Time to 'get real': preliminary insights into the long-term management of schizophrenia

Antipsychotic prescribing for vulnerable populations: a clinical audit at an acute Australian mental health unit at two-time points

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.

Prevalence and nature of antipsychotic polypharmacy among inpatients with schizophrenia spectrum disorders at an Australian mental health service

OBJECTIVE

Though antipsychotic polypharmacy (APP) is widely utilised in many clinical settings for the treatment of people with schizophrenia, the extent of this practice varies considerably between different regions, countries and clinical settings. Studies from Australasia exploring the prevalence and factors associated with APP are sparse and have yielded inconsistent results.

METHODS

We conducted a systematic retrospective audit of the medical records of all admissions in 2010 in the adult wards of a metropolitan public mental health service in Western Australia, having a diagnosis of schizophrenia or schizoaffective disorder. We analysed the rates of APP use, and its association with selected demographic and clinical variables.

RESULTS

The prevalence of APP among our sample of 229 patients was high, at 43.2%. APP was associated with a longer hospital stay (p=0.033) and voluntary admission (p=0.027); but APP was not significantly related to: age, gender, diagnosis and treatment by different psychiatrists.

CONCLUSIONS

Substantial difference exists between everyday clinical practice and recommendations of practice guidelines of schizophrenia, regarding the use of APP. Prospective studies from different settings exploring the relevant clinical, patient, prescriber and system-related issues are warranted, to comprehend the rationale behind high utilisation of APP in clinical practice.

Optimisation of prescription in patients with long-term treatment-resistant schizophrenia

OBJECTIVE

The aim of this clinical review was to investigate the effectiveness and safety of the practice of antipsychotic poly-pharmacy (AP) in the long-term management of hospitalised patients with insufficient response to antipsychotic monotherapy.

METHOD

The databases Medline, PsycINFO, Embase and Scopus were searched. Studies were required to include inpatients with long-term, treatment-resistant schizophrenia on maintenance AP. The search was restricted to systematic review studies.

RESULTS

The review yielded four studies of interest that showed no categorical advantage for maintenance AP for the population of interest. However, clozapine combination faired marginally well. Particular weaknesses of the present literature are low number of participants, and inadequate monitoring of potential adverse effects. The evidence on the risks and benefits of maintenance AP is not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry.

CONCLUSIONS

This review provides a synthesis of the evidence on the maintenance use of AP for hospitalised patients with long-term, treatment-resistant schizophrenia. The results show both no support for AP with some marginal benefit for clozapine combination therapy, and methodological weaknesses of the included studies. These findings have clinical implications for treatment decisions and suggest that sufficiently powered studies are needed.