Prevalence, utilization patterns, and predictors of antipsychotic polypharmacy: experience in a multistate Medicaid population, 1998-2003

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Schizophrenia patients discharged on antipsychotic polypharmacy from a public psychiatric hospital in Taiwan, 2006-2021

The aim of this study was to identify the factors associated with antipsychotic polypharmacy (APP), investigate whether APP could affect the risk of rehospitalization, and explore temporal trends in APP use. Schizophrenia patients discharged from the study hospital between 2006 and 2021 (n = 16,722) were included in the analysis. The logistic regression model was employed to determine the predictors significantly associated with APP use. Survival analysis was used to compare time to rehospitalization between APP and antipsychotic monotherapy (AMT). The temporal trend of APP use was analyzed using the Cochran-Armitage Trend test. In comparison with the patients (n = 10,909) who were discharged on AMT, those (n = 5,813) on APP were significantly more likely to be male gender, to receive LAIs, to take clozapine, to take anticholinergic agents, to have a greater number of previous hospitalizations, and to have a higher CPZ equivalent dose of antipsychotic prescription. The prescription rate of APP significantly increased from 18.4 % in 2006 to 44.9 % in 2021. Compared with AMT, APP was associated with more clozapine use, more LAI use, higher doses of antipsychotics, and an increased risk of rehospitalization. In addition, the prescription of APP continued to increase during the study period.

Nationwide study on antipsychotic polypharmacy among forensic psychiatric patients

This nationwide retrospective cross-sectional study examines the prevalence of antipsychotic polypharmacy (APP) and demographic, forensic, and clinical factors associated with its practice among Greenlandic forensic psychiatric patients. We collected data from electronic patient files, court documents, and forensic psychiatric assessments. We defined APP as two or more concurrent prescriptions of antipsychotic medication. The study population of 74 patients had a mean age of 41.4 years, and 61 were men. All included patients had either schizophrenia or another ICD-10 F2-diagnosis. We used unpaired t-tests and Chi² or Fisher's exact test. The prevalence of APP was 35% (n = 26), and there was a significant association between APP and a prescription of clozapine (Chi², p = 0.010), olanzapine (Fisher's test, p = 0.003), and aripiprazole (Fisher's test, p = 0.013). Furthermore, we found a significant association between APP and prescription of a first-generation antipsychotic (FGA) (Chi², p = 0.011). Despite recommendations in guidelines, the use of APP is common practice. The majority of forensic psychiatric patients suffer from severe psychiatric disorders, often with other comorbidities, including substance use disorder. The severity and complexity in mental health render forensic psychiatric patients at high risk of APP treatment. Further knowledge on APP use is crucial to secure and further improve the psychopharmacological treatment for this group of patients.

Long-Term Antipsychotic Effectiveness and Comparison of the Efficacy of Monotherapy and Polypharmacy in Schizophrenia: A 3-Years Follow-Up “Real World” Study in China

Background: Discontinuation of antipsychotic treatment is a common problem in patients with schizophrenia and could reduce the effectiveness of treatment. Time to discontinuation (TTD) is one of the indicators of compliance and may also be an effective indicator of medication efficacy. The aim of the study was to compare the clinical effectiveness of quetiapine, olanzapine, risperidone, and aripiprazole in the real-world treatment of schizophrenia with 3-years follow-up.

Method: A multi-center, open, cohort, prospective, real-world study was conducted. 706 patients were analyzed without intervention in medication selection and use, followed up for 3 years. Kaplan-Meier survival curves were used to draw the treatment discontinuation rates (TDR) curves at each time point. Cox proportional hazard regression model was used to assess the relative risk of TTD of antipsychotics.

Results: There was a significant difference among monotherapy groups in all-cause antipsychotic treatment discontinuation (p = 0.0057). Among the four medications, the TDR of risperidone was the highest. Compared with polypharmacy, except for aripiprazole, the TDR of other three monotherapy medications were lower than that of polypharmacy, and olanzapine was statistically different (p = 0.0325). The cox regression analysis showed that after correction of Hochberg with multiple tests, only olanzapine had a relative risk lower than risperidone (p < 0.0083).

Conclusions: The findings indicated that risperidone monotherapy and polypharmacy had the highest TDR and the shortest TTD. Olanzapine monotherapy had a relative risk lower than risperidone and was superior to polypharmacy.

Antipsychotic polypharmacy in adult patients diagnosed with schizophrenia: A retrospective study

Antipsychotic polypharmacy (APP) is a common practice in the treatment of schizophrenia. In this study, we aimed to identify the prevalence of APP in our department, as well as the trends associated with co-prescribing antipsychotics. We collected data from the medical records of all 193 inpatients diagnosed with schizophrenia who were admitted to Prof. Dr. Alexandru Obregia Clinical Psychiatry Hospital (Bucharest, Romania), Department 9, during January 2019-December 2019. Demographic characteristics of the patients, clinical diagnosis, psychiatric admission type and duration of hospitalization were examined. Data regarding the antipsychotic regimen at discharge and other psychotropic drugs used were collected. A total of 69 (35.75%) patients received more than 2 antipsychotics upon discharge. Patients treated with APP did not differ in regards to sex, age, education level, employment status, marital status, living situation, type of admission from those receiving antipsychotic monotherapy (APM). Prolonged hospitalization was found to be an independent predictor of APP (P=0.014). Most of the combinations used in our unit included clozapine (47.8%), and the most frequently used treatment in the APP group was the combination of paliperidone and clozapine (14.5%). In the APP group, 30 (43.5%) patients included in their regimen was a long-acting intramuscular antipsychotic. There was no significant difference in terms of the use of mood stabilizers, antiparkinsonian drugs or anxiolytics between the APP and the APM group; yet, a higher prevalence of antidepressant use, although not statistically significant (P=0.067), in the APP group compared to the APM group, was observed. The use of APP as a long-term regimen is a common practice in our department, as it is worldwide. There is a great need for randomized-control trials and evidence-based studies in order to define the safest and most effective combinations of antipsychotics and also the characteristics of patients that may benefit from these combinations.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Off-label use of antipsychotic medications in psychiatric inpatients in China: a national real-world survey

BACKGROUND

The off-label use of antipsychotic medications is common in many countries, and the extent of such use in psychiatric inpatients in China has not been sufficiently studied. The purpose of this study was to survey the incidence and examine the correlates of off-label antipsychotic use in a large, nationally-representative sample in China.

METHODS

This study included discharged psychiatric patients between March 19 and 31, 2019 from 41 tertiary psychiatric hospitals across 29 provinces in China. Their socio-demographic and clinical data were collected and analyzed.

