Polypharmacy and excessive dosing: psychiatrists' perceptions of antipsychotic drug prescription

Trends in Prescribing Antipsychotics for Children and Adolescents in Japan: A Descriptive Epidemiological Study Using a Large-Scale Pharmacy Dataset

Little is known about antipsychotic prescription patterns among children and adolescents in Japan, particularly in outpatient settings. We investigated the prevalence and trends of antipsychotic prescription for outpatients aged ≤ 17 years receiving a first antipsychotic prescription from 2006 to 2012 based on a large-scale dispensation dataset. Measurements included age, sex, department of diagnosis and treatment, type of prescription (monotherapy or polytherapy), antipsychotic dosage, and concomitant psychotropic drugs. Of the 10,511 patients, 65.1% were aged 13-17 years, and 52.9% were males. Second-generation antipsychotic monotherapy prescriptions increased from 53.8% in 2006 to 78.3% in 2012. Risperidone was the most frequently prescribed antipsychotic, followed by aripiprazole and olanzapine. Approximately 25.0% of patients were prescribed an initial dose less than recommended. Second-generation antipsychotic monotherapy is currently the most frequent prescription pattern among outpatients aged ≤ 17 years receiving an initial antipsychotic prescription.

A dissemination and education programme to improve the clinical behaviours of psychiatrists in accordance with treatment guidelines for schizophrenia and major depressive disorders: the Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE) project

BACKGROUND

Clinical practice guidelines for schizophrenia and major depressive disorder have been published. However, these have not had sufficient penetration in clinical settings. We developed the Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE) project as a dissemination and education programme for psychiatrists.

AIMS

The aim of this study is to assess the effectiveness of the EGUIDE project on the subjective clinical behaviour of psychiatrists in accordance with clinical practice guidelines before and 1 and 2 years after participation in the programmes.

METHOD

A total of 607 psychiatrists participated in this study during October 2016 and March 2019. They attended both 1-day educational programmes based on the clinical practice guidelines for schizophrenia and major depressive disorder, and answered web questionnaires about their clinical behaviours before and 1 and 2 years after attending the programmes. We evaluated the changes in clinical behaviours in accordance with the clinical practice guidelines between before and 2 years after the programme.

RESULTS

All of the scores for clinical behaviours in accordance with clinical practice guidelines were significantly improved after 1 and 2 years compared with before attending the programmes. There were no significant changes in any of the scores between 1 and 2 years after attending.

CONCLUSIONS

All clinical behaviours in accordance with clinical practice guidelines improved after attending the EGUIDE programme, and were maintained for at least 2 years. The EGUIDE project could contribute to improved guideline-based clinical behaviour among psychiatrists.

The characteristics of patients receiving psychotropic pro re nata medication at discharge for the treatment of schizophrenia and major depressive disorder: A nationwide survey from the EGUIDE project

BACKGROUND

Although several guidelines indicate that daily pharmacotherapy is an important part of the treatment of schizophrenia and major depressive disorder, there are few reports regarding pro re nata (PRN) prescriptions. The purpose of this study is to clarify the characteristics of patients receiving psychotropic PRN prescription for the treatment of schizophrenia and major depressive disorder.

METHOD

We used data from 'the effectiveness of guideline for dissemination and education in psychiatric treatment' (EGUIDE) project to evaluate the presence or absence of psychotropic PRN prescription at the time of discharge, the age and sex of patients receiving PRN prescription for each diagnosis, and the association between PRN prescription and regular daily psychotropics.

RESULTS

The psychotropic PRN prescription ratio was 29.9% among 2617 patients with schizophrenia and 31.1% among 1248 patients with major depressive disorder at discharge. In schizophrenia, the psychotropic PRN prescription ratio was 21.6% for patients aged 65 years or older, which was lower than that of all other age groups. In major depressive disorder, the psychotropic PRN prescription ratio was 34.2% for female patients, which was significantly higher than that for male patients (25.5%). In schizophrenia, there was an association between psychotropic PRN prescription and regular use of multiple psychotropic medications.

CONCLUSIONS

Psychotropic PRN prescription was less common in elderly patients with schizophrenia and more common in female patients with major depressive disorder. In schizophrenia, psychotropic PRN prescription led to polypharmacy of psychotropics. Further studies are needed to accumulate evidence and to provide education on appropriate PRN prescriptions.

Analysis of the trends of polypharmacy and high-dose prescriptions in Japan

INTRODUCTION

After extensive research, this study explored whether high-dose prescriptions and polypharmacy remain more frequent in Japan than elsewhere. If confirmed, we aimed to identify the factors that contributed to this unique trend.

METHODS

The psychotropic drug prescription patterns for patients with schizophrenia in Japan were reviewed. This was based on a large sample collected from surveys of the Research on Asian Psychotropic Prescription Patterns, an international collaborative research project conducted by Asian psychiatrists to monitor prescriptions of psychotropic drugs for people with mental disorders, in 2001, 2004, 2008, and 2016.

RESULTS

The 2016 Research on Asian Psychotropic Prescription Patterns survey revealed that Japan continued to demonstrate the highest rate of polypharmacy and the highest dosages of psychotropic prescription drugs for patients with schizophrenia among the 15 countries and areas that participated in the survey.

DISCUSSION

The Research on Asian Psychotropic Prescription Patterns surveys demonstrated that science plays a limited role in the decision-making process for prescriptions of psychotropic medications. Such prescriptions are influenced by a wide range of factors, such as the national mental health policy, prescription-financing systems, the history of psychiatry in each country, and the prevailing culture. Hospital-based national mental health policies and mental health financing systems have been the primary obstacles to reducing polypharmacy in Japan.

Training types associated with knowledge and experience in public health workers

BACKGROUND

Training non-specialist workers in mental healthcare improves knowledge, attitude, confidence, and recognition of mental illnesses. However, still little information is available on which type of mental health training is important in the improvement of these capacities.

METHODS

We studied web-based survey data of 495 public health workers to examine training types associated with knowledge and experience in supporting individuals with mental illness. Multivariable logistic regression analysis was conducted to evaluate the association between a lack of knowledge and experience (outcome) and mental health training (exposure). We fitted three regression models. Model 1 evaluated unadjusted associations. Model 2 adjusted for age and sex. Model 3 adjusted for age, sex, years of experience, mental health full-time worker status, and community population. Bias-corrected and accelerated bootstrap confidence intervals (CIs) were used.

RESULTS

For all training types, the association between a lack of knowledge and experience and mental health training attenuated as the model developed. In Model 3, a lack of knowledge and experience was significantly associated with training in specific illness (OR, 0.54; 95% CI, 0.32-0.93) and screening and assessment (OR, 0.63; 95% CI, 0.39-0.99). Non-significant results were produced for training in counseling, psychosocial support, collaborative work, and law and regulation in Model 3.

CONCLUSIONS

We believe that the present study provides meaningful information that training in specific illness and screening and assessment may lead to knowledge and experience of public health workers. Further studies should employ a longitudinal design and validated measurements.

Hypotic medication use among inpatients with schizophrenia and major depressive disorder: results of a nationwide study

STUDY OBJECTIVES

To investigate the proportion of inpatients with schizophrenia and major depressive disorder prescribed hypnotic medication, and the association between such medication and the use of other antipsychotic agents.

METHODS

This was a nationwide cross-sectional study performed as part of the 'Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment' (EGUIDE) project. Data from 2146 inpatients with schizophrenia and 1031 inpatients with major depressive disorder were analyzed. All types and dosages of psychotropic drugs were recorded and the data at the time of discharge were analyzed. Associations between the use of hypnotic medication and other antipsychotic agents were evaluated using multivariate logistic regression analyses.

