the downregulation of mRNA processing and splicing, while drug-specific effects included among others upregulation of insulin resistance (olanzapine), upregulation of fatty acid metabolism (risperidone), and upregulation of nucleic acid metabolism (haloperidol). Our data indicate that deregulation of several energetic and metabolic pathways in adipose tissue is associated with APs administration and is prominent in MAM schizophrenia-like model but not in control animals.

Antipsychotics as a method of suicide: population based follow-up study of suicide in Northern Finland

AIM

This study examined the trend and role of antipsychotics as a method of self-poisoning suicide.

MATERIALS AND METHODS

The basic data covered 483 poisoning suicides, occurring between the years 1988 and 2011, in Northern Finland, of which 178 (115 men, 63 women) were completed using antipsychotics.

RESULTS

During the 23-year follow-up period, second-generation antipsychotics (SGAs) overtook first-generation antipsychotics (FGAs) as a suicide method. Female victims, compared to males, had more commonly used quetiapine (17.5% vs. 6.1%, p = .016), while suicides using promazine were more common in males compared to females (36.5% vs. 22.2%, p = .049). People with unipolar depression had more frequently used SGAs (40.0%) or a combination of SGAs and FGAs (12.5%) than FGAs (19.2%) (p = .019) in their suicides.

CONCLUSION

The use of SGAs in suicides is becoming increasingly common, which calls for further studies.

Trends and characteristics of extra-medical use of quetiapine among people who regularly inject drugs in Australia, 2011-2018

BACKGROUND AND AIMS

There are ongoing concerns regarding the extra-medical use of quetiapine and related harms. We aimed to investigate trends in quetiapine use and extra-medical use among people who regularly inject drugs (PWID) in Australia between 2011-2018, and examine changes in the characteristics associated with extra-medical use of quetiapine, comparing those reporting use in 2011 and 2018.

METHODS

This study examines eight years of survey data (2011-2018; n = 7,135 PWID) from Australia's Illicit Drug Reporting System. Linear regression was used to analyse trends over time, and multinomial logistic regression used to identify factors associated with extra-medical quetiapine use in 2011 and 2018.

FINDINGS

The percentage of PWID reporting extra-medical quetiapine use decreased from 14.9 % in 2011 to 12.0 % in 2018; ranging between 10.5 %-15.8 % across years, and reported use was typically infrequent (less than once a month). In both 2011 and 2018, extra-medical quetiapine use was associated with use of benzodiazepines (2011 Adjusted Odds Ratio (AOR) 4.76, 95 % confidence interval (Cl) 2.31-9.82; 2018 AOR 3.10, 95 % Cl 1.84-5.23) and stimulants (2011 AOR 2.81, 95 % Cl 1.51-5.21; 2018 AOR 2.68, 95 % Cl 1.32-5.46) in the past six months.

CONCLUSIONS

Slightly more than one in ten PWID reported extra-medical quetiapine use between 2011-2018. Overall, the frequency of extra-medical quetiapine use among PWID was low, however, individuals often engaged in polysubstance use that has the potential to cause other drug-related harms. Targeted harm-reduction interventions focused on polysubstance use are therefore warranted to reduce potential risks among this group.

Drugs Affecting Body Weight, Body Fat Distribution, and Metabolic Function-Mechanisms and Possible Therapeutic or Preventive Measures: an Update

PURPOSE OF REVIEW

Weight gain and body fat redistribution are common side effects of many widely used drugs. We summarize recent literature on prevalence data and mechanisms associated with drug-induced body fat changes and mechanisms to prevent or treat metabolic side effects.

RECENT FINDINGS

The highest prevalence of metabolic complications is seen with antipsychotics and antiretroviral drugs used in the treatment of HIV and may, at least partly, be responsible for the increased risk for co-morbid diseases such as diabetes, steatosis of the liver, and cardiovascular disease. The pathogenetic mechanisms leading to weight gain from antipsychotics are increasingly known and help to unravel the complex interaction that exists between psychopathology and metabolic complications. Although the classic lipodystrophy mainly occurred with older HIV drugs, also with the newer HIV treatment, weight gain seems to be a major side effect. Early detection of the metabolic consequences of drugs can lead to an early diagnosis of the complications and their treatment. Different medications, including the newer antidiabetics, are being studied in the therapy of drug-induced obesity. Future research should focus on identifying individuals at risk for metabolic side effects and on early markers to identify individuals with side effects so that timely treatment of metabolic complications can be initiated.

The clinical characterization of the patient with primary psychosis aimed at personalization of management

The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica-tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves "recovery-oriented", it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patient's needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.

