Use of combinations of antipsychotics: McLean Hospital inpatients, 2002

Neuroanatomical Correlates of the Late Positive Potential in Youth with Pediatric Bipolar Disorder

BACKGROUND

The late positive potential (LPP) could be a marker of emotion dysregulation in youth with pediatric bipolar disorder (PBD). However, the neuroanatomical correlates of the LPP are still not clarified.

OBJECTIVE

To provide cortical and deep gray matter correlates of the LPP in youth, specifically, youth with PBD.

METHODS

Twenty-four 7 to 17 years-old children with PBD and 28 healthy controls (HC) underwent cortical thickness and deep gray matter volumes measurements through magnetic resonance imaging and LPP measurement elicited by passively viewing emotional faces through electroencephalography. T-tests compared group differences in LPP, cortical thickness, and deep gray matter volumes. Linear regressions tested the relationship between LPP amplitude and cortical thickness/deep gray matter volumes.

RESULTS

PBD had a more pronounced LPP amplitude for happy faces and a thinner cortex in prefrontal areas than HC. While considering both groups, a higher LPP amplitude was associated with a thicker cortex across occipital and frontal lobes, and with a smaller right globus pallidus volume. In addition, a higher LPP amplitude for happy faces was associated with smaller left caudate and left globus pallidus volumes across both groups. Finally, the LPP amplitude correlated negatively with right precentral gyrus thickness across youth with PBD, but positively across HC.

CONCLUSION

Neural correlates of LPP in youth included fronto-occipital areas that have been associated also with emotion processing and control. The opposite relationship between BPD and HC of LPP amplitude and right precentral gyrus thickness might explain the inefficacy of the emotional control system in PBD.

Comparison of Cerebellar Grey Matter Alterations in Bipolar and Cerebellar Patients: Evidence from Voxel-Based Analysis

The aim of this study was to compare the patterns of cerebellar alterations associated with bipolar disease with those induced by the presence of cerebellar neurodegenerative pathologies to clarify the potential cerebellar contribution to bipolar affective disturbance. Twenty-nine patients affected by bipolar disorder, 32 subjects affected by cerebellar neurodegenerative pathologies, and 37 age-matched healthy subjects underwent a 3T MRI protocol. A voxel-based morphometry analysis was used to show similarities and differences in cerebellar grey matter (GM) loss between the groups. We found a pattern of GM cerebellar alterations in both bipolar and cerebellar groups that involved the anterior and posterior cerebellar regions (p = 0.05). The direct comparison between bipolar and cerebellar patients demonstrated a significant difference in GM loss in cerebellar neurodegenerative patients in the bilateral anterior and posterior motor cerebellar regions, such as lobules I-IV, V, VI, VIIIa, VIIIb, IX, VIIb and vermis VI, while a pattern of overlapping GM loss was evident in right lobule V, right crus I and bilateral crus II. Our findings showed, for the first time, common and different alteration patterns of specific cerebellar lobules in bipolar and neurodegenerative cerebellar patients, which allowed us to hypothesize a cerebellar role in the cognitive and mood dysregulation symptoms that characterize bipolar disorder.

Antipsychotic polypharmacy prescribing and risk of hospital readmission

OBJECTIVES

The aim of this study was to determine if there was an association between being discharged on antipsychotic polypharmacy (APP) and risk of readmission into secondary mental health care.

METHODS

Using data from the South London and Maudsley (SLAM) case register, service users with serious mental illness (SMI), discharged between 1st January 2007 and 31th December 2014, were followed up for 6 months. Patients were classified as receiving either monotherapy or polypharmacy at index discharge. Multivariable Cox regression models were constructed, adjusting for sociodemographic, socioeconomic, clinical and service use factors.

RESULTS

We identified 5523 adults who had been admitted at least once to SLAM, of whom 1355 (24.5%) were readmitted into secondary mental health care. In total, 15% (n = 826) of patients were discharged on APP and 85% (n = 4697) on monotherapy. Of these, 30.9% (n = 255) and 23.4% (n = 1100) were readmitted respectively. Being discharged on APP was associated with a significantly increased risk of readmission, in comparison to patients discharged on monotherapy (HR = 1.4, 1.2-1.7, p < 0.001). This association was maintained in the fully adjusted model and following several sensitivity analyses. We further established that patients receiving clozapine APP (n = 200) were at a significantly increased risk for readmission in comparison to patients on clozapine monotherapy (HR = 1.8, 1.2-2.6, p = 0.008).

CONCLUSIONS

Our results suggest that patients discharged on APP are more likely to be readmitted into hospital within 6 months in comparison to those discharged on monotherapy. This needs to be considered in treatment decisions and the reasons for the association clarified.