RESULTS

The proportions of schizophrenia patients who were prescribed any and two or more hypnotic agents were 55.7% and 17.6%, respectively, and the corresponding proportions for patients with major depressive disorder were 63.6% and 22.6%, respectively. In schizophrenia patients, multivariate logistic regression analyses showed that two or more antipsychotics, anticholinergic drugs, anxiolytics, and mood stabilizers/antiepileptic drugs were positively associated with the use of any hypnotic agent. In patients with major depressive disorder, multivariate logistic regression analyses revealed that two or more antidepressants, two or more antipsychotics, anxiolytics, and mood stabilizers/antiepileptic drugs were positively associated with the use of any hypnotic agent.

CONCLUSIONS

Prescription of hypnotic agents was found to be highly frequent among inpatients with psychiatric disorders. Prescription of two or more main antipsychotic agents was commonly associated with the use of hypnotic medication for both schizophrenia and major depressive disorder.

Antipsychotic polypharmacy in adult patients diagnosed with schizophrenia: A retrospective study

Antipsychotic polypharmacy (APP) is a common practice in the treatment of schizophrenia. In this study, we aimed to identify the prevalence of APP in our department, as well as the trends associated with co-prescribing antipsychotics. We collected data from the medical records of all 193 inpatients diagnosed with schizophrenia who were admitted to Prof. Dr. Alexandru Obregia Clinical Psychiatry Hospital (Bucharest, Romania), Department 9, during January 2019-December 2019. Demographic characteristics of the patients, clinical diagnosis, psychiatric admission type and duration of hospitalization were examined. Data regarding the antipsychotic regimen at discharge and other psychotropic drugs used were collected. A total of 69 (35.75%) patients received more than 2 antipsychotics upon discharge. Patients treated with APP did not differ in regards to sex, age, education level, employment status, marital status, living situation, type of admission from those receiving antipsychotic monotherapy (APM). Prolonged hospitalization was found to be an independent predictor of APP (P=0.014). Most of the combinations used in our unit included clozapine (47.8%), and the most frequently used treatment in the APP group was the combination of paliperidone and clozapine (14.5%). In the APP group, 30 (43.5%) patients included in their regimen was a long-acting intramuscular antipsychotic. There was no significant difference in terms of the use of mood stabilizers, antiparkinsonian drugs or anxiolytics between the APP and the APM group; yet, a higher prevalence of antidepressant use, although not statistically significant (P=0.067), in the APP group compared to the APM group, was observed. The use of APP as a long-term regimen is a common practice in our department, as it is worldwide. There is a great need for randomized-control trials and evidence-based studies in order to define the safest and most effective combinations of antipsychotics and also the characteristics of patients that may benefit from these combinations.

Improvements in the degree of understanding the treatment guidelines for schizophrenia and major depressive disorder in a nationwide dissemination and implementation study

BACKGROUND

To implement clinical practice guidelines (CPGs), it is necessary for psychiatrists to deepen their understanding of the CPGs. The Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE) project is a nationwide dissemination and implementation study of two sets of CPGs for schizophrenia and major depressive disorder (MDD).

METHODS

A total of 413 psychiatrists (n = 212 in 2016; n = 201 in 2017) learned the two CPGs in the education program of the EGUIDE project, and clinical knowledge of these CPGs was evaluated at baseline and after the programs. To improve the correct answer rate for clinical knowledge after the programs, we revised the lecture materials associated with items that had a low correct answer rate in 2016 and used the revised lecture materials with the CPGs in 2017. The rates of correct answers after the programs between the 2016 and 2017 groups were compared.

RESULTS

The correct answer rate of one item on the schizophrenia CPG and one item on the MDD CPG tended to be improved (S-D5 and D-C6) and that of one on the MDD CPG was significantly improved (D-D3, P = 0.0008) in the 2017 group compared to those in the 2016 group.

CONCLUSIONS

We reported improvements in clinical knowledge of CPGs after the EGUIDE program in the 2017 group following revision of the lecture materials based on results from the 2016 group. These attempts to improve the degree of understanding of CPGs may facilitate the successful dissemination and implementation of psychiatric guidelines in everyday practice.

The Additional Effect of Individualized Prescriber-Focused Feedback on General Guideline Instruction in Reducing Antipsychotic Polypharmacy in Inpatients

PURPOSE/BACKGROUND

Antipsychotic polypharmacy (APP) is the concurrent use of more than one antipsychotic by a patient. Multiple antipsychotics are often prescribed, although all relevant guidelines discourage this practice. These recommendations are based on a lack of evidence for effectiveness and an increased risk of serious adverse events with APP. Studies on the effects of educational interventions targeted at physicians have demonstrated inconclusive results. Moreover, it is unclear how individualized these interventions need to be. In this study, we aimed to assess the effect of a general intervention and the additional impact of an individualized, prescriber-focused intervention on guidelines adherence, that is, the prescription of APP.

METHODS/PROCEDURES

We conducted a 36-month 2-step serial intervention study with 4 stages of 9 months each (baseline, general intervention, addition of an individualized intervention, and follow-up) including all 20 inpatient units of one regional mental health organization. The primary outcome was the proportion of patients with regular prescriptions for APP ≥30 consecutive days across all patients with a prescription of at least one antipsychotic. The secondary outcome was the proportion of patient days on APP over the total number of patient days on at least one antipsychotic.

FINDINGS/RESULTS

The general intervention was ineffective on both outcome measures. Addition of an individualized intervention decreased the proportion of patients with prescriptions for episodes of persistent APP significantly by 49.6%. The proportion of patient days on APP significantly decreased by 35.4%.

IMPLICATIONS/CONCLUSIONS

In contrast to a general intervention, the addition of an individualized intervention was effective in improving adherence to guidelines with respect to APP prescription in inpatients.

Factors associated with high-dose antipsychotic prescriptions in outpatients with schizophrenia: An analysis of claims data from a Japanese prefecture

Background

Antipsychotics are commonly prescribed in high doses in combination with multiple psychotropic drugs. This study focused on the high‐dose antipsychotic prescriptions in patients with schizophrenia, while aiming to identify their associations with patients’ characteristics and concurrent psychotropic prescriptions.

Methods

This cross‐sectional study used claims data from a prefecture in Japan, between October 2014 and March 2015, to investigate antipsychotic prescriptions in adult outpatients with schizophrenia. The objective variable was the presence/absence of a high‐dose prescription. The explanatory variables included sex, age (category), presence of comorbid conditions, and the use of psychiatrist's therapy.

Results

After exclusion, a total of 13 471 patients with schizophrenia were analyzed. The frequency of high‐dose prescriptions was higher in men, with chlorpromazine‐equivalent values highest in the age ranges of 45‐54 and 35‐44 years for men and women, respectively. Patients aged below 65 years with cerebrovascular diseases showed a decrease in high‐dose prescriptions. There was a high frequency of polypharmacy psychotropic drug use in combination with a high‐dose antipsychotic prescription in patients aged below 65 years.

Conclusion

High‐dose antipsychotics are often used in combination with several psychotropic agents in patients with schizophrenia. Our findings emphasize the need to evaluate the prescribing behavior of physicians to avoid high‐dose antipsychotic prescriptions for improved patient care.

This study aimed to identify the association between concurrent psychotropic prescriptions and high‐dose antipsychotic prescriptions in patients with schizophrenia in Japan. In this study, high‐dose antipsychotics were often used in combination with several psychotropic agents in patients with schizophrenia. Our findings emphasize the need to evaluate the prescribing behavior of physicians to avoid high‐dose antipsychotic prescriptions for improved patient care.

