Psychotropic medication treatment patterns in community-dwelling schizophrenia in China: comparisons between rural and urban areas

Difficult-to-Engage Patients with Severe Mental Illness in Rural Community Settings: Results of the Greek Hybrid Assertive Community Treatment Model of Mental Healthcare

Background: Modified Assertive Community Treatment (ACT) in rural settings may be effective in the care of patients with severe mental illness (SMI) that are difficult to engage in community care. The objective of the present study was to explore the impact of the care by a hybrid ACT team on SMI patients' hospitalizations, length of hospital stay, symptomatology and functioning in a rural community treatment setting in Greece. Methods: The hybrid ACT team is an expansion of the services of the well-established generic Mobile Mental Health Unit in a rural area of Northwest Greece, and delivers home-based care for patients with SMI. This was a 3-year prospective, mirror image, pre-post observational study. Patients' symptomatology, functioning and general outcome were measured with the use of the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning Scale (GAF), and the Health of the Nation Outcome Scale (HοNOS). Results: The mean age of the 23 enrolled patients was 52.4 years and the mean age of disease onset was 23.5 years, with a mean number of hospitalizations 10.74. Over the 16-month follow-up patients' hospitalizations, both voluntary and involuntary, had been significantly reduced by almost 80%. Length of hospital stay had been significantly reduced by 87%, whereas patients' functioning and symptomatology had been significantly improved, by 17% and 14.5%, respectively. Conclusions: The model of hybrid ACT in rural areas in Greece may be effective in the treatment of difficult-to-engage patients with SMI and may improve patients' outcomes.

Hazardous use of benzodiazepine receptor agonists in psychiatric clinics in China: electronic prescription database study

BACKGROUND

Benzodiazepine receptor agonists (BZRAs) are commonly used clinically and data on their hazardous use from large populations of psychiatric patients is limited.

AIMS

To assess the current status of hazardous BZRA use and related factors in Chinese out-patient psychiatric settings.

METHOD

The study included out-patients with at least one BZRA prescription from five psychiatric settings in east, central and west China in 2018. Demographic and prescription information were extracted from the electronic prescription database. We defined the co-occurrence of overdose and long-term use as hazardous use, and patients whose recorded diagnoses did not meet any indications approved by the Chinese Food and Drug Administration as over-indication users. Additionally, 200 hazardous users were randomly selected for follow-up interview to confirm the actual situation.

RESULTS

Among 720 054 out-patients, 164 450 (22.8%) had at least one BZRA prescription; 55.9% of patients were prescribed over-indication and 3% were defined as hazardous users. Multilevel multivariate regression analysis with hospital as a random effect showed that factors associated with hazardous use were older age (18-64 years: β = 0.018; 95% CI 0.013-0.023; >65 years: β = 0.015; 95% CI 0.010-0.021), male (β = 0.005, 95% CI 0.003-0.007), over-indication (β = 0.013, 95% CI 0.012-0.015), more out-patient visits (β = 0.006, 95% CI 0.006-0.006) and more visits to different doctors (β = 0.007, 95% CI 0.007-0.008); 98.5% of hazardous users (197/200) could not be contacted.

CONCLUSIONS

BZRAs are commonly used and there is a relatively large proportion of over-indication users among Chinese psychiatric out-patients. However, only a small proportion of hazardous users were detected. The study highlights how to use prescription data to support improvements in clinical practice.

Influencing factors of multiple adverse outcomes among schizophrenia patients using count regression models: a cross-sectional study

BACKGROUND

Schizophrenia patients have increased risks of adverse outcomes, including violent crime, aggressiveness, and suicide. However, studies of different adverse outcomes in schizophrenia patients are limited and the influencing factors for these outcomes need clarification by appropriate models. This study aimed to identify influencing factors of these adverse outcomes by examining and comparing different count regression models.

METHODS

This study included schizophrenia patients who had at least one follow-up record in the Guangdong Mental Health Center Network Medical System during 2020. Three types of adverse outcomes were included: a) aggressiveness with police dispatch or violent crime, b) aggressiveness without police dispatch, and c) self-harm or suicide attempts. The incidence density of these adverse outcomes was investigated using the Poisson, negative binomial (NB), zero-inflated Poisson (ZIP), and zero-inflated negative binomial (ZINB) models, accordingly. The best model was chosen based on goodness-of-fit tests. We further analyzed associations between the number of occurrences of adverse outcomes and sociodemographic, clinical factors with the best model.

