Antipsychotic prescribing quality and ethnicity: a study of hospitalized patients in south east London

Clinical outcomes with paliperidone palmitate 3-monthly injection as monotherapy: observational 3-year follow-up of patients with schizophrenia

BACKGROUND

Paliperidone palmitate 3-monthly (PP3M) has been tested in 1-year controlled studies. The aim of this study was to examine the relapse outcomes with PP3M monotherapy at 3 years in patients with schizophrenia.

METHODS

This was an observational, non-interventional study of patients started on PP3M according to their clinical need. All patients had a diagnosis of schizophrenia (ICD-10 F20) and were between 18 and 65 years of age. The study took place in a mental health facility in South East London, UK.

RESULTS

Among the 166 patients who started PP3M, 97 (58%) met inclusion criteria and were observed for 36 months. In total, five patients (5%) experienced a relapse (defined as step-up in clinical care) while on PP3M. There were no relapses between months 18 and 36. Of the original 97 patients, 56 (58%) remained on PP3M monotherapy at 3 years, and 71 (73%) remained on either PP3M or paliperidone palmitate one-monthly. Reasons for discontinuation of PP3M included patient refusal (n = 11, 33% of discontinuations) and adverse effects in (n = 8, 24%).

CONCLUSION

PP3M is a highly effective monotherapy treatment for reducing relapse in people with schizophrenia.

Unraveling ethnic disparities in antipsychotic prescribing among patients with psychosis: A retrospective cohort study based on electronic clinical records

BACKGROUND

Previous studies have shown mixed evidence on ethnic disparities in antipsychotic prescribing among patients with psychosis in the UK, partly due to small sample sizes. This study aimed to examine the current state of antipsychotic prescription with respect to patient ethnicity among the entire population known to a large UK mental health trust with non-affective psychosis, adjusting for multiple potential risk factors.

METHODS

This retrospective cohort study included all patients (N = 19,291) who were aged 18 years or over at their first diagnoses of non-affective psychosis (identified with the ICD-10 codes of F20-F29) recorded in electronic health records (EHRs) at the South London and Maudsley NHS Trust until March 2021. The most recently recorded antipsychotic treatments and patient attributes were extracted from EHRs, including both structured fields and free-text fields processed using natural language processing applications. Multivariable logistic regression models were used to calculate the odds ratios (OR) for antipsychotic prescription according to patient ethnicity, adjusted for multiple potential contributing factors, including demographic (age and gender), clinical (diagnoses, duration of illness, service use and history of cannabis use), socioeconomic factors (level of deprivation and own-group ethnic density in the area of residence) and temporal changes in clinical guidelines (date of prescription).

RESULTS

The cohort consisted of 43.10 % White, 8.31 % Asian, 40.80 % Black, 2.64 % Mixed, and 5.14 % of patients from Other ethnicity. Among them, 92.62 % had recorded antipsychotic receipt, where 24.05 % for depot antipsychotics and 81.72 % for second-generation antipsychotic (SGA) medications. Most ethnic minority groups were not significantly different from White patients in receiving any antipsychotic. Among those receiving antipsychotic prescribing, Black patients were more likely to be prescribed depot (adjusted OR 1.29, 95 % confidence interval (CI) 1.14-1.47), but less likely to receive SGA (adjusted OR 0.85, 95 % CI 0.74-0.97), olanzapine (OR 0.82, 95 % CI 0.73-0.92) and clozapine (adjusted OR 0.71, 95 % CI 0.6-0.85) than White patients. All the ethnic minority groups were less likely to be prescribed olanzapine than the White group.

CONCLUSIONS

Black patients with psychosis had a distinct pattern in antipsychotic prescription, with less use of SGA, including olanzapine and clozapine, but more use of depot antipsychotics, even when adjusting for the effects of multiple demographic, clinical and socioeconomic factors. Further research is required to understand the sources of these ethnic disparities and eliminate care inequalities.

Ethnic inequalities in clozapine use among people with treatment-resistant schizophrenia: a retrospective cohort study using data from electronic clinical records

PURPOSE

Clozapine is the most effective intervention for treatment-resistant schizophrenia (TRS). Several studies report ethnic disparities in clozapine treatment. However, few studies restrict analyses to TRS cohorts alone or address confounding by benign ethnic neutropenia. This study investigates ethnic equity in access to clozapine treatment for people with treatment-resistant schizophrenia spectrum disorder.

