Antipsychotic prescribing trends: a review of pharmaco-epidemiological studies

Translation and cultural adaptation of Glasgow Antipsychotic Side-effects Scale (GASS) in Arabic

Background

In view of a constant increase in the number of patients treated with antipsychotic medications, the problem of nonadherence to the prescribed treatment becomes particularly relevant. Since one of the major contributors to the nonadherence is the presence of side effects of the drugs being used, the availability of tools for assessment of adverse reactions is of great importance.

Objective

The objective of the present work was to develop an Arabic language version of the Glasgow Antipsychotic Side-effect Scale (GASS).

Methods

After confirming the accuracy of translation, the questionnaire was given to 100 patients in two psychiatric centers in Saudi Arabia.

Results

The Cronbach’s alpha (0.793) indicated a good reliability of the survey. The mean GASS score was 19.09, indicating absent or mild side effects of antipsychotics, but 46% of patients experienced moderate, and 25% experienced severe side effects. An analysis of the correlation between patients’ characteristics and side effects revealed the presence of a positive relationship between the side effects and health literacy.

Conclusions

It is expected that the Arabic-GASS will benefit Arabic-speaking psychiatric patients by helping them to express their concerns about side effects of antipsychotics. The collected results also document the importance of patients’ health literacy in achieving high-quality healthcare.

Neuroleptic Prescribing and Monitoring Practices in Pediatric Inpatient Medical and Psychiatric Settings

BACKGROUND

Pediatric use of second-generation antipsychotics, or neuroleptics, has increased over the past decade. Neuroleptic use can have significant and lasting adverse neurologic, metabolic, and cardiovascular effects. In the current literature, neuroleptic prescribing and monitoring is described in outpatient settings, with little description of inpatient pediatric practice. In this study, we are the first to explore prescribing and monitoring in inpatient pediatrics, highlighting similarities and differences in practice between pediatric medicine and psychiatry.

METHODS

This retrospective study included patients <18 years of age who received a neuroleptic during inpatient hospitalization between September 2014 and March 2015, within either the pediatric inpatient medical or psychiatric setting. Data collected included sex, age, race, height, weight, length of stay, service providing care, details involving the neuroleptic(s) administered, comorbidities, lipid and glycemic monitoring, and results, monitoring for extrapyramidal symptoms, and mental health consultation.

RESULTS

Factors associated with improved neuroleptic monitoring included longer length of stay and evidence of an adverse drug effect. Clearly specified indication for use was associated with improved neuroleptic monitoring. Although neuroleptic initiation during admission had improved indication documentation and monitoring practices compared with initiation before admission, a significant gap exists between inpatient psychiatry and medical settings in adverse drug effect monitoring, particularly extrapyramidal symptom monitoring and lipid collection.

CONCLUSIONS

In our study, we describe current practice in the use and monitoring of neuroleptics in inpatient pediatric medical and psychiatric settings. In this study, we suggest that the use of neuroleptics in inpatient pediatrics, particularly inpatient medical settings, is conducted with suboptimal monitoring and, at times, without clear documented indication.

Antipsychotic Use With and Without Comorbid Psychiatric Diagnosis Among Adults with Intellectual and Developmental Disabilities

OBJECTIVE

Antipsychotic use is controversial in the management of adults with intellectual and developmental disabilities (IDD) because of inconclusive evidence for efficacy in the absence of a comorbid psychiatric condition, and substantial concerns about adverse effects. We aimed to characterize antipsychotic use among Ontario adults with IDD and compare profiles of those with and without a documented psychiatric diagnosis.

METHOD

This population-based study included 51,881 adults with IDD under 65 y as of April 2010 receiving provincial drug benefits in Ontario who were followed until March 2016 to identify those dispensed at least one antipsychotic medication. Profiles of those with and without a psychiatric diagnosis were compared.

RESULTS

Overall, 39.2% of adults ( n = 20,316) were dispensed an antipsychotic medication, which increased to 56.4% in a subcohort residing in group homes. Almost one-third (28.91%) of people prescribed an antipsychotic medication did not have a documented psychiatric diagnosis. Those without a psychiatric diagnosis differed considerably from those with a diagnosis. In particular, those without a psychiatric diagnosis were older, less likely to have used antidepressants or benzodiazepines in the year before, and less likely to have used ambulatory and acute care.

CONCLUSIONS

Antipsychotic use in IDD is common, and occurs frequently without a psychiatric diagnosis. Attention toward how antipsychotics are prescribed and monitored for people with IDD in Canada is warranted to ensure appropriate prescribing.

A quantitative analysis of antipsychotic prescribing trends for the treatment of schizophrenia in England and Wales

Objective

This study aims to assess the current antipsychotic prescribing trends for the treatment of schizophrenia and to compare them with available guidelines and research evidence.

Design

An observational retrospective quantitative analysis.

Setting

Data were collected from the prescribing cost analysis for the period between 2007 and 2014, including all drugs from the British National Formulary 4.2.1 and 4.2.2. Prescriptions were included from primary and secondary healthcare settings in England and Wales.

Participants

None.

Main outcome measures

Defined daily doses of antipsychotics were used to compare popularity of individual drugs and classes of antipsychotics.

Results

There is a consistent increase in the proportion of atypical antipsychotics prescribed, compared to typical antipsychotics, between 2007 and 2014, with atypicals accounting for 79.9% of total antipsychotics prescribed in 2014.

Conclusion

The consistent popularity of atypical antipsychotics is not concordant with the current National Institute for Health and Care Excellence guidelines for the treatment of schizophrenia or the most recent research evidence.

Antipsychotics in Dutch Youth: Prevalence, Dosages, and Duration of Use from 2005 to 2015

Objectives: The use of antipsychotic drugs by youth is associated with serious side effects, especially when prescribed in higher dosages and for a longer period. Despite this, little is known about recent trends in the dosages and duration of use of antipsychotic drugs in children and adolescents. The aim of this study was to describe trends in prevalence, incidence, dosages, duration of use, and preceding psychotropic medication in Dutch youth who had been prescribed antipsychotic drugs from 2005 to 2015. Methods: We analyzed 84,828 antipsychotic prescriptions of youths aged 0-19 years between 2005 and 2015, derived from a large Dutch community pharmacy-based prescription database (IADB.nl). Results: Since a peak of 9.8 users per 1000 youths in 2009, prevalence rates stabilized. Dosages in milligram per kilogram declined for the most frequently prescribed antipsychotic drugs during the study period. The median duration of use was 6.0 (95% CI 5.4-6.6) months. Boys used antipsychotic drugs significantly longer than girls, with a median of 6.9 (95% CI 6.1-7.7) versus 4.6 (95% CI 3.9-5.3) months (p < 0.01). Of the youths prescribed antipsychotics, 12.4% used them for at least 48 months. The majority of youths had used other psychotropic agents in the year before the start of an antipsychotic drug (62.4% in 2005 and 64.7% in 2015). Conclusions: Despite a stabilization of usage rates and decline in dosages and duration of use, one in eight youths still used antipsychotic drugs for 4 years or longer. A substantial share of youths may, therefore, be at high risk for serious side effects.

Trial exclusion criteria and their impact on the estimation of antipsychotic drugs effect: A case study using the SOHO database

OBJECTIVES

To explore the impact upon estimation of drug effect as a result of applying exclusion criteria in randomized-controlled trials (RCT) measuring the efficacy of antipsychotics (AP) in schizophrenia.

METHODS

Three characteristics which may act as effect-modifiers of AP, while also common exclusion criteria in RCTs, were identified through literature review: schizophrenia duration, substance use disorder and poor adherence. The SOHO cohort was used to estimate the effect of initiating antipsychotic drugs "A", "B" or "C" (pooled) upon symptom evolution at 3months from baseline (CGI-S scale). "Estimated effectiveness" and "estimated efficacy" were drawn from the "SOHO" and "RCT-like" (patients with none of the above-listed exclusion criteria) samples, respectively. Effect-modification and impact of each exclusion criterion on AP effect estimates were explored using non-adjusted statistics.

RESULTS

The "SOHO sample" included 8250 patients initiating drug A, B or C at baseline, whose AP "estimated effectiveness" was ΔCGI-S=-0.78 (95% CI=-0.80, -0.76). The "RCT-like" sub-sample included 5348 (65%) patients whose AP "estimated efficacy" was ΔCGI-S=-0.73 (95% CI=-0.75, -0.70). Patients with short illness duration (≤3years since first AP; n=2436) experienced significant symptom improvement (ΔCGI-S=-0.89; 95%CI=-0.93, -0.85) compared to patients with duration >3years (mean ΔCGI-S=-0.73; 95%CI=-0.76, -0.71). Excluding patients with short illness duration led to a change in AP effect estimates but this was not the case for substance use disorder or poor adherence.