RESULTS

After excluding patients with schizophrenia spectrum disorder or bipolar disorder, 981 patients were included in the analysis. Overall, antipsychotics were prescribed to 63.2% (95%CI 60.2-66.2%) of the sample. Antipsychotics were used in a wide spectrum of psychiatric disorders, with the rate being the highest among patients with dissociative (conversion) disorders (89.9, 95%CI 83.0-94.8%), organic mental disorders (81.7, 95%CI 73.1-88.7%), dementia (79.0,95%CI 67.8-87.9%), obsessive-compulsive disorder (77.8, 95%CI 55.7-92.5%), mental disorders due to psychoactive substances (75.3,95%CI 64.7-84.2%), behavioural and emotional disorders with onset usually occurring in childhood and adolescence (71.4, 95%CI 45.5-90.1%), somatoform disorders (63.2, 95%CI 40.8%-82..2%), major depression disorder (53.7,95%CI 48.8-58.6%), anxiety disorder (38.8,95%CI 30.5-47.7%), and insomnia (25.0, 95%CI 8.5-28.9%). The top three most commonly used antipsychotics were olanzapine (29.1%), quetiapine (20.3%) and risperidone (6.8%), and their corresponding average doses were 9.04 ± 5.80 mg/day, 185.13 ± 174.72 mg/day, and 2.98 ± 1.71 mg/day, respectively. A binary logistic regression showed that younger age, having the Employee Health Insurance or Residents Health Insurance, having psychotic symptoms and requiring restraint during hospitalization were significantly associated with off-label use of antipsychotics.

CONCLUSION

Off-label use of antipsychotics is very common in psychiatric inpatients in China, mainly with moderate-dose use of single agents. However, the efficacy and safety of this practice is uncertain for many diagnoses and for the elderly. Clinicians should be cautious about this practice while waiting for more research data.

Significance and Factors Associated with Antipsychotic Polypharmacy Utilization Among Publicly Insured US Adults

Antipsychotic polypharmacy (APP) lacks evidence of effectiveness in the care of schizophrenia or other disorders for which antipsychotic drugs are indicated, also exposing patients to more risks. Authors assessed APP prevalence and APP association with beneficiary race/ethnicity and payer among publicly-insured adults regardless of diagnosis. Retrospective repeated panel study of fee-for-service (FFS) Medicare, Medicaid, and dually-eligible white, black, and Latino adults residing in California, Georgia, Iowa, Mississippi, Oklahoma, South Dakota, or West Virginia, filling antipsychotic prescriptions between July 2008 and June 2013. Primary outcome was any monthly APP utilization. Across states and payers, 11% to 21% of 397,533 antipsychotic users and 12% to 19% of 9,396,741 person-months had some APP utilization. Less than 50% of person-months had a schizophrenia diagnosis and up to 19% had no diagnosed mental illness. Payer modified race/ethnicity effects on APP utilization only in CA; however, the odds of APP utilization remained lower for minorities than for whites. Elsewhere, the odds varied by race/ethnicity only in OK, with Latinos having lower odds than whites (odds ratio 0.76; 95% confidence interval 0.60-0.96). The odds of APP utilization varied by payer in several study states, with odds generally higher for Dual eligibles, although the differences were generally small; the odds also varied by year (lower at study end). APP was frequently utilized but mostly declined over time. APP utilization patterns varied across states, with no consistent association with race/ethnicity and small payer effects. Greater use of APP-reducing strategies are needed, particularly among non-schizophrenia populations.

Characteristics and definitions of ultra-treatment-resistant schizophrenia - A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to characterize ultra-treatment-resistant Schizophrenia also known as clozapine-resistant schizophrenia (CRS) patients across clozapine combination and augmentation trials through demographic and clinical baseline data. Furthermore, we investigated the variability and consistency in CRS definitions between studies.

METHODS

Systematic searches of articles indexed in PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and PsycINFO were conducted in March 2020. 1541 randomized and non-randomized clinical trials investigating pharmacological and non-pharmacological clozapine add-on strategies were screened and a total of 71 studies were included. The primary outcome was the overall symptom score at baseline, measured with Positive and Negative Syndrome Scale (PANSS) total or Brief Psychiatric Rating Scale (BPRS) total scores.

RESULTS

Data from 2731 patients were extracted. Patients were overall moderately ill with a mean PANSS total score at baseline of 79.16 (±7.52), a mean duration of illness of 14.64 (±4.14) years with a mean clozapine dose of 436.94 (±87.47) mg/day. Illness severity data were relatively homogenous among patients independently of the augmentation strategy involved, although stark geographical differences were found. Overall, studies showed a large heterogeneity of CRS definitions and insufficient guidelines implementation.

CONCLUSIONS

This first meta-analysis characterizing CRS patients and comparing CRS definitions revealed a lack of consistent implementation of a CRS definition from guidelines into clinical trials, compromising the replicability of the results and their applicability in clinical practice. We offer a new score modeled on a best practice definition to help future trials increase their reliability.

Antipsychotic Polypharmacy in Older Adult Asian Patients With Schizophrenia: Research on Asian Psychotropic Prescription Pattern

BACKGROUND AND OBJECTIVE

Antipsychotic polypharmacy (APP) is a controversial topic in the treatment of older adults with schizophrenia. The objective of this study was to examine the use of APP in older adult Asian patients with schizophrenia and its associated demographic and clinical factors.

METHODS

This study was based on the fourth survey of the consortium known as the Research on Asian Psychotropic Prescription Pattern for Antipsychotics. Fifteen Asian countries/territories participated in this survey, including Bangladesh, Mainland China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Myanmar, Pakistan, Singapore, Sri Lanka, Taiwan, Thailand, and Vietnam. Basic demographic and clinical characteristics were collected using a standardized data collection form.

RESULTS

Among the 879 older adults with schizophrenia included in the survey, the rate of APP was 40.5%. Multiple logistic regression analysis revealed that higher antipsychotic doses (P < .001, odds ratio [OR] = 1.003, 95% confidence interval [CI]: 1.002-1.003), longer duration of illness (P = .02, OR = 1.845, 95% CI: 1.087-3.132), and the prescription of anticholinergics (P < .001, OR = 1.871, 95% CI: 1.329-2.635), second-generation antipsychotics (P = .001, OR = 2.264, 95% CI: 1.453-3.529), and first-generation antipsychotics (P < .001, OR = 3.344, 95% CI: 2.307-4.847) were significantly associated with APP.

CONCLUSION

Antipsychotic polypharmacy was common in older adult Asian patients with schizophrenia. Compared to the results of previous surveys, the use of APP showed a declining trend over time. Considering the general poor health status of older patients with schizophrenia and their increased risk of drug-induced adverse events, the use of APP in this population needs careful consideration.

Prescription practices in the treatment of agitation in newly hospitalized Chinese schizophrenia patients: data from a non-interventional naturalistic study

BACKGROUND

Data on the pharmacological management of acute agitation in schizophrenia are scarce. The aim of this study is to investigate the prescription practices in the treatment of agitation in Chinese patients with schizophrenia.

METHODS

We conducted a large, multicenter, observational study in 14 psychiatry hospitals in China. Newly hospitalized schizophrenia patients with the PANSS-EC total score ≥ 14 and a value ≥4 on at least one of its five items were included in the study. Their drug treatments of the first 2 weeks in hospital were recorded by the researchers.