METHODS

A retrospective cohort study, using information from 11 years of clinical records (2007-2017) from the South London and Maudsley NHS Trust. We identified a cohort of service-users with TRS using a validated algorithm. We investigated associations between ethnicity and clozapine treatment, adjusting for sociodemographic factors, psychiatric multi-morbidity, substance misuse, neutropenia, and service-use.

RESULTS

Among 2239 cases of TRS, Black service-users were less likely to be receive clozapine compared with White British service-users after adjusting for confounders (Black African aOR = 0.49, 95% CI [0.33, 0.74], p = 0.001; Black Caribbean aOR = 0.64, 95% CI [0.43, 0.93], p = 0.019; Black British aOR = 0.61, 95% CI [0.41, 0.91], p = 0.016). It was additionally observed that neutropenia was not related to treatment with clozapine. Also, a detention under the Mental Health Act was negatively associated clozapine receipt, suggesting people with TRS who were detained are less likely to be treated with clozapine.

CONCLUSION

Black service-users with TRS were less likely to receive clozapine than White British service-users. Considering the protective effect of treatment with clozapine, these inequities may place Black service-users at higher risk for hospital admissions and mortality.

Improving quality of antipsychotic polypharmacy: a pilot study

Background: Concurrent prescription of more than one type of antipsychotic for the same patient - antipsychotic polypharmacy (APP) - is associated with increased incidence of side effects, uncertain therapeutic benefit and general guidelines advise against it. Nevertheless, APP is common and there is little evidence about possible interventions to improve practice.Aims: To investigate the prevalence and documentation quality of APP in specialized psychiatric care and assess the feasibility and effect of a simple intervention to improve clinical practice.Methods: We examined the prevalence and the quality of documentation of APP in medical records from a large inpatient treatment department before and 6 months after an intervention, which consisted of giving feedback to doctors on their prescription practices as well as teaching about current guidelines. Prescription and documentation before and after intervention were compared between intervention and control wards.Results: One hundred and twenty-one medical records were examined at baseline. 43% of these had APP, of these 27% was satisfactory documented. After the intervention, the proportion with APP was reduced from 42% to 29% in the intervention group. There was a statistically significant interaction effect of the intervention group and the after-intervention condition on this reduction. The percentage with satisfactory documentation of APP was increased after the intervention in both groups, but we found no corresponding interaction effect.Conclusion: APP is prevalent in inpatient treatment of patients with mainly psychotic disorders but documentation of this is insufficient. Simple education and feedback on prescription and records documentation practices may increase adherence to guidelines.

Ethnic minority inequalities in access to treatments for schizophrenia and schizoaffective disorders: findings from a nationally representative cross-sectional study

BACKGROUND

Ethnic minority service users with schizophrenia and schizoaffective disorders may experience inequalities in care. There have been no recent studies assessing access to evidence-based treatments for psychosis amongst the main ethnic minority groups in the UK.

METHODS

Data from nationally representative surveys from England and Wales, for 10,512 people with a clinical diagnosis of schizophrenia or schizoaffective disorders, were used for analyses. Multi-level multivariable logistic regression analyses were used to assess ethnic minority inequalities in access to pharmacological treatments, psychological interventions, shared decision making and care planning, taking into account a range of potential confounders.

RESULTS

Compared with white service users, black service users were more likely prescribed depot/injectable antipsychotics (odds ratio 1.56 (95% confidence interval 1.33-1.84)). Black service users with treatment resistance were less likely to be prescribed clozapine (odds ratio 0.56 (95% confidence interval 0.39-0.79)). All ethnic minority service users, except those of mixed ethnicity, were less likely to be offered cognitive behavioural therapy, compared to white service users. Black service users were less likely to have been offered family therapy, and Asian service users were less likely to have received copies of care plans (odds ratio 0.50 (95% confidence interval 0.33-0.76)), compared to white service users. There were no clinician-reported differences in shared decision making across each of the ethnic minority groups.

CONCLUSION

Relative to white service users, ethnic minority service users with psychosis were generally less likely to be offered a range of evidence-based treatments for psychosis, which included pharmacological and psychological interventions as well as involvement in care planning.