CONCLUSION

Using certain exclusion criteria in RCTs may impact the drug's effect estimate, particularly when exclusion criteria are AP effect-modifiers representing frequent characteristics among patients with schizophrenia.

Antipsychotics use: 2006-2013 trends in prevalence and incidence and characterization of users

PURPOSE

The present study was conducted to describe antipsychotic (AP) prevalent and incident use, characteristics of AP users, and their trends in the French population.

METHODS

A cross-sectional study was repeated yearly from January 1, 2007 to December 31, 2013 (for prevalence analysis) or to December 31, 2012 (for incidence analysis) using the French Health Insurance reimbursement database (Echantillon Généraliste de Bénéficiaires, EGB). For each year studied, prevalent and incident AP users were described in terms of age and gender overall, and according to the type of AP (FGAPs or SGAPs) used at index date. In addition, concurrent medications and comorbidities that a priori contraindicate the use of drugs having atropinic properties were researched.

RESULTS

Prevalence and incidence remained relatively stable along the 2007-2013 period. Trends slightly decreased, from 2.07% (n = 10,252) to 2.05% (n = 11,015) for prevalence, and from 0.73% (n = 3461) to 0.66% (n = 3363) for incidence, especially in elderly, in contrast of children and adolescents (+ 39% for prevalence, from 184 to 271). The number of coprescribed drugs was found high (median = 5) and remained constant over time. In 2013, about 7% of prevalent AP users presented with a comorbidity increasing the risk of atropinic ADRs, and 36% used at least one concurrent atropinic drug. In incident AP users, these numbers were of 8 and 29%, respectively.

CONCLUSIONS

The present study highlighted a marked shift from FGAPs toward SGAPs, as well as an increase in AP use in children and adolescents in France.

Pattern of psychotropic medication use over two decades in Australian women

OBJECTIVE

Few population-based studies have been used to investigate secular trends in psychotropic medication use. Therefore, the aim of this study was to examine psychotropic medication use over time using data from the Geelong Osteoporosis Study, an on-going, population-based, cohort study of Australian women.

METHODS

Of the 1494 women recruited at Time 1 (1993-1997), self-reported medication use from Time 2 (2004-2008) and/or Time 3 (2011-2014) was available for 889 women. Prevalence of antidepressant/antipsychotic/anxiolytic/sedative/anticonvulsant use by age and cohort strata was calculated using bootstrapping methods. Simultaneous age-cohort patterns were evaluated using logistic regression techniques.

RESULTS

The prevalence of any psychotropic medication use increased from 8.0% (95% confidence interval = [6.3, 9.8]) at Time 1 to 26.0% (95% confidence interval = [22.4, 29.4]) at Time 3, translating to a 4.3-fold increase in the likelihood of psychotropic medication use over the study period (odds ratio = 4.3, 95% confidence interval = [3.2, 5.8], p < 0.001). This increase was driven by the use of antidepressants (odds ratio = 6.4, 95% confidence interval = [4.2, 9.5], p < 0.001) and anticonvulsants (odds ratio = 4.4, 95% confidence interval = [1.8, 11.1]) and modest increases in the use of anxiolytic agents (odds ratio = 1.9, 95% confidence interval = [1.1, 3.1]) and sedatives (odds ratio = 1.7, 95% confidence interval = [1.6, 1.9]). The prevalence of any psychotropic medication use increased with increasing age (40-59.9 years: odds ratio = 1.9, 95% confidence interval = [1.5, 2.6]; 60-79.9 years: odds ratio = 2.6, 95% confidence interval = [1.9, 3.5], compared to the 20- to 39.9-year group). Use of selective serotonin reuptake inhibitors increased dramatically over the study period (odds ratio = 15.3, 95% confidence interval = [7.0, 33.4]).

CONCLUSION

Use of psychotropic medication has increased substantially over the past two decades, especially among older women. Further investigations into the correlates and outcomes of the increased use of psychotropic medications are warranted.

Use of atypical antipsychotics in pregnancy and maternal gestational diabetes

BACKGROUND

Second generation antipsychotic medications (SGAs) are widely used by reproductive-age women to treat a number of psychiatric illnesses. Some SGAs have been associated with an increased risk of developing diabetes, although information regarding their diabetogenic effect in pregnant women is scarce.

OBJECTIVE

To evaluate the risk of gestational diabetes (GDM) among women treated with SGA.

METHOD

The Massachusetts General Hospital (MGH) National Pregnancy Registry for Atypical Antipsychotics (NPRAA) collects data on drug use, pregnancy outcomes, and other characteristics from pregnant women, ages 18-45 years, using 3 phone interviews conducted at (1) enrollment during pregnancy, (2) 7 months' gestation, and (3) 2-3 months postpartum. Information on GDM was abstracted from obstetric and delivery medical records. The study population was restricted to women without pre-gestational diabetes. Pregnancies exposed to SGAs during the first trimester were compared with a reference group of women with psychiatric conditions but not treated with SGAs during pregnancy. Generalized linear models were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) for GDM.

RESULTS

Of 303 women exposed to SGAs, 33 (10.9%) had GDM compared to 16 (10.7%) in the 149 non-exposed women. The crude OR of GDM for SGA was 1.02 (95% CI, 0.54-1.91). After adjustment for maternal age, race, marital status, employment status, level of education, smoking, and primary psychiatric diagnosis, the OR moved to 0.79 (0.40-1.56).

CONCLUSIONS

Findings did not suggest an increased risk of GDM associated with exposure to SGAs during pregnancy in women who had used SGA before pregnancy without developing diabetes, compared to psychiatrically ill women who were not exposed to SGA.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01246765.

Visceral Fat Dysfunctions in the Rat Social Isolation Model of Psychosis

Medication with neuroleptics has been associated with adipose tissue dysfunctions and, in particular, with increased visceral fat amount. However, several studies suggested that antipsychotic treatment might not be the main responsible of fat mass accumulation, as this has been also described in not treated psychotic patients. One of the most used “drug-free” rodent models of psychosis is the social isolation rearing of young adult rats, which provides a non-pharmacologic method of inducing long-term alterations reminiscent of symptoms seen in psychotic patients. Recent data highlighted a crucial role of redox imbalance in adipose tissue dysfunctions, in terms of decreased antioxidant defense and increased reactive oxygen species (ROS). Here, we investigated possible oxidative stress-related biomolecular alterations associated with visceral fat increase in 7 week isolated rats. To this purpose, we quantified total and visceral fat amount by using dual-energy X-ray (DEXA) absorptiometry. On visceral fat, we analyzed the expression of specific ROS-producer genes (Nox1, Nox4, Hmox-1), antioxidant enzymes (Prdx1 and Ucp-1) and oxidative stress-induced damage markers (Cidea, Slc2a4, and Acacb). The impact of oxidative stress on beta3-adrenergic receptors (Adrb3), at both mRNA and protein level, was also assessed. We found that 7 weeks of social isolation induced an increase in total and visceral fat, associated with a decrease in Prdx1 (mRNA and protein) as well as Ucp-1 mRNA levels and an enhanced expression of Nox1 (mRNA and protein) and Hmox-1 mRNA. No differences were detected in Nox4 mRNA levels between grouped and isolated animals. Elevations in Cidea, Slc2a4, and Acacb expression in visceral fat of isolated animals accounted for oxidative stress-related damage in this tissue, further associated with a significant increase in Adrb3 mRNA and protein. Our results provide a novel understanding of the pathological link existing among psychosocial stress-induced psychosis, adipose tissue dysfunctions and redox imbalance, opening new therapeutic perspectives for the treatment of alterations in peripheral tissues associated with this mental disorder.

Drug-induced obesity and its metabolic consequences: a review with a focus on mechanisms and possible therapeutic options

Weight gain is a common side effect of many widely used drugs. Weight gain of a few kilograms to an increase of 10% or more of initial body weight has been described. Not only the weight gain as such puts a burden on the health risks of the involved patients, the accompanying increase in the incidence of the metabolic syndrome, type 2 diabetes mellitus, and cardiovascular risk factors urges the caregiver to identify and to closely monitor the patients at risk. In this review, the different classes of drugs with significant weight gaining properties and the metabolic consequences are described. Specific attention is given to pathogenetic mechanisms underlying the metabolic effects and to potential therapeutic measures to prevent them.

