Clinical use of high-dose neuroleptics

Correlates of high-dose antipsychotic prescription amongst outpatients with Schizophrenia in a Nigerian Hospital

Background

Treatment guidelines recommend the use of antipsychotic monotherapy at effective doses for the treatment of schizophrenia, although about a third of the sufferers still receive high-dose antipsychotic treatment. Current evidence suggests that high-dose antipsychotic prescription (HDAP) not only fails to improve outcomes but also increases side effects.

Aim

Our study aimed to determine the prevalence of HDAP and its association with illness severity, medication adherence behaviour and side effects amongst outpatients with schizophrenia.

Setting

The Federal Neuro-Psychiatric Hospital, Benin-City, Nigeria.

Methods

A cross-sectional study of 320 attendees with schizophrenia at the outpatient department was undertaken. We administered a sociodemographic and antipsychotic medication questionnaire, Mini-International Neuropsychiatric Interview, Positive and Negative Syndrome Scale, Liverpool University Neuroleptic Side Effects Rating Scales and Medication Adherence Rating Scales. High-dose antipsychotic prescription was determined by the ratio of prescribed daily dose to defined daily dose greater than 1.5.

Results

The prevalence of HDAP was 38.4%. Greater severity of illness, experiencing more side effects and poor medication adherence were significantly associated with HDAP.The major predictors of HDAP were antipsychotic polypharmacy and concurrent anticholinergic use.

Conclusion

We conclude that although the use of HDAP amongst patients with schizophrenia remains common, its persistent use should be discouraged.

High-dose antipsychotic medication

The dopamine hypothesis for the mode of action of antipsychotic drugs has been with us for some 30 years and has, by and large, withstood the test of time. It simply states that antipsychotic drugs owe their therapeutic effects to an ability to block central dopamine receptors. This has given us a working and testable explanation for the effects of these drugs and it has prompted the synthesis of new agents. While so-called antipsychotic drugs (otherwise known as neuroleptics or major tranquillisers) are known to be effective in schizophrenia and related psychoses, mania, and the agitation associated with severe depressive illness or organic disorder, this paper is only concerned with the pharmacotherapy of schizophrenia.

High-dose antipsychotic treatment in clinical practice

Aims and method

A trust-wide audit of antipsychotic prescription was conducted in order to investigate the prevalence of high-dose treatment in a population with schizophrenia and assess compliance with Royal College of Psychiatrists' guidelines on the use of high doses. Details of antipsychotic medication were recorded and in cases of high-dose treatment compliance with the College's guidelines was assessed.

Results

Sixteen out of 361 patients (4%) were receiving high-dose medication. At re-audit this figure fell to four patients (1%). High-dose treatment comprised of a combined depot and oral medication in most cases. There was poor compliance with the College's guidelines.

Clinical implications

The study stresses the importance of monitoring patients on high-dose antipsychotics, particularly when taken in combination.

Change in neuroleptic prescribing practice

Concerns about the use of high doses of neuroleptic medication prompted an audit of prescriptions of these drugs in a large psychiatric hospital. Following an initial audit in 1991 of 196 patients, a follow-up of 192 patients was undertaken in 1993. A significant reduction in levels of neuroleptic medication was found, although doses still tended to remain high.

Neuroleptic drug use in psychiatric intensive therapy units: problems with complying with the consensus statement

The pharmacological management of acute behavioural disturbance in psychosis is not straightforward. The real, or perceived, dose:effect relationship of the various neuroleptics in common use has an important influence on prescribing patterns leading, in certain situations, to very high doses of neuroleptic medication being prescribed. Data from a study of the use of neuroleptic medication in two psychiatric intensive therapy units illustrate the potential extent of the problem. Over half of the cases were not amenable to accurate dosage monitoring due to the use of depot neuroleptics, Clopixol Acuphase or polypharmacy. The majority received doses exceeding the limit suggested by the British National Formulary. Efforts to standardise the use of such drugs would help to optimise the clinical management of this challenging group of patients.

