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

Risk of renal impairment in atypical antipsychotics: a systematic review and meta-analysis

PURPOSE

Atypical antipsychotics are associated with several adverse effects including metabolic syndrome, weight gain, QTc interval prolongation, and extrapyramidal effects. This study aims to investigate the risk of renal impairment in patients receiving atypical antipsychotics.

METHODS

A systematic literature search was conducted via PubMed and Ovid SP and Web of Science to retrieve studies reporting the risk of renal impairment in patients receiving atypical antipsychotic treatment. The pooled risk ratio (RR) of renal impairment and the subgroup analysis was calculated using the random-effects generic inverse variance method in Cochrane Review Manager.

RESULTS

A total of 4 studies involving 514,710 patients (221, 873 patients on atypical antipsychotics/CKD and 292, 837 controls) were included in this meta-analysis. Patients on atypical antipsychotics exhibited an increased risk of renal impairment, with a pooled risk ratio of 1.34 (95%CI 1.23-1.47). Subgroup analysis demonstrated that atypical antipsychotic use was associated with an increased risk of both acute kidney injury (AKI) (RR 1.51, 95%CI 1.34-1.71) and chronic kidney disease (CKD) (RR: 1.23, 95%CI 1.12-1.35).

CONCLUSION

Patients receiving atypical antipsychotics have an increased risk of renal impairment. Quetiapine carries the highest risk of renal impairment encompassing both AKI and CKD.

Management of antipsychotics in primary care: Insights from healthcare professionals and policy makers in the United Kingdom

INTRODUCTION

Antipsychotic medication is increasingly prescribed to patients with serious mental illness. Patients with serious mental illness often have cardiovascular and metabolic comorbidities, and antipsychotics independently increase the risk of cardiometabolic disease. Despite this, many patients prescribed antipsychotics are discharged to primary care without planned psychiatric review. We explore perceptions of healthcare professionals and managers/directors of policy regarding reasons for increasing prevalence and management of antipsychotics in primary care.

METHODS

Qualitative study using semi-structured interviews with 11 general practitioners (GPs), 8 psychiatrists, and 11 managers/directors of policy in the United Kingdom. Data was analysed using thematic analysis.

RESULTS

Respondents reported competency gaps that impaired ability to manage patients prescribed antipsychotic medications, arising from inadequate postgraduate training and professional development. GPs lacked confidence to manage antipsychotic medications alone; psychiatrists lacked skills to address cardiometabolic risks and did not perceive this as their role. Communication barriers, lack of integrated care records, limited psychology provision, lowered expectation towards patients with serious mental illness by professionals, and pressure to discharge from hospital resulted in patients in primary care becoming 'trapped' on antipsychotics, inhibiting opportunities to deprescribe. Organisational and contractual barriers between services exacerbate this risk, with socioeconomic deprivation and lack of access to non-pharmacological interventions driving overprescribing. Professionals voiced fears of censure if a catastrophic event occurred after stopping an antipsychotic. Facilitators to overcome these barriers were suggested.

CONCLUSIONS

People prescribed antipsychotics experience a fragmented health system and suboptimal care. Several interventions could be taken to improve care for this population, but inadequate availability of non-pharmacological interventions and socioeconomic factors increasing mental distress need policy change to improve outcomes. The role of professionals' fear of medicolegal or regulatory censure inhibiting antipsychotic deprescribing was a new finding in this study.

Prevalence and Cost of Antipsychotic Prescribing, within the Context of Psycholeptic Prescribing, in the Irish Setting