Incidence, prevalence and prescription patterns of antipsychotic medications use in Asia and US: A cross-nation comparison with common data model

The use of antipsychotic medications (APMs) could be different among countries due to availability, approved indications, characteristics and clinical practice. However, there is limited literature providing comparisons of APMs use among countries. To examine trends in antipsychotic prescribing in Taiwan, Hong Kong, Japan, and the United States, we conducted a cross-national study from 2002 to 2014 b y using the distributed network approach with common data model. We included all patients who had at least a record of antipsychotic prescription in this study, and defined patients without previous exposure of antipsychotics for 6 months before the index date as new users for incidence estimation. We calculated the incidence, prevalence, and prescription rate of each medication by calendar year. Among older patients, sulpiride was the most incident [incidence rate (IR) 11.0-23.3) and prevalent [prevalence rate (PR) 11.9-14.3) APM in Taiwan, and most prevalent (PR 2.5-3.9) in Japan. Quetiapine and haloperidol were most common in the United States (IR 8.1-9.5; PR 18.0-18.4) and Hong Kong (PR 8.8-13.7; PR 10.6-12.7), respectively. The trend of quetiapine use was increasing in Taiwan, Hong Kong and the United States. As compared to older patients, the younger patients had more propensity to be prescribed second-generation APM for treatment in four countries. Trends in antipsychotic prescribing varied among countries. Quetiapine use was most prevalent in the United States and increasing in Taiwan and Hong Kong. The increasing use of quetiapine in the elderly patients might be due to its safety profile compared to other APMs.

Metabolomic profiles associated with a mouse model of antipsychotic-induced food intake and weight gain

Antipsychotic drugs (AP) are used to treat a multitude of psychiatric conditions including schizophrenia and bipolar disorder. However, APs also have metabolic side effects including increased food intake and body weight, but the underlying mechanisms remain unknown. We previously reported that minocycline (MINO) co-treatment abrogates olanzapine (OLZ)-induced hyperphagia and weight gain in mice. Using this model, we investigated the changes in the pharmacometabolome in the plasma and hypothalamus associated with OLZ-induced hyperphagia and weight gain. Female C57BL/6 mice were divided into groups and fed either i) control, CON (45% fat diet) ii) CON + MINO, iii) OLZ (45% fat diet with OLZ), iv) OLZ + MINO. We identified one hypothalamic metabolite indoxylsulfuric acid and 389 plasma metabolites (including 19 known metabolites) that were specifically associated with AP-induced hyperphagia and weight gain in mice. We found that plasma citrulline, tricosenoic acid, docosadienoic acid and palmitoleic acid were increased while serine, asparagine and arachidonic acid and its derivatives were decreased in response to OLZ. These changes were specifically blocked by co-treatment with MINO. These pharmacometabolomic profiles associated with AP-induced hyperphagia and weight gain provide candidate biomarkers and mechanistic insights related to the metabolic side effects of these widely used drugs.

Development of prescribing safety indicators related to mental health disorders and medications: Modified e-Delphi study

AIM

To develop a set of prescribing safety indicators related to mental health disorders and medications, and to estimate the risk of harm associated with each indicator.

METHOD

A modified two-stage electronic Delphi. The first stage consisted of two rounds in which 31 experts rated their agreement with a set of 101 potential mental health related prescribing safety indicators using a five-point scale and given the opportunity to suggest other indicators. Indicators that achieved 80% agreement were accepted. The second stage comprised a single round in which 29 members estimated the risk of harm for each accepted indicator by assessing the occurrence likelihood and outcome severity using two five-point scales. Indicators were considered high or extreme risk when at least 80% of participants rated each indicator as high or extreme.

RESULTS

Seventy-five indicators were accepted in the first stage. Following the second stage, 42 (56%) were considered to be high or extreme risk for patient care. The 42 indicators comprised different types of hazardous prescribing, including drug-disease interactions (n = 12), drug-drug interactions (n = 9), inadequate monitoring (n = 5), inappropriate duration (n = 4), inappropriate dose (n = 4), omissions (n = 4), potentially inappropriate medications (n = 3) and polypharmacy (n = 1). These indicators also covered different mental health related medication classes, including antipsychotics (n = 14), mood stabilisers (n = 8), antidepressants (n = 6), sedative, hypnotics and anxiolytics (n = 6), anticholinergic (n = 6) and nonspecific psychotropics (n = 2).

CONCLUSION

This study has developed the first suite of prescribing safety indicators related to mental health disorders and medications, which could inform the development of future safety improvement initiatives and interventional studies.

'Use of antipsychotics in children and adolescents: a picture from the ARITMO population-based European cohort study'

AIMS

Prevalence of the use of antipsychotics (APs) in the paediatric population is globally increasing. The aim of this study was to describe multinational trends and patterns in AP use in children and adolescents in Europe.