High-dose antipsychotic medication

We audited the use of high-dose antipsychotic drugs in patients admitted to a special (intensive) care unit over two periods. Five out of 57 patients in the first sample and three out of 62 in the second were treated with a single antipsychotic drug above the British National Formulary maximum dose. The proportion of patients treated with antipsychotic drugs such that the total dose in chlorpromazine equivalents was greater than 1000 mg, fed. The audit showed improvements in clinical practice, particularly with respect to the onset of, indication for and outcome of high-dose treatment and in monitoring the patients' physical status.

Monitoring of patients on high dose antipsychotic medication

In the light of recently published Royal College of Psychiatrists' guidelines on the use of high dose antipsychotic medication, electrocardiographic and blood investigations were performed on 11 patients with learning disabilities receiving such treatment. All patients had normal electrocardiograms (ECGs). Four patients had asymptomatic low white cell counts and mild anaemia was detected in three individuals. Three patients were hyponatraemic; liver function tests were essentially normal. Issues around routine monitoring of such patients are discussed.

Prevalence and correlates of "high dose" antipsychotic prescribing: findings from a hospital audit

BACKGROUND

High dose antipsychotic prescribing is common in psychiatric care, despite a lack of its benefit from research evidence. While several studies have explored the prevalence and factors associated with high dose antipsychotic prescribing, no such report has emanated from a developing country like Nigeria.

AIM

The aims of this study were to determine the prevalence of high dose prescribing among in-patients at a tertiary psychiatric hospital and to determine the pattern of antipsychotic drugs prescribed.

MATERIALS AND METHODS

An audit of in-patients at a regional tertiary psychiatric facility was carried out. We examined case notes and conducted oral interviews where necessary, on all patients receiving antipsychotics using a proforma designed for the study.

RESULTS

The prevalence of high dose prescribing was 38% (65/171) using a prescribed daily dose/defined daily dose ratio of 1.5. The rate of antipsychotic polypharmacy was 7% (12/171). The atypical antipsychotic, olanzapine was the most commonly prescribed antipsychotic in monotherapy. Predictors of high dose prescribing were diagnoses (P = 0.04), polypharmacy (P = 0.04), a history of previous in-patient care (P = 0.02), and use of anticholinergic drugs (P = 0.01).

CONCLUSIONS

High dose prescribing was common among in-patients audited. Further studies are needed to examine factors that promote "high dose" prescribing.

Pharmakotherapie der Schizophrenie

The management of schizophrenia patients remains one of the great challenges in psychiatry. Despite the undisputed effectiveness of antipsychotic drugs, patients and their physicians still face considerable difficulties mainly related to incomplete or lacking treatment response and the inability to predict the individual efficacy and tolerability. In this manuscript we review the key elements of pharmacological treatment of this disorder, encompassing acute and long-term management as well as specific management problems ranging from acutely violent patients to treatment-resistant subjects. Along with general treatment principles, the document provides specific information regarding efficacy and safety features of antipsychotics. Many of the currently available treatment recommendations/guidelines are based on the evidence reviewed here. This review is meant to serve as a guide for clinicians involved in managing schizophrenia, whether in a psychiatric hospital setting or as family physicians in private practice.

Atypical and conventional depot medications

The introduction of atypical antipsychotics created a therapeutic dilemma between choosing the oral novel antipsychotic or the conventional depot form. Clinicians want the advantages of both, resulting in higher levels of polypharmacy. Modern psychiatry is probably in a transitional stage from the depot culture to safer oral medications or even to a safer depot culture.

Pharmacotherapy for refractory schizophrenia patients

Most schizophrenic patients experience morbidity over the course of their illness, as the illness runs a chronic course and full remissions are infrequent. Therefore, defining treatment resistance among schizophrenia is problematic. Not all patients respond to antipsychotic medication treatment and an estimated 30-50% are considered resistant to treatment. Treatment resistance normally occurs along a continuum and most patients manifest varying degrees of resistance to antipsychotic medications. Essock and colleagues discovered that more than 60% of the patients in state hospitals met the criteria for clozapine therapy and, therefore, they may qualify for treatment resistance.

