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Lassen S, Heintz T, Pedersen T, Jentz C, Nathanielsen N, Heilmann P, Sørensen LU. Nationwide study on antipsychotic polypharmacy among forensic psychiatric patients. Int J Circumpolar Health 2023; 82:2218654. [PMID: 37300837 DOI: 10.1080/22423982.2023.2218654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
This nationwide retrospective cross-sectional study examines the prevalence of antipsychotic polypharmacy (APP) and demographic, forensic, and clinical factors associated with its practice among Greenlandic forensic psychiatric patients. We collected data from electronic patient files, court documents, and forensic psychiatric assessments. We defined APP as two or more concurrent prescriptions of antipsychotic medication. The study population of 74 patients had a mean age of 41.4 years, and 61 were men. All included patients had either schizophrenia or another ICD-10 F2-diagnosis. We used unpaired t-tests and Chi2 or Fisher's exact test. The prevalence of APP was 35% (n = 26), and there was a significant association between APP and a prescription of clozapine (Chi2, p = 0.010), olanzapine (Fisher's test, p = 0.003), and aripiprazole (Fisher's test, p = 0.013). Furthermore, we found a significant association between APP and prescription of a first-generation antipsychotic (FGA) (Chi2, p = 0.011). Despite recommendations in guidelines, the use of APP is common practice. The majority of forensic psychiatric patients suffer from severe psychiatric disorders, often with other comorbidities, including substance use disorder. The severity and complexity in mental health render forensic psychiatric patients at high risk of APP treatment. Further knowledge on APP use is crucial to secure and further improve the psychopharmacological treatment for this group of patients.
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Affiliation(s)
- Stine Lassen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Thale Heintz
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Tilde Pedersen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Christian Jentz
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Naaja Nathanielsen
- The Directorate of Correctional Services, Prison and Probation Service, Nuuk, Greenland
| | | | - Lisbeth Uhrskov Sørensen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
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Machetanz L, Hofmann AB, Möhrke J, Kirchebner J. Offenders and non-offenders with schizophrenia spectrum disorders: the crime-preventive potential of sufficient embedment in the mental healthcare and support system. Front Psychiatry 2023; 14:1231851. [PMID: 37711423 PMCID: PMC10498463 DOI: 10.3389/fpsyt.2023.1231851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/04/2023] [Indexed: 09/16/2023] Open
Abstract
Background Suffering from schizophrenia spectrum disorder (SSD) has been well-established as a risk factor for offending. However, the majority of patients with an SSD do not show aggressive or criminal behavior. Yet, there is little research on clinical key features distinguishing offender from non-offender patients. Previous results point to poorer impulse control, higher levels of excitement, tension, and hostility, and worse overall cognitive functioning in offender populations. This study aimed to detect the most indicative distinguishing clinical features between forensic and general psychiatric patients with SSD based on the course of illness and the referenced hospitalization in order to facilitate a better understanding of the relationship between violent and non-violent offenses and SSD. Methods Our study population consisted of forensic psychiatric patients (FPPs) with a diagnosis of F2x (ICD-10) or 295.x (ICD-9) and a control group of general psychiatric patients (GPPs) with the same diagnosis, totaling 740 patients. Patients were evaluated regarding their medical (and, if applicable, criminal) history and the referenced psychiatric hospitalization. Supervised machine learning (ML) was used to exploratively evaluate predictor variables and their interplay and rank them in accordance with their discriminative power. Results Out of 194 possible predictor variables, the following 6 turned out to have the highest influence on the model: olanzapine equivalent at discharge from the referenced hospitalization, a history of antipsychotic prescription, a history of antidepressant, benzodiazepine or mood stabilizer prescription, medication compliance, outpatient treatment(s) in the past, and the necessity of compulsory measures. Out of the seven algorithms applied, gradient boosting emerged as the most suitable, with an AUC of 0.86 and a balanced accuracy of 77.5%. Discussion Our study aimed to identify the most influential illness-related predictors, distinguishing between FPP and GPP with SSD, thus shedding light on key differences between the two groups. To our knowledge, this is the first study to compare a homogenous sample of FPP and GPP with SSD regarding their symptom severity and course of illness using highly sophisticated statistical approaches with the possibility of evaluating the interplay of all factors at play.
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Affiliation(s)
- Lena Machetanz
- Department of Forensic Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Andreas B. Hofmann
- Department of Psychiatry, Psychotherapy, and Psychosomatics, University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Jan Möhrke
- Department of Forensic Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Johannes Kirchebner
- Department of Forensic Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland
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High Risk, High Dose?-Pharmacotherapeutic Prescription Patterns of Offender and Non-Offender Patients with Schizophrenia Spectrum Disorder. Biomedicines 2022; 10:biomedicines10123243. [PMID: 36551999 PMCID: PMC9775158 DOI: 10.3390/biomedicines10123243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/01/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022] Open
Abstract
Compared to acute or community settings, forensic psychiatric settings, in general, have been reported to make greater use of antipsychotic polypharmacy and/or high dose pharmacotherapy, including overdosing. However, there is a scarcity of research specifically on offender patients with schizophrenia spectrum disorders (SSD), although they make up a large proportion of forensic psychiatric patients. Our study, therefore, aimed at evaluating prescription patterns in offender patients compared to non-offender patients with SSD. After initial statistical analysis with null-hypothesis significance testing, we evaluated the interplay of the significant variables and ranked them in accordance with their predictive power through application of supervised machine learning algorithms. While offender patients received higher doses of antipsychotics, non-offender patients were more likely to receive polypharmacologic treatment as well as additional antidepressants and benzodiazepines. To the authors' knowledge, this is the first study to evaluate a homogenous group of offender patients with SSD in comparison to non-offender controls regarding patterns of antipsychotic and other psychopharmacologic prescription patterns.
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Anozie IG, James BO, Omoaregba JO, Oriji SO, Erohubie PO, Enebe AC. Correlates of high-dose antipsychotic prescription amongst outpatients with Schizophrenia in a Nigerian Hospital. S Afr J Psychiatr 2022; 28:1791. [PMID: 35547105 PMCID: PMC9082254 DOI: 10.4102/sajpsychiatry.v28i0.1791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 02/22/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Ihechiluru G Anozie
- Department of Clinical Sciences, Federal Neuropsychiatric Hospital, Benin City, Nigeria
| | - Bawo O James
- Department of Clinical Sciences, Federal Neuropsychiatric Hospital, Benin City, Nigeria
| | - Joyce O Omoaregba
- Department of Clinical Sciences, Federal Neuropsychiatric Hospital, Benin City, Nigeria
| | - Sunday O Oriji
- Department of Clinical Sciences, Federal Neuropsychiatric Hospital, Benin City, Nigeria
- Department of Mental Health, Nnamdi Azikiwe University, Awka, Nigeria
| | - Paul O Erohubie
- Department of Clinical Sciences, Federal Neuropsychiatric Hospital, Benin City, Nigeria
- Department of Mental Health, Irrua Specialist Teaching Hospital, Irrua, Nigeria
| | - Anthony C Enebe
- Department of Clinical Sciences, Federal Neuropsychiatric Hospital, Benin City, Nigeria
- Department of Mental Health Services, Federal Medical Centre Asaba, Asaba, Nigeria
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Ordak M, Tkacz D, Golub A, Nasierowski T, Bujalska-Zadrozny M. Polypharmacotherapy in Psychiatry: Global Insights from a Rapid Online Survey of Psychiatrists. J Clin Med 2022; 11:jcm11082129. [PMID: 35456222 PMCID: PMC9025459 DOI: 10.3390/jcm11082129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/01/2022] [Accepted: 04/10/2022] [Indexed: 12/02/2022] Open
Abstract
In recent years, an increase in the problem of polypharmacotherapy in psychiatric patients has been observed, including the widespread problem of groups of people taking new psychoactive substances. One reason for this problem may be the poor knowledge of pharmacological interactions in psychiatry. The aim of this study was to explore the opinions and knowledge of psychiatrists from around the world on various aspects related to polypharmacotherapy. A total of 1335 psychiatrists from six continents were included in the study. The respondents’ opinion on the problem of hepatotoxicity in psychiatry was also examined. The greatest discrepancy among psychiatrists from different continents in the answers given concerned the definition of polypharmacotherapy (p < 0.001) and the approach to hepatotoxicity (p < 0.001). It is noteworthy that only about 20% of the psychiatrists surveyed (p < 0.001) believe that polypharmacotherapy is associated with a higher rate of patients’ hospitalisations. The most commonly used type of polypharmacy by psychiatrists was antidepressants and antipsychotics. Most of them also stated that polypharmacy was associated with reduced patient compliance with the doctor’s recommendations related to taking medications due to the increased complexity of the therapy. The continent that diversified the analysed questions to the greatest extent was Africa. Future educational activities for trainee psychiatrists should include more discussion of polypharmacotherapy in psychiatry.