A multi-national comparison of antipsychotic drug use in children and adolescents, 2005-2012

Over the last decades, an increase in antipsychotic (AP) prescribing and a shift from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA) among youth have been reported. However, most AP prescriptions for youth are off-label, and there are worrying long-term safety data in youth. The objective of this study was to assess multinational trends in AP use among children and adolescents. A repeated cross-sectional design was applied to cohorts from varied sources from Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) for calendar years 2005/2006-2012. The annual prevalence of AP use was assessed, stratified by age group, sex and subclass (FGA/SGA). The prevalence of AP use increased from 0.78 to 1.03% in the Netherlands' data, from 0.26 to 0.48% in the Danish cohort, from 0.23 to 0.32% in the German cohort, and from 0.1 to 0.14% in the UK cohort. In the US cohort, AP use decreased from 0.94 to 0.79%. In the US cohort, nearly all ATP dispensings were for SGA, while among the European cohorts the proportion of SGA dispensings grew to nearly 75% of all AP dispensings. With the exception of the Netherlands, AP use prevalence was highest in 15-19 year-olds. So, from 2005/6 to 2012, AP use prevalence increased in all youth cohorts from European countries and decreased in the US cohort. SGA were favoured in all countries' cohorts.

International trends in antipsychotic use: A study in 16 countries, 2005-2014

The objective of this study was to assess international trends in antipsychotic use, using a standardised methodology. A repeated cross-sectional design was applied to data extracts from the years 2005 to 2014 from 16 countries worldwide. During the study period, the overall prevalence of antipsychotic use increased in 10 of the 16 studied countries. In 2014, the overall prevalence of antipsychotic use was highest in Taiwan (78.2/1000 persons), and lowest in Colombia (3.2/1000). In children and adolescents (0-19 years), antipsychotic use ranged from 0.5/1000 (Lithuania) to 30.8/1000 (Taiwan). In adults (20-64 years), the range was 2.8/1000 (Colombia) to 78.9/1000 (publicly insured US population), and in older adults (65+ years), antipsychotic use ranged from 19.0/1000 (Colombia) to 149.0/1000 (Taiwan). Atypical antipsychotic use increased in all populations (range of atypical/typical ratio: 0.7 (Taiwan) to 6.1 (New Zealand, Australia)). Quetiapine, risperidone, and olanzapine were most frequently prescribed. Prevalence and patterns of antipsychotic use varied markedly between countries. In the majority of populations, antipsychotic utilisation and especially the use of atypical antipsychotics increased over time. The high rates of antipsychotic prescriptions in older adults and in youths in some countries merit further investigation and systematic pharmacoepidemiologic monitoring.

Movement side effects of antipsychotic drugs in adults with and without intellectual disability: UK population-based cohort study

OBJECTIVES

To measure the incidence of movement side effects of antipsychotic drugs in adults with intellectual disability and compare rates with adults without intellectual disability.

DESIGN

Cohort study using data from The Health Improvement Network.

SETTING

UK primary care.

PARTICIPANTS

Adults with intellectual disability prescribed antipsychotic drugs matched to a control group of adults without intellectual disability prescribed antipsychotic drugs.

OUTCOME MEASURES

New records of movement side effect including acute dystonias, akathisia, parkinsonism, tardive dyskinaesia and neuroleptic malignant syndrome.

RESULTS

9013 adults with intellectual disability and a control cohort of 34 242 adults without intellectual disability together contributed 148 709 person-years data. The overall incidence of recorded movement side effects was 275 per 10 000 person-years (95% CI 256 to 296) in the intellectual disability group and 248 per 10 000 person-years (95% CI 237 to 260) in the control group. The incidence of any recorded movement side effect was significantly greater in people with intellectual disability compared with those without (incidence rate ratio 1.30, 95% CI 1.18 to 1.42, p<0.001, after adjustment for potential confounders), with parkinsonism and akathisia showing the greatest difference between the groups. Neuroleptic malignant syndrome, although occurring infrequently, was three times more common in people with intellectual disability-prescribed antipsychotic drugs (incidence rate ratio 3.03, 95% CI 1.26 to 7.30, p=0.013). Differences in rates of movement side effects between the groups were not due to differences in the proportions prescribed first and second-generation antipsychotic drugs.

CONCLUSIONS

This study provides evidence to substantiate the long-held assumption that people with intellectual disability are more susceptible to movement side effects of antipsychotic drugs. Assessment for movement side effects should be integral to antipsychotic drug monitoring in people with intellectual disability. Regular medication review is essential to ensure optimal prescribing in this group.

Drug information update. Atypical antipsychotics and neuroleptic malignant syndrome: nuances and pragmatics of the association

Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal adverse event associated with the use of antipsychotics. Although atypical antipsychotics were initially considered to carry no risk of NMS, reports have accumulated over time implicating them in NMS causation. Almost all atypical antipsychotics have been reported to be associated with NMS. The clinical profile of NMS caused by certain atypical antipsychotics such as clozapine has been reported to be considerably different from the NMS produced by typical antipsychotics, with diaphoresis encountered more commonly, and rigidity and tremor encountered less frequently. This article briefly discusses the evidence relating to the occurrence, presentation and management of NMS induced by atypical antipsychotics.

Pediatric Antipsychotic Use and Outcomes Monitoring

Antipsychotic (ATP) prescription rates have increased in children and adolescents despite concern regarding the safety and effectiveness of ATP usage in community populations. Rising safety concerns and uncertainty regarding ATP effectiveness in children stress the need for improvement in routine clinical outcome monitoring and research. Due to the growing number of children exposed to atypical ATPs, studies assessing the risk/benefit ratio of administering ATPs in this age group-especially in off-label conditions-become of high importance. The Centre for Interventional Pediatric Psychopharmacology and Rare Diseases (CIPPRD) uses a suite of instruments to monitor outcomes using the web-based HealthTracker™, a health monitoring platform. The HealthTracker allows for capture of symptoms, side effects, quality of life, patient experience, and lifetime response to individualized treatments using a multi-informant multimodal methodology. It enables the tracking of ongoing medical treatments and assists in shared treatment decision-making, longitudinal patient centered outcome monitoring, and helps optimize care. An example of its use in the CIPPRD is provided to demonstrate how it can be used for ATP-related outcome monitoring in complex neurodisability within routine clinical practice.

Psychotropic prescriptions for the treatment of schizophrenia in an outpatient clinic

INTRODUCTION

There is an unpredictable pattern in the prescription of antipsychotics and other psychotropic medications for the treatment of schizophrenia, particularly in resource-limited settings in developing countries.

OBJECTIVE

To determine the psychotropic prescriptions given to patients with schizophrenia in an outpatient clinic of a tertiary hospital and to describe the choices and trends of these prescriptions.

METHODS

This was a cross-sectional descriptive study of prescriptions for adults with schizophrenia. After clinical consultation, patients' case notes were randomly selected over a period of 2 years. Using a structured form, data were extracted from the case notes including biodemographic data, psychotropic medications prescribed and changes made to these prescriptions. Data were analyzed by means of descriptive statistics.

RESULTS

A total of 103 patients were selected, with a mean age of 35.96±9.78 years; 48.5% were males and 51.5% were females; 33% were unemployed and 38% had been hospitalized in the past. There were 231 initial prescriptions and 228 current prescriptions, with about 2.2 prescriptions per patient. Haloperidol (mean dose 14.77±6.28mg and 11.44±5.55mg for initial and current) and other old-generation antipsychotics were the most commonly prescribed for new cases (98%). Mean duration of psychotropic use was 7.78±5.6 years. All the patients were prescribed trihexyphenidyl, and 56.3% of the patients had their medications changed as a result of side effects.

CONCLUSION

There was a very high preference for the use of first-generation antipsychotics for all treatment settings (in- and outpatients), a pattern that is likely to persist.

Average duration of treatment with antipsychotics among concession card holders in Australia

OBJECTIVE

To analyse average treatment duration with antipsychotics reimbursed for concession card holders under the Pharmaceutical Benefits Scheme; the proportion of initial prescribing by general practitioners, psychiatrists and other physician; and the trend in drug choice in Australia.

METHOD

Based on a representative 10% sample of patients receiving Pharmaceutical Benefits Scheme prescriptions since 2005, antipsychotics redeemed by concession card holders in the period from 2010 to 2013 were analysed. A 5-year baseline period was used to exclude prevalent users from incident users. Treatment duration was estimated using the epidemiological equation: prevalence/incidence = average duration.