Psycholeptic and specifically antipsychotic prescribing is increasing worldwide each year. This study aims to investigate the prevalence and cost of antipsychotic prescribing, within the wider frame of psycholeptic prescribing, in the Irish context. Quantitative analysis of a dataset from the Primary Care Reimbursement Service relating to cost and prescribing frequency of ATC Class N05 psycholeptic drugs from January 2020-August 2022 inclusive was conducted using Microsoft® Excel® for Microsoft 365 MSO (Version 2311) and STATA 18. Descriptive statistics and time-trend regression analysis were used to investigate the prescribing prevalence of psycholeptics and antipsychotics licensed for use in the Republic of Ireland, and the total cost per funding scheme. The prevalence of psycholeptic prescribing increased yearly from 2020-2022, peaking at 328,572 prescriptions in December 2020 with a total cost of psycholeptic drugs to the State in 2021 of €57,886,250, which was 0.5% of an increase on 2020. Over the 32-month time period, the average monthly cost of psycholeptic drugs was €4,436,469 on the General Medical Services (GMS) scheme and €369,154 on the Drug Payment Scheme (DPS). In 2021, quetiapine, olanzapine, and risperidone were the most prescribed antipsychotics, accounting for 66.58% of antipsychotics prescribed on the GMS scheme. This study identified the large expenditure on psycholeptics and antipsychotics in Ireland, with a higher proportion of the Irish healthcare budget spent on antipsychotics than that of the UK and the USA. The development of Irish antipsychotic prescribing guidelines may allow for structured, cost-effective prescribing.

Antipsychotic quetiapine alters the mouse fecal resistome by impacting antibiotic efflux, cell membrane, and cell wall synthesis genes

IMPORTANCE

This study significantly contributes to our understanding of how certain medications can unintentionally contribute to a major global health issue, i.e., antibiotic resistance. Quetiapine, a widely used antipsychotic medication, was found to increase key resistance mechanisms of gut bacteria to antibiotics in mice. Specifically, these data suggest that quetiapine may target elements of the bacterial cell membrane. If similar effects are found in humans, this medicine could unexpectedly make it harder to treat certain infections. This research emphasizes the importance of being mindful about not just antibiotics themselves, but also about other medications that could inadvertently contribute to this problem. Ultimately, these findings underline the necessity for more in-depth research on the broader impact of pharmaceuticals.

Five-year trend of antipsychotic prescription practices in a district Hospital in Ghana: A retrospective study

INTRODUCTION

Antipsychotics are the mainstay treatment for psychotic conditions. Their prescription, however, should come with some caution since the consequences of their side effects can be dire for the patient receiving the prescription. Because of inadequate experts in low-middle-income countries, non-experts are trained through the Mental Health Gap Action Program (MHGAP) to reduce the treatment gap. This retrospective study analyzed the trend of antipsychotic prescriptions in a district hospital where mental health services are delivered by non-experts.

METHODOLOGY

This was a retrospective descriptive study that gathered data between 2015 and 2019 from the electronic database of the hospital. Statistical analysis was conducted using SPSS version 20. We reported the descriptive statistics of our findings in the form of frequencies and percentages.

RESULTS

There was a year-on-year increase in antipsychotic prescriptions over the study period. Starting with 48.1% in 2015 to 56.4% in 2019. The main condition for which antipsychotics were prescribed was psychosis (58.6%), followed by substance use disorder (SUD) (26%). Patients with age ≥ 50 received the most prescription of antipsychotics. Starting from 2015, there was a high percentage of typical antipsychotic prescriptions (90.14%) with atypical antipsychotics being 9.86% and by 2019 atypical antipsychotic prescriptions had shot up to 74.8%. Polypharmacy prescription rate was 8.1% over the study period.

CONCLUSION

Antipsychotics are essential in the treatment of psychosis and other mental health conditions. Prescribers need to know more about these drugs to prescribe them appropriately and to minimize the likelihood of side effects among patients who use these drugs.

Clinical Presentation and Management of Acute Dystonia from Drug Abuse or Misuse in Adolescents and Young Adults: A Retrospective Cohort Study in Bangkok, Thailand

Objectives

To describe the clinical presentation of acute dystonia (AD) from drug abuse or misuse, as well as the emergency department (ED) management and outcomes in adolescents and young adults.

Methods

This was a retrospective cohort study of patients aged 10-25 years who were admitted to the ED for AD due to intentional abuse or misuse from January 1, 2014, to June 30, 2017. Data were collected from electronic medical records by three investigators with excellent interrater reliability (0.87).