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Affiliation(s)
- Michal Ordak
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, 1B Banacha Street, 02-097 Warsaw, Poland; (D.T.); (A.G.); (M.B.-Z.)
- Correspondence:
| | - Daria Tkacz
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, 1B Banacha Street, 02-097 Warsaw, Poland; (D.T.); (A.G.); (M.B.-Z.)
| | - Aniela Golub
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, 1B Banacha Street, 02-097 Warsaw, Poland; (D.T.); (A.G.); (M.B.-Z.)
| | - Tadeusz Nasierowski
- Department of Psychiatry, Medical University of Warsaw, 1B Banacha Street, 02-097 Warsaw, Poland;
| | - Magdalena Bujalska-Zadrozny
- Department of Pharmacodynamics, Centre for Preclinical, Research and Technology (CePT), Medical University of Warsaw, 1B Banacha Street, 02-097 Warsaw, Poland; (D.T.); (A.G.); (M.B.-Z.)
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Mandarelli G, Carabellese F, Di Sciascio G, Catanesi R. Antipsychotic Polypharmacy and High-Dose Antipsychotic Regimens in the Residential Italian Forensic Psychiatric Population (REMS). Front Psychol 2022; 13:722985. [PMID: 35222172 PMCID: PMC8866699 DOI: 10.3389/fpsyg.2022.722985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
Few data exist regarding treatment with antipsychotics in forensic psychiatric patient populations with high social dangerousness. We performed a secondary analysis of 681 patients treated with at least one antipsychotic, extracted from a 1-year observational retrospective study, conducted on 730 patients treated in the Italian Residencies for Execution of Security Measures (REMS) (96.4% of the REMS population). We aimed at investigating antipsychotic polypharmacy (prescription of two or more concomitant antipsychotics) and high dose/very high-dose antipsychotics, as well as the possible factors associated with such therapeutic regimens. High dose/very high-dose antipsychotics were defined as a prescribed daily dose to WHO-defined daily dose ratio greater than 1.5 or 3.0, respectively. Binary logistic regression analysis was used in three models to test possible predictors of antipsychotic polypharmacy, high-dose antipsychotics, and very high-dose antipsychotic prescription. Antipsychotic polypharmacy resulted in n = 308 (45.2%) of the patients, n = 346 (50.8%) received high-dose antipsychotics, and n = 96 (14.1%) very high-dose antipsychotics. The multivariate analysis disclosed an association between antipsychotic polypharmacy and male gender (odds ratio (OR): 2.75 and 95% CI: 1.34–5.65), long-acting injectable (LAI) antipsychotic prescription (OR: 2.62 and 95% CI: 1.84–3.74), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.13–2.36). High-dose antipsychotics were also associated with male gender (OR: 2.01 and 95% CI: 1.02–3.95), LAI antipsychotic prescription (OR: 2.78 and 95% CI: 1.95–3.97), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.12–2.36). The use of antipsychotic polypharmacy and high-dose antipsychotics is frequent in the REMS population. These results might depend on regulatory and organizational aspects of the REMS system, including variability in structures, lack of a common model of care, and lack of stratified therapeutic security.
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Affiliation(s)
- Gabriele Mandarelli
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari “Aldo Moro”, Bari, Italy
- *Correspondence: Gabriele Mandarelli,
| | - Felice Carabellese
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari “Aldo Moro”, Bari, Italy
| | | | - Roberto Catanesi
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari “Aldo Moro”, Bari, Italy
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Kaikoushi K, Karanikola M, Middleton N, Bella E, Chatzittofis A. Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics. BJPsych Open 2021; 7:e149. [PMID: 34747353 PMCID: PMC8388008 DOI: 10.1192/bjo.2021.982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/01/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients. AIMS We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns. METHOD This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded. RESULTS Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included. CONCLUSIONS A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.
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Affiliation(s)
- Katerina Kaikoushi
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus; and Cyprus mental Health Services, Famagusta, Cyprus
| | - Maria Karanikola
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus
| | - Nicos Middleton
- School of Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus
| | | | - Andreas Chatzittofis
- Medical School, University of Cyprus, Cyprus; and Department of Clinical Sciences, Umeå University, Umeå, Sweden
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Alshehri GH, Keers RN, Carson-Stevens A, Ashcroft DM. Medication Safety in Mental Health Hospitals: A Mixed-Methods Analysis of Incidents Reported to the National Reporting and Learning System. J Patient Saf 2021; 17:341-351. [PMID: 34276036 DOI: 10.1097/pts.0000000000000815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Medication safety incidents commonly occur in mental health hospitals. There is a need to improve the understanding of the circumstances that are thought to have played a part in the origin of these incidents to design safer systems to improve patient safety. AIM This study aimed to undertake a mixed-methods analysis of medication safety incidents reported to the National Reporting and Learning System in England and Wales in 2010 to 2017. METHOD Quantitative analyses of anonymized medication safety incidents occurring in mental health hospitals that were reported to the National Reporting and Learning System during an 8-year period were undertaken to characterize their type, severity, and the medication(s) involved. Second, a content analysis of the free-text reports associated with all incidents of at least moderate harm severity was undertaken to identify the underlying contributory factors. RESULTS Overall, 94,134 medication incident reports were examined, of which 10.4% (n = 9811) were reported to have resulted in harm. The 3 most frequent types of reported medication incidents involved omission of medication (17,302; 18.3%), wrong frequency (11,882; 12.6%), and wrong/unclear dose of medication (10,272; 10.9%). Medicines from the central nervous system (42,609; 71.0%), cardiovascular (4537; 7.6%), and endocrine (3669; 6.1%) medication classes were the most frequently involved with incidents. Failure to follow protocols (n = 93), lack of continuity of care (n = 92), patient behaviors (n = 62), and lack of stock (n = 51) were frequently reported as contributory factors. CONCLUSIONS Medication incidents pose an enduring threat to patient safety in mental health hospitals. This study has identified important targets that can guide the tailored development of remedial interventions.
