On- and off-label utilisation of antipsychotics in Australia (2000-2021): Retrospective analysis of two medication datasets

OBJECTIVE

To determine antipsychotic utilisation patterns in Australian adults from 2005 to 2021, with a focus on on-label and off-label prescriptions.

METHODS

We examined antipsychotic dispensing trends in adults from 2005 to 2021 using a 10% sample of the Pharmaceutical Benefits Scheme (PBS) dataset, which contains patient-level information on medicines dispensed throughout Australia. The lack of diagnostic information in PBS was substituted by analysing BEACH (Bettering the Evaluation And Care of Health) dataset, a cross-sectional national survey from 2000 to 2016, consisting of data from general practitioner-patient encounters.

RESULTS

There were 5.6 million dispensings for 164,993 patients in PBS throughout this period; 69% patients had >1 dispensing, with a median of 6 per patient. Calculating the estimated period of exposure gave a total of 693,562 treatment episodes, with a median duration of 80 days. There were steady increases in both the incidence and prevalence of antipsychotic dispensings, mainly due to oral second-generation antipsychotics. The most commonly prescribed antipsychotics were quetiapine, olanzapine and risperidone, with a significant portion of patients receiving low-dose quetiapine without dose titration. Analysis of diagnostic indications from BEACH indicated that 27% of antipsychotic prescriptions were off-label for indications such as depression, dementia, anxiety and insomnia, at much lower prescribed daily dosages.

CONCLUSION

The increasing prescribing and off-label use highlights concerns about chronic adverse effects caused by antipsychotics. The combined analysis of medication dispensings and the diagnostic indications for which they are prescribed is a novel approach and throws a spotlight on the need for additional monitoring of antipsychotics.

Global Advancement in Pharmacy Services for Mental Health: A Review for Evidence-Based Practices

The symptoms of psychiatric infirmities have variability, and selected drug regimens for mental illness are comparatively complex and individualized; therefore, pharmacy services vary with respect to patients, diseases, healthcare settings, community structures, and countries. Clinical pharmacy services for mental health (MH) are continuously being upgraded. A structured search of the literature was performed in the Cochrane, PubMed (Medline), PsycINFO, Google scholar, Scopus, Science Direct, and Springer Links databases. The title and abstract of each retrieved article were evaluated for relevance. To remove uncertainty and ambiguity, the full-text articles were retrieved and examined for relevance. The articles were further assessed on the basis of inclusion and exclusion criteria. Narrative synthesis was performed, creating new categories and relevant subcategories and further subsections. The articles and the results were assessed for quality and bias. Pharmacists have a range of expertise in psychiatric care. The services can be classified as conventional, extended, and advanced pharmacy services. Conventional services include the quality use of medicines in healthcare settings and medication support services in communities that ensure medication adherence. Pharmacists perform extended roles in collaborative medication therapy management, multidisciplinary community mental health teams, collaborative care, patient education, home medication review, hospital-to-home transit, and screening services. In the USA, the role of pharmacists was advanced by prescribing as collaborative and interim prescribers. Australia launched an accredited program for psychiatric first-aid pharmacists. Pharmacists can provide mental care to rural populations using health technology. The role of pharmacists in MH is appreciated either independently or as a team member. Patients and healthcare providers rank the services of pharmacists in MH highly. Still, there is a margin for improvement in the training of pharmacists. Pharmacists cannot provide sufficient time to their patients. Public awareness about the role of pharmacists in MH needs more attention. Moreover, the training of psychiatric pharmacists should be standardized around the world.

Pharmacist-led interventions for people living with severe and persistent mental illness: A systematic review

OBJECTIVE

People living with severe and persistent mental illness experience poorer physical health, often due to medication and preventable lifestyle factors, and exacerbated by barriers to accessing healthcare services. Pharmacists are well-positioned to improve the physical and mental health of this population. However, little is known about pharmacists' current practices when providing services to this population nor the impact of pharmacist-led interventions on consumer health outcomes. We undertook a systematic review to identify, describe and assess the effectiveness of pharmacist-led interventions for supporting people living with severe and persistent mental illness and the impact on consumer outcomes.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Scopus, Cochrane Library, International Pharmaceutical Abstracts and ProQuest Dissertations and Theses were searched between January 1990 and April 2020. Full-text studies exploring pharmacist-led interventions in any setting for people living with severe and persistent mental illness were included. A risk of bias assessment was conducted.

RESULTS

A total of 37 studies were included. More than half of the pharmacist interventions were multifaceted. The most common components of pharmacist-led interventions included education and/or patient counselling, providing recommendations to healthcare professionals and conducting medication reviews. Multifaceted interventions demonstrated improvements in clinical outcomes, whereas single interventions focused mostly on consumer-reported outcomes. The methodological quality of included studies was moderate-to-high risk of bias and there was considerable heterogeneity in the study design, interventions described, and outcomes reported.