Race and prescribing

Treatment of mental illness in Black and minority ethnic groups differs from that in the White majority. Large differences in admission, detention and seclusion rates have been recorded. These disparities extend into the physical healthcare setting, particularly in the USA but also within the UK National Health Service. There are many influences on prescribing of psychotropic medication, not least the metabolising capacity of the individual. Ethnic differences do occur, particularly for East Asian peoples. However, these differences are broadly similar across ethnic groups, particularly for the cytochrome P450 enzymes responsible for metabolising psychotropic medicines. Psychotropic medication prescribing also differs by ethnicity. Specifically, antipsychotic dose, type and route of administration may differ. However, most data originate in the USA and UK studies have not replicated these findings, even after controlling for multiple confounding factors. Similarly, antidepressant prescribing and access to treatment may differ by ethnicity. These differences may have complex causes that are not well understood. Overall, prescribing of antipsychotics appears to be broadly equitable in Black and minority ethnic groups.

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

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

Does race affect prescribing for acute psychosis? Evaluation by a case vignette

BACKGROUND

Black people are over represented in mental health services and prescribing of antipsychotics differs by race in some countries. Our previous UK research into the prescribing of antipsychotics in large, multicentre studies found no important differences for black and white patients. However, we received several comments challenging our findings. We wanted to test the validity of these anecdotes by devising two case vignettes that differed only by race and asking prescribers to choose antipsychotic treatment.

METHOD

A case study was sent to all medical prescribers in the South London and Maudsley NHS Trust. Half of the prescribers for each grade of staff were sent the case study where the ethnicity of the patient was white and the other half where the ethnicity was black. Participants were asked to describe what they would prescribe for the patient. Outcomes were total percentage maximum dose, high dose, type of antipsychotic, route of administration and antipsychotic polypharmacy.

RESULTS

We received 123 completed case studies and demographic data forms from prescribers. There were no differences in percentage maximum dose, high dose, type, route and number of antipsychotics prescribed by case study ethnicity.

CONCLUSIONS

Prescribing for UK black and white patients is broadly similar when tested in clinical and theoretical studies.

Identification of Adverse Drug Events from Free Text Electronic Patient Records and Information in a Large Mental Health Case Register

OBJECTIVES

Electronic healthcare records (EHRs) are a rich source of information, with huge potential for secondary research use. The aim of this study was to develop an application to identify instances of Adverse Drug Events (ADEs) from free text psychiatric EHRs.

METHODS

We used the GATE Natural Language Processing (NLP) software to mine instances of ADEs from free text content within the Clinical Record Interactive Search (CRIS) system, a de-identified psychiatric case register developed at the South London and Maudsley NHS Foundation Trust, UK. The tool was built around a set of four movement disorders (extrapyramidal side effects [EPSEs]) related to antipsychotic therapy and rules were then generalised such that the tool could be applied to additional ADEs. We report the frequencies of recorded EPSEs in patients diagnosed with a Severe Mental Illness (SMI) and then report performance in identifying eight other unrelated ADEs.

RESULTS

The tool identified EPSEs with >0.85 precision and >0.86 recall during testing. Akathisia was found to be the most prevalent EPSE overall and occurred in the Asian ethnic group with a frequency of 8.13%. The tool performed well when applied to most of the non-EPSEs but least well when applied to rare conditions such as myocarditis, a condition that appears frequently in the text as a side effect warning to patients.

CONCLUSIONS

The developed tool allows us to accurately identify instances of a potential ADE from psychiatric EHRs. As such, we were able to study the prevalence of ADEs within subgroups of patients stratified by SMI diagnosis, gender, age and ethnicity. In addition we demonstrated the generalisability of the application to other ADE types by producing a high precision rate on a non-EPSE related set of ADE containing documents.

AVAILABILITY

The application can be found at http://git.brc.iop.kcl.ac.uk/rmallah/dystoniaml.

Ethnicity, detention and early intervention: reducing inequalities and improving outcomes for black and minority ethnic patients: the ENRICH programme, a mixed-methods study

Background

Black and minority ethnic (BME) service users experience adverse pathways into care. Ethnic differences are evident even at first-episode psychosis (FEP); therefore, contributory factors must operate before first presentation to psychiatric services. The ENRICH programme comprised three interlinked studies that aimed to understand ethnic and cultural determinants of help-seeking and pathways to care.