Treatment of the psychotic patient who is violent

Aggression among patients with serious mental illness occurs relatively infrequently, but it is a significant concern for patients, relatives, mental health professionals, and the public. Recognition of this risk and providing access and continuity of appropriate psychiatric care should be major clinical and administrative objectives in the management of violence in psychotic patients. To date, pharmacologic approaches have been unclear and inconsistent. At present, typical antipsychotics continue to have a primary role in acute management and in long-term management, in which noncompliance necessitates the use of long-acting depot neuroleptic preparations. Atypical antipsychotics in acute and long-acting intramuscular forms doubtless will influence and expand the choice for acute management of hostile psychotic patients and the long-term management of poorly compliant patients who are at risk to become violent on relapse. Persistent aggression should be managed by atypical antipsychotics with a preferential indication for clozapine, for which the most data on efficacy are available. The role of adjunctive medications is presently unclear. A major focus of care should be to refine legal processes and to conduct intervention studies aimed at enhancing treatment compliance. Violence risk reduction is not only crucial from a societal perspective, but also it is a humanitarian necessity to alleviate the burden and stigma for patients with serious mental illness.

Use of high-dose depot neuroleptics

Aims and methods

To identify and reduce the number of patients receiving depot neuroleptics above the British National Formulary maximum. The medical records were scrutinised and individual consultants were informed of the results.

Results

For the team involved in this audit there was a significant reduction in the prescription of high-dose depot medication, but this did not generalise to other teams.

Clinical implications

Different teams should repeat the audit and a new depot card has been developed.

Algorithm for the treatment of schizophrenia in Japan

Evidence-based psychopharmacological algorithms for the treatment of patients with schizophrenia have been developed in many countries in the last decade. While it would be of interest to consider a common algorithm based on international consensus, algorithms and information on antipsychotics available in each country are limited. Inspired by the algorithm generated by the International Psychopharmacology Algorithm (IPA) Project, this algorithm for the treatment of schizophrenia has been developed by the Japan Psychophamacology Algorithm (JPA) Project. New antipsychotics, such as clozapine, olanzapine and quetiapine, are excluded from this algorithm, being currently unavailable in Japan. In the end there was no essential difference between the algorithms for the treatment of acute schizophrenic episodes. However, combined use of antipsychotics appears to be more common in Japan and the adjunctive use of L-DOPS or thyrotropin-releasing hormone is included in the JPA algorithm for the treatment of drug-refractory schizophrenia.

Closing the gap between research and practice

Has Mrs A got schizophrenia? Would Mr B do better with a tricyclic or a selective serotonin reuptake inhibitor? Is Miss C likely to be recovered in six months time? Is St John's wort an effective antidepressant? Clinical psychiatry involves making difficult decisions about diagnosis, therapy and prognosis. Sometimes we may be entirely confident about our decisions, but often we are uncomfortably aware that we are making a choice without being sure there is convincing evidence to justify it. Maybe we don't know or have forgotten what the evidence is, or perhaps there isn't any.

Audit of out-patients on ‘higher dose’ antipsychotics

Standards developed from the Royal College of Psychiatrists' consensus statement on the use of high-dose antipsychotics were audited. The baseline survey and two completed audit cycles are described showing improvement in the monitoring and management of out-patients on higher dose depot antipsychotics. Initially the main problem was poor attendance at hospital appointments. Practice was changed by (a) medical staff becoming more assertive and visiting non-attenders at home; (b) a phlebotomist visiting patients at home. Deinstitutionalisation has relocated many patients with chronic psychoses into the community, but services, including the ancillary services, have sometimes been slow to follow. This audit found that the most effective change was the provision of services to patients in their own home.

The Hampstead Schizophrenia Survey 1991. I: Prevalence and service use comparisons in an inner London health authority, 1986-1991

BACKGROUND

A point prevalence study of schizophrenia was carried out in 1986 in the former Hampstead Health District using a key informant method to identify cases. The point prevalence of broadly defined schizophrenia was 4.7 per 1000.

METHOD

A repeat census of people with schizophrenia, using the same method, was carried out in 1991 and the point prevalence calculated. The accuracy of the census method was estimated. Contact with services, social and occupational activity, and medication usage in the 1986 and 1991 samples were compared.