Diagnose, indicate, and treat severe mental illness (DITSMI) as appropriate care: A three-year follow-up study in long-term residential psychiatric patients on the effects of re-diagnosis on medication prescription, patient functioning, and hospital bed utilization

Background.

While polypharmacy is common in long-term residential psychiatric patients, prescription combinations may, from an evidence-based perspective, be irrational. Potentially, many psychiatric patients are treated on the basis of a poor diagnosis. We therefore evaluated the DITSMI model (i.e., Diagnose, Indicate, and Treat Severe Mental Illness), an intervention that involves diagnosis (or re-diagnosis) and appropriate treatment for severely mentally ill long-term residential psychiatric patients. Our main objective was to determine whether DITSMI affected changes over time regarding diagnoses, pharmacological treatment, psychosocial functioning, and bed utilization.

Methods.

DITSMI was implemented in a consecutive patient sample of 94 long-term residential psychiatric patients during a longitudinal cohort study without a control group. The cohort was followed for three calendar years. Data were extracted from electronic medical charts. As well as diagnoses, medication use and current mental status, we assessed psychosocial functioning using the Health of the Nations Outcome Scale (HoNOS). Bed utilization was assessed according to length of stay (LOS). Change was analyzed by comparing proportions of these data and testing them with chi-square calculations. We compared the numbers of diagnoses and medication changes, the proportions of HoNOS scores below cut-off, and the proportions of LOS before and after provision of the protocol.

Results.

Implementation of the DITSMI model was followed by different diagnoses in 49% of patients, different medication in 67%, some improvement in psychosocial functioning, and a 40% decrease in bed utilization.

Conclusions.

Our results suggest that DITSMI can be recommended as an appropriate care for all long-term residential psychiatric patients.

Drug prescription patterns and factors associated with polypharmacy in >1 million older adults in Tokyo

AIM

To determine the patterns of concomitant drug use for chronic diseases and examine the risk factors of polypharmacy in older outpatients.

METHODS

Data were extracted from an anonymized health insurance claims database of a public insurance program for older adults in Tokyo, Japan. We analyzed individuals aged ≥75 years who had visited an outpatient clinic, and were regularly prescribed orally administered drugs for chronic diseases for ≥14 days between May and August 2014. The prescription patterns for 16 main drug types were studied using exploratory factor analysis, and the risk factors of polypharmacy, defined as the concomitant prescription of five or more drugs, were identified using multivariate logistic regression models.

RESULTS

A total of 1 094 199 outpatients were analyzed (mean age 81.8 years, 38.4% men). We identified five prescription patterns that explained almost 40% of all observed variance: edema/heart failure/atrial fibrillation-related drugs, insomnia/anxiety-related drugs, pain-related drugs, lifestyle disease-related drugs and dementia-related drugs. The significant risk factors of polypharmacy included men, octogenarians and nonagenarians, higher number of medical institutions visited, use of physician home visits, and hospitalization during the study period. The main drug types most strongly associated with polypharmacy were analgesics, diuretics and antidiabetics.

CONCLUSIONS

Polypharmacy was found to be prevalent in older outpatients aged ≥75 years in Tokyo. These findings might provide useful evidence that can contribute to the development of practical countermeasures against adverse events associated with polypharmacy in clinical practice. Geriatr Gerontol Int 2020; 20: 304-311.

Polypharmacy-induced cognitive dysfunction and discontinuation of psychotropic medication: a neuropsychological case report

Polypharmacy is common in patients with a diagnosis of bipolar disorder. Although polypharmacy is known to increase the risk of iatrogenic neurological conditions, the recovery of cognitive function after drug withdrawal has been rarely documented in psychiatric patients using standardized neuropsychological methods. We present a neuropsychological case report of patient SN, a 41-year-old woman who developed a socially and occupationally detrimental condition of cognitive dysfunction likely induced by long-term exposure to lithium and other psychiatric medications. To shed light on SN's cognitive deficits and their recovery after drug withdrawal, neuropsychological assessments were conducted before, and approximately 2 years after, lithium and other psychiatric drugs were discontinued. Selective cognitive impairments were observed before drug discontinuation in visuomotor speed, visuoperceptual reasoning and delayed visual memory. Partial, but not complete, recovery of function was observed 2 years after drug withdrawal.

Antipsychotic Polypharmacy: A Dirty Little Secret or a Fashion?

The term polypharmacy was originally coined to refer to problems related to multiple drug consumption and excessive drug use during the treatment of a disease or disorder. In the treatment of schizophrenia, polypharmacy usually refers to the simultaneous use of 2 or more antipsychotic medications or combined (adjunct) medications such as mood stabilizers, antidepressants, anxiolytics, or hypnotics in addition to single or multiple antipsychotics. Two decades ago, antipsychotic polypharmacy was criticized as being more expensive, having unproven efficacy, and causing more side effects. However, in recent years, antipsychotic polypharmacy has become more or less acceptable in the views of clinical practitioners and academic researchers. Results from recent reviews have suggested that the common practice of antipsychotic polypharmacy lacks double-blind or high-quality evidence of efficacy, except for negative symptom reduction with aripiprazole augmentation. We reviewed some representative studies that enrolled large numbers of patients and compared antipsychotic polypharmacy and monotherapy during the past decade. The results revealed that a certain proportion of select patients can benefit from antipsychotic polypharmacy without further negative consequences. Because most of the current treatment guidelines from different countries and organizations prefer monotherapy and discourage all antipsychotic polypharmacy, guidelines regarding the use of antipsychotic polypharmacy in clinical practice should be revised. On the basis of the findings of 2 large-scale studies from Asia and Europe, we also suggest ideal rates of various maintenance treatments of schizophrenia, which are as follows: antipsychotic polypharmacy, 30%; combined mood stabilizer, 15%; combined antidepressant, 10%; combined anxiolytics, 30%; and combined hypnotic, 10%.

Sexual dysfunction: prevalence and associated factors in patients with mental illness receiving psychotropic medication in Nigeria

OBJECTIVES

The objectives were to determine the prevalence of total and specific sexual dysfunction among psychiatric out-patients taking psychotropic medication, assess its relationship with some demographic and clinical variables, determine the effect of sexual dysfunction on subject's self- esteem and compliance with medication.

METHODS

This descriptive, cross-sectional study was conducted in the psychiatric out-patient clinic of a Tertiary Care Teaching Hospital in Benin City. The International Index of Erectile Functioning (IIEF), Rosenberg's self esteem scale and a socio-demographic and clinical data questionnaire were administered to 300 participants; 150 (50%) psychiatric male patients and 150 (50%) controls.

RESULTS

The prevalence of total sexual dysfunction was 48.7%, while that of the specific SDs ranged from 20.0% to 39.3%, with erectile dysfunction having the highest proportion. Age, marital status, class, dose of psychotropic medication, poly-pharmacy and duration of treatment were significantly associated with SD. Majority of patient with SD reported poor compliance with medication. Self-esteem scores had significant inverse relationship with total SD scores.

CONCLUSION

Sexual dysfunction is prevalent amongst psychiatric patients taking psychiatric medication and has negative implications for self-esteem and medication compliance. Routine enquiry about sexual symptoms by physicians and prompt treatment of SD might enhance overall treatment success.

Antipsychotic Polypharmacy in Older Adult Asian Patients With Schizophrenia: Research on Asian Psychotropic Prescription Pattern

BACKGROUND AND OBJECTIVE

Antipsychotic polypharmacy (APP) is a controversial topic in the treatment of older adults with schizophrenia. The objective of this study was to examine the use of APP in older adult Asian patients with schizophrenia and its associated demographic and clinical factors.