CONCLUSION

There is evidence that pharmacist-led interventions improve consumer-reported and clinical outcomes for people living with severe and persistent mental illness. Pharmacists are capable and have a role in supporting people living with severe and persistent mental illness, either individually or as interprofessional collaborators with other healthcare professionals. Future research should attempt to better understand which particular intervention components have the greatest impact and also evaluate the implementation and long-term sustainability of such interventions.

Clinician perceptions of My Health Record in mental health care: medication management and sharing mental health information

My Health Record (MHR) is a national personally controlled electronic health record, which is projected to be used by all Australian health professionals by 2022. It has also been proposed for use in mental health care, but there is limited information on how clinicians will successfully implement it. This study interviewed seven general practitioners and four psychologists in Tasmania, Australia. Participants were asked about information continuity and barriers and benefits to using My Health Record in mental health care. Thematic analysis identified two pertinent themes: Medication Management and Mental Health Information. Participants reported MHR could improve the quality and frequency of medication information shared between clinicians, but wanted additional medication-related alert features. Mental health information issues were broad in scope and included concerns over sensitive data that might be accessed through MHR and completeness of information. Participants also reported barriers to MHR use, including time burdens and privacy and confidentiality concerns. My Health Record used in mental health care may improve the timely sharing of medication-related information, but clinicians' concerns regarding the sharing of patients' highly sensitive mental health information need to be addressed.

Prevalence of multiple antipsychotic use and associated adverse effects in Australians with mental illness

AIM

This article analyzes the prevalence of use of concurrent multiple antipsychotics and high dosage treatment in people with mental illness, to assess the burden of antipsychotic drug-related side-effects associated with multiple use, and to identify strategies shown to reduce antipsychotic polypharmacy.

METHODS

Literature reviewed was sourced from MEDLINE, Embase, CINAHL, InformIT, PsycINFO, International Pharmaceutical Abstracts, Cochrane Library database and Joanna Briggs Institute databases to identify Australian studies published between January 2000 and February 2015. Studies that reported prevalence of multiple antipsychotic use or addressed the issue of antipsychotic drug-related side-effects were included. Systematic reviews, randomized controlled trials, and observational pre-post studies of Australian and international interventions aiming to reduce multiple antipsychotic use in mental health settings were also identified.

RESULTS

Nineteen studies reporting prevalence of multiple antipsychotic use were identified. The proportion of patients taking more than one antipsychotic ranged from 5 to 61%. Of the studies assessing dosages used, between one-third and one-half of all patients taking multiple antipsychotics received doses higher than recommended. Data from one national study reported that people taking multiple antipsychotics were more likely to experience at least one side-effect in comparison to consumers taking a single antipsychotic (90 verses 80%).International evidence of direct trials of conversion from treatment regimens involving multiple antipsychotics to those based on monotherapy show that between 50 and 75% of people with serious mental illness could be successfully converted to single-agent treatment, with up to 25% obtaining an improvement in health and the remaining 50% staying well managed.

CONCLUSION

Use of multiple antipsychotics is common among Australian people with mental illness, despite guidelines recommending that only one antipsychotic should be used in most cases. People taking more than one antipsychotic at a time are more likely to experience side-effects, and to receive higher than recommended antipsychotic doses. Direct trials that aimed to reduce multiple antipsychotic use suggest it is possible to effectively reduce therapy in the majority of people without worsening outcomes. Simple educational programmes targeting health professionals have not been found to be effective; however, complex multifaceted programmes and quality improvement programmes have demonstrated effect.

New roles for pharmacists in community mental health care: a narrative review

Medicines are a major treatment modality for many mental illnesses, and with the growing burden of mental disorders worldwide pharmacists are ideally positioned to play a greater role in supporting people with a mental illness. This narrative review aims to describe the evidence for pharmacist-delivered services in mental health care and address the barriers and facilitators to increasing the uptake of pharmacist services as part of the broader mental health care team. This narrative review is divided into three main sections: (1) the role of the pharmacist in mental health care in multidisciplinary teams and in supporting early detection of mental illness; (2) the pharmacists' role in supporting quality use of medicines in medication review, strategies to improve medication adherence and antipsychotic polypharmacy, and shared decision making; and (3) barriers and facilitators to the implementation of mental health pharmacy services with a focus on organizational culture and mental health stigma. In the first section, the review presents new roles for pharmacists within multidisciplinary teams, such as in case conferencing or collaborative drug therapy management; and new roles that would benefit from increased pharmacist involvement, such as the early detection of mental health conditions, development of care plans and follow up of people with mental health problems. The second section describes the impact of medication review services and other pharmacist-led interventions designed to reduce inappropriate use of psychotropic medicines and improve medication adherence. Other new potential roles discussed include the management of antipsychotic polypharmacy and involvement in patient-centered care. Finally, barriers related to pharmacists' attitudes, stigma and skills in the care of patients with mental health problems and barriers affecting pharmacist-physician collaboration are described, along with strategies to reduce mental health stigma.