RESULTS

Eight hundred and 53 patients enrolled in and 847 (99.30%) completed the study. All participants were prescribed antipsychotics, 40 (4.72%) were prescribed benzodiazepine in conjunction with antipsychotics and 81 were treated with modified electric convulsive therapy (MECT). Four hundred and 12 (48.64%) patients were prescribed only one antipsychotic, in the order of olanzapine (120 patients, 29.13%), followed by risperidone (101 patients, 24.51%) and clozapine (41 patients, 9.95%). About 435 (51.36%) participants received antipsychotic polypharmacy, mostly haloperidol + risperidone (23.45%), haloperidol+ olanzapine (17.01%), olanzapine+ ziprasidone (5.30%), haloperidol + clozapine (4.37%) and haloperidol + quetiapine (3.90%). Binary logistic regression analysis suggests that a high BARS score (OR 2.091, 95%CI 1.140-3.124), severe agitation (OR 1.846, 95%CL 1.266-2.693), unemployment or retirement (OR 1.614, 95%CL 1.189-2.190) and aggressiveness on baseline (OR 1.469, 95%CL 1.032-2.091) were related to an increased antipsychotic polypharmacy odds. Male sex (OR 0.592, 95%CL 0.436-0.803) and schizophrenia in older persons (age ≥ 55 years, OR 0.466, 95%CL 0.240-0.902) were less likely to be associated with antipsychotic polypharmacy.

CONCLUSION

The present study demonstrates that monotherapy and polypharmacy display equally common patterns of antipsychotic usage in managing agitation associated with schizophrenia in China. The extent and behavioral activities of agitation and several other factors were associated with polypharmacy.

Clozapine augmentation strategies - a systematic meta-review of available evidence. Treatment options for clozapine resistance

BACKGROUND

Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse.

AIMS

We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice.

METHODS

We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified.

RESULTS

Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C-D criteria only.

CONCLUSION

More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.

Variation of the prevalence of pediatric polypharmacy: A scoping review

PURPOSE

To examine the range of prevalence of pediatric polypharmacy in literature through a scoping review, focusing on factors that contribute to its heterogeneity in order to improve the design and reporting of quality improvement, pharmacovigilance, and research studies.

METHODS

We searched Ovid Medline, PubMed, EMBASE, CINAHL, Ovid PsycINFO, Cochrane CENTRAL, and Web of Science Core Collection databases for studies with concepts of children and polypharmacy, along with a hand search of the bibliographies of six reviews and 30 included studies. We extracted information regarding study design, disease conditions, and prevalence of polypharmacy.

RESULTS

Two hundred eighty-four studies reported prevalence of polypharmacy. They were more likely to be conducted in North America (37.7%), published after 2010 (44.4%), cross-sectional (67.3%), in outpatient settings (59.5%). Prevalence ranged from 0.9% to 98.4%, median 39.7% (interquartile range [IQR] 22.0%-54.0%). Studies from Asia reported the highest median prevalence of 45.4% (IQR 27.3%-61.0%) while studies from North America reported the lowest median prevalence of 30.4% (IQR 14.7%-50.2%). Prevalence decreased over time: median 45.6% before 2001, 38.1% during 2001 to 2010, and 34% during 2011 to 2017. Studies involving children under 12 years had a higher median prevalence (46.9%) than adolescent studies (33.7%). Inpatient setting studies had a higher median prevalence (50.3%) than studies in outpatient settings (38.8%). Community level samples, higher number and duration of medications defining polypharmacy, and psychotropic medications were associated with lower prevalence.

CONCLUSIONS

The prevalence of pediatric polypharmacy is high and variable. Studies reporting pediatric polypharmacy should account for context, design, polypharmacy definition, and medications evaluated.

Antipsychotic polypharmacy in the treatment of schizophrenia in China and Japan

BACKGROUND

Although antipsychotic monotherapy is recommended as the main treatment for schizophrenia, antipsychotic polypharmacy is not rare in practice. However, longitudinal data on antipsychotic polypharmacy in schizophrenia treatment are limited.

METHODS

This longitudinal database study described antipsychotic polypharmacy in the treatment of schizophrenia in real-world settings in China and Japan. We retrieved information about antipsychotic treatment for schizophrenia from January 2010 to December 2014 from two hospital Electronic Medical Records databases in China and one claims database, Japan Medical Data Centre in Japan. Eligible patients had a diagnosis of schizophrenia (International Classification of Diseases, Tenth Revision F20.x) and at least one prescription for first or second generation antipsychotics. Antipsychotic polypharmacy was defined as having more than one antipsychotic medication overlapping for ⩾60 days. The Japan Medical Data Centre study cohort was further stratified by employees (insurance beneficiaries) and their dependents.

RESULTS

The study cohorts comprised 11,961 patients from China and 25,034 (10,661 employee sub-cohort and 14,373 dependent sub-cohort) from 14 days Japan Medical Data Centre in Japan. Most patients were prescribed monotherapy (87.3% in China and 80.1% in Japan), of which oral second-generation antipsychotics were the majority (78.9% in China and 65.8% in Japan). The prevalence rate of antipsychotic polypharmacy was 12.7% in China and 19.9% in Japan (13.7% in employees vs 24.5% in dependents). The most common combinations were two oral antipsychotics. Combinations of more than two drugs were uncommon in China (0.3%) but were prescribed for 5.3% of patients in Japan. Among patients treated with monotherapy, 12.6/100 person-years (11.8%) in China and 9.6/100 person-years (11.0%) in Japan switched to antipsychotic polypharmacy during follow-up. Younger patients were more likely to switch to antipsychotic polypharmacy than older patents in all study cohorts.

CONCLUSION

The observed rates of antipsychotic polypharmacy ranged from 12.7% in China to 19.9% in Japan. Switching from monotherapy to antipsychotic polypharmacy was most likely to occur in younger patients with schizophrenia.

Defining pediatric polypharmacy: A scoping review

OBJECTIVES

Lack of consensus regarding the semantics and definitions of pediatric polypharmacy challenges researchers and clinicians alike. We conducted a scoping review to describe definitions and terminology of pediatric polypharmacy.

METHODS

Medline, PubMed, EMBASE, CINAHL, PsycINFO, Cochrane CENTRAL, and the Web of Science Core Collection databases were searched for English language articles with the concepts of "polypharmacy" and "children". Data were extracted about study characteristics, polypharmacy terms and definitions from qualifying studies, and were synthesized by disease conditions.

RESULTS

Out of 4,398 titles, we included 363 studies: 324 (89%) provided numeric definitions, 131 (36%) specified duration of polypharmacy, and 162 (45%) explicitly defined it. Over 81% (n = 295) of the studies defined polypharmacy as two or more medications or therapeutic classes. The most common comprehensive definitions of pediatric polypharmacy included: two or more concurrent medications for ≥1 day (n = 41), two or more concurrent medications for ≥31 days (n = 15), and two or more sequential medications over one year (n = 12). Commonly used terms included polypharmacy, polytherapy, combination pharmacotherapy, average number, and concomitant medications. The term polypharmacy was more common in psychiatry literature while epilepsy literature favored the term polytherapy.

CONCLUSIONS

Two or more concurrent medications, without duration, for ≥1 day, ≥31 days, or sequentially for one year were the most common definitions of pediatric polypharmacy. We recommend that pediatric polypharmacy studies specify the number of medications or therapeutic classes, if they are concurrent or sequential, and the duration of medications. We propose defining pediatric polypharmacy as "the prescription or consumption of two or more distinct medications for at least one day". The term "polypharmacy" should be included among key words and definitions in manuscripts.

Use of Academic Detailing With Audit and Feedback to Improve Antipsychotic Pharmacotherapy

OBJECTIVE

Second-generation antipsychotics vary in their propensity to cause serious cardiometabolic side effects. In addition, use of two or more antipsychotics (polypharmacy) may lead to additive side effects and has not been shown to be consistently more effective than monotherapy. This study examined the use of academic detailing with audit and feedback to improve antipsychotic prescribing practices, including antipsychotic polypharmacy and utilization of medication with high or low risk of cardiometabolic side effects ("high risk" or "low risk," respectively).