Aims and objectives

Study 1: to understand ethnic differences in pathways to care in FEP by exploring cultural determinants of illness recognition, attribution and help-seeking among different ethnic groups. Study 2: to evaluate the process of detention under the Mental Health Act (MHA) and determine predictors of detention. Study 3: to determine the appropriateness, accessibility and acceptability of generic early intervention services for different ethnic groups.

Methods

Study 1: We recruited a prospective cohort of FEP patients and their carers over a 2-year period and assessed the chronology of symptom emergence, attribution and help-seeking using semistructured tools: the Nottingham Onset Schedule (NOS), the Emerging Psychosis Attribution Schedule and the ENRICH Amended Encounter Form. A stratified subsample of user–carer NOS interviews was subjected to qualitative analyses. Study 2: Clinical and sociodemographic data including reasons for detention were collected for all MHA assessments conducted over 1 year (April 2009–March 2010). Five cases from each major ethnic group were randomly selected for a qualitative exploration of carer perceptions of the MHA assessment process, its outcomes and alternatives to detention. Study 3: Focus groups were conducted with service users, carers, health professionals, key stakeholders from voluntary sector and community groups, commissioners and representatives of spiritual care with regard to the question: ‘How appropriate and accessible are generic early intervention services for the specific ethnic and cultural needs of BME communities in Birmingham?’

Results

There were no ethnic differences in duration of untreated psychosis (DUP) and duration of untreated illness in FEP. DUP was not related to illness attribution; long DUP was associated with patients being young (< 18 years) and living alone. Black patients had a greater risk of MHA detention, more criminal justice involvement and more crisis presentations than white and Asian groups. Asian carers and users were most likely to attribute symptoms to faith-based or supernatural explanations and to seek help from faith organisations. Faith-based help-seeking, although offering comfort and meaning, also risked delaying access to medical care and in some cases also resulted in financial exploitation of this vulnerable group. The BME excess in MHA detentions was not because of ethnicity per se; the main predictors of detention were a diagnosis of mental illness, presence of risk and low level of social support. Early intervention services were perceived to be accessible, supportive, acceptable and culturally appropriate. There was no demand or perceived need for separate services for BME groups or for ethnic matching between users and clinicians.

Conclusions

Statutory health-care organisations need to work closely with community groups to improve pathways to care for BME service users. Rather than universal public education campaigns, researchers need to develop and evaluate public awareness programmes that are specifically focused on BME groups.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Antipsychotic polypharmacy: a comprehensive evaluation of relevant correlates of a long-standing clinical practice

Antipsychotic polypharmacy (APP) is common in the treatment of schizophrenia spectrum disorders. The literature indicates that APP is related to patient, illness, and treatment variables that are proxy measures for greater illness acuity, severity, complexity, and chronicity. The largely unknown relative risks and benefits of APP need to be weighed against the known risks and benefits of clozapine for treatment-resistant patients. To inform evidence-based clinical practice, controlled, high-quality antipsychotic combination and discontinuation trials are necessary to determine the effectiveness, safety, and role of APP in the management of severely ill patients with insufficient response to antipsychotic monotherapy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Satisfaction with inpatient treatment for first-episode psychosis among different ethnic groups: a report from the UK AeSOP study

BACKGROUND

There is concern about the level of satisfaction with mental healthcare among minority ethnic patients in the UK, particularly as black patients have more compulsory admissions to hospital.

AIMS

To determine and compare levels of satisfaction with mental healthcare between patients from different ethnic groups in a three-centre study of first-onset psychosis.

METHOD

Data were collected from 216 patients with first-episode psychosis and 101 caregivers from South London, Nottingham and Bristol, using the Acute Services Study Questionnaire (Patient and Relative Version) and measures of sociodemographic variables and insight.

RESULTS

No differences were found between ethnic groups in most domains of satisfaction tested individually, including items relating to treatment by ward staff and number of domains rated as satisfactory. However, logistic regression modelling (adjusting for age, gender, social class, diagnostic category and compulsion) showed that black Caribbean patients did not believe that they were receiving the right treatment and were less satisfied with medication than white patients. Black African patients were less satisfied with non-pharmacological treatments than white patients. These findings were not explained by lack of insight or compulsory treatment.