METHODS

This study was based on the fourth survey of the consortium known as the Research on Asian Psychotropic Prescription Pattern for Antipsychotics. Fifteen Asian countries/territories participated in this survey, including Bangladesh, Mainland China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Myanmar, Pakistan, Singapore, Sri Lanka, Taiwan, Thailand, and Vietnam. Basic demographic and clinical characteristics were collected using a standardized data collection form.

RESULTS

Among the 879 older adults with schizophrenia included in the survey, the rate of APP was 40.5%. Multiple logistic regression analysis revealed that higher antipsychotic doses (P < .001, odds ratio [OR] = 1.003, 95% confidence interval [CI]: 1.002-1.003), longer duration of illness (P = .02, OR = 1.845, 95% CI: 1.087-3.132), and the prescription of anticholinergics (P < .001, OR = 1.871, 95% CI: 1.329-2.635), second-generation antipsychotics (P = .001, OR = 2.264, 95% CI: 1.453-3.529), and first-generation antipsychotics (P < .001, OR = 3.344, 95% CI: 2.307-4.847) were significantly associated with APP.

CONCLUSION

Antipsychotic polypharmacy was common in older adult Asian patients with schizophrenia. Compared to the results of previous surveys, the use of APP showed a declining trend over time. Considering the general poor health status of older patients with schizophrenia and their increased risk of drug-induced adverse events, the use of APP in this population needs careful consideration.

Improvement of psychiatrists' clinical knowledge of the treatment guidelines for schizophrenia and major depressive disorders using the 'Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE)' project: A nationwide dissemination, education, and evaluation study

AIM

Although treatment guidelines for pharmacological therapy for schizophrenia and major depressive disorder have been issued by the Japanese Societies of Neuropsychopharmacology and Mood Disorders, these guidelines have not been well applied by psychiatrists throughout the nation. To address this issue, we developed the 'Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE)' integrated education programs for psychiatrists to disseminate the clinical guidelines. Additionally, we conducted a systematic efficacy evaluation of the programs.

METHODS

Four hundred thirteen out of 461 psychiatrists attended two 1-day educational programs based on the treatment guidelines for schizophrenia and major depressive disorder from October 2016 to March 2018. We measured the participants' clinical knowledge of the treatment guidelines using self-completed questionnaires administered before and after the program to assess the effectiveness of the programs for improving knowledge. We also examined the relation between the participants' demographics and their clinical knowledge scores.

RESULTS

The clinical knowledge scores for both guidelines were significantly improved after the program. There was no correlation between clinical knowledge and participant demographics for the program on schizophrenia; however, a weak positive correlation was found between clinical knowledge and the years of professional experience for the program on major depressive disorder.

CONCLUSION

Our results provide evidence that educational programs on the clinical practices recommended in guidelines for schizophrenia and major depressive disorder might effectively improve participants' clinical knowledge of the guidelines. These data are encouraging to facilitate the standardization of clinical practices for psychiatric disorders.

Exploring predictors of medication adherence among inpatients with schizophrenia in Singapore's mental health settings: A non-experimental study

Schizophrenia is a mental disorder, which is marked by frequent relapses. The main reason for relapse is nonadherence to antipsychotics. A cross-sectional, correlational research study was conducted with a convenience sample of 92 participants. The primary aim of this study was to explore the predictors of medication adherence among inpatients with schizophrenia hospitalised at tertiary hospitals in Singapore. Post-hoc analysis revealed that insight, religion, side effects, types of antipsychotics, social support from significant others, nurse-client relationship, were significant predictive factors. Results from this study added knowledge to the nursing literature about medication adherence of schizophrenia patients and in Singapore setting.

Sudden cardiac death and antipsychotics Part 2: Monitoring and prevention

Cardiac safety of antipsychotic drugs continues to be a concern for both typical and atypical antipsychotics. Risk appears greatest in those with pre-existing cardiac disease but many patients may have occult cardiovascular disease. In addition, several drugs appear to increase the likelihood of diabetes and weight gain, which may have an additive adverse effect. On the basis of risk of sudden cardiac death and risk of QTc prolongation we suggest considering antipsychotics in two categories – higher and lower risk. Of most concern is the use of large cumulative doses of antipsychotics that are sometimes given inadvertently by different prescribers. Clinicians need to be aware how to read an ECG, and how to monitor physical parameters and interpret the significance of QTc prolongation in relation to antipsychotic prescribing. We suggest provisional guidance on antipsychotic monitoring in relation to cardiac safety but acknowledge that future studies will help clarify which antipsychotic drugs and which concomitant risk factors are most important for those with and without established cardiac disease.

Polypharmacy and high-dose antipsychotic regimes in the community

Aims and method

To determine the pattern of psychotropic prescribing in a group of people with psychosis who were living in the community under community mental health team (CMHT) care. Case-note entries over the previous 12 months were examined.

Results

Only a third of individuals were on one psychotropic medication. Atypical antipsychotics were prescribed to 80.6%. Polypharmacy was common. A third of people were taking three or more psychotropic drugs and 13.7% were on high-dose regimes, mostly involving two atypical antipsychotics.

Clinical implications

The use of atypicals has not eliminated polypharmacy or high-dose antipsychotic regimes. Clinicians need to be aware of this long-standing problem.

Audit of combination and high-dose antipsychotic treatment in the community

Aims and method

To estimate the community prevalence of combination antipsychotic therapy and high-dose antipsychotic treatment via audit. Patients with an ICD-10 diagnosis of schizophrenia were identified through the NHS Greater Glasgow and Clyde Health Board patient information management system and their mental health records examined.

Results

In audit 1, 135 records were examined. The age range of patients was 24–74 years; 73% were male. Twelve per cent were on combined antipsychotic treatment and 3.7% required high-dose antipsychotics. Sixty-nine per cent of patients had documented in their record the reason for combined antipsychotic treatment compared with 40% on high-dose antipsychotics. In audit 2 (1 year later), 150 records were examined. Demographic details and prescription patterns remained similar to that of audit 1. However, 10% of patients received combined antipsychotic therapy and 2% remained on high-dose antipsychotics. Documented reasons for combination therapy increased to 87%, and to 67% for patients on high-dose antipsychotics.

Clinical implications

We need robust clinical trials, overcoming the problems of clinical effectiveness and clinical efficiency, to establish the merits of preferred antipsychotic combinations, as combination and high-dose antipsychotic treatments are unlikely to be eliminated in clinical practice in the foreseeable future.

Polypharmacy and high-dose antipsychotics at the time of discharge from acute psychiatric wards

Aims and method

To determine the extent of prescribed antipsychotic polypharmacy and high-dose antipsychotics at the time of discharge from an acute psychiatric ward. Copies of discharge summaries for patients between the ages of 18 and 65 were examined; only those that had antipsychotic medications at the time of discharge were included. Names and doses of antipsychotics and all other medications concurrently prescribed were recorded.

Results

A total of 651 discharge summaries were included in the study. Nearly a quarter of individuals were discharged on one antipsychotic as the only medication to take home; only 6.8% were discharged on a high-dose antipsychotic and of those on combinations 59.6% were on depot medications. Combining antipsychotics significantly predicted the use of high dose.

Clinical implications

Most patients were discharged on doses of antipsychotics within the British National Formulary limits; however, a small proportion is still sent home on high doses of antipsychotics. Combining antipsychotics remains the strongest predictor of high-dose antipsychotic use; clinicians need to be aware of this.