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Martinho S, Poças A, Simões M, Laureano C. Antipsychotic Polypharmacy and High-Dose Antipsychotics in Involuntary Patients: a Seven-Year Audit of Discharge Prescriptions in an Acute Care Unit. Psychiatr Q 2021; 92:1-14. [PMID: 32430698 DOI: 10.1007/s11126-020-09762-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Antipsychotic polypharmacy (APP) is a psychopharmacological practice in which two or more antipsychotics are prescribed simultaneously. Despite the absence of evidence to support it, it is highly prevalent in clinical settings. Another recurrent practice strongly associated with APP is the prescription of high-dose antipsychotics (HDAs). Compulsory treatment is a legal means to impose treatment on an individual suffering from mental illness who refuses therapeutic intervention. Compulsory treatment has been associated with APP and HDAs and rates of both have been proposed to represent indicators of the quality of prescribing. We aimed to perform an antipsychotic prescription audit in a vulnerable psychiatric population, at the psychiatry department of a district hospital in Portugal, across 7 years. We evaluated APP and HDAs in 403 compulsorily admitted patients by reviewing their files at discharge. We used logistic regression to search for factors associated with APP and HDAs. APP was found in 70.5% of individuals, whereas HDAs were found in 51.4%. After adjustment, APP was significantly associated with male gender (Odds Ratio[OR] = 1.85 [1.04; 3.30] 95% Confidence Interval [CI]), involuntary outpatient treatment (OR = .40 [.18; .82] 95% CI), activation of the hospital social services (OR = 1.91 [1.08; 3.38] 95%CI), prescription of antidepressants (OR = .43 [.22; .82] 95%CI) and long-acting injectables (LAI) (OR = 28.29 [13.13; 60.97] 95%CI). HDAs were associated with male gender (OR = 1.76 [1.06; 2.94] 95%CI), the prescription of LAI (OR = 12.92 [6.93; 24.09] 95%CI) and oral first-generation antipsychotics (OR = 2.90 [1.51; 5.60] 95%CI).
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Affiliation(s)
- Sérgio Martinho
- Psychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal.
| | - Ana Poças
- Psychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal
| | - Mário Simões
- Psychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal
| | - Cláudio Laureano
- Psychiatry and Mental Health Department, Leiria Hospital Center, Leiria, Portugal
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Günther MP, Kirchebner J, Kling S, Lau S. Antipsychotic Overdosing and Polypharmacy in Schizophrenic Delinquents Explored. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2020; 64:938-952. [PMID: 31884869 DOI: 10.1177/0306624x19895903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A logistic regression model for 289 cases of schizophrenic offenders in a Swiss forensic hospital between 1995 and 2016 revealed the following factors for above average levels of antipsychotic overdosing and polypharmacy: Odds for overdosing increased in absence of a personality disorder (237%), for each point increase in emotional withdrawal (63.5%) and motor retardation (71.7%), and decreased for poor rapport (42.3%) recorded at admission. Odds for polypharmacy increased with complaints about physicians (157%), for each point increase in IQ (3.6%; range = 65-131, M = 92, SD = 14), reduction of the security level of the ward (36.8%; four levels), and for each point increase in poor attention (27.6%) at admission. It decreased with each previous conviction (10.9%; range = 1-21, M = 3, SD = 2), breaking of rules (46.4%) and the administration of compulsory measures (55.7%) on the ward, a poor legal prognosis (29.4%, four levels), and each point increase in grandiosity (40.3%), passive social withdrawal (42.3%), and depressive symptoms (38.7%) at admission.
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Affiliation(s)
- M P Günther
- University Hospital of Psychiatry Zurich, Switzerland
| | - J Kirchebner
- University Hospital of Psychiatry Zurich, Switzerland
| | - S Kling
- Swiss Federal Institute of Technology (ETH) Zurich, Switzerland
| | - S Lau
- University Hospital of Psychiatry Zurich, Switzerland
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Wheeler AJ, Hu J, Profitt C, McMillan SS, Theodoros T. Is higher psychotropic medication burden associated with involuntary treatment under the Mental Health Act? A four-year Australian cohort study. BMC Psychiatry 2020; 20:294. [PMID: 32527250 PMCID: PMC7291489 DOI: 10.1186/s12888-020-02661-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/11/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Involuntary treatment for individuals who lack sufficient capacity to make informed decisions regarding treatment has been associated with increased rates of injectable antipsychotics, antipsychotic polytherapy, and/or high doses. However, little is known about non-antipsychotic psychotropic prescription, or psychotropic medication burden as a more encompassing approach for people treated involuntarily. The aim of this study was to examine the relationship between Mental Health Act (MHA) status and psychotropic polypharmacy and/or high-dose medication prescribing practices in an Australian inpatient mental health unit. METHODS A retrospective cohort study of 800 adults discharged from a large metropolitan Queensland mental health unit was undertaken. Data was collected for 200 individuals, discharged on at least one psychotropic medicine, at four time periods; Cohort 1 (on or before 31st January 2014), Cohort 2 (2015), Cohort 3 (2016) and Cohort 4 (2017). The number of prescribed medicines and total daily doses were recorded and reviewed for alignment with current clinical guidelines. Participant demographics and clinical characteristics were compared by individual MHA status using chi-square test for categorical variables and analysis of variance for continuous variables. Associations between MHA status and prescribing practices (psychotropic polypharmacy and/or high-dose prescribing) were assessed using bivariate and multivariate binomial logistic regression models. Age, gender, birth country, year of admission, admissions in previous 12 months, primary diagnosis, ECT/clozapine treatment, and other psychotropic medications were adjusted as covariates. RESULTS Regression analysis found that compared to their voluntary counterparts, individuals treated involuntarily were 2.7 times more likely to be prescribed an antipsychotic at discharge, 8.8 times more likely to be prescribed more than one antipsychotic at discharge and 1.65 times more likely to be prescribed high-dose antipsychotic treatment at discharge. The adjusted model also found that they were half as likely to be prescribed an antidepressant at discharge. CONCLUSION Implicit review of justifications for increased psychotropic medication burden (antipsychotic polypharmacy and high-doses) in those treated involuntarily is required to ensure clinical outcomes and overall quality of life are improved in this vulnerable group. Clearly documented medication histories, reconciliation at discharge and directions for medication management after discharge are necessary to ensure quality use of medicines.
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Affiliation(s)
- Amanda J Wheeler
- Menzies Health Institute Queensland, Nathan Campus, Griffith University, 170 Kessels Road, Brisbane, QLD, 4111, Australia.
- Faculty of Medical and Health Sciences, Auckland University, Auckland, New Zealand.
| | - Jie Hu
- Menzies Health Institute Queensland, Nathan Campus, Griffith University, 170 Kessels Road, Brisbane, QLD, 4111, Australia
| | - Caitlin Profitt
- School of Pharmacy and Pharmacology, Griffith University, Brisbane, Australia
| | - Sara S McMillan
- Menzies Health Institute Queensland, Nathan Campus, Griffith University, 170 Kessels Road, Brisbane, QLD, 4111, Australia
| | - Theo Theodoros
- University of Queensland Faculty of Medicine; Metro South Mental Health Services, Brisbane, Australia
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Jacobs R, Aylott L, Dare C, Doran T, Gilbody S, Goddard M, Gravelle H, Gutacker N, Kasteridis P, Kendrick T, Mason A, Rice N, Ride J, Siddiqi N, Williams R. The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.
Objectives
We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.
Design and setting
We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.
Participants
Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.
Interventions
Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).
Main outcome measures
Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.
Results
Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.
Limitations
There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.
Conclusions
Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.
Future work
Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
| | - Lauren Aylott
- Expert by experience
- Hull York Medical School, York, UK
| | | | | | - Simon Gilbody
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | | | - Tony Kendrick
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Jemimah Ride
- Centre for Health Economics, University of York, York, UK
| | - Najma Siddiqi
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Rachael Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
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Kasteridis P, Ride J, Gutacker N, Aylott L, Dare C, Doran T, Gilbody S, Goddard M, Gravelle H, Kendrick T, Mason A, Rice N, Siddiqi N, Williams R, Jacobs R. Association Between Antipsychotic Polypharmacy and Outcomes for People With Serious Mental Illness in England. Psychiatr Serv 2019; 70:650-656. [PMID: 31109263 PMCID: PMC6890489 DOI: 10.1176/appi.ps.201800504] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although U.K. and international guidelines recommend monotherapy, antipsychotic polypharmacy among patients with serious mental illness is common in clinical practice. However, empirical evidence on its effectiveness is scarce. Therefore, the authors estimated the effectiveness of antipsychotic polypharmacy relative to monotherapy in terms of health care utilization and mortality. METHODS Primary care data from Clinical Practice Research Datalink, hospital data from Hospital Episode Statistics, and mortality data from the Office of National Statistics were linked to compile a cohort of patients with serious mental illness in England from 2000 to 2014. The antipsychotic prescribing profile of 17,255 adults who had at least one antipsychotic drug record during the period of observation was constructed from primary care medication records. Survival analysis models were estimated to identify the effect of antipsychotic polypharmacy on the time to first occurrence of each of three outcomes: unplanned hospital admissions (all cause), emergency department (ED) visits, and mortality. RESULTS Relative to monotherapy, antipsychotic polypharmacy was not associated with increased risk of unplanned hospital admission (hazard ratio [HR]=1.14; 95% confidence interval [CI]=0.98-1.32), ED visit (HR=0.95; 95% CI=0.80-1.14), or death (HR=1.02; 95% CI=0.76-1.37). Relative to not receiving antipsychotic medication, monotherapy was associated with a reduced hazard of unplanned admissions to the hospital and ED visits, but it had no effect on mortality. CONCLUSIONS The study results support current guidelines for antipsychotic monotherapy in routine clinical practice. However, they also suggest that when clinicians have deemed antipsychotic polypharmacy necessary, health care utilization and mortality are not affected.