Evaluation of Concurrent Oral and Long-Acting Injectable Antipsychotic Prescribing at the Minneapolis Veterans Affairs Health Care System

BACKGROUND

Antipsychotic polypharmacy is defined as the concomitant prescribing of more than 1 antipsychotic medication for an individual patient. Despite clinical guideline recommendations, long-acting injectable antipsychotics (LAIAs) are often used together with oral antipsychotics (OAPs) to treat a variety of psychiatric illnesses. Little research exists to address this form of antipsychotic polypharmacy, and its role in therapy is poorly understood. The purpose of this evaluation was to determine the prevalence of this prescribing pattern at our facility, identify provider rationale for polypharmacy, and analyze trends. To our knowledge, this study is the first to describe the prevalence of and rationale for concomitant LAIA and OAP prescribing in the veteran population.

METHODS

All patients receiving an LAIA at the time of study initiation were included. Long-acting injectable antipsychotics/oral antipsychotics polypharmacy was defined as the use of both agents outside the manufacturer's recommendations for titration and overlap. Statistical analysis was performed to further evaluate prescribing patterns by agent, dose, and indication.

RESULTS

Long-acting injectable antipsychotics/oral antipsychotics polypharmacy occurred in 28% (22/79) of subjects. Of these, 50% (11/22) were prescribed the same antipsychotic in both dosage forms, of which 73% (8/11) were risperidone. Patients on LAIA/OAP polypharmacy were half as likely to be on a maximum dose LAIA compared with those on monotherapy (13% vs. 26%).

CONCLUSIONS

Although LAIA/OAP polypharmacy occurred less frequently than reported in previous literature, this study highlights the need for further research to better understand this prescribing practice.

Antipsychotic combinations for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with their initial antipsychotic drug treatment. Sometimes a second antipsychotic, in combination with the first, is used in these situations.

OBJECTIVES

To examine whether:1. treatment with antipsychotic combinations is effective for schizophrenia; and2. treatment with antipsychotic combinations is safe for the same illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's register which is based on regular searches of CINAHL, BIOSIS, AMED, Embase, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There are no language, time, document type, or publication status limitations for inclusion of records in the register. We ran searches in September 2010, August 2012 and January 2016. We checked for additional trials in the reference lists of included trials.

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials comparing antipsychotic combinations with antipsychotic monotherapy for the treatment of schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and the 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CIs. For the meta-analysis we used a random-effects model. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for included studies.

MAIN RESULTS

Sixty-two studies are included in the review, 31 of these compared clozapine monotherapy with clozapine combination. We considered the risk of bias in the included studies to be moderate to high. The majority of trials had unclear allocation concealment, method of randomisation and blinding, and were not free of selective reporting.There is some limited evidence that combination therapy is superior to monotherapy in improving clinical response (RR 0.73, 95% CI 0.63 to 0.85; participants = 2364; studies = 29, very low-quality evidence), although subgroup analyses show that the positive result was due to the studies with clozapine in both the monotherapy and combination groups (RR 0.66, 95% CI 0.53 to 0.83; participants = 1127; studies = 17). Few studies reported on rate of relapse, most likely due to the short length of the studies. Overall, a combination of antipsychotics was not superior or inferior to antipsychotic monotherapy in preventing relapse (RR 0.63, 95% CI 0.31 to 1.29; participants = 512; studies = 3, very low-quality evidence), but the pooled data showed high heterogeneity (I² = 82%). A combination of antipsychotics was not superior or inferior to antipsychotic monotherapy in reducing the number of participants discontinuing treatment early (RR 0.89, 95% CI 0.73 to 1.07; participants = 3103; studies = 43, low-quality evidence). No difference was found between treatment groups in the number of participants hospitalised (RR 0.96, 95% CI 0.36 to 2.55; participants = 202; studies = 3, low-quality evidence) . We did not find evidence of a difference between treatment groups in serious adverse events or those requiring discontinuation (RR 1.05, 95% CI 0.65 to 1.69; participants = 2398; studies = 30, very low-quality evidence). There is as lack of evidence on clinically important change in quality of life, with only four studies reporting average endpoint or change data for this outcome on three different scales, none of which showed a difference between treatment groups.

AUTHORS' CONCLUSIONS

Currently, most evidence regarding the use of antipsychotic combinations comes from short-term trials, limiting the assessment of long-term efficacy and safety. We found very low-quality evidence that a combination of antipsychotics may improve the clinical response. We also found low-quality evidence that a combination of antipsychotics is may make no difference at preventing participants from leaving the study early, preventing relapse and/or causing more serious adverse events than monotherapy.

Predictors of long-term (≥6months) antipsychotic polypharmacy prescribing in secondary mental healthcare

INTRODUCTION

The predictors of long-term antipsychotic polypharmacy (APP) initiation are poorly understood. Existing research has been hampered by residual confounding, failure to exclude cross-titration, and difficulties in separating the timing of predictors and APP administration.

MATERIALS AND METHODS

Using data from the South London and Maudsley (SLaM) case register, we identified all adult patients with serious mental illness (SMI) who were receiving care between 1st July 2011 and 30th June 2012. Exposures measured between 1st July and 31st December 2011 included socio-demographic, socioeconomic, clinical and service use characteristics. We then determined if long-term APP (six or more months) had been initiated between 1st January and 30th June 2012. Multivariable logistic regression models, adjusted for socio-demographic and socioeconomic factors, were built to investigate the associations between the above factors and the initiation of long-term APP.