Attitudes towards and rationale for antipsychotic polypharmacy among psychiatrists in Nigeria: Characteristics associated with high reported antipsychotic polypharmacy

Antipsychotic polypharmacy (APP) is commonplace despite lacking evidence of its effectiveness. We aimed to identify psychiatrists' rationale for and attitudes towards APP and to determine if attitudes influence antipsychotic polypharmacy prescription rates in a survey of a nationally representative sample of Nigerian psychiatrists (of which a majority were senior trainees: 74.2%). Prescriber characteristics, practices and attitudes were compared in 'high' (>30%) vs. 'low' (≤30%) antipsychotic polypharmacy prescribers and results were adjusted for multiple comparisons. Altogether, prescribers reported utilizing antipsychotic polypharmacy in 36.2% of their patients. Compared to 'low' antipsychotic polypharmacy prescribers, 'high' prescribers were significantly more likely using first-generation antipsychotics (FGA) combination, to have attempted a switch to monotherapy in less patients, or been successful in doing so. 'High' and 'low' antipsychotic polypharmacy prescribers were equally moderately concerned about the effects of antipsychotic polypharmacy and also did not differ regarding reasons not justifying antipsychotic polypharmacy. In a multivariable, backward elimination logistic regression model, 'low' antipsychotic polypharmacy was associated with having successfully switched patients to monotherapy, whereas the 'high' antipsychotic polypharmacy was associated with preferring FGA+FGA combinations and aiming for a reduction of non-antipsychotic medications. Antipsychotic polypharmacy is common among psychiatrists in Nigeria, with 'high' and 'low' antipsychotic polypharmacy prescribers sharing similar concerns/attitudes, but differing regarding their primary aim for antipsychotic polypharmacy and in their specific antipsychotic polypharmacy use characteristics.

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.

Predictors of long-term (≥6months) antipsychotic polypharmacy prescribing in secondary mental healthcare

INTRODUCTION

The predictors of long-term antipsychotic polypharmacy (APP) initiation are poorly understood. Existing research has been hampered by residual confounding, failure to exclude cross-titration, and difficulties in separating the timing of predictors and APP administration.

MATERIALS AND METHODS

Using data from the South London and Maudsley (SLaM) case register, we identified all adult patients with serious mental illness (SMI) who were receiving care between 1st July 2011 and 30th June 2012. Exposures measured between 1st July and 31st December 2011 included socio-demographic, socioeconomic, clinical and service use characteristics. We then determined if long-term APP (six or more months) had been initiated between 1st January and 30th June 2012. Multivariable logistic regression models, adjusted for socio-demographic and socioeconomic factors, were built to investigate the associations between the above factors and the initiation of long-term APP.

RESULTS

We identified 6857 adults with SMI receiving SLaM care, of whom 115 (1.7%) were newly prescribed long-term APP. In the adjusted models, predictors of long-term APP initiation included: symptoms (severity of hallucinations and/or delusions), previous treatments (clozapine and long-acting injectable antipsychotic agents), service use (more contact with outpatient services, community treatment order receipt), social factors (higher area-level deprivation, homelessness) and socio-demographic status (younger age, not in a relationship).

CONCLUSION

Our findings highlight that certain patient groups are at an increased risk for long-term APP initiation. Identifying these groups earlier in their treatment could encourage clinicians to employ a broader range of interventions in addition to pharmacotherapy to reduce the risk of APP prescribing.

Effect of pharmacist intervention on physician prescribing in patients with chronic schizophrenia: a descriptive pre/post study

BACKGROUND

Although pharmacotherapy is one of the most important treatments for schizophrenia, the prominent levels of antipsychotic polypharmacy and high-dose regimens used in Japan are thought to be inconsistent with treatment regimens used in other countries. In this study, we evaluated the effect of pharmacist intervention on physician prescribing in patients with chronic schizophrenia.

METHODS

Participants comprised 52 inpatients at Sawa Hospital (Osaka, Japan), treated with at least one antipsychotic agent, who received pharmacist intervention for 1 year (2012). We compared the dose and the number of antipsychotics prescribed, and the rate of concurrent prescribing of anti-Parkinson, benzodiazepine and mood-stabilizer medication, pre- and post-pharmacist intervention. As an indicator of psychosis symptoms, the rate of seclusion room use was recorded. Additionally, we evaluated the impact of pharmacist intervention on medicine costs. Continuous variables were analyzed by Wilcoxon signed-rank sum tests, and categorical data were analyzed using Fisher's exact tests.

RESULTS

Compared with pre-intervention, the dose (982.6 mg pre vs. 857.6 mg post; p < 0.01) and the number of antipsychotics (2.0 pre vs. 2.0 post; p < 0.05) at 1 year were significantly lower post-intervention. The seclusion room use rate was not significantly different but tended to be lower post-intervention than pre-intervention (p < 0.1). The cost (in USD) for all medicines (10.33 pre vs. 8.76 post; p < 0.05), antipsychotics (8.04 pre vs. 6.48 post; p < 0.05), and psychotropics (9.24 pre vs. 7.68 post; p < 0.01) were significantly lower post-intervention than pre-intervention.

CONCLUSION

Pharmacist intervention has the potential to optimize medication prescribing and reduce medication costs in patients with chronic schizophrenia. It might be suggested that clinical practitioners as well as medical hospital administrators consider the pharmacists' ability to rationalize medication therapy in schizophrenia.

Barriers to mental health care in Japan: Results from the World Mental Health Japan Survey

AIMS

The reasons for accessing and maintaining access to mental health services in Japan may be different to those in other countries. Using the World Health Organization World Mental Health Japan survey data, this study investigated the prevalence of sociodemographic correlates of barriers for the use of, reasons for delayed access to, and reasons for dropping out from mental health care in a Japanese community-based sample.

METHODS

An interview survey was conducted with a random sample of residents living in 11 communities across Japan during the years 2002-2006. Data from 4130 participants were analyzed.

RESULTS

The most frequently reported reason for not seeking mental health care was a low perceived need (63.9%). The most common reason for delaying access to help was the wish to handle the problem on one's own (68.8%), while the most common reason for dropping out of care was also a low perceived need (54.2%). Being a woman and of younger age were key sociodemographic barriers to the use of mental health services.

CONCLUSIONS

Low perceived need was a major reason for not seeking, delay in using, and dropout from mental health services in Japan. In addition, low perceived need and structural barriers were more frequently reported than attitudinal barriers, with the exception of a desire to handle the problem on one's own. These findings suggest that improving therapist-patient communication and quality of mental health care, as well as mental health literacy education in the community, might improve access to care in Japan.

Reducing the rates of prescribing high-dose antipsychotics and polypharmacy on psychiatric inpatient and intensive care units: results of a 6-year quality improvement programme

BACKGROUND

There is no conclusive evidence that either high doses or combinations of antipsychotics are more effective than standard doses or monotherapy alone. Nonetheless, prescription of both remains prevalent in the UK. In 2006 the South London and Maudsley NHS Foundation Trust (SLAM) participated in a national survey of prescription of antipsychotic medications, organized by the Prescribing Observatory for Mental Health. Over half of the patients on SLAM inpatient or psychiatric intensive care units were prescribed a high-dose antipsychotic or a combination of antipsychotics. Prescribing high-dose antipsychotics and polypharmacy in SLAM was found to be among the highest in the UK.

AIM

To assess the impact of a 6-year quality improvement programme aimed at reducing the rates of prescribing high-dose antipsychotics and polypharmacy on SLAM inpatients and psychiatric intensive care units.