METHODS

Four intervention sessions were provided over two years to psychiatric care providers at community mental health centers. Segmented regression within the general estimating equation model framework used Medicaid pharmacy claims to examine prescribing patterns before and after the intervention among all beneficiaries (67,721 person-months) over a five-year period.

RESULTS

After the intervention, 10.9% of beneficiaries with antipsychotic claims were on polypharmacy, compared with 13.1% before the invention. Use of high-risk and low-risk antipsychotics did not change. The final adjusted polypharmacy model showed that antipsychotic polypharmacy decreased among young adults and adults ages 40 or older compared with beneficiaries ages 30-39 (β=-.02, p=.04, and β=-.02, p=.007, respectively). The raw proportion of beneficiaries on high- and low-risk agents did not change, although final adjusted models demonstrated changes in use of high- and low-risk agents by diagnosis and risk group.

CONCLUSIONS

Polypharmacy decreased among young and older adults after academic detailing with audit and feedback. Although further research is needed, this low-intensity intervention may help mental health systems reduce antipsychotic polypharmacy.

Characteristics of Medicaid Recipients Receiving Persistent Antipsychotic Polypharmacy

Antipsychotic polypharmacy (APP) is a common strategy despite guidelines advising against this practice. This article seeks to quantify the prevalence and correlates of APP using Medicaid Analytic eXtract files from 2003 to 2004. Nineteen percent of Medicaid recipients who received an antipsychotic were treated with APP. Individuals who received APP were more likely to be white, male, disabled, between the ages of 18-29, diagnosed with a psychotic disorder, and diagnosed with a higher number of psychiatric conditions. Geographic variation in APP rates was also observed. Quality improvement initiatives may help reduce APP for medically vulnerable patients.

Gender differences and psychotropic polypharmacy in psychiatric patients in Brazil: a cross-sectional analysis of the PESSOAS Project

We aimed to estimate the prevalence and correlates of psychotropic polypharmacy in Brazilian psychiatric patients by gender. Sociodemographic, behavioral and clinical data were obtained through face-to-face interviews and medical charts of 2,475 patients. Psychotropic polypharmacy was defined as the use of two or more psychotropic drugs and occurred in 85.7% of men (95%CI: 83.6%-87.6%) and 84.9% of women (95%CI: 82.8%-86.8%; p > 0.05). The mean number of psychotropic drugs/patient was 2.98 ± 1.23 and most common combinations included antipsychotics. Multivariate analysis showed that for both genders, previous hospitalization, severe mental illness, multiple psychiatric diagnoses and an insufficient number of professionals in the health care unit was associated with psychotropic polypharmacy. However, other correlates such as inpatient care, use of non-psychotropic drugs, living in unstable conditions and current smoking vary among them. Psychotropic polypharmacy was a common practice in this national sample. The results highlighted the need for national guidelines to manage patients with mental illness, considering the difference among genders and disease severity, to reduce the burden of polyphamacy in this population.

Antipsychotic Medication Prescribing Practices Among Adult Patients Discharged From State Psychiatric Inpatient Hospitals

OBJECTIVES

The goal of this study was to explore antipsychotic medication prescribing practices in a sample of 86,034 patients discharged from state psychiatric inpatient hospitals and to find the prevalence of patients discharged with no antipsychotic medications, on antipsychotic monotherapy, and on antipsychotic polypharmacy. For patients discharged on antipsychotic polypharmacy, the study explored the adjusted rates of antipsychotic polypharmacy, the reasons patients were discharged on antipsychotic polypharmacy, the proportion of antipsychotic polypharmacy by mental health disorder, and the characteristics associated with being discharged on antipsychotic polypharmacy.

METHODS

This cross-sectional study analyzed all discharges for adult patients (18 to 64 y of age) from state psychiatric inpatient hospitals between January 1 and December 31, 2011. The relationship among variables was explored using χ, t test, and analysis of variance. Logistic regression was used to determine predictors of antipsychotic polypharmacy.

RESULTS

The prevalence of antipsychotic polypharmacy was 12%. Of the discharged patients receiving at least 1 antipsychotic medication (adjusted rate), 18% were on antipsychotic polypharmacy. The strongest predictors of antipsychotic polypharmacy being prescribed were having a diagnosis of schizophrenia and a length of stay of 90 days or more. Patients were prescribed antipsychotic polypharmacy primarily to reduce their symptoms.

CONCLUSIONS

Antipsychotic polypharmacy continues at a high enough rate to affect nearly 10,000 patients with a diagnosis of schizophrenia each year in state psychiatric inpatient hospitals. Further analysis of the clinical presentation of these patients may highlight particular aspects of the illness and its previous treatment that are contributing to practices outside the best-practice guideline. An increased understanding of trend data, patient characteristics, and national benchmarks provides an opportunity for decision-making that is sensitive to the patient's needs and cognizant of the hospital's accomplishments in adopting best practices.

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.

Prevalence and clinical features associated with bipolar disorder polypharmacy: a systematic review

BACKGROUND

Uncertainty exists regarding the prevalence and clinical features associated with the practice of polypharmacy in bipolar disorder (BD), warranting a systematic review on the matter.

METHODS

Three authors independently searched major electronic databases from inception till September 2015. Articles were included that reported either qualitative or quantitative data about the prevalence and clinical features associated with polypharmacy in adult cases of BD.

RESULTS

The operative definitions of polypharmacy adopted across varying studies varied, with concomitant use of two or more psychotropic medications or use of four or more psychotropic medications at once being the most common and the most reliable, respectively. Regardless of type or current mood episode polarity of BD, prevalence rates up to 85% and 36% were found using the most permissive (two or more medications at once) and the most conservative (four or more) operative definitions for polypharmacy, respectively. Point prevalence prescription rates of one or more antidepressant or antipsychotic as part of a polypharmacy regimen occurred in up to 45% or 80% of the cases, respectively, according to the most permissive definition of polypharmacy. In contrast, lithium prescription rates ranged from 13% to 33% in BD patients receiving polypharmacy according to conservative and permissive definitions, possibly suggesting a reduced need for augmentation of combination strategies for those cases of BD with a favorable lifetime lithium response and/or long-lasting treatment as well as less likelihood of lithium response over the time most severe cases possibly exposed to a more complex polypharmacy overall.

LIMITATIONS

"Apples and oranges" bias; publication bias for most recently introduced compounds.

CONCLUSION

Polypharmacy is common among people with BD across varying type and mood episode phases of illness. Special population, including BD patients at high risk of familial load for suicidal behavior, solicit further research as well as the plausible "protective" role of lithium toward polypharmacy in BD. The PROSPERO registration number is CRD42014015084.

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.

The use of complementary and alternative medicine in adults with depressive disorders. A critical integrative review

BACKGROUND

Depression has been identified as one of the most frequent indications for CAM use and is a strong predictor of CAM use. The present article provides a critical review of CAM use for depressive disorders including bipolar depression by addressing prevalence of CAM use and CAM users׳ characteristics, motivation, decision-making and communication with healthcare providers.