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Affiliation(s)
- Panagiotis Kasteridis
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Jemimah Ride
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Nils Gutacker
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Lauren Aylott
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Ceri Dare
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Tim Doran
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Simon Gilbody
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Maria Goddard
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Hugh Gravelle
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Tony Kendrick
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Anne Mason
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Nigel Rice
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Najma Siddiqi
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Rachael Williams
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Rowena Jacobs
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
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Kirilochev OO, Umerova AR. Safety of psychopharmacotherapy: a clinical and pharmacological approach. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:127-133. [DOI: 10.17116/jnevro2019119101127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Haw C, Stubbs J. Combined antipsychotics for ‘difficult-to-manage’ and forensic
patients with schizophrenia: reasons for prescribing and perceived
benefits. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.27.12.449] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodWe aimed to examine reasons for initiating and continuing the
prescription of combined antipsychotics. A structured interview was
carried out with the responsible medical officers for 40
‘difficult-to-manage’ tertiary referral patients with schizophrenia who
were regularly treated with two or more antipsychotics.ResultsLack of efficacy of monotherapy was the main reason for initiating and
continuing combined antipsychotics. Other reasons for continuing combined
antipsychotics included not wishing to change medication as the patient
was reasonably well, and safety considerations. Perceived benefits of
combined antipsychotics included fewer positive symptoms and less
disturbed behaviour.Clinical Implications‘Difficult-to-manage’ and forensic treatment-resistant patients with
schizophrenia pose a particular therapeutic challenge. Use of combined
antipsychotics, although not evidence-based, is perceived by some
psychiatrists as beneficial when other options have failed.
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Aspinall PJ. Informing progress towards race equality in mental healthcare: is routine data collection adequate? ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.12.2.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The quality, completeness and coverage of ethnicity data in mental health services has long been regarded as unsatisfactory. The Department of Health's new 5-year action plan for delivering race equality in mental healthcare seeks to improve this key building block by setting out actions to improve both the quality of information and its analysis and dissemination. However, those that are tangible and specific are few: annual surveys of service users, national censuses of mental health in-patients and tables of National Confidential Inquiry suicide cases and in-patient deaths by ethnicity. The opportunity to seek improvements in the quality and coverage of key routine data-sets such as ethnic monitoring in primary care and the Hospital Episode Statistics database has not been seized. Moreover, the plan does not mention proposed changes in civil registration (births and deaths) and the coroner service and their potential benefit. The continuing gaps in the information base justify a stronger emphasis on the processes necessary to bring about change rather than on what ethnic monitoring should provide.
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Abdelmawla N, Mitchell AJ. Sudden cardiac death and antipsychotics Part 2: Monitoring and prevention. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.12.2.100] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Tungaraza TE, Gupta S, Jones J, Poole R, Slegg G. Polypharmacy and high-dose antipsychotic regimes in the community. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/pb.bp.108.020776] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and methodTo 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.ResultsOnly 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 implicationsThe use of atypicals has not eliminated polypharmacy or high-dose antipsychotic regimes. Clinicians need to be aware of this long-standing problem.
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Combined antipsychotics for ‘difficult-to-manage’ and forensic patients with schizophrenia: reasons for prescribing and perceived benefits. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1017/s0955603600003615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Aims and Method
We aimed to examine reasons for initiating and continuing the prescription of combined antipsychotics. A structured interview was carried out with the responsible medical officers for 40 ‘difficult-to-manage’ tertiary referral patients with schizophrenia who were regularly treated with two or more antipsychotics.
Results
Lack of efficacy of monotherapy was the main reason for initiating and continuing combined antipsychotics. Other reasons for continuing combined antipsychotics included not wishing to change medication as the patient was reasonably well, and safety considerations. Perceived benefits of combined antipsychotics included fewer positive symptoms and less disturbed behaviour.
Clinical Implications
‘Difficult-to-manage’ and forensic treatment-resistant patients with schizophrenia pose a particular therapeutic challenge. Use of combined antipsychotics, although not evidence-based, is perceived by some psychiatrists as beneficial when other options have failed.
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Sub-optimal prescribing in an adult community mental health service: prevalence and determinants. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1017/s0955603600002567] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Aims and Method
To compare prescribing practice in a community mental health service with evidence-based guidelines and identify factors related to sub-optimal prescribing. All current patients (n=640) were assessed regarding six key aspects of prescribing (polypharmacy, high-dose treatment, use of thioridazine/maintenance benzodiazepine/maintenance hypnotic or routine anticholinergic treatment). The relationship of quality of prescribing practice to demographic, illness and service variables was examined by regression analysis.
Results
Five-hundred and five (79%) patients were receiving psychotropic medication. Of these, 232 (46%) had evidence of sub-optimal prescribing practice. Mean prescribing practice quality score was 0.75 ± 0.99. Maintenance benzodiazepine/ hypnotic (31%) and anticholinergic (30%) use were particularly common. Prescribing practice quality score was higher in those receiving depot antipsychotic treatment (P < 0.01) and in older patients (P < 0.01). Scores were significantly lower in patients whose principal medical contacts were with a consultant rather than a junior doctor (P < 0.001).
Clinical Implications
Prescribing practices in real-world settings frequently deviate from evidence-based guidelines. The quality of prescribing is related to patient, illness and service variables. In particular, greater contact with consultant staff is linked to better practices. Patients receiving depot antipsychotics are especially liable to less judicious prescribing practice.
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Meagher D, Moran M. Sub-optimal prescribing in an adult community mental health service: prevalence and determinants. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.27.7.266] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodTo compare prescribing practice in a community mental health service with evidence-based guidelines and identify factors related to sub-optimal prescribing. All current patients (n=640) were assessed regarding six key aspects of prescribing (polypharmacy, high-dose treatment, use of thioridazine/maintenance benzodiazepine/maintenance hypnotic or routine anticholinergic treatment). The relationship of quality of prescribing practice to demographic, illness and service variables was examined by regression analysis.ResultsFive-hundred and five (79%) patients were receiving psychotropic medication. Of these, 232 (46%) had evidence of sub-optimal prescribing practice. Mean prescribing practice quality score was 0.75 ± 0.99. Maintenance benzodiazepine/ hypnotic (31%) and anticholinergic (30%) use were particularly common. Prescribing practice quality score was higher in those receiving depot antipsychotic treatment (P < 0.01) and in older patients (P < 0.01). Scores were significantly lower in patients whose principal medical contacts were with a consultant rather than a junior doctor (P < 0.001).Clinical ImplicationsPrescribing practices in real-world settings frequently deviate from evidence-based guidelines. The quality of prescribing is related to patient, illness and service variables. In particular, greater contact with consultant staff is linked to better practices. Patients receiving depot antipsychotics are especially liable to less judicious prescribing practice.