METHODS

This was a dynamic retrospective cohort study comprising all children and adolescents (⩽18 years of age). Data were extracted from five population-based electronic healthcare databases in Europe (Denmark, Germany, Italy, the Netherlands and United Kingdom) from 2000 to 2010. Yearly prevalence and incidence of AP use was expressed per 1000 person-years (PYs).

RESULTS

Prevalence increased from 1.44 to 3.41/1000 PYs (2008) in Denmark and from 2.07 to 4.35/1000 PYs in the NL (2009), moderately increased from 2.8 to 3.24/1000 in UK (2009) and from 1.53 to 1.74/1000 PYs in Germany (2008) and remained low from 0.61 to 0.34/1000 PYs in Italy (2010). Similarly, incidence rates increased from 0.69 to 1.52/1000 PYs in Denmark and from 0.86 to 1.49/1000 PYs in the NL, stabilised from 2.29 to 2.37/1000 PYs in the UK and from 0.79 to 0.80/1000 PYs in Germany and remained low from 0.32 to 0.2/1000 PYs in Italy. AP use was highest in 15-18 year olds and in boys compared to girls. Yet, the use observed in the 5-9 year olds was found to be comparatively high in the NL. Prescriptions of second generation APs, especially risperidone, were privileged but the first generation APs were still prescribed in the youngest.

CONCLUSIONS

A steady increase in AP use in children and adolescents was observed essentially in the NL and Denmark. The use in Germany and Italy was lowest among countries. The use of APs under 9 years of age underlines their off-label use and should be carefully monitored as the risk/benefit ratio of these medications remains unclear in young children. AP use was altogether lower in Europe as compared to that reported in North America.

Changing prescribing patterns in an Irish community mental health service

OBJECTIVES

Medication is an important component of the treatment of many mental illnesses. Very little information is available about the particular medications that are being prescribed by community mental health services and how this has changed over time. We set out to obtain details of psychiatric medications being prescribed by one Irish community mental health service.

METHOD

All prescribing by the Cluain Mhuire Community Mental Health Service became electronic during 2004. Using Business Intelligence software, we obtained details of all psychiatric medications prescribed from 2005 to 2016. We compared numbers of prescriptions written in the first 6 years (2005-2010) with the following 6 (2011-2016).

RESULTS

Olanzapine was the most commonly prescribed medication throughout but its use declined by one-quarter over the study period. Clozapine, quetiapine, aripiprazole and haloperidol prescribing increased. Prescriptions for mood stabilisers and antidepressants fell by 25%. Sedative prescriptions declined by almost 50%. Absolute numbers of prescriptions written for methylphenidate and pregabalin were small but increased dramatically over the time period.

CONCLUSIONS

This community mental health service prescribed less of most psychiatric medications in 2016, than had been the case in 2005. This is despite an increase in the numbers of patients seen over the same period. It is not clear if this pattern is echoed in other services.

Susceptibility of male wild type mouse strains to antipsychotic-induced weight gain

While both men and women gain weight as a side effect of antipsychotic (AP) treatment, studies in mice have found only female mice are susceptible to weight gain. Therefore, to we set out to identify a strain of male mice that gain significant weight in response to APs which could better model AP-induced weight gain observed in humans. These studies determined that male Balb/c mice developed late onset olanzapine-induced weight gain. Patients often take APs for many years and thus understanding AP-mediated changes in food intake, energy expenditure and body weight regulation is particularly important.

Oral antipsychotic prescribing and association with neighbourhood-level socioeconomic status: analysis of time trend of routine primary care data in England, 2011-2016

BACKGROUND

Increasing rates of antipsychotic prescribing have been reported previously, particularly for second-generation antipsychotics (SGAs), which are generally better tolerated than the older first-generation antipsychotics (FGAs). Prescribers, however, may exert bias, favouring prescriptions of novel drugs for patients of higher socioeconomic status (SES). We aimed to examine time trends in: (1) prescriptions of oral FGAs vs. SGAs and (2) associations between antipsychotic prescriptions and neighbourhood-level SES in England between 2011 and 2016.

METHODS

We used publicly available data for prescriptions made in primary care and linked general practices' postcodes with the Index of Multiple Deprivation (IMD) as a measure for neighbourhood-level SES. Absolute numbers of antipsychotic prescriptions were calculated. Linear regression analysis was used to examine the association of SGA vs. FGA prescription pattern with time and with SES.