RESULTS

We identified 6857 adults with SMI receiving SLaM care, of whom 115 (1.7%) were newly prescribed long-term APP. In the adjusted models, predictors of long-term APP initiation included: symptoms (severity of hallucinations and/or delusions), previous treatments (clozapine and long-acting injectable antipsychotic agents), service use (more contact with outpatient services, community treatment order receipt), social factors (higher area-level deprivation, homelessness) and socio-demographic status (younger age, not in a relationship).

CONCLUSION

Our findings highlight that certain patient groups are at an increased risk for long-term APP initiation. Identifying these groups earlier in their treatment could encourage clinicians to employ a broader range of interventions in addition to pharmacotherapy to reduce the risk of APP prescribing.

Gray and white matter trajectories in patients with bipolar disorder

OBJECTIVES

Findings on brain structural abnormalities in patients with bipolar disorder (BP) are inconsistent and little is known about age-related evolution of these changes. We employed a cross-sectional, case-control study to compare structural age-related brain trajectories in patients with BP and healthy control subjects (HC) over a period of approximately 50 years. The primary aim was to understand whether white (WM) and gray matter (GM) abnormalities are present from the beginning of the illness and how they change over time.

METHODS

Seventy-eight patients with BP and 78 HC matched for age, gender, and educational level underwent a high-resolution structural magnetic resonance imaging protocol. A voxel-based morphometry (VBM) analysis was used to capture GM and WM differences between subjects with BP and HC. Factorial analysis of covariance was used to compare brain volume alterations at different ages between the groups.

RESULTS

We found an age-related atrophy in GM and WM volumes both in patients with BP and HC. A main effect of diagnosis emerged in the posterior cingulate cortex bilaterally, in the right thalamus, in the cerebellum bilaterally, and in the left posterior limb of the internal capsule. No interaction between diagnosis and age emerged, indicating that the volumes of these areas were permanently reduced in subjects with BP throughout the entire age range under investigation.

CONCLUSIONS

Brain alterations in patients with BP are present from the beginning of the illness and remain stable over time. All the affected areas are involved in mood and psychomotor control process. This suggests a possible neurodevelopmental involvement in the mechanism of BP.

Extracting antipsychotic polypharmacy data from electronic health records: developing and evaluating a novel process

BACKGROUND

Antipsychotic prescription information is commonly derived from structured fields in clinical health records. However, utilising diverse and comprehensive sources of information is especially important when investigating less frequent patterns of medication prescribing such as antipsychotic polypharmacy (APP). This study describes and evaluates a novel method of extracting APP data from both structured and free-text fields in electronic health records (EHRs), and its use for research purposes.

METHODS

Using anonymised EHRs, we identified a cohort of patients with serious mental illness (SMI) who were treated in South London and Maudsley NHS Foundation Trust mental health care services between 1 January and 30 June 2012. Information about antipsychotic co-prescribing was extracted using a combination of natural language processing and a bespoke algorithm. The validity of the data derived through this process was assessed against a manually coded gold standard to establish precision and recall. Lastly, we estimated the prevalence and patterns of antipsychotic polypharmacy.

RESULTS

Individual instances of antipsychotic prescribing were detected with high precision (0.94 to 0.97) and moderate recall (0.57-0.77). We detected baseline APP (two or more antipsychotics prescribed in any 6-week window) with 0.92 precision and 0.74 recall and long-term APP (antipsychotic co-prescribing for 6 months) with 0.94 precision and 0.60 recall. Of the 7,201 SMI patients receiving active care during the observation period, 338 (4.7 %; 95 % CI 4.2-5.2) were identified as receiving long-term APP. Two second generation antipsychotics (64.8 %); and first -second generation antipsychotics were most commonly co-prescribed (32.5 %).

CONCLUSIONS

These results suggest that this is a potentially practical tool for identifying polypharmacy from mental health EHRs on a large scale. Furthermore, extracted data can be used to allow researchers to characterize patterns of polypharmacy over time including different drug combinations, trends in polypharmacy prescribing, predictors of polypharmacy prescribing and the impact of polypharmacy on patient outcomes.

Antipsychotic polypharmacy and high-dose prescription in schizophrenia: a 5-year comparison

OBJECTIVE

The co-prescription of multiple antipsychotic drugs continues to increase despite a lack of evidence supporting this practice. The purpose of this study was to quantify and describe recent trends of antipsychotic polypharmacy in Korean schizophrenic inpatients by comparing prescribed medications between the years of 2005 and 2010.

METHODS

We reviewed comprehensive medication profiles of schizophrenic patients discharged from a university psychiatric hospital in 2005 (n=194) or 2010 (n=201). Antipsychotic polypharmacy was defined as the concurrent receipt of two or more chemically distinct antipsychotics for at least 14 days. High antipsychotic dose was defined as a prescribed daily dose to defined daily dose ratio of greater than 1.5.