Results

Sixty-two cases met the criteria with male predominance (85.5%); the mean age was 16.7 years. Perphenazine was the most common cause of AD (38.7%), followed by haloperidol (32.2%). The most common AD manifestations were torticollis (51.6%), oromandibular dystonia (45.2%), and oculogyric crisis (22.6%). Intravenous (IV) diazepam combined with oral trihexyphenidyl and IV diazepam alone were the most frequently used first treatment in our ED (41.7% and 35.0%, respectively). Overall, the improvement rates from IV diazepam alone or combined with trihexyphenidyl ranged from 46.2%-75.0%. These rates were inferior to those observed with IV benztropine (100%) alone or combined with trihexyphenidyl. All patients were treated on an outpatient basis, except for one who was admitted to a pediatric ward.

Conclusions

In recent years, drug-induced AD caused by intentional abuse among adolescents and young adults has become a concern in Thailand. The most common suspected drugs of abuse were first-generation antipsychotics, perphenazine, and haloperidol. The most effective treatment was benztropine.

Adherence to Typical Antipsychotics among Patients with Schizophrenia in Uganda: A Cross-Sectional Study

BACKGROUND

There has been a recent transition from typical to atypical antipsychotics in managing schizophrenia. This has been attributed to the acute side effects experienced by patients on typical antipsychotics that lead to nonadherence. However, the treatment cost with typical antipsychotics is cheaper (preferred in low-income settings), and there is no difference in the effectiveness, efficacy, discontinuation rate, or side effect symptom burden with atypical antipsychotics. This study is aimed at determining the prevalence of nonadherence and the associated factors to typical antipsychotics among patients with schizophrenia attending a psychiatric outpatient clinic at a rural tertiary facility in Uganda.

METHOD

A cross-sectional study among 135 patients with schizophrenia for at least six months on typical antipsychotics (mean age of 39.7 (±11.9) and 55.6% were female) from a rural tertiary facility in Uganda. Data were collected regarding sociodemographics, adherence, insight for psychosis, attitude towards typical antipsychotics, side effects, satisfaction with medications, and explanations from health workers about medications and side effects. Logistic regression was used to determine the factors associated with nonadherence.

RESULTS

The prevalence of nonadherence was 16.3%, and the likelihood of being nonadherent was more among the poor (monthly earning below the poverty line). However, having reduced energy was associated with reducing the likelihood of having nonadherence.

CONCLUSION

The prevalence of nonadherence was lower than many previously obtained prevalence and was comparable to nonadherence for atypical antipsychotics. However, to reduce nonadherence, we need all stakeholders (such as the government, insurance companies, and caregivers) to assist patients living in poverty with access to medication.

Two New HPLC Methods, Assessed by GAPI, for Simultaneous Determination of Four Antipsychotics in Pharmaceutical Formulations: A Comparative Study

Antipsychotics are widely used to treat various mental disorders. Combination therapies were approved by the FDA to treat manic states. Quetiapine fumarate, aripiprazole, asenapine maleate, and chlorpromazine HCl are frequently used for treatment of these disorders. Green analytical chemistry is primarily concerned with reducing waste generated during sample preparation or analysis. Green solvents, such as ethanol, are being used in HPLC as an alternative to acetonitrile. To this purpose, two new chromatographic methods were developed to determine these four drugs simultaneously in their bulk and pharmaceutical formulations. The greenness of both methods was assessed by the green analytical procedure index (GAPI)—one of them was found to be green ecofriendly, and the other had some environmental hazards (conventional)—and this helps laboratories to choose a method that suits their capabilities. The chromatographic separation for both methods was carried out on a Thermo® C18 column. The total separation times were about 11 min and 9 min for the green and the conventional methods, respectively. Using the Student’s t-test and the F-ratio, there was no significant difference between the results of the two methods. These methods have been validated and successfully applied to the analysis of commercial pharmaceutical formulations. Our study could successfully be used in central quality control laboratories, which need a single analytical method to separate more than one compound with similar pharmacological action.