RESULTS

The overall average treatment duration was 3.0 years, ranging from 1.5 years in patients aged 75 years and older to more than 4 years among patients aged 25-64 years. The most commonly used antipsychotics were olanzapine, risperidone and quetiapine, with average duration of 2.9, 2.1 and 1.7 years, respectively. Amisulpride was used longest with an average duration of 3.7 years. Quetiapine is currently the most prescribed antipsychotic and the main antipsychotic prescribed by psychiatrists to new users. The increased prescribing of quetiapine among general practitioners explains the rapid increase in the overall use of quetiapine. General practitioners initiated therapy in about 70% of cases, while psychiatrists and other physicians in about 15% each. In children younger than 15 years of age, paediatricians initiated such treatment in 47%.

CONCLUSION

General practitioners both initiate and maintain treatment with antipsychotics for most adults, while paediatricians mainly begin such treatment in children. The substantial increase in use of quetiapine among general practitioners, along with the short treatment duration for quetiapine, strengthens a concern about antipsychotics increasingly used for less severe disorders. Increased collaboration between paediatricians and psychiatrists regarding the youngest and between general practitioners and psychiatrists or geriatricians regarding adults and older patients seems required.

Factors Associated with Management of Teen Aggression: Child Psychiatric Clinical Decision Making

OBJECTIVE

This study explores whether patient-specific and clinician-specific factors are associated with child psychiatrists' use of second generation antipsychotics (SGAs) in the management of aggression in children with attention-deficit/hyperactivity disorder (ADHD). The patient-specific factors included patient's race, caregiver status, and patient engagement in psychotherapy.

METHODS

Child psychiatrists attending an annual conference (n = 156) were asked to complete an anonymous questionnaire on clinical decision making. Each participant was randomized to one of eight vignettes on a physically aggressive male teenager with methylphenidate-responsive ADHD. Patient race, caregiving status, and patient engagement in psychotherapy were systematically varied. Respondents rated how likely they were to prescribe an SGA and whether they would adjust the patient's current medication.

RESULTS

Seventy-five percent of participants (n = 117) were uncomfortable with adding an SGA, and 61% (n = 95) were likely to make medication adjustments to the current stimulant. None of the patient-specific factors were related to management recommendations. However, inpatient psychiatrists compared with non-inpatient psychiatrists reported a higher likelihood of using antipsychotics (OR = 2.40, 95% CI [1.181, 4.879], p = 0.016). Midwestern psychiatrists compared with those from other regions also reported a higher likelihood of using antipsychotics (OR = 3.07, 95% CI [1.376, 6.857], p = 0.005). Academic psychiatrists compared with nonacademics were less likely to endorse making adjustments to the current medication regimen (OR = 0.49, 95% CI [0.860, 0.274], p = 0.013).

CONCLUSIONS

When presented with a hypothetical case, the vast majority of child psychiatrists surveyed advised that additional information was needed before adding an SGA. Many felt the need for more psychosocial information and greater clarity of possible comorbid diagnoses.

Trends in antipsychotic prescriptions for Japanese outpatients during 2006-2012: a descriptive epidemiological study

PURPOSE

This study aimed to assess the trends in antipsychotic prescriptions for outpatients in Japan, where a community-based approach to mental healthcare is emphasized.

METHODS

This descriptive epidemiological study used claims data from 1038 community pharmacies across Japan. Outpatients who were ≥18 years old and receiving their initial antipsychotic prescription during 2006-2012 were evaluated. The annual trends were reported for monotherapies, polypharmacy, antipsychotic doses, and the concurrent prescription of psychotropic medications.

RESULTS

The 152 592 outpatients included 101 133 (66%) adults (18-64 years old) and 51 459 (34%) older adults (≥65 years old). Among the adults, second-generation antipsychotic monotherapy prescriptions increased from 49% in 2006 to 71% in 2012, first-generation antipsychotic monotherapy prescriptions decreased from 29 to 14%, and antipsychotic polypharmacy decreased from 23 to 15%, respectively. Among the older adults, second-generation antipsychotic monotherapy prescriptions increased from 64 to 82%, first-generation antipsychotic monotherapy prescriptions decreased from 29 to 12%, and antipsychotic polypharmacy decreased from 7 to 6%, respectively. During the study period, >80% of the adults and >90% of the older adults received antipsychotics at risperidone-equivalent doses of <6 mg/day. Anxiolytics/hypnotics, antidepressants, antiparkinson agents, mood stabilizers, and anti-dementia agents were concurrently prescribed with antipsychotics for 70, 33, 20, 20, and 0.3% of the adults and for 43, 16, 19, 8, and 16% of the older adults, respectively.

CONCLUSIONS

The present study evaluated large-scale claims-based datasets and found that high-dose prescriptions and antipsychotic polypharmacy among Japanese outpatients were not as prevalent as has been previously thought. Copyright © 2017 John Wiley & Sons, Ltd.

Influence of socioeconomic status on antipsychotic prescriptions among youth in France

BACKGROUND

Recent studies analysing the trends in antipsychotic (AP) prescriptions for children and adolescents have raised concerns regarding the influence of socioeconomic status. Previous findings have also shown variable prescription rates for first-generation (FG) and second-generation (SG) APs.

METHOD

Our objectives were to assess the proportion of patients from low-income families receiving APs and the most commonly prescribed APs in France. We conducted a descriptive analysis of AP drugs dispensed during a 1-year period (July 1, 2013-June 30, 2014) in a northwestern region of France with 941,857 subjects less than 18 years old. All data were extracted from an exhaustive, individual and anonymous social security database. We obtained each subject's socioeconomic status (by identifying their affiliation with a specific social security program) and also collected sociodemographic data, drug type, prescribing and dispensing dates and amount, and prescriber type (e.g., hospital physician, general practitioner, psychiatrist, paediatrician).

RESULTS

There were two main novel findings. First, we found that the proportion of patients with AP prescriptions was nearly ten times higher in low-income families than in the general population: 35.9% of CMU-C patients compared to 3.7% in all of Pays de la Loire (X ² = 7875.1, p < 0.001). Additionally, we found a higher rate of FGAP than SGAP prescriptions (65% vs. 57%).

CONCLUSIONS

Our study suggests two types of AP misuse that could provide interesting targets for public healthcare interventions. First, our results strongly suggest an over-representation of patients from low-income families. Low-income families primarily resided in areas with low physician density and appeared to receive drugs to treat their conditions more frequently than other individuals. This increased prescription rate is a public health issue, potentially requiring political action. Second, the use of FGAPs did not adhere to the latest recommendations for drug use in this population, and this discrepancy should be addressed with informational campaigns targeted to medical practitioners.

Risks and benefits of psychotropic medication in pregnancy: cohort studies based on UK electronic primary care health records

BACKGROUND

Although many women treated with psychotropic medication become pregnant, no psychotropic medication has been licensed for use in pregnancy. This leaves women and their health-care professionals in a treatment dilemma, as they need to balance the health of the woman with that of the unborn child. The aim of this project was to investigate the risks and benefits of psychotropic medication in women treated for psychosis who become pregnant.

OBJECTIVE(S)

(1) To provide a descriptive account of psychotropic medication prescribed before pregnancy, during pregnancy and up to 15 months after delivery in UK primary care from 1995 to 2012; (2) to identify risk factors predictive of discontinuation and restarting of lithium (multiple manufacturers), anticonvulsant mood stabilisers and antipsychotic medication; (3) to examine the extent to which pregnancy is a determinant for discontinuation of psychotropic medication; (4) to examine prevalence of records suggestive of adverse mental health, deterioration or relapse 18 months before and during pregnancy, and up to 15 months after delivery; and (5) to estimate absolute and relative risks of adverse maternal and child outcomes of psychotropic treatment in pregnancy.

DESIGN

Retrospective cohort studies.

SETTING

Primary care.

PARTICIPANTS

Women treated for psychosis who became pregnant, and their children.

INTERVENTIONS

Treatment with antipsychotics, lithium or anticonvulsant mood stabilisers.

MAIN OUTCOME MEASURES

Discontinuation and restarting of treatment; worsening of mental health; acute pre-eclampsia/gestational hypertension; gestational diabetes; caesarean section; perinatal death; major congenital malformations; poor birth outcome (low birthweight, preterm birth, small for gestational age, low Apgar score); transient poor birth outcomes (tremor, agitation, breathing and muscle tone problems); and neurodevelopmental and behavioural disorders.

DATA SOURCES

Clinical Practice Research Datalink database and The Health Improvement Network primary care database.

