Patterns of hypnotic medication use for sleep disturbance amongst hospital inpatients

The impact of COVID-19 on benzodiazepine usage in psychiatric inpatient units

OBJECTIVE

This study aims to investigate whether COVID-19 has led to increased usage of benzodiazepines in acute psychiatric settings.

METHOD

We evaluated the rates of benzodiazepine usage in two acute psychiatric inpatient units over a period of two years, 2019 and 2020 (the year of the pandemic). Rates of oral atorvastatin usage over the same period were used as a comparator.

RESULTS

We saw a significant increase in the usage of benzodiazepines in the period between April and December 2020 compared to the same period in 2019 despite a decline in the total number of admissions in 2020. Usage peaked further at the time of eased pandemic restrictions which coincided with higher rates of emergency department mental health (MH) presentations and acute MH hospital admissions. We also noticed higher rates of substance use disorder recorded on admission. Hospital leave restrictions due to COVID-19 also led to further restrictions on smoking.

CONCLUSION

Benzodiazepine usage increased in the context of the COVID-19 pandemic. The study encourages more research to better understand the impact of the pandemic on acute psychiatric settings.

Sleep at night and association to aggressive behaviour; Patients in a Psychiatric Intensive Care Unit

Evaluations of associations between sleep at night and aggressive behaviour in Psychiatric Intensive Care Units (PICU) are lacking. The aims were to explore if sleep duration or night-to-night variations in sleep duration correlated with aggressive behaviour and aggressive incidents the next day and through the whole admission. Fifty consecutive patients admitted to a PICU were included (521 nights) and the nurses registered the time patients were sleeping, aggressive behaviour with The Brøset Violence Checklist (BVC) and aggressive incidents with The Staff Observation Aggression Scale-Revised (SOAS-R). At admission, short sleep duration the first night correlated with aggressive behaviour the next day and admissions with violent incidents had a median of 4.0 h difference in sleep from night one to night two compared to 2.1 h for the rest of the admissions. During the stay, large absolute difference in sleep duration between two nights correlated with aggressive behaviour the next day and short sleep duration was associated with violent incidents. Short sleep duration and night-to-night variations in sleep duration are both associated with increased risk for aggression in PICUs. This observation might help to predict and prevent aggressive incidents.

A point prevalence study of the use of psychotropic medication in an acute general hospital

BACKGROUND

There are high rates of cognitive problems and organic and functional psychiatric disorders in patients admitted to general hospital wards, which may necessitate the use of psychotropic medications. There is evidence of over-prescription of medications such as antipsychotics and antidepressants in community settings such as residential care. However, the prevalence of psychotropic use in general hospitals is unknown.

METHODS

A point prevalence study of the use of psychotropic medications in an acute general hospital was conducted by auditing medication charts for type, dose, indication, and other clinical processes associated with their use.

RESULTS

The files of 197 patients were audited, 139 (70%) were aged 65 years and over. Eighty-nine (45%) of patients were prescribed a psychotropic, with 35 (17.7%) antidepressants; 21 (11%) antipsychotics; 19 (10%) benzodiazepines; six (3%) mood stabilizer; five (2%) cholinesterase inhibitors; one (0.5%) anti-parkinsonian medication, and one (1%) patient on zolpidem and another patient melatonin (1%). Most prescriptions (72%) were in people 65 years and over and 27 (20%) of indications were found to be off label prescribing. There were deficits in the documentation of indications for the use of psychotropic medications and follow up arrangements.

CONCLUSIONS

Rates of benzodiazepines use were less than that reported incomparable settings. Concerns regarding off label prescribing, under-dosing, and lack of adequate documentation of indications and follow-up instructions were raised. Given the potential adverse effects of psychotropic medication, improved governance, and education regarding their use is required.

Sleep patterns as a predictor for length of stay in a psychiatric intensive care unit

Systematic evaluations of the relationship between sleep patterns and length of stay in psychiatric intensive care units (PICUs) are lacking. The aims of the present study were to explore if sleep duration or night-to-night variations in sleep duration the first nights predict length of stay in a PICU. Consecutive patients admitted to a PICU were included (N=135) and the nurses registered the time patients were observed sleeping. In the three first nights, the mean sleep duration was 7.5 (±3.2)h. Sleep duration the first night correlated negatively with the length of stay for patients with schizophrenia. The mean difference in sleep duration from night one to night two were 3.3 (±3.0)h and correlated with length of stay for the whole group of patients, but especially for patients with schizophrenia. Patients of all diagnostic groups admitted to a PICU had pronounced intra-individual night-to-night variations in sleep duration. Stabilizing night-to-night variations of sleep duration might be a major goal in treatment.