METHODS

A comprehensive search of 2003-2014 international literature in the Medline, CINAHL, AMED, and SCOPUS databases was conducted. The search was confined to peer-reviewed articles published in English with abstracts and reporting new empirical research findings regarding CAM use and depressive disorders.

RESULTS

A considerable level of CAM use was observed among both general and clinical populations of people suffering from depressive disorders, many of whom use CAM concurrently with their conventional medicine. In particular, high rates of CAM use were found among those with bipolar disorder, an illness known to cause substantial impairments in health-related quality of life. Concomitant prescription medication use ranged from 0.52% to as high as 100%.

LIMITATIONS

Study design such as the inclusion of bipolar and depression in the same diagnostic category hamper the differentiation and attribution of CAM usage for symptoms.

CONCLUSION

Findings of our review show that enduring impairments in function and persistence of symptoms (as reflected by increased CAM use proportional to severity of illness and comorbidity) are the impetus for sufferers of depressive illness to seek out CAM. The psychosocial factors associated with CAM use in depressive illnesses and severe mental illness are yet to be established. Subsequent research amongst those with depressive disorders would be informative in clarifying the range of motivations associated with mental illness.

[Maintenance Treatment With Antipsychotics for Adult Patients Diagnosed With Schizophrenia]

OBJECTIVES

To determine the effectiveness and security of the antipsychotics available for the management of adult patients with schizophrenia in the maintenance phase. To develop recommendations of treatment for the maintenance phase of the disease.

METHODS

A clinical practice guideline was elaborated under the parameters of the Methodological Guide of the Ministerio de Salud y Protección Social to identify, synthesize and evaluate the evidence and make recommendations about the treatment and follow-up of adult patients with schizophrenia. The evidence of NICE guide 82 was adopted and updated. The evidence was presented to the Guideline Developing Group and recommendations, employing the GRADE system, were produced.

RESULTS

18 studies were included to evaluate the effectiveness and / or safety of different antipsychotic drugs first and second generation. Overall, antipsychotics (AP) showed superiority over placebo in relapse rate over 12 months (RR 0.59 95% CI 0.42, 0.82) and hospitalization rate over 24 months of follow-up (RR 0.38 95% 0.27, 0.55); its use is associated with increased risk of treatment dropout (RR 0.53 95% CI 0.46, 0.61) and adverse events such as weight gain, dystonia, extrapyramidal symptoms and sedation. There was no difference in the outcome of re hospitalizations, comparisons on quality of life, negative symptoms or weight gain between AP first and second generation. Continuous or standard dose regimens appear to be superior to intermittent or low doses in reducing the risk of abandonment of treatment regimes.

CONCLUSION

Adult patients diagnosed with schizophrenia should receive maintenance treatment with antipsychotics. The medication of choice will depend on the management of the acute phase, the patient's tolerance to it and the presentation of adverse events.

Predictors of concomitant use of antipsychotics and stimulants and its impact on stimulant persistence in pediatric attention deficit hyperactivity disorder

BACKGROUND

Concomitant use of stimulants and atypical antipsychotics is common in pediatric attention deficit hyperactivity disorder (ADHD). However, little is known about the determinants of concomitant use and its utility in the management of pediatric ADHD.

OBJECTIVES

To (a) examine predictors of concomitant stimulant and atypical antipsychotic use and (b) evaluate the impact of concomitant atypical antipsychotic use on the persistence of stimulants in children and adolescents diagnosed with ADHD.

METHODS

The retrospective cohort study was conducted using 4 years (January 2004-December 2007) of IMS LifeLink claims data. The study population included children and adolescents aged 6-16 years with a diagnosis of ADHD and those who initiated long-acting stimulants (LAS) from July 2004 to December 2006. Patients were followed for 1 year after index stimulant use. Concomitant use was defined as the concurrent prescription for LAS and atypical antipsychotic agents with at least 14 days overlap after the index LAS claim. Persistence was measured by summing the total number of days a patient remained on the index LAS from the index prescription date with an allowable gap of no more than 30 days. Multiple logistic regression within the conceptual framework of the Andersen Behavioral Model was performed to determine the predictors of concomitant stimulant and atypical antipsychotic use. Multivariate Cox proportional hazards regression within the conceptual framework of the Andersen Behavioral Model was used to examine the impact of concomitant atypical antipsychotic use on persistence of stimulants.

RESULTS

The study cohort consisted of 39,981 children who initiated LAS treatment. Most (96.10%) received LAS monotherapy, and 3.90% received LAS and atypical antipsychotic concomitantly. The multiple logistic regression analysis found that gender, health insurance, region, year of cohort entry, season, physician specialty, coexisting mental health conditions, and general mental health status influenced the concomitant use of LAS and atypical antipsychotic agents. Bivariate analyses revealed that concomitant users had longer persistence (by 71 days) than the stimulant-alone users. Cox proportional hazards regression revealed that concomitant atypical antipsychotic was associated with improvement in LAS persistence by 15% (HR = 0.85, 95% CI = 0.76-0.94) in comparison with the LAS recipients who did not use atypical antipsychotic concomitantly. Other factors such as age, region, season, coexisting mental health conditions, use of comedications, and general mental health status influenced the LAS treatment persistence among children and adolescents.

CONCLUSIONS

Various predisposing, enabling, and need factors were associated with the concomitant stimulant and atypical antipsychotic use. Concomitant use of atypical antipsychotics was associated with improved LAS treatment persistence in children and adolescents with ADHD.

Antipsychotic polypharmacy among elderly patients with schizophrenia and dementia during hospitalization at a Taiwanese psychiatric hospital

BACKGROUND

This study was to investigate the prescribing patterns for antipsychotic drugs in elderly hospitalized patients with a diagnosis of schizophrenia or dementia at a psychiatric hospital in Taiwan from 2007 to 2012. This study also explored the predictors of antipsychotic polypharmacy (APP).

METHODS

We collected patients' demographic data, including year of admission, age, gender, and length of hospital stay, and drug-related information.

RESULTS

Second-generation antipsychotic (SGA) monotherapy was the most common type of therapy in both those with dementia and with schizophrenia, and quetiapine and risperidone were the most commonly prescribed drugs for these conditions, respectively. In late-life schizophrenia, 33.8% of the patients used first-generation antipsychotics (FGA) alone. Regarding APP, a combination of FGA and SGA and combinations of SGA were most commonly noted in schizophrenia patients and dementia patients, respectively. Overall, APP increased from 2007 to 2012. It was significantly more common in patients with dementia (odds ratio: 3.49, 95% confidence interval: 1.29-9.39, P = 0.014), less concurrent use of hypnotics and sedatives (odds ratio: 0.41, 95% confidence interval: 0.17-0.99, P = 0.046), and a higher-than-recommended dose of antipsychotic drugs (odds ratio: 4.98, 95% confidence interval: 2.75-9.02, P < 0.001).

CONCLUSIONS

FGA are still commonly used for the late-life schizophrenia at our hospital. Given their potentially hazardous side effects, FGA must be employed with caution. The use of APP involving SGA increased over the 6 years of the study period, especially among patients with dementia. However, the use of SGA in dementia began to decline after the US Food and Drug Administration's 2005 warning about SGA being associated with increased mortality in dementia patients, which contrasts with the trends examined in this study. Further controlled trials exploring the efficacy, safety, and tolerability of APP in this population are warranted to gain an additional insight into this practice.