The Atypical Antipsychotic Quetiapine Promotes Multiple Antibiotic Resistance in Escherichia coli

Atypical antipsychotic (AAP) medication is a critical tool for treating symptoms of psychiatric disorders. While AAPs primarily target dopamine (D2) and serotonin (5HT2A and 5HT1A) receptors, they also exhibit intrinsic antimicrobial activity as an off-target effect. Because AAPs are often prescribed to patients for many years, a potential risk associated with long-term AAP use is the unintended emergence of bacteria with antimicrobial resistance (AMR). Here, we show that exposure to the AAP quetiapine at estimated gut concentrations promotes AMR in Escherichia coli after 6 weeks. Quetiapine-exposed isolates exhibited an increase in MICs for ampicillin, tetracycline, ceftriaxone, and levofloxacin. By whole-genome sequencing analysis, we identified mutations in genes that confer AMR, including the repressor for the multiple antibiotic resistance mar operon (marR), and real-time reverse transcription-quantitative PCR (RT-qPCR) analysis showed increased levels of marA, acrA, and tolC mRNAs and reduced levels of ompF mRNA in the isolates carrying marR mutations. To determine the contribution of each marR mutation to AMR, we constructed isogenic strains carrying individual mutant marR alleles in the parent background and reevaluated their resistance phenotypes using MIC and RT-qPCR assays. While marR mutations induced robust activity of the mar operon, they resulted in only modest increases in MICs. Interestingly, although these marR mutations did not fully recapitulate the AMR phenotype of the quetiapine-exposed isolates, we show that marR mutations promote growth fitness in the presence of quetiapine. Our findings revealed an important link between the use of AAPs and AMR development in E. coli. IMPORTANCE AAP medication is a cornerstone in the treatment of serious psychiatric disease. The AAPs are known to exhibit antimicrobial activity; therefore, a potential unintended risk of long-term AAP use may be the emergence of AMR, although such risk has received little attention. In this study, we describe the development of multidrug antibiotic resistance in Escherichia coli after 6 weeks of exposure to the AAP quetiapine. Investigation of mutations in the marR gene, which encodes a repressor for the multiple antibiotic resistance (mar) operon, reveals a potential mechanism that increases the fitness of E. coli in the presence of quetiapine. Our findings establish a link between the use of AAPs and AMR development in bacteria.

Temporal trends in associations between severe mental illness and risk of cardiovascular disease: A systematic review and meta-analysis

BACKGROUND

Severe mental illness (SMI; schizophrenia, bipolar disorders (BDs), and other nonorganic psychoses) is associated with increased risk of cardiovascular disease (CVD) and CVD-related mortality. To date, no systematic review has investigated changes in population level CVD-related mortality over calendar time. It is unclear if this relationship has changed over time in higher-income countries with changing treatments.

METHODS AND FINDINGS

To address this gap, a systematic review was conducted, to assess the association between SMI and CVD including temporal change. Seven databases were searched (last: November 30, 2021) for cohort or case-control studies lasting ≥1 year, comparing frequency of CVD mortality or incidence in high-income countries between people with versus without SMI. No language restrictions were applied. Random effects meta-analyses were conducted to compute pooled hazard ratios (HRs) and rate ratios, pooled standardised mortality ratios (SMRs), pooled odds ratios (ORs), and pooled risk ratios (RRs) of CVD in those with versus without SMI. Temporal trends were explored by decade. Subgroup analyses by age, sex, setting, world region, and study quality (Newcastle-Ottawa scale (NOS) score) were conducted. The narrative synthesis included 108 studies, and the quantitative synthesis 59 mortality studies (with (≥1,841,356 cases and 29,321,409 controls) and 28 incidence studies (≥401,909 cases and 14,372,146 controls). The risk of CVD-related mortality for people with SMI was higher than controls across most comparisons, except for total CVD-related mortality for BD and cerebrovascular accident (CVA) for mixed SMI. Estimated risks were larger for schizophrenia than BD. Pooled results ranged from SMR = 1.55 (95% confidence interval (CI): 1.33 to 1.81, p < 0.001), for CVA in people with BD to HR/rate ratio = 2.40 (95% CI: 2.25 to 2.55, p < 0.001) for CVA in schizophrenia. For schizophrenia and BD, SMRs and pooled HRs/rate ratios for CHD and CVD mortality were larger in studies with outcomes occurring during the 1990s and 2000s than earlier decades (1980s: SMR = 1.14, 95% CI: 0.57 to 2.30, p = 0.71; 2000s: SMR = 2.59, 95% CI: 1.93 to 3.47, p < 0.001 for schizophrenia and CHD) and in studies including people with younger age. The incidence of CVA, CVD events, and heart failure in SMI was higher than controls. Estimated risks for schizophrenia ranged from HR/rate ratio 1.25 (95% CI: 1.04 to 1.51, p = 0.016) for total CVD events to rate ratio 3.82 (95% CI: 3.1 to 4.71, p < 0.001) for heart failure. Incidence of CHD was higher in BD versus controls. However, for schizophrenia, CHD was elevated in higher-quality studies only. The HR/rate ratios for CVA and CHD were larger in studies with outcomes occurring after the 1990s. Study limitations include the high risk of bias of some studies as they drew a comparison cohort from general population rates and the fact that it was difficult to exclude studies that had overlapping populations, although attempts were made to minimise this.

