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

Factors predicting high-dose and combined antipsychotic prescribing in New Zealand: High-dose antipsychotic prescribing

OBJECTIVE

Guidelines recommend using antipsychotic monotherapy at the lowest effective dose, however high-dose and antipsychotic polypharmacy prescribing (APP) remain commonplace. The aim of this study was to determine the prevalence and patterns of high-dose antipsychotic prescribing and APP among mental health service users in New Zealand (NZ).

METHODS

A retrospective audit of service users discharged from inpatient (n=657), or registered with community (n=1560), mental health services at Auckland District Health Board was undertaken. Case notes were reviewed and data on demographics, antipsychotic routes and doses were collected. Outcomes measures included: frequency of total high-dose prescribing, high-dose monotherapy, APP, high-dose APP, and factors associated with these prescribing practices. Logistic regression models were used to examine the relationships between explanatory and outcome variables.

RESULTS

Of the service users prescribed an antipsychotic (n = 2217), 14% were prescribed a high-dose antipsychotic. The frequency of high-dose monotherapy, APP, and high-dose APP was 3%, 26% and 11%, respectively. Being male, Māori, on compulsory treatment, having a schizophrenia diagnosis, or being prescribed polypharmacy were associated with high-dose antipsychotics. Olanzapine was most frequently prescribed in both high dosing (55%) and APP (40%).

CONCLUSIONS

There is a high prevalence of high-dose prescribing and APP in this NZ setting.

Sociodemographic and clinical variables associated with discharge under compulsory treatment orders

OBJECTIVE

To document the sociodemographic and clinical variables associated with discharge under compulsory treatment orders in patients with schizophrenia or related disorders.

METHOD

Information on various sociodemographic and clinical variables were extracted from the clinical files of 349 patients discharged from an adult (age 18-65) inpatient psychiatric unit with diagnoses of schizophrenia or related disorders. Univariate and multiple logistic regression analyses with legal compulsion (compulsory versus voluntary) as outcomes were applied.

RESULTS

Two hundred of the 349 discharged patients were placed under compulsory treatment orders. In the univariate logistic regression analysis, unemployment, diagnosis of schizophrenia, forensic history, dosage of antipsychotics, prescription and frequency of injectable antipsychotics, polypharmacy and a hospital stay of more than 28 days were associated with compulsory status. Being married or in partnership and living with partner was associated with voluntary status. Multiple regression models respectively confirmed most of these relationships observed in the univariate analyses.

CONCLUSION

Clarification of the apparent drivers for compulsory treatment may help thoughtful reductions in the use of compulsion.

Antipsychotic Polypharmacy and High-Dose Antipsychotics in Involuntary Patients: a Seven-Year Audit of Discharge Prescriptions in an Acute Care Unit

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).

Antipsychotic Use Pattern in Schizophrenia Outpatients: Correlates of Polypharmacy

Background:

This study investigates the antipsychotic use patterns of patients with schizophrenia and its correlations in their daily drug use patterns.

Methods:

Patients with schizophrenia who have regular records at two different community counselling centres (CCS) were included in the study. Information about their medications and sociodemographic data was recorded through face-to-face interviews and supporting information about their drug use patterns was obtained from their relatives/caregivers/nurse. The Clinical Global Impression Scale (severity of illness) and the General Assessment of Functionality scales were also administered.

Results:

Patients with schizophrenia used 2.0 ± 0.81 antipsychotics daily and 3.52 ± 2.55 pills (1–18). Seventy-one percent of the patients used two or more kinds of psychotropic drugs. The most frequently used antipsychotics were quetiapine, a second generation antipsychotic, and haloperidol, a typical antipsychotic. Clinical severity, regular visits to a CCS and use of depot antipsychotics were independent predictors for polypharmacy.

Conclusion:

The rate of polypharmacy use is high in Turkey. There are multiple risk factors related with polipharmacy. New studies should focus risk factors for preventing polypharmacy.

Prevalence and correlates of antipsychotic polypharmacy among outpatients with schizophrenia attending a tertiary psychiatric facility in Nigeria

BACKGROUND

The study aimed to determine the prevalence, pattern and correlates of antipsychotic polypharmacy (APP) among outpatients with schizophrenia attending a tertiary psychiatric facility in Nigeria.

METHOD

A cross-sectional study of 250 patients with schizophrenia attending the outpatient clinic of a regional tertiary psychiatric facility in Nigeria was undertaken. They were administered a sociodemographic questionnaire, the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning (GAF) scale and the Liverpool University Side Effects Rating Scale (LUNSERS).

RESULTS

Of the 250 subjects interviewed, 176 (70.4%) were on APP. APP was significantly associated with higher prescribed chlorpromazine equivalent doses of antipsychotics (p < 0.001), increased frequency of dosing (p < 0.001), negative symptoms (p < 0.01), poorer functioning (p = 0.04) and greater side-effect burden (p = 0.04).

CONCLUSION

The APP rate reported from this study is high. Clinicians should be mindful of its impact on dosage and side-effect profiles as APP use is associated with negative symptoms and poor psychosocial functioning.

High-dose antipsychotics: addressing patients' resistance to physical health monitoring

High-dose antipsychotics are sometimes used in clinical practice when patients fail to respond to treatment at standard doses. Owing to the potential physical complications associated with this, strict adherence to physical health monitoring is essential. Challenges arise for clinicians when patients refuse to cooperate with this monitoring. We discuss different interventions to overcome this problem, many of which are coercive in nature, and consider their professional, ethical and legal implications. We include a flow diagram to assist clinicians in their documentation and decision-making in these circumstances as well as case vignettes showing when monitoring under restraint is and is not justifiable.

Factors associated with antipsychotic polypharmacy and high-dose antipsychotics among individuals receiving compulsory treatment in the community

Community treatment orders (CTOs) are a form of compulsory treatment of individuals with a mental illness in the community. The objectives of this study were to determine the demographic, clinical, and treatment plan factors associated with antipsychotic polypharmacy and high-dose antipsychotics among individuals issued with a CTO. This was a secondary analysis of all 377 individuals who were prescribed an antipsychotic, extracted from a retrospective study of 378 individuals issued with a CTO by the New South Wales Mental Health Review Tribunal in Australia in 2009. Deidentified information relating to individuals' treatment plans, demographic, and clinical details were systematically extracted. Of the 377 individuals, 121 (32%) were prescribed antipsychotic polypharmacy and 101 (27%) high-dose antipsychotics. Unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for factors associated with antipsychotic polypharmacy and high-dose antipsychotics were computed using binary logistic regression. There was a strong association between the use of antipsychotic polypharmacy and high-dose antipsychotics (P < 0.001). Only treatment plan factors were associated with antipsychotic polypharmacy and high-dose antipsychotics in adjusted models. Although first-generation long-acting injectable antipsychotics and clozapine were associated with antipsychotic polypharmacy (adjusted OR, 9.12; 95% CI, 4.21-19.74; adjusted OR, 7.97; 95% CI, 2.93-21.72), oral second-generation antipsychotics and risperidone long-acting injection were associated with high-dose antipsychotics (adjusted OR, 5.67; 95% CI, 2.89-11.12; adjusted OR, 8.14; 95% CI, 3.22-20.53). Therefore, the use of antipsychotic polypharmacy and high-dose antipsychotics among individuals issued with CTOs is associated only with the drugs prescribed in their treatment plans and not their individual demographic and clinical characteristics.