CONCLUSIONS

The study found that black patients were less satisfied with specific aspects of treatment, particularly medication, but were equally satisfied with nursing and social care. Understanding the reasons behind this may improve the acceptability of psychiatric care to black minority ethnic groups.

Antipsychotic prescribing in Black and White hospitalised patients

Ethnicity may affect the prescribing of antipsychotic treatment. Previous UK studies conducted in south London have found few differences in antipsychotic prescribing quality for Black and White patients. This larger multicentre study examined the effect of ethnicity on antipsychotic prescribing quality in areas serving the largest proportions of Black patients in the UK. A cross-sectional survey with collection of multiple confounding factors potentially affecting outcomes in eight secondary care units in England over a three month period. Participants were Black or White inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose (expressed as a percentage of licensed maximum), high dose (being prescribed antipsychotic medication above maximum dose), polypharmacy (more than one antipsychotic prescribed), type (typical or atypical antipsychotic) and costs were the main outcome measures. Data were collected for 938 patients. There were no significant differences in any outcome by ethnicity: dose (adjusted percentage difference 0.97 [95% confidence interval (CI) -4.28, 6.22], p = 0.72); high dose (adjusted odds ratio (AOR) 0.98 [CI 0.63, 1.51], p = 0.92); polypharmacy prescribed (AOR 1.15 [CI 0.87, 1.51], p = 0.33); polypharmacy administered (AOR 1.08 [CI 0.78, 1.49], p = 0.66); use of typical antipsychotics (AOR 1.25 [CI 0.87, 1.79], p = 0.22); and cost (adjusted effect size 1.75 [CI -9.81, 13.31], p = 0.77). Antipsychotic prescribing practice did not differ between Black and White patients.

Shooting the messenger: the science and politics of ethnicity research

Scientific arguments showing 'how the world is' are fundamentally different from political assertions about 'how the world should be'. Ideologically motivated political attacks can hamper our understanding of mental disorders by preventing academics from pursuing research in contentious areas. Evidence should be countered by better evidence, not by shooting the messenger.

Ethnicity and quality of antipsychotic prescribing among in-patients in south London

Ethnicity may influence treatment decisions in mental disorders. We undertook a survey of the prescribing of antipsychotics for in-patients in three south London mental health trusts. A total of 255 patients (152 White, 103 Black) were included. Median dose of antipsychotic (% of licensed dose) was 58.3% for White and 50.0% for Black patients (adjusted effect size=0.14, 95% CI -0.34 to 0.63). High-dose antipsychotics were prescribed to 15.1% of White and 11.7% of Black patients (adjusted odds ratio (OR)=0.5, 95% CI 0.19-1.33), and antipsychotic polypharmacy was recorded for 25.7% and 31.1% respectively (adjusted OR=3.05, 95% CI 1.44-6.46). Prescribing quality was similar for Black and White patients.

High-dose and combination antipsychotic prescribing in acute adult wards in the UK: the challenges posed by p.r.n. prescribing

BACKGROUND

Clinical guidelines recommend the routine use of a single antipsychotic drug in a standard dose, but prescriptions for high-dose and combined antipsychotics are common in clinical practice.

AIMS

To evaluate the effectiveness of a quality improvement programme in reducing the prevalence of high-dose and combined antipsychotic prescribing in acute adult in-patient wards in the UK.

METHOD

Baseline audit was followed by feedback of benchmarked data and delivery of a range of bespoke change interventions, and then by a further audit 1 year later.

RESULTS

Thirty-two services participated, submitting data for 3,942 patients at baseline and 3,271 patients at the 1-year audit. There was little change in the prevalence of high-dose (baseline 36%; re-audit 34%) or combined antipsychotic prescribing (baseline 43%; re-audit 39%). As required ('p.r.n.') prescriptions were the principal cause of both high-dose and combined antipsychotic prescribing on both occasions.

CONCLUSIONS

The quality improvement programme did not have a demonstrable impact on prescribing practice in the majority of services. Future efforts to align practice with clinical guidelines need to specifically target the culture and practice of p.r.n. prescribing.