CONCLUSIONS

In this study, we found that SMI was associated with an approximate doubling in the rate ratio of CVD-related mortality, particularly since the 1990s, and in younger groups. SMI was also associated with increased incidence of CVA and CHD relative to control participants since the 1990s. More research is needed to clarify the association between SMI and CHD and ways to mitigate this risk.

Analysis of the prescription pattern of psychotropics in an outpatient department of a general hospital psychiatry unit

BACKGROUND

World Health Organization has prescribed drug use indicators for evaluating rational prescribing. Very few studies have been conducted on rational prescriptions for psychotropic drugs; hence, this study was undertaken at a tertiary care center of North India.

METHODS

After obtaining approval of the Institutional Ethics Committee, all prescriptions deposited with the dispensary of the psychiatry department of the hospital between 01 October 2017 and 31 December 2017 were included in the study. The prescriptions were analyzed for drug use indicators, namely the average number of drugs per encounter, percentage of prescriptions with generic name, percentage of prescriptions from the essential drug list, percentage of prescriptions with antibiotics, and percentage of prescriptions with an injection. In addition, the prescriptions were analyzed for patterns of psychotropics prescribed.

RESULTS

A total of 3770 prescriptions were analyzed. On an average, 2.35 medicines were prescribed per prescription. Injectable comprised 2.39% of prescriptions and fixed drug combinations were 0.16% of the total. Of all prescriptions, 91.3% were by generic name, while 55.02% of prescriptions were from the essential drug list. Polypharmacy constituted 4.53% of prescriptions. Risperidone, escitalopram, sodium valproate, and clonazepam were the most commonly prescribed drugs.

CONCLUSION

While we fared well with respect to the percentage of prescriptions with injections and those with an antibiotic, we have not been able to achieve the prescribed standards in prescription with generic names, number of drugs per prescription, and prescriptions from the essential drug list. The study emphasizes that there is scope for improvement.

Systemic medicines taken by adult special care dental patients and implications for the management of their care

Introduction Significant changes have taken place in the profile of prescription medicines being taken by the adult UK population over the last decade. The aims of this article are to review the literature to understand the overall trends and underlying factors, and then to compare this with the medication profile of a cohort of adult special care dental (SCD) patients. Materials and method Five hundred patient records were examined and retrospective data on systemic medicines being taken were obtained and classified according to the index used in the British National Formulary (BNF).Results The results revealed a high level of polypharmacy with 57% of SCD patients taking three or more medicines compared to 24% of the population in England. Antiepileptic drugs were the most frequently taken group of medicines (42%), followed by antidepressants (39.7%) and antipsychotics (37.6%). Conclusions Our results demonstrate the medical complexity of patients in this cohort and enable clinicians to increase their familiarity with the most commonly taken medicines and the tools available to manage the implications for dental care.