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Harrington M, Lelliott P, Paton C, Konsolaki M, Sensky T, Okocha C. Variation between services in polypharmacy and combined high dose of antipsychotic drugs prescribed for in-patients. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.26.11.418] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodA 1-day census provided an opportunity to examine the variation between 44 mental health services in the frequency of prescribing high doses and polypharmacy of antipsychotic drugs to in-patients on acute psychiatric wards.ResultsThe proportion of patients prescribed a high dose ranged 0–50% and simultaneous use of more than one antipsychotic drug ranged 12–71%. A number of case-mix variables explained 26% and 40%, respectively, of the variance between services on these two indicators of prescribing practice.Clinical ImplicationsServices with high rates of prescription of high dose or polypharmacy might consider a review of clinical practice and of service-level factors that might affect prescribing.
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Moran M, Raju B, Saunders J, Meagher D. Achieving evidence-based prescribing practice in an adult community mental health service. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.30.2.51] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodPrescribing in everyday practice frequently deviates from evidence-based guidelines. Previous work compared practice in a community mental health service with evidence-based guidelines and identified factors related to suboptimal prescribing. This study reports the impact of a multifaceted intervention on prescribing practice. A Prescribing Practice Quality (PPQ) score was generated from six key aspects of prescribing at initial assessment and again 1 year later after an intervention to reduce suboptimal prescribing practices.ResultsA total of 264 patients were attending the service at both the initial and follow-up phase and were thus exposed to the prescribing intervention. In this population, PPQ scores were significantly lower at follow-up (0.96v.0.67,P<0.001). Improved prescribing practice was predicted by receipt of adjunctive supportive inputs, such as anxiety management (P=0.003).Similarly, mean PPQ scores substantially decreased when the total patient population was considered at each time point (0.75 in 2001 and 0.52 in 2002). These results suggest a reduction in both the initiation and continuation of suboptimal practices.Clinical ImplicationsPrescribing in real-world settings can be improved by interventions that target multiple aspects of service activity. The provision of supportive inputs is a key factor in improving practice.
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McMillan SS, Jacobs S, Wilson L, Theodoros T, Robinson G, Anderson C, Mihala G, Wheeler AJ. Antipsychotic prescribing for vulnerable populations: a clinical audit at an acute Australian mental health unit at two-time points. BMC Psychiatry 2017; 17:139. [PMID: 28407747 PMCID: PMC5390470 DOI: 10.1186/s12888-017-1295-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 03/31/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Antipsychotics are recognised as a critical intervention for schizophrenia and bipolar disorder. Guidelines globally endorse the routine practice of antipsychotic monotherapy, at the minimum effective dose. Even in treatment-resistant schizophrenia, clozapine use is endorsed before combining antipsychotics. This aim of this study was to review antipsychotic polytherapy alone, high-dose therapy alone, polytherapy and high-dose prescribing patterns in adults discharged from an inpatient mental health unit at two time-points, and the alignment of this prescribing with clinical guideline recommendations. Additionally, associations with polytherapy and high-dose antipsychotic prescribing, including patient and clinical characteristics, were explored. METHODS A retrospective clinical audit of 400 adults (200 patients at two different time-points) discharged with at least one antipsychotic. Preliminary findings and education sessions were provided to physicians between Cohorts. Outcomes (polytherapy alone, high-dose therapy alone, polytherapy and high-dose therapy) were compared between study Cohorts using chi-squared and rank-sum tests. Associations between outcomes and covariates were assessed using multivariable logistic regression. RESULTS Most patients (62.5%) were discharged on a single antipsychotic within the recommended dose range. There was a clear preference for prescribing second generation antipsychotics, and in this respect, prescribing is aligned with current evidence-based guidelines. However, sub-optimal prescribing practices were identified for both Cohorts in relation to polytherapy and high-dose antipsychotic rates. Involuntary treatment, frequent hospitalisations and previous clozapine use significantly increased the risk of all three prescribing outcomes at discharge. CONCLUSIONS In a significant minority, antipsychotic prescribing did not align with clinical guidelines despite increased training, indicating that the education program alone was ineffective at positively influencing antipsychotic prescribing practices. Further consideration should be given when prescribing antipsychotics for involuntary patients, people with frequent hospitalisations, and those who have previously trialled clozapine.
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Affiliation(s)
- Sara S McMillan
- Menzies Health Insitute, Griffith University, Brisbane, Australia.
| | - Sara Jacobs
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Louise Wilson
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Theo Theodoros
- grid.1003.2Faculty of Medicine, University of Queensland, Brisbane, Australia ,Royal Australia and New Zealand College of Psychiatrists Trainee, Melbourne, Victoria Australia ,Metro South Addiction and Mental Health Services, Department of Health, Brisbane, Queensland Australia
| | - Gail Robinson
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia ,grid.1003.2Faculty of Medicine, University of Queensland, Brisbane, Australia ,Metro North Mental Health Services, Department of Health, Brisbane, Queensland Australia
| | - Claire Anderson
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Gabor Mihala
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia
| | - Amanda J Wheeler
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia ,grid.9654.eFaculty of Medical and Health Sciences, Auckland University, Auckland, New Zealand
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Campos Mendes J, Azeredo-Lopes S, Cardoso G. Patterns of antipsychotics' prescription in Portuguese acute psychiatric wards: A cross-sectional study. Psychiatry Res 2016; 246:142-148. [PMID: 27693867 DOI: 10.1016/j.psychres.2016.09.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 08/09/2016] [Accepted: 09/21/2016] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- João Campos Mendes
- Departamento de Psiquiatria e Saúde Mental, Hospital Sousa Martins, Unidade Local de Saúde da Guarda, Guarda, Portugal.
| | - Sofia Azeredo-Lopes
- Department of Biostatistics and Informatics, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Graça Cardoso
- Chronic Diseases Research Center (CEDOC), NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
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Law S, Haddad PM, Chaudhry IB, Husain N, Drake RJ, Flanagan RJ, David AS, Patel MX. Antipsychotic therapeutic drug monitoring: psychiatrists' attitudes and factors predicting likely future use. Ther Adv Psychopharmacol 2015; 5:214-23. [PMID: 26301077 PMCID: PMC4535047 DOI: 10.1177/2045125315588032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This study aimed to explore predictive factors for future use of therapeutic drug monitoring (TDM) and to further examine psychiatrists' current prescribing practices and perspectives regarding antipsychotic TDM using plasma concentrations. METHOD A cross-sectional study for consultant psychiatrists using a postal questionnaire was conducted in north-west England. Data were combined with those of a previous London-based study and principal axis factor analysis was conducted to identify predictors of future use of TDM. RESULTS Most of the 181 participants (82.9%, 95% confidence interval 76.7-87.7%) agreed that 'if TDM for antipsychotics were readily available, I would use it'. Factor analysis identified five factors from the original 35 items regarding TDM. Four of the factors significantly predicted likely future use of antipsychotic TDM and together explained 40% of the variance in a multivariate linear regression model. Likely future use increased with positive attitudes and expectations, and decreased with potential barriers, negative attitudes and negative expectations. Scientific perspectives of TDM and psychiatrist characteristics were not significant predictors. CONCLUSION Most senior psychiatrists indicated that they would use antipsychotic TDM if available. However, psychiatrists' attitudes and expectations and the potential barriers need to be addressed, in addition to the scientific evidence, before widespread use of antipsychotic TDM is likely in clinical practice.