RESULTS

A total of 27,486,000 oral antipsychotics were prescribed during the study period, mostly SGAs (n = 21,700,000; 78.9%). There was a significant increase in the ratio of SGA/FGA prescriptions over time (β = 0.376, 95% CI 0.277-0.464, P < 0.001). Individual FGAs were increasingly prescribed in areas of lower SES and the converse for SGAs except amisulpride. During the study period, a significantly larger proportion of total SGA prescriptions relative to total FGAs were made in areas of higher SES (β = 0.182, 95% CI 0.117-0.249, P < 0.001).

CONCLUSION

Prescriptions of antipsychotics continue to rise overall, with SGAs taking preference especially in areas of higher SES. The pattern of antipsychotic prescription favouring people in areas of lower social deprivation carries implications on inequalities even among sub-groups of people with mental disorders.

Conventional mood stabilizers and/or second-generation antipsychotic drugs in bipolar disorders: A population-based comparison of risk of treatment failure

BACKGROUND

The study compared treatment failure when using three therapeutic strategies in bipolar disorders: (i) mood stabilizers (MSs: lithium, valpromide, divalproate, carbamazepine, lamotrigine) without second-generation antipsychotic (SGAP); (ii) SGAPs (aripiprazole, olanzapine, risperidone, quetiapine) without MS; (iii) combination of MSs and SGAPs.

METHODS

A historical cohort study was conducted using the French national healthcare databases in 20,086 outpatients aged 21+, newly treated with one of the three treatment strategies in 2011-2012, and diagnosed with a bipolar disorder. A composite outcome was based on indicators of treatment failure identified over 12 months: treatment discontinuation, switch or addition, psychiatric hospitalisation, suicide attempt, and death. For each strategy, the cumulative incidence of treatment failure was calculated while adjusting for covariates by propensity score weighting.

RESULTS

A total of 8,225 patients (40.9%) were newly dispensed MSs, 9,342 (46.5%) SGAPs, and 2,519 (12.5%) both MSs and SGAPs. The one-year adjusted cumulative incidence of treatment failure was 75.7% (95%CI 74.9;76.3) in patients using MSs, 75.3% (74.6;76.0) in patients using SGAPs, and 60.5% (58.3;62.6) in patients with the combination. The adjusted difference in incidence for SGAPs compared with MSs was -0.40% (-1.4;0.6 p = 0.4) in the whole population, -2.2% (-3.3; -1.2 p < 0.002) in patients under 65 years and +6.7% (4.1;9.1 p < 0.002) in patients 65 years and over.

LIMITATIONS

Combinations of MSs and SGAPs could not be directly compared with MS or SGAP monotherapies.

CONCLUSIONS

One-year treatment failure was high. Overall, no difference in treatment failure was observed between MS or SGAP strategy but differences might exist depending on age.

A population-based study of prescribing trends in a potentially vulnerable paediatric population from 1999 to 2012

OBJECTIVES

There is a limited understanding of paediatric medication prescribing trends and patterns, thus poorly positioning decision-makers to identify quality and safety concerns related to medication use. The objective of this study was to determine overall medication prescribing trends and patterns among children receiving Ontario Drug Benefits over a thirteen-year period in the province of Ontario, Canada.

METHODS

Administrative health databases housed within the Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada, were used to identify outpatient prescriptions dispensed from 1999 to 2012 through a publicly funded programme to children ≤18 years of age. Medications were classified according to the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system. Descriptive statistics were used to summarize prescribing patterns.

KEY FINDINGS

This study identified 457 037 children who were dispensed a new prescription between 1999 and 2012. About 56% received their first prescription before 6.5 years of age, and 85% of the children in this study were from families who received social assistance. The most commonly prescribed drugs were antiinfectives (56.1%). Prescriptions for several central nervous system agents, including antipsychotics and agents for attention-deficit/hyperactivity disorder, increased across the study period. Changes in prescribing patterns within opioids, hormones and autonomic agents were noted. The results suggest that historically, prescribing trends have shifted with public policy, pharmaceutical marketing and diagnostic patterns, thus identifying them as a possible tool to measure the impact of policydriven practice changes. Anti-infective prescribing increased markedly with the global H1N1 pandemic. Pharmaceutical marketing, formulary decisions and diagnostic trends may affect the prescribing of ADHD medications globally. The prescribing of codeine-containing products and medroxyprogesterone appeared to fluctuate in response to important publications in the medical literature, and the use of epinephrine syringes increased after public policy changes in the province of Ontario. The steady rise in the use of medications whose long-term effects in children are unknown, such as antipsychotics and proton pump inhibitors, identifies areas in need of future research.

CONCLUSIONS

This study presents the first overview of Canadian prescribing trends for children, the majority of which are of low socioeconomic status and represent a potentially vulnerable population. Our analysis suggests that future research is required to determine whether prescribing trends could be used as indicators of policy effectiveness, pharmacovigilance and diagnostic trends.