Antipsychotic polypharmacy in schizophrenia patients in China and its association with treatment satisfaction and quality of life: findings of the third national survey on use of psychotropic medications in China

OBJECTIVE

This study examined the use, demographic and clinical correlates of antipsychotic polypharmacy (APP) and its associations with treatment satisfaction and quality of life (QOL) in schizophrenia patients in China.

METHOD

A total of 4239 patients in 45 nationwide Chinese psychiatric hospitals/centers were interviewed in 2012 in the third cross-sectional study, with the first two having been conducted in 2002 and 2006. Patients' socio-demographic and clinical characteristics, including psychopathology, side effects, satisfaction with treatment and QOL, were recorded using a standardized protocol and data collection procedure.

RESULTS

The proportion of APP prescriptions in 2012 was 34.2%, which was significantly higher than the frequency of APP in 2002 (26.1%) and 2006 (26.4%) (p<0.001). Of patients on APP, 91.1% received two antipsychotics, 8.6% received three and 0.3% received four or more antipsychotics. Multiple logistic regression analyses revealed that compared to those on antipsychotic monotherapy, patients on APP and their families had lower satisfaction with treatment, had higher QOL in the mental domain, younger age of onset, more side effects, higher doses of antipsychotics and were more likely to receive first-generation antipsychotics and less likely to receive benzodiazepines (total R (2)=0.31, p<0.001).

CONCLUSIONS

APP was found in about one in three schizophrenia patients. The prevalence of APP seems to have been increasing since 2002. Considering the increased frequency of drug-induced side effects and the patients' and their relatives' dissatisfaction with antipsychotic treatment, further examination of the rationale and appropriateness of APP and its alternatives is warranted.

Antipsychotic polypharmacy in children and adolescents at discharge from psychiatric hospitalization

STUDY OBJECTIVE

Antipsychotic polypharmacy-the use of more than one antipsychotic concomitantly-has increased in children and adolescents and may be associated with increased adverse effects, nonadherence, and greater costs. Thus, we sought to examine the demographic and clinical characteristics of psychiatrically hospitalized children and adolescents who were prescribed antipsychotic polypharmacy and to identify predictors of this prescribing pattern.

DESIGN

Retrospective medical record review.

SETTING

The inpatient psychiatric unit of a large, acute care, urban children's hospital.

PATIENTS

One thousand four hundred twenty-seven children and adolescents who were consecutively admitted and discharged between September 2010 and May 2011.

MEASUREMENTS AND MAIN RESULTS

At discharge, 840 (58.9%) of the 1427 patients were prescribed one or more antipsychotics, and 99.3% of these received second-generation antipsychotics. Of these 840 patients, 724 (86.2%) were treated with antipsychotic monotherapy, and 116 (13.8%) were treated with antipsychotic polypharmacy. Positive correlations with antipsychotic polypharmacy were observed for placement or custody outside the biological family; a greater number of previous psychiatric admissions; longer hospitalizations; admission for violence/aggression or psychosis; and intellectual disability, psychotic, disruptive behavior, or developmental disorder diagnoses. Negative correlations with antipsychotic polypharmacy included admission for suicidal ideation/attempt or depression, and mood disorder diagnoses. Significant predictors of antipsychotic polypharmacy included admission for violence or aggression (odds ratio [OR] 2.76 [95% confidence interval (CI) 1.36-5.61]), greater number of previous admissions (OR 1.21 [95% CI 1.10-1.33]), and longer hospitalizations (OR 1.08 [95% CI 1.04-1.12]). In addition, diagnoses of intellectual disability (OR 2.62 [95% CI 1.52-4.52]), psychotic disorders (OR 5.60 [95% CI 2.29-13.68]), and developmental disorders (OR 3.18 [95% CI 1.78-5.65]) were predictors of antipsychotic polypharmacy.

CONCLUSION

Certain youth may have a higher likelihood of being prescribed antipsychotic polypharmacy, which should prompt careful consideration of medication treatment options during inpatient hospitalization. Future examinations of the rationale for combining antipsychotics, along with the long-term safety, tolerability, and cost effectiveness of these therapies, in youth are urgently needed.

Critical review of antipsychotic polypharmacy in the treatment of schizophrenia

Antipsychotic polypharmacy remains prevalent; it has probably increased for the treatment of schizophrenia in real-world clinical settings. The current evidence suggests some clinical benefits of antipsychotic polypharmacy, such as better symptom control with clozapine plus another antipsychotic, and a reversal of metabolic side-effects with a concomitant use of aripiprazole. On the other hand, the interpretation of findings in the literature should be made conservatively in light of the paucity of good studies and potentially serious side-effects. Also, although the available data are still limited, two smaller-scale clinical trials provide preliminary evidence that converting antipsychotic polypharmacy to monotherapy could be a valid and reasonable treatment option. Several studies have explored strategies to change physicians' antipsychotic polypharmacy prescribing behaviours. These have revealed that, while the impact of purely educational interventions may be limited, more aggressive procedures such as directly notifying physicians by letters or phone calls can be more effective in reducing antipsychotic polypharmacy. In conclusion, antipsychotic polypharmacy can work for some clinically difficult conditions; however, it should be the exception rather than the rule and may be avoidable in many patients. More importantly, the paucity of the data clearly emphasizes the need for further investigations on not only advantages and disadvantages of antipsychotic polypharmacy, but also regarding effective interventions in already prescribed polypharmacy regimens.

Prevalence and correlates of antipsychotic polypharmacy in children and adolescents receiving antipsychotic treatment

Antipsychotic polypharmacy (APP), which is common in adults with psychotic disorders, is of unproven efficacy and raises safety concerns. Although youth are increasingly prescribed antipsychotics, little is known about APP in this population. We performed a systematic PubMed search (last update 26 January 2013) of studies reporting the prevalence of APP in antipsychotic-treated youth. Summary statistics and statistical tests were calculated at the study level and not weighted by sample size. Fifteen studies (n = 58 041, range 68-23 183) reported on APP in youth [mean age = 13.4 ± 1.7 yr, 67.1 ± 10.2% male, 77.9 ± 27.4% treated with second-generation antipsychotics (SGAs)]. Data collected in these studies covered 1993-2008. The most common diagnoses were attention-deficit hyperactivity disorder (ADHD; 39.9 ± 23.5%) and conduct disorder/oppositional defiant disorder (CD/ODD; 33.6 ± 24.8). In studies including predominantly children (mean age = <13 yr, N = 5), the most common diagnosis were ADHD (50.6 ± 25.4%) and CD/ODD (39.5 ± 27.5%); while in studies with predominantly adolescents (mean age = ⩾13 yr, N = 7) the most common diagnoses were schizophrenia-spectrum disorders (28.6 ± 23.8%), anxiety disorders (26.9 ± 14.9%) and bipolar-spectrum disorders (26.6 ± 7.0%), followed closely by CD/ODD (25.8 ± 17.7). The prevalence of APP among antipsychotic-treated youth was 9.6 ± 7.2% (5.9 ± 4.5% in child studies, 12.0 ± 7.9% in adolescent studies, p = 0.15). Higher prevalence of APP was correlated with a bipolar disorder or schizophrenia diagnosis (p = 0.019) and APP involving SGA+SGA combinations (p = 0.0027). No correlation was found with APP definition [⩾1 d (N = 10) vs. >30-⩾90 d (N = 5), p = 0.88]. Despite lacking safety and efficacy data, APP in youth is not uncommon, even in samples predominantly consisting of non-psychotic patients. The duration, clinical motivations and effectiveness of this practice require further study.