RESULTS

Antipsychotic polypharmacy increased between 2005 (37.1%) and 2010 (48.3%, p=0.025). The most frequently used drug within combinations of antipsychotics was haloperidol in 2005 (51.4%) and quetiapine in 2010 (48.5%). Overall, no changes were observed between 2005 and 2010 in the rate of prescribing high-dose antipsychotics. High-dose antipsychotic monotherapy decreased across years (from 30.4 to 18.4%), but high-dose antipsychotic polypharmacy increased (from 34.0 to 45.3%). Regression analysis revealed that antipsychotic polypharmacy was strongly associated with high doses of prescribed antipsychotics (odds ratio=18.60, p<0.001).

CONCLUSIONS

The practice of prescribing multiple antipsychotics to patients with schizophrenia is increasing, and high-dose antipsychotic drugs are more likely to be prescribed in combination than in isolation. The reasons for this pattern of prescription and its impact warrants further study.

Antipsychotic polypharmacy: a comprehensive evaluation of relevant correlates of a long-standing clinical practice

Antipsychotic polypharmacy (APP) is common in the treatment of schizophrenia spectrum disorders. The literature indicates that APP is related to patient, illness, and treatment variables that are proxy measures for greater illness acuity, severity, complexity, and chronicity. The largely unknown relative risks and benefits of APP need to be weighed against the known risks and benefits of clozapine for treatment-resistant patients. To inform evidence-based clinical practice, controlled, high-quality antipsychotic combination and discontinuation trials are necessary to determine the effectiveness, safety, and role of APP in the management of severely ill patients with insufficient response to antipsychotic monotherapy.

Antipsychotic polytherapy on an inpatient psychiatric unit: how does clinical practice coincide with Joint Commission guidelines?

OBJECTIVE

A recently developed quality measure set for inpatient psychiatric care includes measurement of antipsychotic polytherapy at discharge. Our objective was to use detailed chart reviews to assess the use of antipsychotic polytherapy and place this use in the context of these measures.

METHODS

Patients (N=75) discharged on multiple antipsychotics and a comparable set (N=114) of comparison patients (a randomly selected set of all admitted inpatients) were identified from consecutive admissions to a psychiatric inpatient unit. Medical records were reviewed to ascertain the clinical rationale for antipsychotic polytherapy and assess differences in characteristics between these groups.

RESULTS

Patients discharged on antipsychotic polytherapy were more likely to have public insurance, longer lengths of stay, psychotic illness, more prior admissions, and state-funded services for persons with chronic mental illness. We identified subgroups of patients based on the clinical rationale for the antipsychotic co-prescription (refractory illness, regimen unchanged from admission and use of antipsychotic for nonpsychosis symptoms). Some, but not all, such rationales appeared to be clinically justified.

CONCLUSIONS

The majority of patients discharged on antipsychotic polytherapy had justifiable clinical rationales that were concordant with the new quality measures. However, two additional subsets were identified, one where quality improvement efforts may be warranted and another where revision of existing quality measure definitions should be considered. Given the implications of public reporting of quality measures, further study and refinement of these measures are required to provide meaningful information to all concerned stakeholders.

Relapse according to antipsychotic treatment in schizophrenic patients: a propensity-adjusted analysis

OBJECTIVE

To compare the rate of relapse as a function of antipsychotic treatment (monotherapy vs. polypharmacy) in schizophrenic patients over a 2-year period.

METHODS

Using data from a multicenter cohort study conducted in France, we performed a propensity-adjusted analysis to examine the association between the rate of relapse over a 2-year period and antipsychotic treatment (monotherapy vs. polypharmacy).

RESULTS

Our sample consisted in 183 patients; 50 patients (27.3%) had at least one period of relapse and 133 had no relapse (72.7%). Thirty-eight (37.7) percent of the patients received polypharmacy. The most severely ill patients were given polypharmacy: the age at onset of illness was lower in the polypharmacy group (p = 0.03). Patients that received polypharmacy also presented a higher general psychopathology PANSS subscore (p = 0.04) but no statistically significant difference was found in the PANSS total score or the PANSS positive or negative subscales. These patients were more likely to be given prescriptions for sedative drugs (p < 0.01) and antidepressant medications (p = 0.03). Relapse was found in 23.7% of patients given monotherapy and 33.3% given polypharmacy (p = 0.16). After stratification according to quintiles of the propensity score, which eliminated all significant differences for baseline characteristics, antipsychotic polypharmacy was not statistically associated with an increase of relapse: HR = 1.686 (0.812; 2.505).

CONCLUSION

After propensity score adjustment, antipsychotic polypharmacy is not statistically associated to an increase of relapse. Future randomised studies are needed to assess the impact of antipsychotic polypharmacy in schizophrenia.