RESULTS

There was a significant reduction between baseline and final survey in the rates of prescription of both high-dose antipsychotics and polypharmacy on SLAM inpatients and intensive care units (58% versus 10% p < 0.0001 and 57% versus 16%, p < 0.0001 respectively). The proportion of patients at final survey prescribed a high-dose antipsychotic and a combination was substantially lower in SLAM than in the national sample (10% versus 28%, p < 0.0001 and 16% versus 38%, p < 0.0001 respectively).

CLINICAL IMPLICATIONS

A sustained change in the prescribing culture of an organization can be achieved through a targeted improvement programme.

Antipsychotic patterns of use in patients with schizophrenia: polypharmacy versus monotherapy

BACKGROUND

The objective of this study was to characterize real-world treatment patterns in the prescription of antipsychotic polypharmacy (≥ 2 concurrent antipsychotics) compared with antipsychotic monotherapy for patients with schizophrenia.

METHODS

This study was a retrospective claims-based analysis of patients (aged 13-64 years) with schizophrenia belonging to an employer-based health plan. Duration of therapy was measured as the number of treatment days over one year following the initial date of antipsychotic therapy. Discontinuation was defined as a 90-day gap in antipsychotic treatment (or in at least one antipsychotic for the polypharmacy group). Logistic regression analyses were used to predict discontinuation within one year. Ordinary Least Squares (OLS) regressions were used to predict duration of therapy (by type of therapy) when controlling for gender, region, number of somatic and psychiatric comorbidities, Deyo-Charlson comorbidity score, and number of psychiatric and somatic medications.

RESULTS

Of the 4,156 patients, 3,188 received monotherapy and 968 received polypharmacy. Mean age was 40 years (37.8 years for polypharmacy vs 40.3 years for monotherapy, p < 0.001). Within one year, 77% of the polypharmacy group and 54% of the monotherapy group discontinued treatment. The average duration of therapy was 163 [SD = 143] days in the polypharmacy group vs 253 [SD = 147] days in the monotherapy group. In both cohorts, patients <25 years had a higher frequency of discontinuations than those ≥ 26 years. Age and polypharmacy were independent predictors of treatment duration and discontinuation prior to one year.

CONCLUSIONS

One quarter of patients with schizophrenia received antipsychotic polypharmacy. Discontinuation was higher in the polypharmacy group. Age and polypharmacy were significant predictors of treatment discontinuation.

Critical review of antipsychotic polypharmacy in the treatment of schizophrenia

Antipsychotic polypharmacy remains prevalent; it has probably increased for the treatment of schizophrenia in real-world clinical settings. The current evidence suggests some clinical benefits of antipsychotic polypharmacy, such as better symptom control with clozapine plus another antipsychotic, and a reversal of metabolic side-effects with a concomitant use of aripiprazole. On the other hand, the interpretation of findings in the literature should be made conservatively in light of the paucity of good studies and potentially serious side-effects. Also, although the available data are still limited, two smaller-scale clinical trials provide preliminary evidence that converting antipsychotic polypharmacy to monotherapy could be a valid and reasonable treatment option. Several studies have explored strategies to change physicians' antipsychotic polypharmacy prescribing behaviours. These have revealed that, while the impact of purely educational interventions may be limited, more aggressive procedures such as directly notifying physicians by letters or phone calls can be more effective in reducing antipsychotic polypharmacy. In conclusion, antipsychotic polypharmacy can work for some clinically difficult conditions; however, it should be the exception rather than the rule and may be avoidable in many patients. More importantly, the paucity of the data clearly emphasizes the need for further investigations on not only advantages and disadvantages of antipsychotic polypharmacy, but also regarding effective interventions in already prescribed polypharmacy regimens.

History, background, concepts and current use of comedication and polypharmacy in psychiatry

Based on a careful literature search a review is presented of the history, background, concepts and current use of comedication and polypharmacy in psychiatry. The pros and cons of comedication and polypharmacy are presented, as well as their apparent increase in recent times. Possible reasons for the increase of comedication/polypharmacy are described. Both the potential advantages as well as the potential risks are discussed. The one sided view that all comedication/polypharmacy is nothing but problematic is questioned. Comedication/polypharmacy seems to be, among others, the current answer to the well-known limited efficacy and effectiveness of current monotherapy treatment strategies.

Physical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions

Schizophrenia is a major psychotic disorder with significant comorbidity and mortality. Patients with schizophrenia are said to suffer more type-2 diabetes mellitus (T2DM) and diabetogenic complications. However, there is little consistent evidence that comorbidity with physical diseases leads to excess mortality in schizophrenic patients. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital mortality differed between patients with and without schizophrenia in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 31 June 2012, 1418 adult patients with schizophrenia were admitted to three General Manchester NHS Hospitals. All comorbid diseases with a prevalemce ≥1% were compared with those of 14,180 age- and gender-matched hospital controls. Risk factors, i.e. comorbid diseases that were predictors for general hospital mortality were identified using multivariate logistic regression analyses. Compared with controls, schizophrenic patients had a higher proportion of emergency admissions (69.8 vs. 43.0%), an extended average length of stay at index hospitalization (8.1 vs. 3.4 days), a higher number of hospital admissions (11.5 vs. 6.3), a shorter length of survival (1895 vs. 2161 days), and a nearly twofold increased mortality rate (18.0 vs. 9.7%). Schizophrenic patients suffered more depression, T2DM, alcohol abuse, asthma, COPD, and twenty-three more diseases, many of them diabetic-related complications or other environmentally influenced conditions. In contrast, hypertension, cataract, angina, and hyperlipidaemia were less prevalent in the schizophrenia population compared to the control population. In deceased schizophrenic patients, T2DM was the most frequently recorded comorbidity, contributing to 31.4% of hospital deaths (only 14.4% of schizophrenic patients with comorbid T2DM survived the study period). Further predictors of general hospital mortality in schizophrenia were found to be alcoholic liver disease (OR = 10.3), parkinsonism (OR = 5.0), T1DM (OR = 3.8), non-specific renal failure (OR = 3.5), ischaemic stroke (OR = 3.3), pneumonia (OR = 3.0), iron-deficiency anaemia (OR = 2.8), COPD (OR = 2.8), and bronchitis (OR = 2.6). There were no significant differences in their impact on hospital mortality compared to control subjects with the same diseases except parkinsonism which was associated with higher mortality in the schizophrenia population compared with the control population. The prevalence of parkinsonism was significantly elevated in the 255 deceased schizophrenic patients (5.5 %) than in those 1,163 surviving the study period (0.8 %, OR = 5.0) and deceased schizophrenic patients had significantly more suffered extrapyramidal symptoms than deceased control subjects (5.5 vs. 1.5 %). Therefore patients with schizophrenia have a higher burden of physical comorbidity that is associated with a worse outcome in a 12-year follow-up of mortality in general hospitals compared with hospital controls. However, schizophrenic patients die of the same physical diseases as their peers without schizophrenia. The most relevant physical risk factors of general hospital mortality are T2DM, COPD and infectious respiratory complications, iron-deficiency anaemia, T1DM, unspecific renal failure, ischaemic stroke, and alcoholic liver disease. Additionally, parkinsonism is a major risk factor for general hospital mortality in schizophrenia. Thus, optimal monitoring and management of acute T2DM and COPD with its infectious respiratory complications, as well as the accurate detection and management of iron-deficiency anaemia, of diabetic-related long-term micro- and macrovascular complications, of alcoholic liver disease, and of extrapyramidal symptoms are of utmost relevance in schizophrenia.