RESULTS

Prescribing of psychotropic medication was relatively constant before pregnancy, decreased sharply in early pregnancy and peaked after delivery. Antipsychotic and anticonvulsant treatment increased over the study period. The recording of markers of worsening mental health peaked after delivery. Pregnancy was a strong determinant for discontinuation of psychotropic medication. However, between 40% and 76% of women who discontinued psychotropic medication before or in early pregnancy restarted treatment by 15 months after delivery. The risk of major congenital malformations, and neurodevelopmental and behavioural outcomes in valproate (multiple manufacturers) users was twice that in users of other anticonvulsants. The risks of adverse maternal and child outcomes in women who continued antipsychotic use in pregnancy were not greater than in those who discontinued treatment before pregnancy.

LIMITATIONS

A few women would have received parts of their care outside primary care, which may not be captured in this analysis. Likewise, the analyses were based on prescribing data, which may differ from usage.

CONCLUSIONS

Psychotropic medication is prescribed before, during and after pregnancy. Many women discontinue treatment before or during early pregnancy and then restart again in late pregnancy or after delivery. Our results support previous associations between valproate and adverse child outcomes but we found no evidence of such an association for antipsychotics.

FUTURE WORK

Future research should focus on (1) curtailing the use of sodium valproate; (2) estimating the benefits of psychotropic drug use in pregnancy; and (3) investigating the risks associated with lifestyle choices that are more prevalent among women using psychotropic drugs.

FUNDING DETAILS

The National Institute for Health Research Health Technology Assessment programme.

Clinical use of second-generation antipsychotics in children

Background

The use of second-generation antipsychotic (SGA) medication among child and adolescent psychiatric patients has increased worldwide in recent years. The increase appears to have been more extensive in the USA than in European countries, but the tendency is similar. However, after a peak the use seems to have declined in the USA. Simultaneously with the increasing numbers, the duration of SGA use has lengthened, indications have broadened, and off-label use has increased. Despite existing follow-up recommendations and evidence for the metabolic adverse effects of SGAs in children, research evidence has not translated into clinical practice.

Objective

The aim of this study was to assess the clinical use and follow-up practices of SGA medication among child psychiatric patients of one university hospital in Finland.

Method

This retrospective patient report-based study was conducted at the Child Psychiatric Clinic of Tampere University Hospital, Finland. The study sample consisted of 133 patients who were younger than 13 years when initiating SGA treatment and had an ongoing SGA medication during the study period. The study sample was divided into two groups according to diagnosis to examine whether there were differences between patients with an autistic or a developmental disorder (F83-84) and patients with other psychiatric diagnoses.

Results:

This study showed that SGA use in children younger than 13 years was mainly off-label. Irrespective of diagnosis, the most common indication was aggression. Especially children with psychiatric diagnoses other than developmental disorders had multiple socio-demographic risk factors and adverse life experiences in their background. The follow-up practices were diverse and partly irregular.

Conclusions:

A need for systematic SGA monitoring practices and dialogue between the medical specialities treating children and their families is evident.

Antipsychotic long-acting injections: A community-based study from 2007 to 2014 of prescribing trends and characteristics associated with initiation

OBJECTIVE

To explore the impact of the introduction of newer antipsychotic long-acting injections (LAIs) on trends in LAI prescribing and characteristics associated with initiation of LAIs in naturalistic conditions.

METHODS

The study was performed using reimbursement data from the French Insurance Healthcare system. Prescribing trends were investigated from 2007 to 2014 in 382,572 persons aged 18years and over. Characteristics associated with delay in transition from oral antipsychotic to LAIs were explored in a cohort of 6904 persons newly treated with an oral antipsychotic using multivariate survival analyses.

RESULTS

LAI prescribing rates slightly increased over the study period. The likelihood of being prescribed LAIs was stable for FGA LAIs (around 1.8 per 1000) (aOR=0.99, 95%CI 0.98-1.00) and increased for SGA LAIs from 0.5 to 1 per 1000 (aOR=1.11, 95%CI 1.08-1.14). In persons initiating an LAI (n=288), shorter transition from oral antipsychotic to LAI was independently predicted by male gender, younger age, dispensing of an oral SGA and a higher number of oral antipsychotics dispensed over the follow-up. Transition was longer in persons dispensed antidepressants or mood-stabilizers over the follow-up. Male gender, low income and higher number of antipsychotics were associated only with shorter transition to FGA LAIs, while initial prescription by a public practitioner, no mood-stabilizer dispensing and lack of somatic severe chronic condition were associated only with SGA LAIs dispensing.

CONCLUSIONS

It is of interest to explore whether similar prescribing trends are observed in other countries and to further assess the effectiveness of new LAIs in real-life conditions.

Experimental and in silico assessment of fate and effects of the antipsychotic drug quetiapine and its bio- and phototransformation products in aquatic environments

The antipsychotic drug quetiapine (QUT) has been frequently detected in sewage treatment plants. However, information on the fate of QUT in aquatic environments and its behavior during UV treatment is limited. In this study, QUT is shown not to be readily biodegradable in the Closed Bottle Test and the Manometric Respirometry Test according to OECD guidelines. The main biotransformation product (BTP) formed in the tests, a carboxylic acid derivative, was identified by means of high-resolution mass spectrometry. This BTP is presumably a human metabolite and showed higher detection rates than QUT in a river sampling campaign conducted in northern Germany. UV elimination kinetics of QUT at different initial concentrations (226.5, 45.3, 11.3, and 2.3 μmol L^-1) were faster at lower initial concentrations. All seven phototransformation products (PTPs) could be still identified at initial concentration of 11.3 μmol L^-1. The photolytic mixture generated after 128 min of photolysis of QUT was not better biodegradable than QUT. Initial UV treatment of QUT led to the formation of several additional BTPs. Four of them were identified. The bacterial cytotoxicity and genotoxicity before and after phototransformation of QUT in a modified luminescent bacteria test (LBT) and the umu-test (ISO/FDIS 13829) showed cytotoxic effects in the LBT for QUT. Furthermore, PTPs had similar cytotoxic effects on luminescent bacteria. The umu-test did not reveal any genotoxic activity for QUT or PTPs. In conclusion, the release of QUT into sewage treatment plants and aquatic environments could result in the formation of a main BTP. Additional UV treatment of QUT would lead to the formation of additional BTPs. Moreover, treatment did not result in lower toxicity to tested organisms. In conclusion, UV treatment of QUT should be considered critically as a potential treatment for QUT in aquatic systems.

Estimating 10-year cardiovascular disease risk in Asian patients with schizophrenia

OBJECTIVE

This study aims to describe the cardiovascular risk profile of Asian patients with schizophrenia.

METHODS

Data was extracted from the databases of 139 patients with schizophrenia and 206 controls from two previous studies conducted at the Institute for Mental Health (IMH), Singapore. Their medical and smoking histories were obtained, and anthropometric parameters measured. Framingham risk score (FRS) calculator using body mass index was used to compute the 10-year cardiovascular disease risk (FRS_BMI) and the vascular age (VA_BMI) for each participant. Data on fasting lipids were available for 80 patients and all the controls; hence the FRS for lipids (FRS_lipids) and VA (VA_lipids) were also computed. The difference between VA and actual age was computed as VA_diff.

RESULTS

The 10-year CVD risk and VA_diff based on lipids as well as BMI were significantly higher for patients compared to controls (all p<0.01). There was a strong correlation between FRS_lipids and FRS_BMI (r=0.97, p<0.001). Significantly higher numbers of patients than controls were smokers and obese; and reported having dyslipidaemia.

CONCLUSIONS

We found a high risk of CVD in patients with schizophrenia as compared to controls; and conclude that patients with schizophrenia need regular physical health monitoring, especially for cardiovascular risk factors.

Determination of antipsychotic drugs in hospital and wastewater treatment plant samples by gas chromatography/tandem mass spectrometry

The development and performance evaluation of a method for the simultaneous determination of six antipsychotic drugs in hospital effluents and wastewater treatment plants (WWTP) samples are herein presented. The method involves an off-line mixed mode (reversed-phase and strong cation exchange) solid phase extraction (SPE) with gas chromatography (GC) coupled to tandem mass spectrometry (MS/MS). The present methodology was validated following internationally accepted criteria, and the studied parameters included selectivity, linearity, limits of detection (LOD) and quantitation (LLOQ), instrumental limits, precision and accuracy, stability and recovery. The procedure was linear for concentrations ranging from 0.1 to 10μg/L (0.02 to 2μg/L for haloperidol), with determination coefficients higher than 0.99 for all analytes. Intra- and inter-day precision was lower than 15% for all analytes at the studied concentrations, while accuracy remained between a ±15% interval. Recoveries ranged from 31% to 83%. Low LODs were achieved, between 2 and 10ng/L, allowing a reliable identification of all analytes at trace levels, using only 50mL as sample volume. All studied parameters complied with the defined criteria and the method was successfully applied to gather preliminary results of the determination of antipsychotics on hospital effluents and on influent and effluent of WWTPs, opening perspectives for the study of their fate in the aquatic environment.