Predictors of the discharge dosage of an atypical antipsychotic agent among hospitalized, treatment-naive, first-episode psychosis patients in naturalistic, public-sector settings

OBJECTIVE

Little is known about determinants of second-generation antipsychotic dosages during initial hospitalization of first-episode psychosis. This study examined potential predictors of dosage of an atypical antipsychotic agent, risperidone, at hospital discharge after initial evaluation and treatment of first-episode nonaffective psychosis in 3 naturalistic, public-sector treatment settings.

METHODS

The number of psychotropic agents prescribed and discharge antipsychotic dosage were abstracted from the medical record. Demographic and extensive clinical characteristics were assessed through a clinical research study conducted at the 3 sites. One-way analyses of variance, trend tests using specific linear combinations of estimates, and χ² tests assessed for associations between atypical antipsychotic dosage and 5 hypothesized predictors, as well as 12 exploratory variables.

RESULTS

Among 155 hospitalized first-episode patients, 121 (78.1%) were discharged on risperidone, and subsequent analyses focused on that subset. The mean risperidone dosage among those 121 patients was 4.26 mg; 31 received 1 to 2 mg, 45 received 3 to 4 mg, 37 received 5 to 6 mg, and 8 received more than 6 mg. Analyses suggested that older age at hospitalization, the number of psychotropic agents prescribed, excited symptoms, and premorbid social functioning may be predictors of the discharge dosage.

CONCLUSIONS

Although several factors emerged, in general, predictors of discharge dosages of second-generation agents, here exemplified by risperidone, in real-world practice settings remain to be clarified. Given the importance of antipsychotic initiation during first hospitalization, future research should test an even broader array of potential predictors.

Understanding antipsychotic non-classical prescriptions: a quantitative and qualitative approach

AIMS

To date only a few studies investigated the clinical reasons supporting and explaining non-classical antipsychotic prescriptions. The present study was carried out to develop concepts which help understand this phenomenon in a natural setting, giving emphasis to views of clinicians according to quali - quantitative research methodologies.

SUBJECTS

From the South-Verona Psychiatric Case Register all antipsychotic prescriptions issued during 2005 were extracted. Concurrent prescribing of two or more antipsychotics, prescribing antipsychotic drugs outside the licensed indications, and outside the licensed ranges of doses reported in the Italian National Formulary, were considered non-classical prescriptions. Reasons for non-classical prescriptions were collected by means of brainstorming sessions with clinicians. Non-classical prescriptions and the corresponding reasons were grouped according to whether they were "clinically sound" or "clinically not sound".

RESULTS

During 2005 a total of 259 patients received 376 non-classical prescriptions. The most frequently reported reasons for non-classical prescribing were that prescriptions were inherited from another clinician with or without benefit, and that prescriptions were motivated by the need of reducing psychotic symptoms. More than 60% of these non-classical prescriptions were categorised as "clinically sound". Clinically not sound prescriptions were related with negative clinicians' views and opinions about the patient/clinician relationship.

CONCLUSION

Clinically not sound prescriptions appeared just a reflection of a problematic doctor/patient relationship, where no individual treatment plan existed and psychiatric visits had the only goal of monitoring ongoing prescriptions.

Comparison of mania patients suitable for treatment trials versus clinical treatment

It remains uncertain whether bipolar disorder (BPD) patients in randomized-controlled trials (RCTs) are sufficiently representative of clinically encountered patients as to guide clinical-therapeutic practice. We complied inclusion/exclusion criteria by frequency from reports of 21 RCTs for mania, and applied them in a pilot study of patients hospitalized for DSM-IV BPD manic/mixed states to compare characteristics and clinical responses of patients who did versus did not meet exclusion criteria. From 27 initially identified inclusion/exclusion criteria ranked by citation frequency, we derived six inclusion, and 10 non-redundant-exclusion factors. Of 67 consecutive patients meeting inclusion criteria, 15 (22.4%) potential "research subjects" met all 10 exclusion criteria. The remaining 52 "clinical patients" differed markedly on exclusion criteria, including more psychiatric co-morbidity, substance abuse, involuntary hospitalization, and suicide attempts or violence, but were otherwise similar. In both groups responses to clinically determined inpatient treatments were similar, including improvement in mania ratings. Based on applying reported inclusion/exclusion criteria for RCTs to a pilot sample of hospitalized-manic patients, those likely to be included in modern RCTs were similar to patients who would be excluded, most notably in short-term antimanic-treatment responses. The findings encourage further comparisons of subjects included/excluded from RCTs to test potential clinical generalizability of research findings. The pilot study is limited in numbers and exposure times with which to test for the minor differences between "research subjects" and "clinical patients."

Factors associated with treatment nonadherence among US bipolar disorder patients

OBJECTIVE

Since sustained treatment-adherence is often problematic and may limit clinical outcomes among bipolar disorder (BPD) patients, we sought risk factors to guide clinical prediction of nonadherence.

METHODS

Data were from a 2005 US national sample providing questionnaire responses by 131 randomly selected prescribing psychiatrists and their adult BPD patients. We contrasted demographic and clinical factors in treatment-adherent versus nonadherent patients (strictly defined as missing > or =1 dose within 10 days) in univariate analyses followed by multivariate logistic-regression modeling.