Sex Selection Bias in Schizophrenia Antipsychotic Trials—An Update Systematic Review

The lack of female participation in antipsychotic trials for schizophrenia poses an important issue regarding its applicability, with direct and real-life repercussions to clinical practice. Here, our aim is to systematically review the sampling sex bias among randomized clinical trials (RCTs) of second-generation antipsychotics—namely risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole—as an update to a previous 2005 review. We searched MEDLINE and the Cochrane database for studies published through 7 September 2020 that assessed adult samples of at least 50 subjects with a diagnosis of schizophrenia, schizophrenia spectrum disorder, or broad psychosis, in order to investigate the percentage of women recruited and associated factors. Our review included 148 RCTs, published from 1993 to 2020, encompassing 43,961 subjects. Overall, the mean proportion of women was 34%, but only 17 trials included 50% or more females. Younger samples, studies conducted in North America, pharmaceutical funding and presence of specific exclusion criteria for women (i.e., pregnancy, breast-feeding or lack of reliable contraceptive) were associated with a lower prevalence of women in the trials. Considering the possible different effects of antipsychotics in both sexes, and our lack of knowledge on the subject due to sampling bias, it is imperative to expand actions aimed at bridging this gap.

Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection

BACKGROUND

Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia. Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing.

METHODS

The study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care. Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice. The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults.

RESULTS

We included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18. The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing. Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic.

CONCLUSIONS

The levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.

Examining the dispensing patterns of antipsychotics in Australia from 2006 to 2018 - A pharmacoepidemiology study

BACKGROUND

Antipsychotic medications can be prescribed in Australia by medical and nurse practitioners under the Pharmaceutical Benefits Scheme (PBS). The current pharmacoepidemiology study aims to determine the dispensing rates of antipsychotic medicines in Australia, and to produce and examine a time-trend of the dispensing patterns of these medicines.

METHODS

Dispensing counts of antipsychotic medication from 2006 to 2018 were accessed from the PBS dataset. All of the antipsychotic medicines dispensed were included for time trend analysis. Cumulative dispensing counts and defined daily dose (DDD) per 1000 concessional population days (DPD) were analysed for the purpose of time trend analysis.

RESULTS

Sixteen antipsychotic medications were assessed and had a total cumulative dispensing count of 33, 732, 404. Olanzapine had the highest cumulative prescription count and Quetiapine experienced the highest average dispensing count and rate as determined by DPD. Twelve out of the sixteen medications were second-generation antipsychotics (SGAs). Overall, eleven out of the sixteen medications (aripiprazole, asenapine, brexpiprazole, clozapine, flupentixol, lurasidone, olanzapine, paliperidone, quetiapine, ziprasidone, zuclopenthixol) had an increase in both dispensing count and rate, as expressed per DPD.

CONCLUSIONS

The current study highlights the increasing prescription rates of SGAs and the stagnation of FGA prescription among Australian health practitioners. This is observed through particularly large increase in the dispensing rates of Olanzapine and Quetiapine. Further interdisciplinary investigation is required to ensure that these medications are being prescribed under the appropriate medical rationale, particularly to groups that are vulnerable to the adverse effects of the medications.

Understanding increasing rates of psychiatric hospital detentions in England: development and preliminary testing of an explanatory model

BACKGROUND

The steep rise in the rate of psychiatric hospital detentions in England is poorly understood.

AIMS

To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions.

METHOD

Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions.

RESULTS

Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers.

CONCLUSIONS

Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.

Signals of Adverse Drug Reactions of Paliperidone Compared to Other Atypical Antipsychotics Using the Korean Adverse Event Reporting System Database

BACKGROUND AND OBJECTIVES

Schizophrenia is a severe public health problem and one of the top ten causes of disability, affecting about 1.1% of the world's population. Paliperidone is a new atypical antipsychotic used to treat schizophrenia. Several case reports about unexpected adverse drug reactions of paliperidone have been consistently reported around the world. The purpose of this study was to detect signals of adverse events (AEs) after paliperidone treatment using the Korea Institute of Drug Safety and Risk Management-Korea Adverse Event Reporting System database (KIDS-KD).