Risks associated with antipsychotic treatment in pregnancy: Comparative cohort studies based on electronic health records

BACKGROUND

Limited information is available on whether antipsychotics prescribed in pregnancy are associated with increased risks of adverse outcomes.

METHODS

We used electronic health records from pregnant women and their children to examine risks of adverse maternal and child outcomes in three cohorts of women who: (A) received antipsychotic treatment in pregnancy (n=416) (B) discontinued antipsychotic treatment before pregnancy (n=670), and (C) had no records of antipsychotic treatment before or during pregnancy (n=318,434). Absolute and risk ratios were estimated and adjusted for health and lifestyle and concomitant medications.

RESULTS

Caesarean section was more common in cohort A (25%) than C (18%), but non-significant after adjustment for health and lifestyle factors (Risk Ratio (adj.) 1.09 (95% CI: 0.92, 1.30). Proportion of gestational diabetes was similar in cohort A (2.6%) and B (2.7%), but lower in A than B after adjustments (RRadj: 0.43 (0.20, 0.93). Premature birth/low birthweight were more common in cohort A (10%) than B (4.3%) and C (3.9%), A versus B (RRadj: 2.04 (1.13, 3.67), A versus C (RRadj: 1.43 (0.99, 2.05). Major congenital malformations were more common in A (3.4%), than B (2.2%) and C (2%). However no significant difference was observed (A versus B: RRadj: 1.79 (0.72, 4.47) A versus C RRadj: 1.59 (0.84, 3.00)). Risks estimates were similar for women prescribed atypical and typical antipsychotics.

CONCLUSIONS

Antipsychotic treatment in pregnancy carries limited risks of adverse pregnancy and birth outcomes once adjustments have been made for health and lifestyle factors.

Role and clinical implications of atypical antipsychotics in anxiety disorders, obsessive-compulsive disorder, trauma-related, and somatic symptom disorders: a systematized review

Atypical antipsychotics (AAs) may play a role in the treatment of anxiety disorders, obsessive-compulsive disorder (OCD), and trauma-related disorders. No reviews on their differential use in these different disorders have been performed recently. The aim of this systematized review was to obtain data on efficacy and comparative effectiveness of AAs as a treatment of anxiety disorders, OCD, and trauma-related disorders to provide guidance for clinicians on when and which AA to use. We searched on PubMed, Psychnet, and Cochrane Libraries from inception to July 2015. Search results were limited to randomized, placebo-controlled trials of adult patients. Evidence of efficacy was considered the presence of positive results in two or more double-blind placebo-controlled studies. Our systematized search identified 1298 papers, of which 191 were subjected to a full-text review and 56 were included. Quetiapine extended-release showed a role in both acute and maintenance treatment of uncomplicated generalized anxiety disorder, whereas more studies are needed before drawing practical recommendations on the use of olanzapine and risperidone; aripiprazole and risperidone are effective in resistant OCD as augmentation treatments. Risperidone and olanzapine add-on may have a role in resistant or chronic post-traumatic stress disorder patients, although only risperidone addition can be recommended on the basis of the criterion of two or more positive placebo-controlled trials. This systematized review supports the evidence that only a few AAs are effective in only a minority of the off-label conditions in which they are currently used and confirms that AAs are not all the same. Their use should be on the basis of a balance between efficacy and side effects, and the characteristics as well as the preference of the patient.

Risk Factors for Inpatient Psychiatric Readmission: Are There Gender Differences?

The objectives of the study were to compare characteristics of women and men discharged from an inpatient psychiatric facility and to identify gender-specific risk factors associated with 30-day and 1-year readmission using administrative data. The sample included adults discharged from an inpatient psychiatric facility in a Midwestern city (N = 1853). The analysis showed that the 30-day readmission rate was significantly lower among women, but there was no difference in the 1-year readmission rate. Risk factors for readmission differed by gender. For example, for 30-day readmission, being on Medicare versus commercial insurance increased the odds for women (OR 3.08; 95 % CI 1.35-7.04) and taking first-generation antipsychotics versus no antipsychotics increased the odds for men (OR 2.09; 95 % CI 1.26-3.48). These findings suggest there are important differences between women and men readmitted to an inpatient psychiatric facility. Future strategies need to take into account gender-specific risk factors in order to improve long-term patient outcomes.

Atypical antipsychotics and effects on feeding: from mice to men

RATIONALE

So-called atypical antipsychotics (AAPs) are associated with varying levels of weight gain and associated metabolic disturbances, which in patients with serious mental illness (SMI) have been linked to non-compliance and poor functional outcomes. Mechanisms underlying AAP-induced metabolic abnormalities are only partially understood. Antipsychotic-induced weight gain may occur as a result of increases in food intake and/or changes in feeding.

OBJECTIVE

In this review, we examine the available human and preclinical literature addressing AAP-related changes in feeding behavior, to determine whether changes in appetite and perturbations in regulation of food intake could be contributing factors to antipsychotic-induced weight gain.

RESULTS

In general, human studies point to disruption by AAPs of feeding behaviors and food consumption. In rodents, increases in cumulative food intake are mainly observed in females; however, changes in feeding microstructure or motivational aspects of food intake appear to occur independent of sex.

CONCLUSIONS

The findings from this review indicate that the varying levels of AAP-related weight gain reflect changes in both appetite and feeding behaviors, which differ by type of AAP. However, inconsistencies exist among the studies (both human and rodent) that may reflect considerable differences in study design and methodology. Future studies examining underlying mechanisms of antipsychotic-induced weight gain are recommended in order to develop strategies addressing the serious metabolic side effect of AAPs.

Trends in the use of antipsychotics in the Israeli inpatient population, 2004-2013

Background

Although serious mental illneses are treated with both typical and atypical antipsychotic grugs, trends in their use in psychiatric inpatient population in Israel are unrecognized. The aim of this study was to detect trends in the use of typical and atypical antipsychotic drugs in the Israeli inpatient psychiatric population throughout the last decade.

Methods

Data regarding allocation of typical and atypical antipsychotics, over the period 2004 to 2013, were extracted from the electronic records of SAREL, Israel’s largest private supplier of drugs to healthcare and medical facilities. The data were converted to defined daily doses (DDD) per 1000 inpatients per day.

Results

Usage of the ten atypical antipsychotic agents allocated through Israel’s national health care system increased by 73 %, from 128.09 DDD/1000 inpatients/day in 2004 to 221.69 DDD/1000 inpatients/day in 2013. This rise from 2004 to 2013 was largely due to a 1.6-fold increase in the administration of olanzapine (48.31 to 79.57 DDD/1000 inpatients/day), a 4.4-fold increase of quetiapine (9.74 to 43.04 DDD/1000 inpatients/day) and 3.7-fold increase of amisulpride (5.54 to 20.38 DDD/1000 inpatients/day). At the same period, the total utilization of 12 main typical antipsychotics decreased by 15.5 %, from 148.67 DDD/1000 inpatients/day in 2004 to 125.57 DDD/1000 inpatients/day in 2013. Over the entire period, total DDDs of both classes of antipsychotics (typical and atypical) increased by 38 %.

Conclusions

Similar to trends in the treatment of psychiatric outpatients in other countries, there was a substantial increase in the administration of atypical antipsychotic drugs to the Israeli psychiatric inpatient population across the study period. A decrease in the use of typical antipsychotics (substitution), polypharmacy, administration for more indications (supplementation) and the use of larger doses of antipsychotics may account, in part, for this increase. The findings have implications for mental health policy in the context of the Mental Health Care System Reform. Systematic studies on appropriate dosing of antipsychotics and augmentation strategies are warranted.

Geographical disparities in prescription practices of lithium and clozapine: a community-based study

OBJECTIVE

To explore the socioeconomic and health resource characteristics associated with geographical variations of lithium and clozapine dispensing rates in France.

METHOD

The study was performed using reimbursement data from the French Insurance Healthcare system over the period 2006-2013 in a community-based sample of persons aged 16 years and over. An ecological design was used to assess whether lithium and clozapine prescribing rates were associated with socioeconomic and health resource characteristics of the zone of residence (n = 95 French administrative subdivisions).

RESULTS

Large geographical disparities were observed in dispensing rates: lithium dispensing rates by zone of residence ranged from 0 to 6.6 per 1000 (mean 2.4 per 1000) and clozapine dispensing rates ranged from 0 to 4.9 per 1000 (mean 0.8 per 1000). Higher density of GPs and regular communication between mental health services and primary care were independently associated with higher rates of lithium and clozapine dispensing and with a higher proportion of lithium users among mood-stabilizer users.