RESULTS

Of 429 DSM-IV BPD patients (79% type-I; 62% women; 17% minorities), 34% reported missing > or = 1 dose of psychotropic medication within 10 days, 20% missed entire daily doses at least once, and only 2.5% missed all doses for 10 days. However, their prescribing psychiatrists considered only 6% as treatment-nonadherent. Factors significantly associated with nonadherence in multivariate modeling ranked: alcohol-dependence > youth > greater affective morbidity > various side effects > or = comorbid obsessive-compulsive disorder > or = recovering from mania-hypomania. Unrelated were sex, diagnostic subtype, and other comorbidities. Since most patients received > or = 2 psychotropics, potential relationships between treatment-complexity and adherence were obscured.

CONCLUSIONS

Prevalent treatment-nonadherence among American BPD patients, and striking underestimation of the problem by prescribing clinicians may encourage increasingly complex treatment-regimens of untested value, but added expense, risk of adverse effects, and uncertain impact on treatment-adherence itself.

Developing the role of pharmacists as members of community mental health teams: perspectives of pharmacists and mental health professionals

BACKGROUND

People living with bipolar mood disorder and psychotic illnesses in Australia primarily access public-sector mental health care through community mental health teams (CMHTs). Adverse drug events are common among clients of CMHTs taking psychotropic medications.

OBJECTIVE

The study aimed to investigate and describe a potential role for pharmacists as members of CMHTs.

METHODS

Five study pharmacists were employed 1 day per week to work with 5 mental health teams over a 24-week period. The pharmacists conducted both client and team specific activities designed to optimize the use of medications. The pharmacists recorded their professional activities in diaries. Audiotaped focus groups were conducted with the pharmacists (n=1) and mental health team staff (n=3) at the conclusion of the study. Pharmacists' diaries and the transcripts of focus groups were thematically content analyzed.

RESULTS

Study pharmacists were perceived as valuable sources of unbiased and evidence-based drug information for both mental health team staff and their clients and caregivers. Mental health team staff particularly appreciated the provision of information about nonpsychotropic medications. Pharmacists' participation in clinical team meetings was used as an opportunity to present medication review findings and recommendations. Liaising between medication prescribers and dispensers working in primary and secondary care settings was deemed an important additional role; however, participating only 1 day per week was considered to delay rapport building and the establishment of collaborative working relationships with mental health team staff.

CONCLUSIONS

Including pharmacists as members of CMHTs addressed an unmet need for pharmaceutical services among clients and staff of CMHTs. Pharmacists' contributions were welcomed by mental health team staff. The study raised the issue of whether pharmacists should be considered as essential and legitimate members of interdisciplinary CMHTs.

Hospital use of antipsychotic drugs: polytherapy

OBJECTIVE

Growing acceptance of new psychotropic drugs encouraged a survey of current use of antipsychotic drugs alone and in combinations, with comparisons with previous findings.

METHOD

Records from a random sample of McLean Hospital (Belmont, Mass) inpatients treated with an antipsychotic from March to May 2004 were reviewed for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, discharge diagnosis; all current psychotropic drug treatments; initial, peak, and final chlorpromazine-equivalent milligram-per-day dose of antipsychotics (APD); initial, peak, and final lithium-equivalent dose (milligram per day) of mood stabilizers (MS); weight change; clinical status at admission and discharge; and days of hospitalization.

RESULTS

In the 305 inpatients sampled (n = 184 women, 60.3%), Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, clinical conditions ranked as follows: major affective (n = 161, 52.8%), psychotic (n = 99, 32.5%), and other disorders (n = 45, 14.8%). Modern drugs comprised 92% of antipsychotic prescriptions, and quetiapine (usually at low doses) was most frequently prescribed. "Polytherapy" (simultaneous treatment with > or =2 psychotropic agents) at discharge was identified in 80% of antipsychotic-treated patients. Use of at least 2 antipsychotics (in 23% of cases) was associated with a 2.8-fold increase in total dose vs monotherapy (651 +/- 403 vs 232 +/- 205 mg/d). Total antipsychotic doses also were higher with mood stabilizer (most often divalproex) or sedative (usually high-potency benzodiazepine) cotreatment, use of older neuroleptics, psychotic-disorder diagnoses, and substance use comorbidity. Polytherapy was not associated with superior clinical improvement or shorter hospitalization but was associated with higher body weight.

CONCLUSIONS

Polytherapy involving antipsychotic drugs continues to increase despite limited empirical evidence for greater effectiveness or of safety of such combinations.

Adding or switching antipsychotic medications in treatment-refractory schizophrenia

OBJECTIVE

This study compared patients with schizophrenia whose antipsychotic medications were switched to manage treatment-resistant positive psychotic symptoms with those for whom another antipsychotic was added. Psychiatrists' characteristics and perceptions of effectiveness of the medication change on clinical outcomes were also reported.