Validation of a claims-based antipsychotic polypharmacy measure

Purpose Given the metabolic and neurologic side effects of antipsychotics and concerns about the increased risks associated with concomitant use, antipsychotic polypharmacy is a quality concern. This study assessed the operating characteristics of a Medicaid claims-based measure of antipsychotic polypharmacy. Methods A random sample from 10 public mental health clinics and 312 patients met criteria for this study. Medical record extractors were blind to measure status. We examined the prevalence, sensitivity, specificity, and positive predictive value (PPV) in Medicaid claims, testing nine different definitions of antipsychotic polypharmacy, including >14, >60, or >90 days concurrent use of ≥2 antipsychotic agents, each with allowable gaps of up to 0, 14, or 32 days in days' supply of antipsychotic medications. Results All Medicaid claims measure definitions tested had excellent specificity and PPV (>91%). Good to excellent sensitivity was dependent upon use of a 32-day gap allowance, particularly as duration of concurrent antipsychotic use increased. The proposed claims-based measure (90-day concurrent use of ≥2 or more antipsychotics, allowing for a 32-day gap) had excellent specificity (99.1%, 95%CI: 98.2-99.6) and PPV (90.9%, 95%CI: 83.1-95.7) with good sensitivity (79.4%, 95%CI: 70.4-86.6). The overall level of concordance between claims and medical record-based categorization of antipsychotic polypharmacy was high (96.4%, n = 301/312 clients, Cohen's K = 84.7, 95%CI: 75.9-93.5). Discrepant cases were reviewed, and implications are discussed. Conclusions Administrative claims data can be used to construct valid measures of antipsychotic polypharmacy.

Lessons learned from our elders: how to study polypharmacy in populations with intellectual and developmental disabilities

Polypharmacy is the concurrent use of multiple medications, including both psychotropic and non-psychotropic drugs. Although it may sometimes be clinically indicated, polypharmacy can have a number of negative consequences, including medication nonadherence, adverse drug reactions, and undesirable drug-drug interactions. The objective of this paper was to gain a better understanding of how to study polypharmacy among people with intellectual and developmental disabilities (IDD). To do this, we reviewed literature on polypharmacy among the elderly and people with IDD to inform future research approaches and methods on polypharmacy in people with IDD. Results identified significant variability in methods used to study polypharmacy, including definitions of polypharmacy, samples studied, analytic strategies, and variables included in the analyses. Four valuable methodological lessons to strengthen future polypharmacy research in individuals with IDD emerged. These included the use of consistent definitions of polypharmacy, the implementation of population-based sampling strategies, the development of clinical guidelines, and the importance of studying associated variables.

Diffusion of antipsychotics in the US And French markets, 1998-2008

OBJECTIVE

Second-generation antipsychotics captured most of the U.S. antipsychotic market shortly after their introduction. Little is known about how second-generation antipsychotics have diffused in other countries with different health systems. The study objective was to describe trends in antipsychotic use in the United States and France from 1998 to 2008.

METHODS

Pharmaceutical policies in France and the United States are briefly described, followed by descriptive data on quarterly prescriptions for oral antipsychotics dispensed between January 1998 and September 2008. Data are from Xponent for the United States and the GERS database for France. Trends in the use of first- versus second-generation antipsychotics and in ingredient formulations of second-generation antipsychotics used are reported.

RESULTS

Between 1998 and 2008, total antipsychotic use in the United States increased by 78%. Total use in France was consistently higher despite a 9% decrease during the period. By 2008, second-generation antipsychotics represented 86% of the antipsychotics sold in the U.S. market, versus only 40% of the French market. However, average annual growth rates in use of second-generation antipsychotics were similar in the two countries. In France, use of all but one second-generation antipsychotic steadily increased, whereas in the United States trends in the use of newer drugs varied substantially by drug. For example, use of olanzapine decreased after 2003, but use of quetiapine increased.

CONCLUSIONS

These results highlight markedly divergent trends in the diffusion of new antipsychotics in France and the United States. Some differences may be explained by differences in health systems; others may reflect physicians' preferences and norms of practice.

Improving psychotherapeutic medication prescribing in Florida: implementation of the Florida Medicaid Drug Therapy Management Program (MDTMP)

This paper describes a program that was established by Florida Medicaid to improve the quality of prescribing of psychotherapeutic medications. It relates the process used for defining quality medication treatment including the definitions of unusual psychotherapeutic medication indicators (UPMI). It details the results of analysis of FY 2007-2008 pharmacy claims data using these indicators that enabled the Program to identify practices and prescribers that required targeted interventions. The most frequently triggered UPMI for adults involved the use of 2 or more antipsychotics for greater than 60 days; high doses of psychotherapeutic medications was the indicator most frequently triggered for children closely followed by the use of 2 or more antipsychotics for more than 45 days. Prescriptions that triggered UPMI were concentrated in a small number of prescribers. These results led to the Program focusing on these high frequency practices and on the prescribers most associated with them. They also led to the implementation of new quality improvement initiatives like the implementation of a psychiatric telephone consultation line for pediatricians who are treating children with serious emotional disturbances who do not have access to child psychiatrists.

Pharmacological augmentation strategies for schizophrenia patients with insufficient response to clozapine: a quantitative literature review

BACKGROUND

When schizophrenia patients have insufficient response to clozapine, pharmacological augmentation is often applied. This meta-analysis summarizes available evidence on efficacy of pharmacological augmentation of clozapine treatment in schizophrenia spectrum disorder.

METHODS

Only double-blind randomized controlled studies were included. Primary outcome measure was total symptom severity, and secondary outcome measures were subscores for positive and negative symptoms. Effect sizes were calculated from individual studies and combined to standardized mean differences (Hedges's g).

RESULTS

Twenty-nine studies reporting on 15 different augmentations were included. Significant better efficacy than placebo on total symptom severity was observed for lamotrigine, citalopram, sulpiride, and CX516 (a glutamatergic agonist). The positive effect of lamotrigine disappeared after outlier removal. The other positive findings were based on single studies. Significantly better efficacy on positive symptom severity was observed for topiramate and sulpiride. The effect of topiramate disappeared after outlier removal. Results for sulpiride were based on a single randomized controlled trial. Citalopram, sulpiride, and CX516 showed better efficacy for negative symptoms than placebo, all based on single studies.

CONCLUSIONS

Evidence for efficacy of clozapine augmentation is currently scarce. Efficacy of lamotrigine and topiramate were both dependent on single studies with deviating findings. The effect of citalopram, sulpiride, and CX516 were based on single studies. Thus, despite their popularity, pharmacological augmentations of clozapine are not (yet) demonstrated to be superior to placebo.

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.

[Eligibility of schizophrenia inpatients to participate in clinical trials]

INTRODUCTION

This study assesses the potential eligibility of patients admitted to a psychiatric hospitalisation unit to take part in the major clinical trials based on schizophrenia treatment in clinical practice (CATIE, CUtLASS and EUFEST).