CONCLUSION

A sufficient density of GPs and an effective communication and collaboration between mental healthcare services and primary care seems to favor greater access to psychotropic drugs with demonstrated efficacy but often viewed as 'risky' to prescribe.

Second-Generation Antipsychotics During the Lactation Period: A Comparative Systematic Review on Infant Safety

OBJECTIVE

This review examined the safety of second-generation antipsychotics (SGAs) in exposed breastfed infants.

METHODS

PubMed was searched for English language reports between January 1, 1990, to June 30, 2015, by using combinations of the key words breastfeeding, lactation, postpartum period, puerperium, antipsychotics, second-generation antipsychotics, olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole, amisulpride, clozapine, asenapine, lurasidone, and iloperidone. Case reports, case series, and prospective or cross-sectional studies including relevant data such as relative infant dose (RID), milk-to-plasma ratio (M/P ratio), infant drug plasma levels, and adverse events were identified.

RESULTS

A total of 37 relevant reports were examined. These reports included a total of 206 infants exposed to olanzapine (n = 170), quetiapine (n = 14), risperidone/paliperidone (n = 8), clozapine (n = 6), aripiprazole (n = 4), ziprasidone (n = 2), and amisulpride (n = 2). Approximately half of the available data on the M/P ratio, RID, and infant drug plasma levels included olanzapine. Relatively adequate reports suggest that olanzapine has low RID values. Limited reports suggest low RID values for quetiapine and ziprasidone, moderate RID values for risperidone/paliperidone and aripiprazole, and high RID values for amisulpride. Antipsychotic levels were undetectable in the plasma of most of the exposed infants. Other than clozapine, adverse events were rarely reported in infants exposed to SGAs.

CONCLUSIONS

The current data suggest that SGAs seem to be relatively safe in the exposed breastfed infants for short-term usage. However, additional studies, in particular for antipsychotics other than olanzapine, examining short-term and especially long-term effects of SGAs on the breastfed infants are required.

The antipsychotic story: changes in prescriptions and overdose without better safety

AIMS

Morbidity and mortality from drug overdose has decreased over three decades. This is credited to safer drugs and therefore better outcomes in overdose. We aimed to investigate changing prescriptions of antipsychotic medications and associated changes in antipsychotic overdoses over a 26-year period.

METHODS

All antipsychotic poisoning presentations to a tertiary referral toxicology unit between 1987 and 2012 were reviewed. Data were collected prospectively on demographics, ingestion information, clinical effects, complications and treatment. Rates of antipsychotic drug use in Australia were obtained from Australian government publications for 1990-2011 and linked to overdose admissions by postcode.

RESULTS

There were 3180 antipsychotic overdoses: 1235 first generation antipsychotics, 1695 'atypical' second generation antipsychotics and 250 lithium overdoses. Over 26 years, antipsychotic overdoses increased 1.8-fold, with first generation antipsychotics decreasing to one-fifth of their peak (≈80/year to 16) and second generation antipsychotics increasing to double this (≈160/year), olanzapine and quetiapine accounting for 78%. All antipsychotic overdoses had a median length of stay of 18.6 h, 15.7% admitted to intensive care unit, 10.4% ventilated and 0.13% died in hospital, which was the same for first generation compared to second generation antipsychotics. There was a 2.3-fold increase in antipsychotic prescriptions over the same period; first generation antipsychotics declined whereas there was a dramatic rise in second generation antipsychotics, mainly olanzapine, quetiapine and risperidone (79%).

CONCLUSION

Over 26 years there was an increase in antipsychotic prescribing associated with an increase in antipsychotic overdoses. Although the type of antipsychotics changed, the morbidity and mortality remained the same, so that antipsychotics are an increasing proportion of overdose admissions.

Incident users of antipsychotics: who are they and how do they fare?

PURPOSE

In Denmark, as well as in many other countries, consumption of antipsychotics is on the rise, partly due to increasing off-label use. The aim of this study was to analyze and quantify the extent of off-label use and polypharmacy in incident users of antipsychotic medication, and to examine initial antipsychotic prescribing patterns and associated use of mental health care services.

METHOD

Population-based cohort study linking the following Danish national registers: the Central Psychiatric Research Register, the Register of Medicinal Product Statistics, and Statistics Denmark.

RESULTS

From 2007 to 2012, 154,351 Danish subjects initiated treatment with antipsychotics. Among these, 71,254 (46 %) subjects had a psychiatric diagnosis recorded. The most frequent diagnoses were reaction to severe stress and adjustment disorders (10,106; 14 %), depressive episode (8876; 12 %), and recurrent depressive disorder (6810; 10 %). We found high antipsychotic discontinuation rates during the first few months (45 % in 4 months) and frequent antidepressant co-prescribing from treatment onset (47 %). Significantly greater likelihood of psychiatric hospitalization was observed for antipsychotic polypharmacy (HR 1.38; 95 % CI 1.32-1.45), whereas antipsychotic discontinuation was associated with decreased hospitalization risk in most off-label conditions.

CONCLUSIONS

The brief duration of most antipsychotic prescriptions suggests that antipsychotics are prescribed more liberally than recommended. As a consequence of the range of adverse effects associated with antipsychotic drug use, the documented widespread off-label prescribing practices warrant careful monitoring for adverse effects and prompt discontinuation in case of an unfavorable risk-benefit ratio.

Antipsychotic-related fatal poisoning, England and Wales, 1993-2013: impact of the withdrawal of thioridazine

CONTEXT

Use of second generation antipsychotics in England and Wales has increased in recent years whilst prescription of first generation antipsychotics has decreased.

METHODS

To evaluate the impact of this change and of the withdrawal of thioridazine in 2000 on antipsychotic-related fatal poisoning, we reviewed all such deaths in England and Wales 1993-2013 recorded on the Office for National Statistics drug poisoning deaths database. We also reviewed antipsychotic prescribing in the community, England and Wales, 2001-2013. Use of routine mortality data: When an antipsychotic was recorded with other drug(s), the death certificate does not normally say if the antipsychotic caused the death rather than the other substance(s). A second consideration concerns intent. A record of "undetermined intent" is likely to have been intentional self-poisoning, the evidence being insufficient to be certain that the individual intended to kill. A record of drug abuse/dependence, on the other hand, is likely to have been associated with an unintentional death. Accuracy of the diagnosis of poisoning: When investigating a death in someone prescribed antipsychotics, toxicological analysis of biological samples collected post-mortem is usually performed. However, prolonged attempts at resuscitation, or diffusion from tissues into blood as autolysis proceeds, may serve to alter the composition of blood sampled after death from that circulating at death. With chlorpromazine and with olanzapine a further factor is that these compounds are notoriously unstable in post-mortem blood. Deaths from antipsychotics: There were 1544 antipsychotic-related poisoning deaths. Deaths in males (N = 948) were almost twice those in females. For most antipsychotics, the proportion of deaths in which a specific antipsychotic featured either alone, or only with alcohol was 30-40%, but for clozapine (193 deaths) such mentions totalled 66%. For clozapine, the proportion of deaths attributed to either intentional self-harm, or undetermined intent was 44%, but for all other drugs except haloperidol (20 deaths) the proportion was 56% or more. The annual number of antipsychotic-related deaths increased from some 55 per year (1.0 per million population) between 1993 and 1998 to 74 (1.5 per million population) in 2000, and then after falling slightly in 2002 increased steadily to reach 109 (1.9 per million population) in 2013. Intent: The annual number of intentional and unascertained intent poisoning deaths remained relatively constant throughout the study period (1993: 35 deaths, 2013: 38 deaths) hence the increase in antipsychotic-related deaths since 2002 was almost entirely in unintentional poisoning involving second generation antipsychotics. Clozapine, olanzapine, and quetiapine were the second generation antipsychotics mentioned most frequently in unintentional poisonings (99, 136, and 99 deaths, respectively). Mentions of diamorphine/morphine and methadone (67 and 99 deaths, respectively) together with an antipsychotic were mainly (84 and 90%, respectively) in either unintentional or drug abuse-related deaths. Deaths and community prescriptions: Deaths involving antipsychotics (10 or more deaths) were in the range 11.3-17.1 deaths per million community prescriptions in England and Wales, 2001-2013. Almost all (96%) such deaths now involve second generation antipsychotics. This is keeping with the increase in annual numbers of prescriptions of these drugs overall (<1 million in 2000, 7 million in 2013), largely driven by increases in prescriptions for olanzapine and quetiapine. In contrast, deaths involving thioridazine declined markedly (from 40 in 2000 to 10 in 2003-2013) in line with the fall in prescriptions for thioridazine from 2001.