METHODS

Psychiatrists participating in a nationally representative mailed survey (N=209) reported on the clinical features, management, and response to the change in antipsychotic medication (added versus switched) of one adult patient with treatment-refractory schizophrenia under their care for at least one year.

RESULTS

Thirty-three percent of patients were treated with an added antipsychotic medication. Compared with patients whose antipsychotic medications were switched, those with an added antipsychotic medication were more likely to be female, to have received care from the same psychiatrist for more than two years, and to have been recently prescribed an antidepressant. Compared with psychiatrists who switched antipsychotic prescriptions, those who added an antipsychotic reported that the change was less likely to reduce positive symptoms, improve functioning, and prevent hospitalization. Psychiatrists who added rather than switched antipsychotics reported more frequent attendance at educational programs sponsored by a pharmaceutical company.

CONCLUSIONS

Consistent with other lines of research and practice guideline recommendations, psychiatrists perceive antipsychotic polypharmacy to be a generally ineffective strategy for treatment-resistant positive psychotic symptoms. In light of these findings, efforts to identify and implement more effective evidence-based pharmacologic approaches should be undertaken.

Factors associated with antipsychotic dosing in psychiatric inpatients: a prospective study

The persistent use of doses in excess of recommended levels is associated with increased risks of adverse reactions without evidence of additional benefits. Such treatment modality was evaluated in hospitalized psychiatric patients. During a 6-year recruitment period, a consecutive series of psychiatric inpatients receiving antipsychotic therapy were included. At admission, sociodemographic and clinical data, including antipsychotic drug use, were collected, and the 18-item version of the Brief Psychiatric Rating Scale was administered. At discharge, data on antipsychotic drug therapy were collected. Prescribed daily doses were converted into multiples of the defined daily doses. Using a cut-off score of a prescribed daily dose/defined daily dose as a ratio of more than 1.5 both at admission and at discharge assessments, a total of 62 (15.4%) patients persistently received high antipsychotic dose. With less stringent criteria (prescribed daily dose/defined daily dose as a ratio of more than 2), however, only 4.4% of the entire sample was persistently exposed to high antipsychotic doses. Bootstrapped linear regression analysis revealed that positive symptoms were positively associated with high antipsychotic dose, whereas negative symptoms were negatively associated with high antipsychotic dose. Antipsychotic polypharmacy at admission was the strongest predictor of persistently receiving antipsychotic doses in excess of recommended levels. This study showed that the use of high antipsychotic dosing is not an occasional event. Clinicians should consider that concurrent prescribing of two or more antipsychotic agents increases the probability of administering excessive dosing in the long-term.

Adding or switching antipsychotic medications in treatment-refractory schizophrenia

OBJECTIVE

This study compared patients with schizophrenia whose antipsychotic medications were switched to manage treatment-resistant positive psychotic symptoms with those for whom another antipsychotic was added. Psychiatrists' characteristics and perceptions of effectiveness of the medication change on clinical outcomes were also reported.

METHODS

Psychiatrists participating in a nationally representative mailed survey (N=209) reported on the clinical features, management, and response to the change in antipsychotic medication (added versus switched) of one adult patient with treatment-refractory schizophrenia under their care for at least one year.

RESULTS

Thirty-three percent of patients were treated with an added antipsychotic medication. Compared with patients whose antipsychotic medications were switched, those with an added antipsychotic medication were more likely to be female, to have received care from the same psychiatrist for more than two years, and to have been recently prescribed an antidepressant. Compared with psychiatrists who switched antipsychotic prescriptions, those who added an antipsychotic reported that the change was less likely to reduce positive symptoms, improve functioning, and prevent hospitalization. Psychiatrists who added rather than switched antipsychotics reported more frequent attendance at educational programs sponsored by a pharmaceutical company.

CONCLUSIONS

Consistent with other lines of research and practice guideline recommendations, psychiatrists perceive antipsychotic polypharmacy to be a generally ineffective strategy for treatment-resistant positive psychotic symptoms. In light of these findings, efforts to identify and implement more effective evidence-based pharmacologic approaches should be undertaken.

Long-term antipsychotic polypharmacy in the VA health system: patient characteristics and treatment patterns

OBJECTIVE

Although antipsychotic polypharmacy is being prescribed with increasing frequency, few studies have described patient characteristics and treatment patterns associated with long-term use of this treatment strategy.

METHODS

By using data from the National Psychosis Registry of the Department of Veterans Affairs, 5,826 patients with schizophrenia or schizoaffective disorder who received long-term antipsychotic polypharmacy (simultaneous treatment with two or more antipsychotics for 90 or more days) during fiscal year 2000 and 39,745 patients who received long-term antipsychotic monotherapy were identified. By using multivariate regression models, patient demographic and clinical characteristics, antipsychotic dosages, and use of antiparkinson and adjunctive psychotropic medications were compared between the two groups.