Multi-trajectories of antidepressant and antipsychotic use: a 11-year naturalistic study in a community-based sample

OBJECTIVE

To explore the temporal dynamic of antidepressant and antipsychotic co-prescribing in real-life conditions.

METHODS

The study was performed using reimbursement data from the French Insurance Healthcare system in a cohort of 118 454 persons with at least one dispensing of antidepressants and/or antipsychotics over the period 2006-2016. Latent class analyses were used to identify homogeneous groups of persons following similar multi-trajectories of antidepressant and/or antipsychotic dispensing. Multivariate polynomial logistic regression models were used to explore the characteristics independently associated with distinct trajectories.

RESULTS

Five multi-trajectories of antidepressant and/or antipsychotic dispensing were identified: more than half of the sample (58%) had very low antidepressant and antipsychotic use; two groups had chronic (12%) or decreasing (11%) antidepressant use with very low antipsychotic use; two groups used both antidepressants and antipsychotics simultaneously either in an increasing (12%) or chronic (7%) way. Persons with chronic antidepressant-antipsychotic use presented with markers of poor social and mental health conditions.

CONCLUSIONS

Most persons using antipsychotics over the follow-up also used antidepressants over the same period. The benefit/risk ratio of these prescribing practices should be further explored as the long-term efficacy of antidepressant-antipsychotic polypharmacy is poorly documented, while this combination increases the risk of adverse effects.

Trends in utilization and dosing of antipsychotic drugs in Scandinavia: Comparison of 2006 and 2016

AIMS

The aim of this study was to investigate time trends in dosing and prevalence of antipsychotic prescriptions in Scandinavia.

METHODS

We retrieved data on antipsychotic use between 2006 and 2016 from Danish, Norwegian and Swedish national prescription registers. For each antipsychotic, we calculated prevalence of use and mean doses, overall and for specific age groups (young, adults and elderly).

RESULTS

Antipsychotic use in Scandinavia increased from 16.5 to 17.2 users/1000 inhabitants between 2006 and 2016 (+2.4%, annual change: 0.07 users/1000 inhabitants/year, 95% CI: 0.02-0.20, P = 0.02). In 2006, chlorprothixene and levomepromazine were the most commonly used antipsychotics. By 2016, quetiapine was the most used antipsychotic in all three countries and across all age groups, with an overall 1-year prevalence of 4.05-9.97 users/1000 inhabitants (annual change: 0.57 users/1000 inhabitants/year, 95% CI: 0.54-0.60, P < 0.001). Quetiapine showed a marked decrease in mean doses during the 11-year study period (0.46-0.28 defined daily doses (DDD)/user/day: 39.1%, -0.02 DDD/user/day/year, 95% CI: -0.020 to -0.015, P < 0.001). In 2016, the highest mean doses were seen for clozapine (0.90-1.07 DDD/user/day) and olanzapine (0.66-0.88 DDD/user/day).

CONCLUSIONS

There is an increased prevalence of antipsychotic prescriptions that coincides with low and/or decreasing mean doses of the majority of commonly used antipsychotics in Scandinavia. Of all antipsychotics, this development was most pronounced for quetiapine. Reasons for and consequences of increased antipsychotic use that lasts shorter periods of time requires further study.

Interest of pharmacoepidemiology for the study of psychotropic drugs

In psychiatry, drug evaluation using pharmacoepidemiological methods has been of growing interest in recent decades. Studies based on observational databases are particularly useful for psychotropic drugs due to their important prevalence in populations, and their use over long period. The authors discussed the specific interest of pharmacoepidemiological studies in the field of psychiatry through two examples: first, the use of antidepressants, and, second, the risks associated with antipsychotics.

Attitudes and behaviour towards psychotropic drug prescribing in Swedish primary care: a questionnaire study

Background

The prescribing of psychotropic drugs, i.e. antidepressants, sedatives (anxiolytics, hypnotics), and antipsychotics is considerable and a large proportion is prescribed by general practitioners (GPs). There are concerns about dependency and medicalisation, and treatment decisions in psychiatry may appear arbitrary. Increased knowledge of GPs’ opinions on the prescribing of psychotropics may lead to more rational use of these drugs. We aimed to quantify GPs’ attitudes, beliefs and behaviour towards various aspects of psychotropic drug prescribing.

Methods

A questionnaire was distributed to physicians in all 199 GP practices in Region Västra Götaland, Sweden. The questions concerned determinants of psychotropic drug prescribing that had been identified in a previous, qualitative study.