Antipsychotic polypharmacy: a Japanese survey of prescribers' attitudes and rationales

While combining antipsychotics is common in schizophrenia treatment, the literature on the reasons for antipsychotic polypharmacy (APP) is limited. We aimed to identify prescriber attitudes and rationales for APP in Japan where high APP utilization is reported. Two-hundred and seventeen psychiatrists participated in the survey, which assessed APP attitudes and behaviors. Prescribing APP to 47.7±24.7% (mean±S.D.) of their patients, psychiatrists reported that they were "moderately" concerned about APP. The most APP-justifiable factors were (1="not at all" to 5="extreme") cross titration (4.50±0.67), randomized controlled evidence (3.67±0.83), and treatment of comorbid conditions (3.31±0.83). Conversely, APP-discouraging factors were chronic side effects (4.14±0.64), difficulty determining cause and effect (4.07±0.74), and acute side effects (3.99±0.81). Comparing high to low APP prescribers (>50% vs. ≤50% of patients), no differences emerged regarding APP justification and concerns. In multivariate analyses, high APP use was associated with practice at a psychiatric hospital (OR: 2.70, 95% CI: 1.29-5.67, p=0.009), concern about potential drug-drug interactions (OR: 1.56, 95% CI: 1.04-2.35, p=0.031), and less reliance on case reports of APP showing efficacy (OR: 0.64, 95% CI: 0.44-0.92, p=0.017) (r(2)=0.111, p=0.001). High and low APP prescribers shared a comparable degree of justifications and concerns. Future research should examine the impact of cultural determinants on APP.

Resistance to changing practice from pro re nata prescriptions to patient group directions in acute mental health settings

Poor practice associated with pro re nata (PRN) prescriptions in mental health is known to be common and can increase the risk of serious and potentially fatal side effects. A contributing factor to poor practice is the lack of a clear chain of accountability between the decision to prescribe and administer PRN prescriptions. To address this problem, a patient group direction (PGD) for acute behavioural disturbance (lorazepam 0.5-2 mg) and staff training materials were developed. The intention was to replace PRN prescriptions with the PGD in two mental health trusts. One of the potential benefits of this would be the removal of the contribution of PRN to high and combined dose antipsychotic prescriptions. This proposal, however, was met with significant resistance in both trusts and did not replace PRN as a result. A series of interviews and focus groups were conducted with 16 RMNs working in the two trusts, to explore the reasons why the PGD was met with resistance. Senior nurses perceived resistance to be associated with anxieties over increased responsibility for decision making. Junior nurses reported concerns regarding the medicalization of the nursing role, the paperwork associated with the PGD and the training approach used. Future efforts to implement PGDs in mental health settings must carefully consider the methods for engaging effectively with participating organizations, in terms of managing change and completing the necessary groundwork for successful implementation.

Excessive dosing and polypharmacy of antipsychotics caused by pro re nata in agitated patients with schizophrenia

AIMS

It has been recommended that for patients with schizophrenia, antipsychotics should be prescribed simply, using an optimal dose. However, pro re nata (p.r.n., meaning to use on an as-needed basis) antipsychotics may increase the risk of excessive dosing (defined as mean chlorpromazine-equivalent doses above 1000 mg) and polypharmacy (combination use of different antipsychotics). This study aimed to investigate the increased risk caused by p.r.n. antipsychotics.

METHOD

The subjects included 413 patients with schizophrenia from 17 acute psychiatric wards in nine hospitals. Over a 24-h period on a survey day, data on regular medication and the use of p.r.n. were collected. The analysis focused on p.r.n. antipsychotics in agitated patients. We used McNemar's test to evaluate differences in the proportions of patients prescribed antipsychotics with excessive dosing or polypharmacy before (i.e., regular medication only) and after prescribed p.r.n. antipsychotics were added to regular medication (i.e., regular medication plus p.r.n. antipsychotics).

RESULTS

Of 413 patients, 312 (75.5%) were prescribed p.r.n. for agitated status. Of those, 281 (90.1%) were prescribed p.r.n. antipsychotics. The total doses were significantly higher and more compounded in case patients prescribed p.r.n. antipsychotics than in those who were not. Seventeen patients (4.1%) were actually administered p.r.n. antipsychotics. Their total medication, including p.r.n. on the current day, represented excessive dosing or polypharmacy of antipsychotics.

CONCLUSION

The use of p.r.n. antipsychotics may cause hidden excessive dosing and polypharmacy. Our results indicate the importance of careful monitoring of p.r.n. antipsychotics to agitated patients with schizophrenia.

Polypharmacy in psychiatry: a review

Psychiatric polypharmacy refers to the prescription of two or more psychiatric medications concurrently to a patient. It can be categorised as same-class, multi-class, adjunctive, augmentation and total polypharmacy. Despite advances in psychopharmacology and a better understanding of the principles of therapeutics, its practice is increasing rapidly. The prevalence of polypharmacy in psychiatry varies between 13%-90%. There are various clinical and pharmaco-economic factors associated with it. Dealing with polypharmacy requires an understanding of its associated factors. Education, guidelines and algorithms for the appropriate management of various conditions are effective ways to avoid irrational polypharmacy.

Clozapine: key discussion points for prescribers

Clozapine is the most effective antipsychotic medication for treatment-refractory schizophrenia and is also approved for suicidality in schizophrenia patients. However, it can cause significant medical morbidity and requires intensive medical monitoring once prescribed. Perhaps due to lack of familiarity with its use, it is underused in clinical practice and its initiation often delayed. This article reviews the literature on clozapine in order to measure its potential effectiveness against its adverse effects and ultimately aims to serve as a useful summary for clinicians in their everyday prescribing.

Antipsychotic polypharmacy in psychotic disorders: a critical review of neurobiology, efficacy, tolerability and cost effectiveness

OBJECTIVE

The purpose of this study was to review the scientific evidence for neurobiological rationale, efficacy, tolerability and cost effectiveness of antipsychotic polypharmacy (APP).

DATA SOURCES

A systematic literature search of Medline, Embase, Ovid and the Cochrane Database of Systematic Reviews until April 2012 was carried out.

RESULTS

Theories behind APP have only modest pre-clinical and clinical evidence. We found limited statistical evidence supporting modest efficacy of APP in patients with psychotic symptoms refractory to clozapine. APP is associated with increased mortality, metabolic syndrome, decreased cognitive functioning, high dose prescription and non-adherence. It brings up extra costs, lacking evidence for cost-effectiveness.

CONCLUSIONS

Pre-clinical studies underpinning neurobiological hypotheses in APP are lacking. Evidence supporting efficacy of APP is limited with modest beneficial clinical relevance. APP is associated with several serious adverse effects and increased health costs. In the absence of more convincing pre-clinical support and clinical evidence we advise adherence to existing guidelines and limiting combinations of antipsychotics (in consideration with other pharmacotherapeutic, somatic and psychotherapeutic options) to patients with clozapine-refractory psychosis in well-evaluated individual trials that might need 10 weeks or more.

Interventions to reduce antipsychotic polypharmacy: a systematic review

BACKGROUND

It still remains unclear as to how to counteract antipsychotic polypharmacy that remains controversial but common. The objective of this study was to synthesize the clinical evidence to reduce antipsychotic polypharmacy (i.e. use of multiple antipsychotics) in schizophrenia.

METHODS

A literature search was performed to identify clinical trials that attempted to reduce antipsychotic polypharmacy in patients with schizophrenia by any form of systematic intervention using PubMed as well as MEDLINE, EMBASE, and PsycINFO (last search: June 2012). The search terms included "antipsychotics" and "polypharmacy". Cross-referencing was also performed.