A retrospective study of psychotropic drug use among individuals with mental illness issued a community treatment order

BACKGROUND

Community treatment orders (CTOs) are legal orders which require individuals with mental illness to accept treatment in the community. Previous studies report that long-acting injectable (LAI) antipsychotics are associated with CTOs, however, little is known about the specific treatment plans prescribed in CTOs. The objective of this study was to describe the patterns of psychotropic drugs prescribed to individuals issued a CTO, focusing on LAI antipsychotics, antipsychotic polypharmacy and high-dose antipsychotics.

METHODS

This was a retrospective cross-sectional study of 378 individuals randomly selected from a sample of 1317 individuals with a CTO expiry date up to and including 30 April 2010, taken from all 2856 individuals issued a CTO by the New South Wales Mental Health Review Tribunal, Australia, in 2009. De-identified information relating to individuals' treatment plans, demographic and clinical details were systematically extracted.

RESULTS

A total of 377 (99.7%) individuals were prescribed at least one antipsychotic. Of these, 310 (82%) were prescribed a LAI antipsychotic, either alone (45%), or in combination with, an oral antipsychotic (37%). Risperidone was the most prevalent antipsychotic, prescribed to 164 (43%) individuals. Antipsychotic polypharmacy was prescribed to 121 (32%) individuals and between 20% and 27% of individuals were prescribed high-dose antipsychotics. Antipsychotic polypharmacy accounted for 74-80% of individuals prescribed high-dose antipsychotics.

CONCLUSIONS

The results from this study confirm that LAI antipsychotics are commonly prescribed in CTOs. Antipsychotic polypharmacy was also common, and accounted for the majority of individuals prescribed high-dose antipsychotics. Further research is needed to determine the potential outcomes and implications of the patterns observed.

A systematic review of psychotropic drug prescribing for prisoners

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.

An expert panel assessment of comprehensive medication reviews for clients of community mental health teams

BACKGROUND

Few studies have investigated strategies to identify and resolve drug-related problems among clients of community mental health teams (CMHTs).

OBJECTIVE

The objective of this study was to evaluate the clinical impact and appropriateness of comprehensive medication reviews for clients of CMHTs.

METHODS

Trained pharmacists conducted interviews (30-45 min each) with clients of CMHTs to identify actual and potential drug-related problems. The pharmacists prepared medication review reports that detailed their findings and recommendations to optimize drug therapy. An expert panel comprising a psychiatrist, general medical practitioner, mental health pharmacist and medication review pharmacist evaluated reviews for 48 clients of 5 CMHTs. Panelists independently assessed review findings, review recommendations, likelihood of recommendation implementation and the overall expected clinical impact.

RESULTS

Two hundred and nine medication review findings and 208 medication review recommendations were evaluated. Panelists agreed with 76% of findings and considered that 81% of recommendations were appropriate. Collectively, 69% of recommendations were considered likely to be implemented. Thirty-seven (77%) reviews were deemed potentially to have a positive clinical impact. The agreement between panelists was statistically significant (P < 0.01) for the assessment of the findings, recommendations and likelihood of recommendation implementation.

CONCLUSIONS

Pharmacists' findings and recommendations to optimize drug therapy were considered appropriate and likely to result in improved clinical outcomes. Comprehensive medication reviews may be a valuable strategy to identify and resolve drug-related problems among clients of CMHTs.

Differential pharmacological regulation of drug efflux and pharmacoresistant schizophrenia

Pharmacoresistant schizophrenia is a significant impediment to the successful management of the disease. The expression and function of P-glycoprotein (P-gp) has recently been implicated in this phenomenon. P-gp is a multidrug efflux transporter that prevents drug substrates from crossing the blood-brain barrier (BBB). Although the direct interaction between individual antipsychotic agents and P-gp has been demonstrated, the effect of antipsychotic drug combinations used in disease management on P-gp transport function remains to be elucidated. This could have important clinical implications in some individuals as dosage adjustments based on plasma drug concentration changes may not always be appropriate if drug-drug interactions and the resulting changes in drug concentration in the brain are not considered. This paper introduces the potential impact that combination antipsychotic therapy may have on P-gp function at the BBB and discusses the consequences of this in the prevention and circumvention of unfavourable therapeutic response in schizophrenic disorders.

Pharmacotherapy of first episode psychosis in Estonia: comparison with national and international treatment guidelines

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.