CONCLUSIONS

The removal of thioridazine has had no apparent effect on the incidence of antipsychotic-related fatal poisoning in England and Wales. That such deaths have increased steadily since 2001 is in large part attributable to an increase in unintentional deaths related to (i) clozapine, and (ii) co-exposure to opioids, principally diamorphine and methadone.

Psychotropic prescribing patterns among adolescents in Northern Ireland presenting with psychotic symptoms during a 5-year period

OBJECTIVE

To report new prescriptions of psychotropic medications among adolescents presenting with new onset psychotic symptoms during a 5-year period.

METHODS

The Northern Ireland Early Onset Psychosis Study is a naturalistic longitudinal observational study of patients with an early onset first psychotic episode. All patients aged <18 years presenting to specialist mental health services across Northern Ireland with new onset psychotic symptoms between 2001 and 2006 were recruited (n=113). Clinical case notes were analysed retrospectively for details of subsequent treatment with psychotropic medications.

RESULTS

A total of 100 patients (88.5%) were prescribed some form of psychotropic medication. Over three-quarters of patients received an antipsychotic as their first medication. Risperidone (45.8%), olanzapine (24.0%) and chlorpromazine (12.5%) were the most commonly prescribed first-line antipsychotic medications. Of a total of 160 antipsychotic prescriptions, 81 (50.6%) were off-label. Prescriptions were most likely to have been deemed off-label owing to medications not being licensed in under-18s (71.6% of off-label prescriptions) but other reasons were medications being used outside licensed age ranges (23.5%) and outside licensed indications (4.9%).

CONCLUSIONS

This is the first study examining psychotropic prescribing patterns in a complete sample of all children and adolescents presenting with early onset psychotic episodes in a single geographical area. The observation of risperidone as the most commonly prescribed antipsychotic was in keeping with previous studies in child and adolescent populations. Rates of off-label prescribing were lower than previously observed although our study was the first to investigate off-label prescribing solely in children and adolescents presenting with psychotic symptoms.

Second-generation antipsychotics in a tertiary care hospital: prescribing patterns, metabolic profiles, and drug interactions

We carried out an observational study that analyzed population characteristics, metabolic profiles, potentially interacting pharmacotherapy, and related adverse events in second-generation antipsychotics (SGAs) users of a tertiary care hospital. Within our pharmacoepidemiological database derived from electronic medical records of 82,358 hospitalizations, we identified 1136 hospitalizations contributing 9165 patient-days with exposure to SGA. Blood pressure, blood glucose, lipids, and BMI had been documented in 97.7, 75.7, 24.6, and 77.4% of hospitalizations, respectively. Among these, the prevalence of hypertension, hyperglycemia, dyslipidemia, and BMI 30 kg/m or more was 36.9, 22.6, 61.1, and 23.1%, respectively. A total of 63.4, 70.8, and 37.1% of SGA users with hyperglycemia, dyslipidemia, and hypertension, respectively, received no pharmacotherapy for these conditions. We identified 614 patient-days with SGA plus formally contraindicated comedication and another 1066 patient-days with other high-risk combinations for QTc prolongation. Among those there was one case with associated neutropenia and four cases with abnormal QTc interval. However, specific monitoring for such adverse events was not documented in 45.5% of hospitalizations with contraindicated and 89.8% with high-risk QTc-prolonging combinations. Our study identified targets for improved monitoring and management in SGA users. These may be implemented as automated alerts into electronic prescribing systems and thereby efficiently support safer pharmacotherapy in clinical practice.

Changing trends in hospitalization rates associated with psychosis: Spain, 1980-2009

PURPOSE

To analyze the prevalence of hospitalization attributable to psychosis in Spain over the last three decades.

METHODS

Longitudinal analysis (1980-2009) of age-adjusted hospital discharges rates associated with psychosis (ICD9 290-8) in all Spanish hospitals.

DATA SOURCE

Spanish Hospital Morbidity Survey.

RESULTS

The hospitalization rate associated with psychotic episodes had been gradually increasing since 1980 until 2004; an abrupt turnaround observed in 2004 marks the beginning of a steady decline in the rate. The turning point described is not observed for each of the psychotic diagnoses separately analyzed. However, it is clearly seen when data are grouped in diagnosis-related groups (organic-psychosis, functional psychosis and substance-induced psychosis) since the time course of the diseases within the major diagnostic groups are interrelated as evidenced by shared turning points which collectively display a common time course pattern. Main hospital indicators and antipsychotic drug prescriptions were analyzed for any possible turning point in mid-2000s. Psychiatric hospital beds and length of stays remained stable by 2004; the hospitalizations associated with non-psychotic psychiatric pathologies show no turning point in 2004. However, an abrupt change on antipsychotic drug prescriptions is precisely observed in 2004.

CONCLUSIONS

After decades of linear growth, hospitalizations for psychotic patients begin to decline in 2004, coinciding with the start of last generation atypical antipsychotic drug consumption in Spain. Some of the psychotic diagnostic rates evolve in an interrelated manner which calls into question the diagnosis and nosological boundaries between some of these pathologies.

The Growing Trend of Prescribing Antipsychotics for Young People in Finland, 2000 to 2010

Background:

According to previous reports from many countries (e.g., the United States, Germany, the United Kingdom), the use of antipsychotic drugs has increased among young people. Antipsychotics have also increasingly been prescribed for non-psychotic disorders.

Objective

The purpose of this study was to estimate the rate at which antipsychotics were prescribed for young people in the age groups of 10 to 14 years, 15 to 19 years, and 20 to 24 years in Finland in the years 2000, 2005, and 2010.

Methods

This was a nationwide register study using data from the databases of Statistics Finland and the Finnish National Prescription Register. Statistics Finland’s databases provided background information, including the total number of young people and the Finnish National Prescription Register keeps record of all drug orders reimbursed by the Social Insurance Institution of Finland.

Results

The prescription of antipsychotics grew 6.8-, 4.6-, and 2.6-fold over the study period for these three age groups, respectively. For the youngest age group, use was more common among males than females in all three periods studied. During the course of the study period, the use of antipsychotics became more common among females: in 2010, antipsychotics were more commonly used among females than males in both the 15- to 19-year-old age group and the 20- to 24-year-old age group. The younger the patient, the higher the probability that the indication for medication was a non-psychotic disorder.

Conclusions

In Finland, the trends involved in the prescription of antipsychotic medications resemble those seen in many Western countries. Therefore, it is important that the safety and effectiveness of these pharmaceuticals be investigated among young people as well.

Role of serotonin 5-HT2C and histamine H1 receptors in antipsychotic-induced diabetes: A pharmacoepidemiological-pharmacodynamic study in VigiBase

Pharmacodynamic mechanisms of diabetes induced by antipsychotic drugs remain unclear, while numerous receptors have been suspected to be involved in the genesis of this Adverse Drug Reaction (ADR). We investigated potential relationships between antipsychotics׳ receptor occupancy (serotonin 5-HT1A, 5-HT2A, 5-HT2C, histamine H1, muscarinic M3, adrenergic α1, α2 or dopaminergic D2 D3 occupancies) and reports of diabetes using VigiBase(®), the World Health Organization (WHO) global Individual Case Safety Report (ICSR) database. All ADR reports from 15 first and second generation antipsychotic drugs recorded in VigiBase(®) were extracted. Logistic regression models, completed by disproportionality analysis, were used to determine the associations between antipsychotics׳ receptor occupancy and ICSRs of diabetes on VigiBase(®). During the study period, 94,460 ICSRs involved at least one of the 15 antipsychotics of interest. Diabetes was reported in 1799 (1.9%) patients. Clozapine was the most frequently suspected drug (n=953; 53.0%). A significant and positive association was found between histamine H1, muscarinic M3 and serotonin 5-HT2C, 5-HT2A receptor occupancies and reports of diabetes. A multivariable stepwise regression model showed that only serotonin 5-HT2c (AOR=2.13, CI 95% 1.72-2.64) and histamine H1 (AOR=1.91, CI 95% 1.38-2.64) predicted the risk for diabetes mellitus (p<0.001). Using an original pharmacoepidemiology-pharmacodynamic (PE-PD) approach, our study supports that antipsychotic drugs blocking simultaneously histamine H1 and serotonin 5-HT2C receptors are more frequently associated with diabetes reports in VigiBase(®) than other antipsychotics. These findings should encourage investigation of histamine H1 and serotonin 5-HT2C properties for predicting the risk of glycemic effects in candidate antipsychotics.