METHODS

We applied data-mining techniques based on a disproportionality analysis to KIDS-KD consisting of spontaneously reported AE reports related to atypical antipsychotics between January 2009 and December 2018. We calculated three data-mining indices of paliperidone compared to all other atypical antipsychotics. We defined signals that satisfied all three criteria of the indices. We checked if the signals identified were included in the drug labels for South Korea, the USA, the UK, Japan, Germany, and France.

RESULTS

The total number of suspected AE reports related to all atypical antipsychotics in the KIDS-KD from January 2009 to December 2018 was 43,970. Among those, the number of AE reports related to paliperidone was 9453. Overall, 13 signals such as seborrhea, hallucination, obesity, gingivitis, and intervertebral disorder were classified into newly detected meaningful signals.

CONCLUSION

We detected new AE signals of paliperidone that were not listed on the drug labels of six countries, and many that were related to psychotic symptoms, metabolic problems, and endocrine disorders.

Epidemiology of schizophrenia and its management over 8-years period using real-world data in Spain

BACKGROUND

Real-World Data (RWD) studies provide important insights in disease epidemiology, in real clinical populations, with long follow-up periods. The aim of the present study was to describe the epidemiology of schizophrenia spectrum disorders (SD) during an 8-year period in Spain.

METHODS

A retrospective cohort of subjects aged 15 to 64 years was followed-up using electronic healthcare databases of the Valencia region (2008-2015). SD cases included outpatient and inpatient settings (ICD 9 codes 295.XX). Prevalence of SD was assessed. Incidence rate (IR) in the subpopulation aged between 15 and 34 years was also provided. Healthcare utilization (HCU) rates, including outpatient, specialists, hospitalizations and antipsychotic dispensations were estimated.

RESULTS

The cohort included 3,976,071 subjects; 24,749 of them had a prevalent diagnosis of SD. The overall prevalence for SD was 6.2 per 1000 persons. SD were 76% more prevalent in men than women. IR in the subpopulation aged between 15 and 34 years was 50.25 per 100,000 persons years and was more than 2 times higher for men than for women. 83.4% of the overall outpatient visits from the cohort of patients were related to SD. The 21,095 overall hospitalizations with the SD code resulted in 286,139 days of hospitalization, with a median of 4 days (IQR: 1.6-9.2) per person-year. 93.2% of subjects diagnosed with SD were ever treated with some antipsychotic drug during the study period, and 70% of the patients were ever treated with antipsychotic polypharmacy.

CONCLUSIONS

This large population-based study using RWD provides novel and recent information SD in a southern European country. The prevalence and IR of SD showed is greater than previously published and higher in men than in women. The fact of having used a large arsenal of electronic data (including outpatient and inpatient) for 8 years may have influenced. SD represents high burden and healthcare utilization. Contrary to guidelines recommendations the majority of patients were ever treated with antipsychotic polypharmacy.

A thematic analysis assessing clinical decision-making in antipsychotic prescribing for schizophrenia

BACKGROUND

In recent decades atypical antipsychotics have increased treatment options available for schizophrenia, however there is conflicting evidence concerning the trade-off between clinical efficacy and side effects for the different classes of antipsychotics. There has been a consistent increase in atypical antipsychotic prescribing compared to typical, despite evidence showing that neither class is superior. This leads to the question of whether prescribers are selective in their uptake of research evidence and clinical guidelines and if so, what influences their choice.. This study aims to identify the factors that contribute to the prescribing choice and how these can be used to aid knowledge translation and guideline implementation.

METHODS

A thematic analysis study was conducted using data from 11 semi-structured interviews with clinicians with experience in prescribing for schizophrenia.

RESULTS

The analysis identified five themes underpinning prescribing behaviour: (1) ownership and collaboration; (2) compromise; (3) patient involvement; (4) integrating research evidence; and (5) experience.

CONCLUSION

The themes mapped to various degrees onto current models of evidence-based decision making and suggest that there is scope to re-think the guideline implementation frameworks to incorporate recurring themes salient to clinicians who ultimately use the guidelines. This will further translation of future evidence into clinical practice, accelerating clinical progress.