RESULTS

The literature search identified 17 studies. Only 3 studies (1 randomized controlled trial and 2 open-label trials) were found that systematically switched antipsychotic polypharmacy to monotherapy. In two of them, more than two thirds of the subjects successfully completed the switch (40/58, 69.0%; 34/44, and 77.3%, respectively) while less than half the subjects tolerated it in the other study (6/14 and 42.9%) although the sample size was very small. On the other hand, 14 studies that examined impacts of interventions have physicians refrain from antipsychotic polypharmacy. While a modest intervention with educational approach alone was effective in three of the five articles, a more assertive intervention that directly cautioned physicians on the use of polypharmacy was effective in 10 of 12 articles.

CONCLUSION

The literature search revealed the paucity of the data. Careful switching from polypharmacy to monotherapy seems feasible in a majority of patients with schizophrenia. Assertive interventions, rather than passive educational approaches alone, appear more effective in reducing antipsychotic polypharmacy.

Antipsychotic polypharmacy: a needle in a haystack?

OBJECTIVE

The aim of our study was to assess the antipsychotic polypharmacy (APP) prevalence in a psychiatric hospital and to find the supporting evidence for the 10 most prescribed two-drug combinations. Secondarily, how many included clozapine, prevalence in the elderly, high dosage and clinically relevant interactions were also assessed.

METHOD

Clinicodemographic and computerized prescription data on 29th March 2011 were collected. High dosage was defined as more than 1000 mg of chlorpromazine equivalents (CPZeqs). A t test for unpaired measures was applied to compare means of dosage (CPZeq) and age among patients on APP vs. monotherapy. The χ(2) test was applied to compare proportions of patients on a high dose on APP vs. monotherapy. GraphPad Prism 5 software was used to perform statistical analysis.

RESULTS

From 201 patients admitted on 29th March, 172 had any antipsychotic prescription. APP prevalence was 47.1%, corresponding almost to 24% of elderly patients. Quetiapine was the drug most prescribed in combination, achieving a prevalence rate of 56.8%. Clozapine was not included in 67% of all combinations. Supporting evidence for two-drug combinations was only found for 6 of the 10 most prescribed. Relevant interactions were found in 12 patients on APP. The mean CPZeq dose and percentage of patients on high dosage were significantly higher in the APP than in the monotherapy group (1162±776.1 mg vs. 455.4±369.3 mg; 54% vs. 9%, respectively; P<.0001).

CONCLUSIONS

Our study shows that APP was being considered earlier in the management plan than what guidelines recommend. This practice was associated with higher total antipsychotic doses. Until further clinical trials are available, a wise APP practice will require a thoughtful choice of products guided by patient's prior history and interaction liability, a proper consent by the patients or their representatives and a careful monitoring of clinical outcomes and emerging side effects in order to avoid indefinite administration of ineffective and potentially harmful combinations.

Demographic and clinical correlates of sexual dysfunction among Nigerian male outpatients on conventional antipsychotic medications

BACKGROUND

In psychotic disorders, early intervention with antipsychotic medications increases the likelihood of favourable long-term course. However, the pharmacologic management especially with conventional antipsychotic medications is complicated by a high rate of adverse effects including sexual dysfunction. This study aims to determine the demographic and clinical factors associated with sexual dysfunction among male psychiatric outpatients on conventional antipsychotic medications in South-western Nigeria.

METHODS

Two hundred and seventy five consecutive male outpatients with psychotic disorders on conventional antipsychotic medications were interviewed. Data was collected on demographic characteristics, illness-related and medication-related variables. Illness severity was assessed with the Brief psychiatric rating scale. The International Index of Erectile Function questionnaire was used to assess for sexual dysfunctions.

RESULTS

A total of 111 (40.4%) respondents had one or more forms of sexual dysfunction. Sexual desire dysfunction was present in 47 (17.1%) of respondents, erectile dysfunction in 95 (34.5%), orgasmic dysfunctions in 51 (18.5%), intercourse dissatisfaction in 72 (26.2%) and overall dissatisfaction in 64 (23.3%). Sexual dysfunction was significantly associated with employment status, age, marital status, haloperidol use, medication dosage, and presence of psychopathology. Unemployment was the only significant independent correlate of sexual dysfunction, with unemployed respondents twice more likely to have sexual dysfunction compared with those employed (Wald = 3.865, Odds Ratio = 2.033, 95% confidence interval = 1.002 - 4.124, p = 0.049).

CONCLUSIONS

The high prevalence of sexual dysfunction found in this study suggests a need among clinicians for increased awareness and recognition of the sexual side effects in patients taking conventional antipsychotic medications. This knowledge should guide conventional antipsychotic medication prescription in the at-risk population to improve treatment adherence.

Association of antipsychotic polypharmacy with health service cost: a register-based cost analysis

OBJECTIVE

To investigate the association of antipsychotic polypharmacy in schizophrenia with cost of primary and secondary health service use.

METHOD

Comparative analysis of health service cost for patients prescribed antipsychotic polypharmacy versus antipsychotic monotherapy. Resource utilisation and costs were described using central Danish registers for a 2 year period (2007-2008). We included patients attached to one of two Danish psychiatric referral centres in 1 January 2008 and/or 1 January 2009. Their prescribed treatment with either antipsychotic polypharmacy or monotherapy at the two cross-sectional dates was recorded and used as proxy of polypharmacy exposure during the preceding year. A multivariate generalised linear model was fitted with total costs of primary and secondary health service use as dependent variable, and antipsychotic polypharmacy, diagnosis, age, gender, disease duration, psychiatric inpatient admissions, and treatment site as covariates.

RESULTS

The sample consisted of 736 outpatients with a diagnosis in the schizophrenia spectrum. Antipsychotic polypharmacy was associated with significantly higher total health service costs compared with monotherapy (2007: 25% higher costs; 2008: 17% higher costs) when adjusting for potential confounders and risk factors. A subgroup analysis suggested that the excessive costs associated with antipsychotic polypharmacy were partly accounted for by the functional level of the patients.

CONCLUSION

The results demonstrate that antipsychotic co-prescribing is associated with increased use of health care services, even though no causal relations can be inferred from an observational study.

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.

Payer types associated with antipsychotic polypharmacy in an ambulatory care setting

Objectives

Antipsychotic polypharmacy is increasingly prescribed despite little documented evidence of a therapeutic benefit. There is also a limited understanding of the role that health insurance plays on the prevalence of antipsychotic polypharmacy. This study was undertaken to investigate the relationship between antipsychotic polypharmacy and individuals' intended source of payment in a US national sample of ambulatory care patients.

Methods

The study combined 2002, 2003 and 2004 data from the National Ambulatory Medical Care Survey (NAMCS) among adults seeking outpatient-based physician medical care services in the USA. We investigated characteristic differences among patients who were prescribed multiple antipsychotics versus individuals receiving only a single antipsychotic medication. Multivariable logistic regression examined the association between antipsychotic polypharmacy and patients' primary payment type classified as private insurance, Medicaid, Medicare or other (primarily out-of-pocket) payment type.

Key findings

Use of more than one antipsychotic agent was recorded in 68 of 830 (8.2%) outpatient physician visits in the 3-year period 2002–2004. Among the payer types studied, Medicaid payment status was correlated with increased risk of antipsychotic polypharmacy (odds ratio 2.7, 95% confidence interval 1.1–6.7).

Conclusions

Insurance status was associated with antipsychotic polypharmacy among non-institutionalized US residents prescribed antipsychotic medications. Patients reporting Medicaid as their primary payer were nearly three times as likely to be prescribed multiple antipsychotic drugs, potentially increasing their risk of adverse side effects as well as greater taxpayer burden. Future research should determine whether these trends continued after 2004 and to determine the costs of treating patients in the public sector with multiple antipsychotic drugs, a common scenario despite financial pressures and uncertain medical benefit.