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Affiliation(s)
- Suzanne Law
- Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Peter M Haddad
- Greater Manchester West NHS Foundation Trust, Manchester, UK
| | | | | | - Richard J Drake
- Manchester Mental Health and Social Care Trust, Manchester, UK
| | | | - Anthony S David
- Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Maxine X Patel
- Institute of Psychiatry, King's College London, Box 68, 16 DeCrespigny Park, London SE5 8AF, UK
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Connolly A, Taylor D. Factors associated with non evidence-based prescribing of antipsychotics. Ther Adv Psychopharmacol 2014; 4:247-56. [PMID: 25489476 PMCID: PMC4257982 DOI: 10.1177/2045125314540298] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Non evidence-based prescribing of antipsychotics is common in the UK and internationally with high doses and polypharmacy the norm. These practices often remain even after systematic attempts are made to change. We aimed to establish which factors are linked to antipsychotic prescribing quality so we can identify and target patients for interventions to improve quality and allow us to understand further the drivers of non evidence-based prescribing. OBJECTIVES A cross-sectional survey with a collection of factors potentially affecting antipsychotic prescribing quality outcomes was carried out in eight secondary care units in England. Participants were inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose, polypharmacy, type and route were the main outcome measures. OBJECTIVES Data were collected for 1198 patients. Higher total dose was associated with greater weight, higher number of previous admissions, longer length of admission, noncompliance with medication and use of an atypical antipsychotic. A lower total dose was associated with clozapine use. Polypharmacy was associated with not being a patient at the South London and Maudsley NHS Trust centre, the subject having a forensic history, a greater number of previous admissions and higher total dose. Younger age, not being detained under a Mental Health Act section, atypical antipsychotic use and oral route were predictors of antipsychotic monotherapy. Atypical antipsychotic use was associated with oral route, higher total dose, being administered only one antipsychotic, having had fewer previous antipsychotics and no anticholinergic use. Use of the oral route was associated with not being sectioned under the Mental Health Act, atypical antipsychotic use, younger age, non-schizophrenia diagnosis, fewer previous admissions and a lower total dose. OBJECTIVES In patients with chronic illness who are detained, heavier, noncompliant, not taking clozapine and on a depot antipsychotic, prescribers use larger doses and antipsychotic polypharmacy. We found that use of percentage of licensed maximum doses favours typical antipsychotics arbitrarily, and that high doses and polypharmacy are inextricably linked.
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Affiliation(s)
| | - David Taylor
- Pharmacy Department, Maudsley Hospital, London SE5 8AZ, UK
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Patel MX, Bishara D, Jayakumar S, Zalewska K, Shiers D, Crawford MJ, Cooper SJ. Quality of prescribing for schizophrenia: evidence from a national audit in England and Wales. Eur Neuropsychopharmacol 2014; 24:499-509. [PMID: 24491953 DOI: 10.1016/j.euroneuro.2014.01.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 01/11/2014] [Indexed: 11/16/2022]
Abstract
The National Audit of Schizophrenia (NAS) examined the quality of care received in England and Wales. Part of the audit set out to determine whether six prescribing standards, set by the national clinical guidelines for schizophrenia, were being implemented and to prompt improvements in care. Mental Health Trusts and Health Boards provided data obtained from case-notes for adult patients living in the community with schizophrenia or schizoaffective disorder. An audit of practice tool was developed for data collection. Most of the 5055 patients reviewed were receiving pharmacological treatment according to national guidelines. However, 15.9% of the total sample (95%CI: 14.9-16.9) were prescribed two or more antipsychotics concurrently and 10.1% of patients (95%CI: 9.3-10.9) were prescribed medication in excess of recommended limits. Overall 23.7% (95%CI: 22.5-24.8) of patients were receiving clozapine. However, there were many with treatment resistance who had no clear reason documented as to why they had not had a trial of clozapine (430/1073, 40.1%). In conclusion, whilst most people were prescribed medication in accordance with nationally agreed standards, there was considerable variation between service providers. Antipsychotic polypharmacy, high dose prescribing and clozapine underutilisation in treatment resistance were all key concerns which need to be further addressed.
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Affiliation(s)
- Maxine X Patel
- Institute of Psychiatry, King׳s College London, Department of Psychosis Studies, Box 68, 16 De Crespigny Park, London SE5 8AF, United Kingdom.
| | - Delia Bishara
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom.
| | - Simone Jayakumar
- College Centre for Quality Improvement, Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, United Kingdom.
| | - Krysia Zalewska
- College Centre for Quality Improvement, Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, United Kingdom.
| | - David Shiers
- College Centre for Quality Improvement, Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, United Kingdom.
| | - Mike J Crawford
- Faculty of Medicine, Imperial College London, Centre for Mental Health, Claybrook Centre. 37, Claybrook Road, London W6 8LN, United Kingdom.
| | - Stephen J Cooper
- College Centre for Quality Improvement, Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, United Kingdom.
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Sugarman P, Mitchell A, Frogley C, Dickens GL, Picchioni M. Off-licence prescribing and regulation in psychiatry: current challenges require a new model of governance. Ther Adv Psychopharmacol 2013; 3:233-43. [PMID: 24167695 PMCID: PMC3805431 DOI: 10.1177/2045125312472530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The growing worldwide use of pharmaceuticals is managed in some countries by a regulatory system which sharply divides legal use into licensed and unlicensed categories. We examine how for the range of psychotropics this simultaneously restricts the possible benefits to patients, prescribers and producers in some domains, while failing to manage the risks in others. A more flexible system, which shares at an earlier stage experience and evidence on benefits and risks in patients, previously marginalized on the grounds of age, diagnosis or comorbidity, would aid the development of safer, more effective 'real-world prescribing'. Practical recommendations are made for a new model of research and prescribing governance, to enable more effective repurposing of these treatments.
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Affiliation(s)
- Philip Sugarman
- Chief Executive Officer, St Andrew's Healthcare, Northampton, UK
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Abstract
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.
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Affiliation(s)
- Michele Hill
- MGH Schizophrenia Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Ranceva N, Ashraf W, Odelola D. Antipsychotic Polypharmacy in Outpatients at Birch Hill Hospital: Incidence and Adherence to Guidelines. J Clin Pharmacol 2013; 50:699-704. [DOI: 10.1177/0091270009350625] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Polypharmacy among psychiatric outpatients in Kuwait. MIDDLE EAST CURRENT PSYCHIATRY 2012. [DOI: 10.1097/01.xme.0000418716.82323.da] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Griffiths EV, Willis J, Spark MJ. A systematic review of psychotropic drug prescribing for prisoners. Aust N Z J Psychiatry 2012; 46:407-21. [PMID: 22535291 DOI: 10.1177/0004867411433893] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To conduct a review of the literature on prescribing psychotropic drugs for prisoners. METHODS Articles were retrieved from nine databases, reference lists, citations, governmental prison websites, and contact with authors. The articles included were written in English, focused on adults' time as prisoners, included at least one drug of interest, and discussed prescribing. Thirty-two articles met these inclusion criteria. RESULTS Five main themes were identified from the reviewed studies: polypharmacy, high-dose therapy, duration of treatment, documentation and monitoring, and issues associated with the prisoners' environment. CONCLUSIONS Consideration of these themes within the included studies identified areas for future research, particularly models of good practice, as numerous descriptions of poor practice exist. Policy-makers and prescribers should review current systems and practices, to ensure the care being offered to prisoners is optimal.