RESULTS

The point prevalence rate of broadly defined schizophrenia in 1991 was 5.1 per 1000. The results of both censuses showed we underestimated the number of individuals with DSM-III-R positive schizophrenia by about 14%. The level of contact with specialist services was greater in 1991 than 1986. Patients in 1991 were discharged on higher doses of medication, and their most recent admission was more likely to be due to non-compliance, than the 1986 group.

CONCLUSION

The point prevalence confirmed the high rate reported in 1986. The accuracy of the census was within acceptable limits for service planning. Contact with specialist services increased between 1986 and 1991.

Drug strategies and treatment-resistant schizophrenia

OBJECTIVES

The aims of the paper are to review the notion of treatment resistance in schizophrenia and consider the factors important in determining non-responsiveness to standard neuroleptic treatment, and to review the strategies currently available in the treatment of such patients, including an evaluation of recently-introduced, novel drug treatments.

METHOD

A selective review of the literature relating to treatment resistance was undertaken using medline searches, followed by cross-checking for further articles identified in these references.

RESULTS

The various treatment approaches available are considered, including adjunctive treatment with lithium or carbamazepine. The risks and benefits of high dose antipsychotic treatment are discussed. The possible benefits and side-effects of new treatments, particularly the atypical neuroleptics, are also reviewed.

CONCLUSIONS

The reasons why a proportion of patients with schizophrenia fail to respond to standard neuroleptic treatment are ill-understood. Nevertheless, initial assessment should include identification of any factors that may be related to a patient's poor response, such as poor compliance, substance use or epilepsy. This may help to determine an appropriate treatment strategy. There is a need to be systematic and to ensure that patients be given an adequate trial of each treatment tested in terms of duration and dosage. The available evidence does not support the use of high doses of neuroleptics for the majority of patients. Adjunctive treatments, such as lithium, carbamazepine or benzodiazepines may be beneficial in non-responsive patients, particularly if certain target symptoms are present. Atypical neuroleptics, particularly clozapine, have proved particularly effective in non-responsive patients as well as those sensitive to the motor side-effects of standard drugs. However, the high risk of agranulocytosis with clozapine is a problem; also the drug and the necessary haematological monitoring are expensive. There are hints that some of the other, new, atypical neuroleptics have some benefit in non-responsive patients, but controlled studies are required.

Clozapine treatment of schizophrenia: implications for forensic psychiatry

Clozapine, a new antipsychotic medication, is now the first-line treatment for neuroleptic refractory schizophrenia. Preliminary observations on its efficacy in treating schizophrenic patients with co-morbid substance abuse and, particularly, schizophrenic patients with persistent aggressive behaviour suggests that clozapine may provide a useful treatment option in forensic patient populations. Potential applications of clozapine and management considerations that are relevant to the forensic setting are discussed.

Treatment models

Antipsychotic drugs are used in a range of schizophrenic patients from the acutely disturbed to the chronically inert. Acute psychotic breakdowns usually involve secondary phenomena such as anxiety, depression and hostility superimposed on a worsening of the psychotic illness: a threshold of arousal is exceeded. This sets up a vicious circle which requires a major therapeutic effort to interrupt. Unfortunately, patients still relapse despite apparently adequate medication, suggesting only partial protection. Relapse is influenced by drug-related factors such as compliance and substance abuse, psychological factors such as cultural context, family dynamics and life events, and illness features such as poor insight. Treatment strategies, such as low-dose and intermittent medication, have proved disappointing. The most pragmatic model is the classic stressor-vulnerability model, but this does not explain the enhanced efficacy of clozapine.

The use of high-dose antipsychotic medication

Antipsychotic medication is the mainstay of treatment for the functional psychotic illnesses. Such drugs are also referred to as neuroleptics (meaning a drug with both antipsychotic effects and effects on movement) and major tranquillisers. The psychotic illnesses for which they are prescribed include schizophrenia, mania in the course of a bipolar mood disorder, and, more rarely, depression accompanied by psychotic symptoms. These are not uncommon illnesses. At some time during their lives approximately 1% of the population will suffer at least one episode of schizophrenia and a further 1% will suffer at least one episode of mania. During an episode some patients, but by no means all, suffer extreme changes in their thinking, mood and behaviour which can be very distressing to experience and which can make patients a danger to themselves or other people.