Results

Questionnaires from 516 physicians (64% of whom were specialists in family medicine, 21% interns in family medicine, 15% others) at 152 GP practices (59% of which were state owned, 72% in an urban area, with a median of 7808 registered patients) were returned (estimated response rate: 48%). A majority – 62% – of GPs found it easier to start prescribing psychotropic drugs than to stop (95% confidence interval, 57%, 66%) vs. 8% (6%, 10%). Most GPs considered psychotherapy more suitable than psychotropic drugs in cases of mild psychiatric disease: 81% (77%, 84%) vs. 4% (3%, 6%). The problems treated with psychotropic drugs were considered to be mostly socioeconomic, or mostly medical, by similar proportions of physicians: 38% (34%, 42%) vs. 40% (36%, 45%). GPs were on average satisfied with their levels of antidepressant and sedative prescribing in relation to medical needs. More GPs regarded their prescribing of antipsychotics as being too low rather than too high: 33% (28%, 39%) vs. 7% (4%, 10%).

Conclusions

This study illustrates the complexities of psychiatric drug treatment in primary care and identifies potential drivers of increased prescribing of psychotropics. The manifold factors, medical and non-medical, that affect prescribing decisions may explain a sense of arbitrariness surrounding psychotropic drug treatment. This notwithstanding, GPs seem mostly content with their prescribing.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0885-4) contains supplementary material, which is available to authorized users.

Trajectories of Antipsychotic Drug Use Over 10 Years in a French Community-Based Sample of Persons Aged 50 and Older

OBJECTIVE

To identify the temporal prescribing patterns of antipsychotics among persons aged 50 and older and to explore the demographic and clinical characteristics associated with each trajectory of antipsychotic drug use.

METHODS

This was a historical fixed cohort study on a community-based sample of persons affiliated with the French Insurance Healthcare system. Data from community drug reimbursement claims were collected by the French Insurance Healthcare system over the period 2006-2015. The study included 160,853 persons aged 50 and older. Trajectories of antipsychotic drug use were identified by examining the distribution of antipsychotic use within consecutive 3-month periods over the entire follow-up period. Latent class analyses were used to identify distinct trajectories. Multivariate polynomial logistic regression models were used to explore the characteristics independently associated with trajectories.

RESULTS

Five trajectories of antipsychotic use were identified: null or very low use (93.8%), occasional use (2%), decreasing use (1.6%), chronic use (1.5%), and increasing use (1.1%). Occasional users were older and had a lower use of other psychotropic drugs and a high use of health resources. Chronic users had the highest frequency of chronic psychiatric diseases and were less likely to present with dementia or Parkinson disease. Persons with increasing use of antipsychotics were more frequently males and had a high frequency of dementia; half of them died over the follow-up period compared with 20% in the total sample.

CONCLUSION

Further studies should explore whether the benefit-risk ratio of antipsychotic drugs in older adults differs according to trajectories of use.

A phenotypic Caenorhabditis elegans screen identifies a selective suppressor of antipsychotic-induced hyperphagia

Antipsychotic (AP) drugs are used to treat psychiatric disorders but are associated with significant weight gain and metabolic disease. Increased food intake (hyperphagia) appears to be a driving force by which APs induce weight gain but the mechanisms are poorly understood. Here we report that administration of APs to C. elegans induces hyperphagia by a mechanism that is genetically distinct from basal food intake. We exploit this finding to screen for adjuvant drugs that suppress AP-induced hyperphagia in C. elegans and mice. In mice AP-induced hyperphagia is associated with a unique hypothalamic gene expression signature that is abrogated by adjuvant drug treatment. Genetic analysis of this signature using C. elegans identifies two transcription factors, nhr-25/Nr5a2 and nfyb-1/NFYB to be required for AP-induced hyperphagia. Our study reveals that AP-induced hyperphagia can be selectively suppressed without affecting basal food intake allowing for novel drug discovery strategies to combat AP-induced metabolic side effects.

Safety of psychotropic medicines: contribution from observational evidence

The risks associated with psychotropic drugs use should be accurately documented at the population level in view of the growing number of persons exposed to these drugs. The strengths of observational studies regarding the identification of drug-related harms mirror the limitations of randomised controlled trials and vice-versa. Observational studies can be carried out in large samples of unselected participants treated in real-life conditions and who may be followed up over long periods. Serious adverse effects undetected during pre-marketing clinical trials may be observed only in post-marketing use, such as metabolic effects of second-generation antipsychotics. Observational studies play a key role in the identification of teratogenic risks, such as those induced by prenatal exposure to anticonvulsants. These studies are the main source of information to investigate the long-term effects of drugs, such as the possible increased risk of dementia in benzodiazepine users. They may also contribute to the accurate assessment at population level of risks overestimated by studies carried out in non-representative samples, such as the risk of congenital heart diseases in babies prenatally exposed to lithium. Owing to the lack of random allocation of drugs, confounding by indication or by disease severity are the major sources of biases in observational studies exploring drug safety. An adverse outcome may be wrongly imputed to drug exposure while it is a symptom/outcome of the disease motivating the decision to prescribe. Such a bias may occur in studies investigating the link between exposure to antidepressants and suicidality. As several methods have been developed to lessen the impact of such biases, pharmaco-epidemiological studies based upon stringent methodological designs should be regarded as a valid approach for assessing psychotropic drug safety.