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Affiliation(s)
- Elise V Griffiths
- School of Pharmacy and Applied Science, La Trobe University, Bendigo, Australia
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Ito H, Okumura Y, Higuchi T, Tan CH, Shinfuku N. International variation in antipsychotic prescribing for schizophrenia: Pooled results from the research on East Asia psychotropic prescription (reap) studies. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ojpsych.2012.224048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tomasi R, de Girolamo G, Santone G, Picardi A, Micciolo R, Semisa D, Fava S. Drug prescription in Italian Residential Facilities. ACTA ACUST UNITED AC 2011; 14:77-90. [PMID: 16001704 DOI: 10.1017/s1121189x0000628x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
SUMMARYAims — To investigate in a representative national sample (N=2,962) of patients living in Residential Facilities (RFs) patterns of polypharmacy as well as related variables, association between diagnoses and therapeutic patterns, and the rate of adverse events. Methods — Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF. Patients were rated with the HoNOS and the SOFAS, and comprehensive information about their sociodemographic and clinical status, and their pharmacological regimes were collected. Results — Conventional antipsychotics and second-generation antipsychotics were prescribed to 65% and 43% of the sample, respectively. Benzodiazepines were prescribed to two-thirds of the sample, while antidepressants were the least-used class of psychotropics. Polypharmacy was common: on average, each treated patient was taking 2.7 drugs (±1.1); antipsychotic polypharmacy was also common. Many prescriptions were loosely related to specific diagnoses. Antiparkinsonianian drugs were prescribed to approximately 1/4 of the sample. Mild or severe adverse events in the previous month were reported for 9.9% and 1.4% of the sample, respectively. About 15% of patients suffered from tardive dyskinesia. Conclusions — Psychotropic drug prescription patterns for severe patients living in RFs are only sometimes satisfactory and offer the opportunity of improvement. Specific actions are required to improve prescription patterns for severe patients in RFs.Declaration of Interest: in the past two years GdG has received two speaker fees from Janssen-Cilag and from Eli Lilly; GS has received one speaker fee from Solvay. RM, AP, SF and RT have received no fees or other financial support from pharmaceutical companies.
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Abstract
OBJECTIVE To evaluate the prescribing practices in psychiatric residential facilities, with particular focus both on the antipsychotic dose and polypharmacy as well as the variation of antipsychotic patterns during a patient's stay within the facilities. METHODS Fifteen residential facilities of Liguria region in Italy were included. Data were collected through a chart review during a one-day census. Frequency of psychotropic patterns was estimated. Different non-parametric tests were used to analyse the changes in prescription patterns as well as the relationship among antipsychotic dose, the number of antipsychotics and anticholinergic use. RESULTS The study sample includes 362 patients, 61.9% males. On the census day 77.5% of patients received psychotropic polypharmacy and 57.2% antipsychotic polypharmacy. Antipsychotic polypharmacy was related to the total antipsychotic daily dose and to anticholinergic use. A trend towards an increase of antipsychotic and psychotropic polypharmacy and higher doses of antipsychotics over the period of stay within the facilities was noted. This tendency was related to the length of stay in the facility. CONCLUSIONS Compared to earlier studies in the same clinical environment a significant increase in the use of psychotropic and antipsychotic polypharmacy was observed. The risk of prescribed polypharmacy seems to be related to time spent in the facility.
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Baker J. Multi-disciplinary perceptions of patient group directions as a replacement for the pro re nata prescribing of antipsychotic medications in acute mental health settings. J Adv Nurs 2011; 67:2191-9. [DOI: 10.1111/j.1365-2648.2011.05661.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Connolly A, Taylor D, Sparshatt A, Cornelius V. Antipsychotic prescribing in Black and White hospitalised patients. J Psychopharmacol 2011; 25:704-9. [PMID: 21511740 DOI: 10.1177/0269881109387841] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ethnicity may affect the prescribing of antipsychotic treatment. Previous UK studies conducted in south London have found few differences in antipsychotic prescribing quality for Black and White patients. This larger multicentre study examined the effect of ethnicity on antipsychotic prescribing quality in areas serving the largest proportions of Black patients in the UK. A cross-sectional survey with collection of multiple confounding factors potentially affecting outcomes in eight secondary care units in England over a three month period. Participants were Black or White inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose (expressed as a percentage of licensed maximum), high dose (being prescribed antipsychotic medication above maximum dose), polypharmacy (more than one antipsychotic prescribed), type (typical or atypical antipsychotic) and costs were the main outcome measures. Data were collected for 938 patients. There were no significant differences in any outcome by ethnicity: dose (adjusted percentage difference 0.97 [95% confidence interval (CI) -4.28, 6.22], p = 0.72); high dose (adjusted odds ratio (AOR) 0.98 [CI 0.63, 1.51], p = 0.92); polypharmacy prescribed (AOR 1.15 [CI 0.87, 1.51], p = 0.33); polypharmacy administered (AOR 1.08 [CI 0.78, 1.49], p = 0.66); use of typical antipsychotics (AOR 1.25 [CI 0.87, 1.79], p = 0.22); and cost (adjusted effect size 1.75 [CI -9.81, 13.31], p = 0.77). Antipsychotic prescribing practice did not differ between Black and White patients.
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Santone G, Bellantuono C, Rucci P, Picardi A, Preti A, de Girolamo G. Patient characteristics and process factors associated with antipsychotic polypharmacy in a nationwide sample of psychiatric inpatients in Italy. Pharmacoepidemiol Drug Saf 2010; 20:441-9. [DOI: 10.1002/pds.2083] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 11/02/2010] [Accepted: 11/05/2010] [Indexed: 11/12/2022]
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Trends in adult antipsychotic polypharmacy: progress and challenges in Florida's Medicaid program. Community Ment Health J 2010; 46:523-30. [PMID: 20099030 DOI: 10.1007/s10597-009-9288-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 12/28/2009] [Indexed: 10/19/2022]
Abstract
We studied trends in antipsychotic polypharmacy over a 4 year period in order to see if a change occurred when a statewide quality improvement program aimed at reducing the practice was implemented. Antipsychotic polypharmacy prevalence rates were calculated for eight 6-month periods for enrollees with schizophrenia and schizoaffective disorder and for those with all other diagnoses. Prevalence increased from 1/2003 to 12/2004 and then declined for 4 successive 6 month periods beginning in the 1/2005-6/05 period when the program began. Piecewise linear regression results for both diagnostic groups confirmed that the change in the likelihood of antipsychotic polypharmacy during the four 6 month periods before program implementation were significantly different than during the four 6 month periods following implementation. While it is impossible to control for the effects of all variables in evaluating the impact of any system wide intervention the data suggest that the program did help to reduce the use of antipsychotic polypharmacy.
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Baandrup L, Allerup P, Lublin H, Nordentoft M, Peacock L, Glenthoj B. Evaluation of a multifaceted intervention to limit excessive antipsychotic co-prescribing in schizophrenia out-patients. Acta Psychiatr Scand 2010; 122:367-74. [PMID: 20456285 DOI: 10.1111/j.1600-0447.2010.01553.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the effect of a multifaceted educational intervention on the frequency of antipsychotic co-prescribing in adult schizophrenia out-patients. METHOD Controlled quasi-experimental study performed in two Danish municipalities matched for baseline prevalence of antipsychotic polypharmacy, socioeconomic status and functional level of patients. The intervention was aimed at psychiatric healthcare providers and consisted of 1 day of didactic lectures, six 3-h educational outreach visits and an electronic reminder during drug prescribing. RESULTS Between-group use of antipsychotic polypharmacy was compared at baseline (intervention group, N = 232/control group, N = 351) and after 1 year of intervention (intervention group, N = 216/control group, N = 386). The prevalence of antipsychotic polypharmacy at follow-up was not significantly different between treatment settings when adjusting for differences in case-mix (P = 0.07). CONCLUSION This multifaceted educational intervention failed to reduce the frequency of antipsychotic co-prescribing, but it suggested that future efforts to improve prescribing practice should address organizational barriers to implementation.
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Affiliation(s)
- Lone Baandrup
- Center for Neuropsychiatric Schizophrenia Research, Copenhagen University Hospital, Psychiatric Center Glostrup, Glostrup, Denmark.