'Is it the crime of the century?': factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives

Given the longstanding controversy about hypnosedative use, we aimed to investigate the attitudes of prescribing psychiatrists and service users towards long-term use of hypnosedative medication, and their perceptions of barriers to evidence-based nonmedication alternatives. Qualitative data from focus groups in Aotearoa/NZ were analysed thematically. A novel research design involved a service user researcher contributing throughout the research design and process. Service users and psychiatrists met to discuss each other's views, initially separately, and subsequently together. Analysis of the data identified four key themes: the challenge, for both parties, of sleep disturbance among service users with mental health problems; the conceptual and ethical conflicts for service users and psychiatrists in managing this challenge; the significant barriers to service users accessing evidence-based nonmedication alternatives; and the initial sense of disempowerment, shared by both service users and psychiatrists, which was transformed during the research process. Our results raise questions about the relevance of the existing guidelines for this group of service users, highlight the resource and time pressures that discourage participants from embarking on withdrawal regimes and education programmes on alternatives, highlight the lack of knowledge about alternatives and reflect the complex interaction between sleep and mental health problems, which poses a significant dilemma for service users and psychiatrists.

Patterns of psychotropic medication prescriptions by psychiatrists for private clinic outpatients in kerman province, iran

OBJECTIVES

The aim of this study was to assess the pattern and utilisation of psychotropic drug prescriptions by psychiatrists in Kerman Province, Iran.

METHODS

The prescriptions of 27 psychiatrists were randomly selected from two Iranian public insurance organisations and were analysed for the mean number of drugs/prescriptions, drug category and the most frequently prescribed drug in each category as well as overall.

RESULTS

A total of 6,414 prescriptions were analysed. The mean number of drugs per prescription was 2.9. Antidepressants (61.0%) were the most frequently prescribed category of psychotropic medications, followed by antipsychotics (29.5%), sedative/hypnotics or anti-anxiety drugs (27.5%) and mood stabilisers (18.5%). The combination of antidepressants with antipsychotics was the most commonly prescribed combination (18.8%). Fluoxetine (16.5%) and trifluoperazine (13.5%) were among the most frequently prescribed antidepressants and antipsychotics, respectively. Clonazepam (10.5%) was the most commonly prescribed benzodiazepine agent, followed by alprazolam (8.5%). In terms of total drug utilisation, sertraline (12.4%) was the most commonly used psychotropic medication followed by fluoxetine (9.7%), trifluoperazine (6.6%), propranolol (4.5%) and clonazepam (3.7%).

CONCLUSION

A high proportion of psychotropic prescriptions in Kerman Province were for antidepressants, followed by antipsychotics and the benzodiazepines. Further research is needed to determine the underlying correlation between prescription practice and the diagnosis and patient characteristics, as well as to investigate the use of different psychotropic medications.

'Out of the frying pan': the challenges of prescribing for insomnia in psychiatric patients

OBJECTIVES

Managing insomnia is a common challenge for psychiatrists and their patients. We have observed an increasing use of quetiapine as a hypnosedative.

METHODS

We conducted an audit with the aim of establishing the prescribing patterns of local general psychiatrists in New Zealand, comparing them with established guidelines and determining the extent of the prescribing of quetiapine as a hypnosedative. Participant psychiatrists were recruited from peer review groups. Each participant provided anonymised prescribing information from 10 patients and noted their intention when prescribing.

RESULTS

Twenty-five clinicians (58% response rate) responded with prescriptions for 100 in-patients and 177 community mental health patients. 60% of in-patients and 62% of community patients were prescribed medications to aid with sleep. The most commonly prescribed medications were zopiclone, quetiapine and benzodiazepines. Prescribing adhered with the recommended guidelines for 20% of benzodiazepine and 35% of zopiclone prescriptions. Two thirds (60%) of the community prescriptions for quetiapine were primarily for hypnosedation.

CONCLUSIONS

There is little concordance between guidelines for hypnosedative prescribing and the practices of general psychiatrists. Less zopiclone and fewer benzodiazepines were prescribed than in other studies, while more quetiapine was prescribed. The 'off-label' use of quetiapine and the duration of zopiclone and benzodiazepine use are discussed.