RESULTS

A total of 130,474 schizophrenia patients were enrolled. Adverse outcomes rates were reported to be less than 1% for schizophrenia patients in 2020, in Guangdong. The NB model performed the best in terms of goodness-of-fit and interpretation when fitting for the number of occurrences of aggressiveness without police dispatch, whereas the ZINB models performed better for the other two outcomes. Age, sex, and history of adverse outcomes were influencing factors shared across these adverse outcomes. Higher education and employment were protective factors for aggressive and violent behaviors. Disease onset aged ≥ 18 years served as a significant risk factor for aggressiveness without police dispatch, and self-harm or suicide attempts. Family history of mental diseases was a risk factor for self-harm or suicide attempts individually.

CONCLUSIONS

NB and ZINB models were selected for fitting the number of occurrences of adverse outcomes among schizophrenia patients in our studies. Influencing factors for the incidence density of adverse outcomes included both those shared across different types and those individual to specific types. Therefore, comprehensive and customized tools in risk assessment and intervention might be necessary.

Patterns and predictors of oral antipsychotic prescribing in adult patients with schizophrenia

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Research on psychotic disorders in rural areas: Recent advances and ongoing challenges

BACKGROUND

Research on patients with chronic psychotic disorders in rural areas is scarce. Those patients may not receive adequate mental health care. Mental health disparities among rural and urban areas have been recognized.

AIMS

This review aims to present the most recent research on psychotic disorders in rural areas.

METHOD

We conducted a search in the PubMed and Scopus databases. The search involved articles published over the last decade (2011-2020). All types of research design were included, if studies had used a controlled group of urban patients and reported on the differences among rural/urban residents with psychotic disorders. The focus of the review was on outcome and treatment.

RESULTS

A total of 12 studies were included in this review. Most have been conducted in China or India. Reports from Western countries are rare. Outcome studies showed that employment rates are significantly higher in rural patients, as well as rates of marriage in women. It is not clear what is the impact of those outcomes on patients' lives. The finding of lower cost of psychotic disorders in some rural areas, should be viewed with scepticism. Studies on treatment aspects suggested that rural patients were less likely to receive antipsychotics, antipsychotic combination or clozapine. Those results were attributed to limited access to specialized treatment. When rural patients receive specialized community care they seem to have better outcomes than urban patients.

CONCLUSION

There is an ongoing, but still scarce research on patients with chronic psychotic disorders in rural areas. Researchers pointed out the impact of socioeconomic inequalities on outcome and treatment, and stressed the importance of minimizing mental health disparities. These findings may have potential implications for future research; for the introduction of accessible, locally based mental health services in rural areas; and for political initiatives that would address poverty and social inequalities.

Antipsychotic Polypharmacy in Treatment of Schizophrenia; Should or Should Not?

Antipsychotics have been utilized as the standard treatment for schizophrenia regardless of illness phase where antipsychotic monotherapy (APM) is routinely recommended as the gold standard rather than antipsychotic polypharmacy (APP). However, approximately 20 to 40% of patients with schizophrenia do not respond to APM based on randomized controlled clinical trials and large practical clinical trials indicating that the subgroup of patients with schizophrenia would need differential treatment approaches beyond traditional treatment strategies such as APM. Numerous studies have supported the use of APP in particular for patients with certain clinical situations including: failure to show efficacy or tolerability from treatment with APM, need for different treatment for targeting specific symptom domains, severe illness, failure to treatment with clozapine, skepticism about following treatment guidelines, or cross titration periods. Furthermore, recent large cohort studies and practical clinical trials have proposed more benefits of APP rather than APM in terms of rehospitalization, mortality, and specific symptoms. APP has recently become more widely utilized and recognized as one of the next treatment strategies to clinicians for patients with schizophrenia. Some experts have already proposed the revision of treatment guidelines incorporating APP as evidence-based treatment option for certain patients with schizophrenia. Taken together, APP now deserves an evidence-based and acceptable treatment strategy, not an empirical or preferential treatment approach for treatment of schizophrenia in contemporary clinical practice.