RESULTS

Patients were more likely to receive antipsychotic polypharmacy if they were younger, were unmarried, had a military service-connected disability, had schizophrenia rather than schizoaffective disorder, or had greater use of inpatient and outpatient mental health services. Patients were less likely to receive antipsychotic polypharmacy if they were African American, had concurrent diagnoses of depression or substance use disorder, or had greater medical comorbidity. For most antipsychotics, dosages prescribed for patients receiving polypharmacy were the same or modestly higher than those prescribed for patients receiving monotherapy. Patients given prescriptions for polypharmacy were more likely to receive antiparkinson medications, antianxiety agents, and mood stabilizers and equally likely to receive concurrent treatment with antidepressants.

CONCLUSIONS

Long-term antipsychotic polypharmacy appears to be reserved for more severely ill patients with psychotic symptoms rather than mood symptoms. These patients may experience increased adverse effects as a result of excess antipsychotic exposure.

Persistence with polypharmacy and excessive dosing in patients with schizophrenia treated in four European countries

The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia.

[Prevalence and characteristics of neuroleptic association in a patient cohort with psychotic disorders]

OBJECTIVES

Combined antipsychotic drugs are often prescribed, despite a lack of objective supporting data. Therefore, it is especially important to determine the scope of this practice and to better understand the characteristics of affected patients to identify which associations to study first.

METHOD

We studied patients with psychotic disorders followed for at least 1 year at an outpatient psychiatric clinic in Geneva (n = 253). We collected data on prescriptions given at baseline and during that period, as well as sociodemographic and clinical data.

RESULTS

During the follow-up period, 36% of patients were prescribed a neuroleptic. These patients differ by negative changing characteristics: less activity, financial assistance, nursing home placement, and numerous admissions with earlier onset of disorder. Three-quarters of patients did not change treatment during that period. Treatment stability is associated with treatment compliance and lack of hospital admission during the follow-up period.

CONCLUSION

Without any scientific substantiation, patients with negative changing characteristics are often prescribed neuroleptics. Such treatment options are likely relatively inefficient strategies. Moreover, this practice risks further complicating patients who are already characterized by negative elements.

Generating psychotropic drug exposure data from computer-based medical records

PURPOSE

To develop a methodology for extracting psychotropic drug exposure data from computer-based medical records and for generating drug exposure variables suitable for secondary use.

METHODS

In South-Verona, Italy, a registry including every patient receiving psychotropic medications is operating since 2004. The basic structure of the registry is the medication record. Each record stores data on a specific prescription, and patients with more than one prescription have more than one record.

RESULTS

The longitudinal history of drug use was described identifying consecutive prescriptions of a specific drug, concomitant prescriptions of a specific drug and distinct prescriptions of a specific drug. Consecutive prescriptions implies that the beginning of the second prescription coincides with the end of the first prescription, concomitant prescriptions implies that the beginning of the second prescription precedes the end of the first prescription, distinct prescriptions implies that a gap of at least 1 day exists between prescriptions. Using this framework of drug representation, we identified episodes of drug therapy, where each episode is constituted of consecutive and/or concomitant prescriptions. Within each episode, prescriptions were categorised into theoretical phases, where the beginning of the new phase always coincides with the end of the previous phase. On the basis of this data representation, a module operating in Access and using Visual Basic for Applications was developed for creating episodes and phases on a routine basis (available from authors). A graphical representation of this conceptual model is presented.

CONCLUSION

The development of a simple methodology for extracting and generating drug exposure data suitable for secondary use will allow a better understanding of the beneficial and adverse consequences of psychotropic drug use in ordinary practice.

Long-term combination antipsychotic treatment in VA patients with schizophrenia

Treatment guidelines consider antipsychotic monotherapy the standard of care for patients with schizophrenia. However, previous studies have reported widely varying, and sometimes high, rates of antipsychotic polypharmacy. We identified 61,257 VA patients with schizophrenia in fiscal year 2000 who had >or=90 non-institutionalized days and one or more fills of antipsychotic medications. We used criteria of increasing stringency (>or=30, >or=60, or >or=90 overlapping days' supply of antipsychotic medications) and several cross-sectional criteria from previous studies to compare the prevalence of antipsychotic polypharmacy using these definitions. We also describe specific treatment combinations among patients receiving long-term polypharmacy. The prevalence of antipsychotic polypharmacy was 20.0%, 13.1%, and 9.5% when defined by a >or=30, >or=60, or >or=90-day overlap, respectively. Cross-sectional definitions used in previous studies did not identify 32-89% of patients receiving long-term polypharmacy (>or=90 days). In addition, approximately half of patients identified by cross-sectional criteria had only short-term overlaps of antipsychotic medications. Among patients receiving long-term polypharmacy, 74% received a first- and a second-generation agent, 18% received two second-generation agents, and 6% received two first-generation agents. Definitions of polypharmacy that rely on cross-sectional data or narrow observation periods do not accurately identify patients receiving long-term treatment; in this study, only 10% of patients with schizophrenia received combination treatments for >or=90 days. The most commonly used antipsychotic combinations have little support for safety or efficacy. Further research is needed to understand the impact of these treatments on symptoms, side effects, and costs.