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Kontis D, Theochari E, Kleisas S, Kalogerakou S, Andreopoulou A, Psaras R, Makris Y, Karouzos C, Tsaltas E. Doubtful association of antipsychotic polypharmacy and high dosage with cognition in chronic schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:1333-41. [PMID: 20691745 DOI: 10.1016/j.pnpbp.2010.07.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Revised: 07/13/2010] [Accepted: 07/28/2010] [Indexed: 10/19/2022]
Abstract
Despite consistent recommendations for antipsychotic monotherapy, antipsychotic polypharmacy (the use of two or more antipsychotic agents) and the administration of excessive doses (higher than 1000 mgr/day of chloropromazine equivalents) is a common practice in schizophrenia. The therapeutic and adverse effects of this practice are poorly studied, in particular with regards to the cognitive symptoms of the disease. In this cross-sectional study we investigated the cognitive effects of antipsychotic polypharmacy and excessive doses in 53 patients with chronic schizophrenia using non-verbal cognitive tasks involving speed of movement, memory and executive functions. No significant difference in performance scores was found between the groups under polypharmacy and monotherapy, or the groups receiving either excessive or normal doses of antipsychotics. Since these groups did not also differ in demographic, clinical, other pharmacologic parameters, in the relative anticholinergic potency of antipsychotics, or in intelligence scores, we raise doubts about the association of polypharmacy and excessive doses with non-verbal cognitive performance in chronic schizophrenia.
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Affiliation(s)
- Dimitrios Kontis
- 1st Psychiatric Department, Psychiatric Hospital of Attica, 374, Athinon avenue, 12462, Athens, Greece.
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Hayhurst KP, Drake RJ, Lewis SW. Patient factors associated with receipt of combination antipsychotic drug therapy in the treatment of schizophrenia. J Psychopharmacol 2010; 24:83-9. [PMID: 18719041 DOI: 10.1177/0269881108095169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although discouraged in available treatment guidelines, combination antipsychotic prescribing (CAP) is a common practice in the treatment of schizophrenia. Patient characteristics may be associated with this type of treatment. A dataset (N = 363) derived from parallel randomised controlled trials was interrogated to identify factors associated with the receipt of CAP, and a logistic regression analysis was used to predict the occurrence of CAP. Significant predictors of CAP were longer illness, low global functioning score and high treatment adherence rating. Co-prescribed patients received a higher combined dose.
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Affiliation(s)
- K P Hayhurst
- Psychiatry Research Group, The University of Manchester, Manchester, UK.
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Ben Makhlouf W, Besbes C, El Hechmi Z. Doses d’entretien des neuroleptiques dans le traitement au long cours de la schizophrénie. ANNALES MEDICO-PSYCHOLOGIQUES 2009. [DOI: 10.1016/j.amp.2007.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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46
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Abstract
OBJECTIVE To use structured implicit review following large-scale explicit audit of antipsychotic polyprescribing to: (1) determine the true rate of antipsychotic polytherapy that deviated from best practice for schizophrenia treatment; and (2) assess whether explicit antipsychotic polytherapy criterion was appropriate for identifying patients at risk for medication problems and assessing quality of care. METHODS Antipsychotic prescribing was reviewed for outpatients in four public health services in Auckland, New Zealand on 31 October 2004 (T1). Schizophrenia patients in one service (n = 794) prescribed antipsychotic polytherapy (n = 84, 10.6%) were followed up 10 months later (T2). Historical medication summaries were prepared for those remaining on polytherapy, including diagnosis, clinical problems and treatment plan. Criteria for structured implicit review and rating form for quality of antipsychotic management were piloted. All medication summaries were independently rated by two reviewers, and a third independent rater reviewed summaries where disagreement was found. RESULTS Forty-nine patients remained on long-term polytherapy at T2 (6.2% of original population). All but two cases included a second-generation antipsychotic. At T2, average polytherapy duration was 35.8 months, and average antipsychotic dose was 699 mg day(-1) chlorpromazine equivalents. Two raters achieved agreement for 24/49 summaries, and the remaining 25 were rated independently by a third reviewer. Consensus agreement of antipsychotic management (by two raters) was reached for 44/49 cases (89.8%). Polytherapy was rated 'well-justified' in 32.7%, 'some justification' in 10.2% and 'lacked justification' in 46.9% cases. The final rate of polytherapy deviating from best practice reduced from 10.6% to 3.5% when short-term polytherapy was excluded, and details of the clinical situation and care plan were included in implicit review. CONCLUSIONS Audit of prescribing in routine practice using explicit guideline-based criteria may be a useful baseline performance indicator. It does not provide an accurate measurement of quality of care because it overestimates the deviation rate from good practice. It may also identify complex patients at risk for poor treatment outcomes who may benefit from structured treatment review.
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Affiliation(s)
- Amanda Wheeler
- Clinical Research and Resource Centre, Mental Health and Addiction Services, Waitakere Hospital, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Paton C, Barnes TRE, Cavanagh MR, Taylor D, Lelliott P. High-dose and combination antipsychotic prescribing in acute adult wards in the UK: the challenges posed by p.r.n. prescribing. Br J Psychiatry 2008; 192:435-9. [PMID: 18515893 DOI: 10.1192/bjp.bp.107.042895] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clinical guidelines recommend the routine use of a single antipsychotic drug in a standard dose, but prescriptions for high-dose and combined antipsychotics are common in clinical practice. AIMS To evaluate the effectiveness of a quality improvement programme in reducing the prevalence of high-dose and combined antipsychotic prescribing in acute adult in-patient wards in the UK. METHOD Baseline audit was followed by feedback of benchmarked data and delivery of a range of bespoke change interventions, and then by a further audit 1 year later. RESULTS Thirty-two services participated, submitting data for 3,942 patients at baseline and 3,271 patients at the 1-year audit. There was little change in the prevalence of high-dose (baseline 36%; re-audit 34%) or combined antipsychotic prescribing (baseline 43%; re-audit 39%). As required ('p.r.n.') prescriptions were the principal cause of both high-dose and combined antipsychotic prescribing on both occasions. CONCLUSIONS The quality improvement programme did not have a demonstrable impact on prescribing practice in the majority of services. Future efforts to align practice with clinical guidelines need to specifically target the culture and practice of p.r.n. prescribing.
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Affiliation(s)
- Carol Paton
- Oxleas NHS Foundation Trust, Pinewood House, Pinewood Place, Dartford, Kent DA2 7WG, UK.
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Lass J, Männik A, Bell JS. Pharmacotherapy of first episode psychosis in Estonia: comparison with national and international treatment guidelines. J Clin Pharm Ther 2008; 33:165-73. [PMID: 18315782 DOI: 10.1111/j.1365-2710.2008.00900.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES The pharmacotherapy of psychosis often differs between countries and with respect to treatment guidelines. Little is known about the treatment of first episode psychosis in countries of the former Soviet Union. The objective of the study was to analyse and describe the pharmacotherapy of first episode psychosis in Estonia. METHODS Case notes for consecutive patients with schizophrenia, schizotypal or delusional disorders admitted to the psychiatry clinics of the North Estonia Regional Hospital (NERH) and Tartu University Hospital (TUH) between September 2005 and September 2006 were retrospectively reviewed by a trained researcher. Treatment regimens were assessed according to prescribed doses, the incidence of antipsychotic polypharmacy and prescribing of conventional vs. atypical agents. RESULTS There were 234 patients admitted to the NERH and TUH, 142 of which were included in the final analyses (mean age 30.3 years for males, 40.4 years for females). Patients were most frequently treated with risperidone (n = 94), olanzapine (n = 43), chlorpromazine (n = 31), haloperidol (n = 21) and quetiapine (n = 24). Fourteen patients received concurrent treatment with two or more antipsychotics for three or more treatment days. Nine patients received antipsychotics in doses exceeding the maximum recommended doses in the British National Formulary. CONCLUSIONS The pharmacotherapy of first episode psychosis in Estonia was largely consistent with Estonian and international guidelines, however, the use of conventional antipsychotics and antipsychotic polypharmacy remained common. Estonian treatment guidelines may need to be revised to reflect the best available research evidence.
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Affiliation(s)
- J Lass
- Pharmacy Department, Tartu University Hospital, Tartu, Estonia.
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Anti-psychotic polypharmacy and combined high-dose anti-psychotic prescribing in schizophrenia. Ir J Psychol Med 2008; 25:33-34. [PMID: 30290580 DOI: 10.1017/s0790966700010867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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