American Psychological Association practice guidelines for psychopharmacology: Ethical practice considerations for psychologists involving psychotropic use with children and adolescents

OBJECTIVES

This study discusses the implications of the American Psychological Association's 2011 Practice Guidelines for Pharmacology as they apply to psychologists working with juvenile clients. Special considerations apply due to concerns about the developmental side effects that occur when psychotropic medications are prescribed to children and adolescents.

METHODS OR DESIGN

This study provides recommendations for implementing each of the Practice Guidelines. Constructive criticism of the Practice Guidelines is also discussed with the aim of improving service delivery.

RESULTS

This study provides specific recommendations for psychologists regarding obtaining adequate knowledge about psychopharmacology to inform clients or consult with physicians. Suggestions are made for continuing education requirements for psychologists who work with juveniles.

CONCLUSIONS

Recommendations are made for psychologists working with juveniles to increase their knowledge of psychotropic medications for a more ethical and informed voice regarding the prescribing of such medications.

Tardive dyskinesia update: treatment and management

The development of rational treatments for tardive dyskinesia has been held back by limitations to our understanding of its aetiology, which even now does not extend far beyond its association with centrally acting dopamine-blocking drugs. This article reviews briefly the major aetiological theories and addresses general management and specific treatment options. Primary prevention and early recognition remain the crucial management issues because, once the condition is established, there are no satisfactory treatments. The article considers two newly developed drugs, valbenazine and deutetrabenazine, in some detail as, although they are not yet licensed in Europe, they have largely been responsible for an upsurge in interest in tardive dyskinesia in the North American literature and are likely to be widely promoted in the future. Although possessed of undoubted benefits, the evidence suggests that these represent small steps rather than large leaps forward in treatment.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

D.C.O. is psychiatric commissioner on the Commission on Human Medicines, the UK drug regulator, and chair of its expert advisory group on CNS drugs. He is also a member of the psychiatry Scientific Advisory Group of the European Medicines Agency.

Mental illness in primary care: a narrative review of patient, GP and population factors that affect prescribing rates

BACKGROUND

Mental illness poses a large and growing disease burden worldwide. Its management is increasingly provided by primary care. The prescribing of psychotropic drugs in general practice has risen in recent decades, and variation in prescribing rates has been identified by a number of studies. It is unclear which factors lead to this variation.

AIM

To describe the variables that cause variation in prescribing rates for psychotropic drugs between general practices.

METHODS

A narrative review was conducted in January 2018 by searching electronic databases using the PRISMA statement. Studies investigating causal factors for variation in psychotropic prescribing between at least two general practice sites were eligible for inclusion.

RESULTS

Ten studies met the inclusion criteria. Prescribing rates varied considerably between practices. Positive associations were found for many variables, including social deprivation, ethnicity, patient age and gender, urban location, co-morbidities, chronic diseases and GP demographics. However studies show conflicting findings, and no single regression model explained more than 57% of the variation in prescribing rates.

DISCUSSION

There is no consensus on the factors that most predict prescribing rates. Most research was conducted in countries with central electronic databases, such as the United Kingdom; it is unclear whether these findings apply in other healthcare systems. More research is needed to determine the variables that explain prescribing rates for psychotropic medications.

Translation and cultural adaptation of Glasgow Antipsychotic Side-effects Scale (GASS) in Arabic

Background

In view of a constant increase in the number of patients treated with antipsychotic medications, the problem of nonadherence to the prescribed treatment becomes particularly relevant. Since one of the major contributors to the nonadherence is the presence of side effects of the drugs being used, the availability of tools for assessment of adverse reactions is of great importance.

Objective

The objective of the present work was to develop an Arabic language version of the Glasgow Antipsychotic Side-effect Scale (GASS).

Methods

After confirming the accuracy of translation, the questionnaire was given to 100 patients in two psychiatric centers in Saudi Arabia.

Results

The Cronbach’s alpha (0.793) indicated a good reliability of the survey. The mean GASS score was 19.09, indicating absent or mild side effects of antipsychotics, but 46% of patients experienced moderate, and 25% experienced severe side effects. An analysis of the correlation between patients’ characteristics and side effects revealed the presence of a positive relationship between the side effects and health literacy.

Conclusions

It is expected that the Arabic-GASS will benefit Arabic-speaking psychiatric patients by helping them to express their concerns about side effects of antipsychotics. The collected results also document the importance of patients’ health literacy in achieving high-quality healthcare.

Neuroleptic Prescribing and Monitoring Practices in Pediatric Inpatient Medical and Psychiatric Settings

BACKGROUND

Pediatric use of second-generation antipsychotics, or neuroleptics, has increased over the past decade. Neuroleptic use can have significant and lasting adverse neurologic, metabolic, and cardiovascular effects. In the current literature, neuroleptic prescribing and monitoring is described in outpatient settings, with little description of inpatient pediatric practice. In this study, we are the first to explore prescribing and monitoring in inpatient pediatrics, highlighting similarities and differences in practice between pediatric medicine and psychiatry.

METHODS

This retrospective study included patients <18 years of age who received a neuroleptic during inpatient hospitalization between September 2014 and March 2015, within either the pediatric inpatient medical or psychiatric setting. Data collected included sex, age, race, height, weight, length of stay, service providing care, details involving the neuroleptic(s) administered, comorbidities, lipid and glycemic monitoring, and results, monitoring for extrapyramidal symptoms, and mental health consultation.

RESULTS

Factors associated with improved neuroleptic monitoring included longer length of stay and evidence of an adverse drug effect. Clearly specified indication for use was associated with improved neuroleptic monitoring. Although neuroleptic initiation during admission had improved indication documentation and monitoring practices compared with initiation before admission, a significant gap exists between inpatient psychiatry and medical settings in adverse drug effect monitoring, particularly extrapyramidal symptom monitoring and lipid collection.

CONCLUSIONS

In our study, we describe current practice in the use and monitoring of neuroleptics in inpatient pediatric medical and psychiatric settings. In this study, we suggest that the use of neuroleptics in inpatient pediatrics, particularly inpatient medical settings, is conducted with suboptimal monitoring and, at times, without clear documented indication.

Antipsychotic Use With and Without Comorbid Psychiatric Diagnosis Among Adults with Intellectual and Developmental Disabilities

OBJECTIVE

Antipsychotic use is controversial in the management of adults with intellectual and developmental disabilities (IDD) because of inconclusive evidence for efficacy in the absence of a comorbid psychiatric condition, and substantial concerns about adverse effects. We aimed to characterize antipsychotic use among Ontario adults with IDD and compare profiles of those with and without a documented psychiatric diagnosis.

METHOD

This population-based study included 51,881 adults with IDD under 65 y as of April 2010 receiving provincial drug benefits in Ontario who were followed until March 2016 to identify those dispensed at least one antipsychotic medication. Profiles of those with and without a psychiatric diagnosis were compared.

RESULTS

Overall, 39.2% of adults ( n = 20,316) were dispensed an antipsychotic medication, which increased to 56.4% in a subcohort residing in group homes. Almost one-third (28.91%) of people prescribed an antipsychotic medication did not have a documented psychiatric diagnosis. Those without a psychiatric diagnosis differed considerably from those with a diagnosis. In particular, those without a psychiatric diagnosis were older, less likely to have used antidepressants or benzodiazepines in the year before, and less likely to have used ambulatory and acute care.

CONCLUSIONS

Antipsychotic use in IDD is common, and occurs frequently without a psychiatric diagnosis. Attention toward how antipsychotics are prescribed and monitored for people with IDD in Canada is warranted to ensure appropriate prescribing.

A quantitative analysis of antipsychotic prescribing trends for the treatment of schizophrenia in England and Wales

Objective

This study aims to assess the current antipsychotic prescribing trends for the treatment of schizophrenia and to compare them with available guidelines and research evidence.

Design

An observational retrospective quantitative analysis.

Setting

Data were collected from the prescribing cost analysis for the period between 2007 and 2014, including all drugs from the British National Formulary 4.2.1 and 4.2.2. Prescriptions were included from primary and secondary healthcare settings in England and Wales.

Participants

None.

Main outcome measures

Defined daily doses of antipsychotics were used to compare popularity of individual drugs and classes of antipsychotics.

Results

There is a consistent increase in the proportion of atypical antipsychotics prescribed, compared to typical antipsychotics, between 2007 and 2014, with atypicals accounting for 79.9% of total antipsychotics prescribed in 2014.

Conclusion

The consistent popularity of atypical antipsychotics is not concordant with the current National Institute for Health and Care Excellence guidelines for the treatment of schizophrenia or the most recent research evidence.