MATERIAL AND METHODS

A retrospective evaluation by consulting the medical records of 241 subjects (59.8% males and 40.2% females, mean age 39.7±13.0 years), admitted consecutively over one year to psychiatric hospitalisation unit with a diagnosis of schizophrenia or another psychosis. The influence of the factors involved in the non-eligibility in each of the clinical trials is analysed using logistic regression analysis.

RESULTS

Only 20.7%, 22.3%, and 22.5% of patients with schizophrenia or another psychosis would be eligible to participate in the CATIE, CUtLASS and EUFEST studies, respectively. The main factors involved in the non-eligibility were polytherapy with anti-psychotics (2 or more) (Odds Ratio (OR): 7.64, 95% confidence interval (CI): 3.06-19.06, P<.001), mental retardation (OR: 16.67, 95% CI: 1.75-166.67, P=.014), and resistance, intolerance or contraindication to any of the anti-psychotics of the study (OR: 3.68, 95% CI: 1.13-11.99, P=.030).

CONCLUSIONS

Three out of every four patients with schizophrenia or another psychosis admitted to a psychiatric hospitalisation unit are not represented in the major clinical trials on schizophrenia treatment.

Prevalence and correlates of antipsychotic polypharmacy: a systematic review and meta-regression of global and regional trends from the 1970s to 2009

OBJECTIVE

To assess the prevalence and correlates of antipsychotic polypharmacy (APP) across decades and regions.

METHODS

Electronic PubMed/Google Scholar search for studies reporting on APP, published from 1970 to 05/2009. Median rates and interquartile ranges (IQR) were calculated and compared using non-parametric tests. Demographic and clinical variables were tested as correlates of APP in bivariate and meta-regression analyses.

RESULTS

Across 147 studies (1,418,163 participants, 82.9% diagnosed with schizophrenia [IQR=42-100%]), the median APP rate was 19.6% (IQR=12.9-35.0%). Most common combinations included first-generation antipsychotics (FGAs)+second-generation antipsychotics (SGAs) (42.4%, IQR=0.0-71.4%) followed by FGAs+FGAs (19.6%, IQR=0.0-100%) and SGAs+SGAs (1.8%, IQR=0.0-28%). APP rates were not different between decades (1970-1979:28.8%, IQR=7.5-44%; 1980-1989:17.6%, IQR=10.8-38.2; 1990-1999:22.0%, IQR=11-40; 2000-2009:19.2% IQR=14.4-29.9, p=0.78), but between regions, being higher in Asia and Europe than North America, and in Asia than Oceania (p<0.001). APP increased numerically by 34% in North America from the 1980s 12.7%) to 2000s (17.0%) (p=0.94) and decreased significantly by 65% from 1980 (55.5%) to 2000 (19.2%) in Asia (p=0.03), with non-significant changes in Europe. APP was associated with inpatient status (p<0.001), use of FGAs (p<0.0001) and anticholinergics (<0.001), schizophrenia (p=0.01), less antidepressant use (p=0.02), greater LAIs use (p=0.04), shorter follow-up (p=0.001) and cross-sectional vs. longitudinal study design (p=0.03). In a meta-regression, inpatient status (p<0.0001), FGA use (0.046), and schizophrenia diagnosis (p=0.004) independently predicted APP (N=66, R(2)=0.44, p<0.0001).

CONCLUSIONS

APP is common with different rates and time trends by region over the last four decades. APP is associated with greater anticholinergic requirement, shorter observation time, greater illness severity and lower antidepressant use.

Antipsychotic polypharmacy in a regional health service: a population-based study

BACKGROUND

To analyse the extent and profile of outpatient regular dispensation of antipsychotics, both in combination and monotherapy, in the Barcelona Health Region (Spain), focusing on the use of clozapine and long-acting injections (LAI).

METHODS

Antipsychotic drugs dispensed for people older than 18 and processed by the Catalan Health Service during 2007 were retrospectively reviewed. First and second generation antipsychotic drugs (FGA and SGA) from the Anatomical Therapeutic Chemical classification (ATC) code N05A (except lithium) were included. A patient selection algorithm was designed to identify prescriptions regularly dispensed. Variables included were age, gender, antipsychotic type, route of administration and number of packages dispensed.

RESULTS

A total of 117,811 patients were given any antipsychotic, of whom 71,004 regularly received such drugs. Among the latter, 9,855 (13.9%) corresponded to an antipsychotic combination, 47,386 (66.7%) to monotherapy and 13,763 (19.4%) to unspecified combinations. Of the patients given antipsychotics in association, 58% were men. Olanzapine (37.1%) and oral risperidone (36.4%) were the most common dispensations. Analysis of the patients dispensed two antipsychotics (57.8%) revealed 198 different combinations, the most frequent being the association of FGA and SGA (62.0%). Clozapine was dispensed to 2.3% of patients. Of those who were receiving antipsychotics in combination, 6.6% were given clozapine, being clozapine plus amisulpride the most frequent association (22.8%). A total of 3.800 patients (5.4%) were given LAI antipsychotics, and 2.662 of these (70.1%) were in combination. Risperidone was the most widely used LAI.

CONCLUSIONS

The scant evidence available regarding the efficacy of combining different antipsychotics contrasts with the high number and variety of combinations prescribed to outpatients, as well as with the limited use of clozapine.

Payer types associated with antipsychotic polypharmacy in an ambulatory care setting

Objectives

Antipsychotic polypharmacy is increasingly prescribed despite little documented evidence of a therapeutic benefit. There is also a limited understanding of the role that health insurance plays on the prevalence of antipsychotic polypharmacy. This study was undertaken to investigate the relationship between antipsychotic polypharmacy and individuals' intended source of payment in a US national sample of ambulatory care patients.

Methods

The study combined 2002, 2003 and 2004 data from the National Ambulatory Medical Care Survey (NAMCS) among adults seeking outpatient-based physician medical care services in the USA. We investigated characteristic differences among patients who were prescribed multiple antipsychotics versus individuals receiving only a single antipsychotic medication. Multivariable logistic regression examined the association between antipsychotic polypharmacy and patients' primary payment type classified as private insurance, Medicaid, Medicare or other (primarily out-of-pocket) payment type.

Key findings

Use of more than one antipsychotic agent was recorded in 68 of 830 (8.2%) outpatient physician visits in the 3-year period 2002–2004. Among the payer types studied, Medicaid payment status was correlated with increased risk of antipsychotic polypharmacy (odds ratio 2.7, 95% confidence interval 1.1–6.7).

Conclusions

Insurance status was associated with antipsychotic polypharmacy among non-institutionalized US residents prescribed antipsychotic medications. Patients reporting Medicaid as their primary payer were nearly three times as likely to be prescribed multiple antipsychotic drugs, potentially increasing their risk of adverse side effects as well as greater taxpayer burden. Future research should determine whether these trends continued after 2004 and to determine the costs of treating patients in the public sector with multiple antipsychotic drugs, a common scenario despite financial pressures and uncertain medical benefit.

Rates of 5 common antidepressant side effects among new adult and adolescent cases of depression: a retrospective US claims study

BACKGROUND

Antidepressants are the first-line treatment for depression, yet medication-related side effects may be associated with antidepressant discontinuation before reaching a period of exposure believed to result in effectiveness. There is a gap in knowledge of the prevalence of side effects across commonly prescribed antidepressants and the effect of the type of antidepressant on the likelihood of side effects in real-world clinical practice.

OBJECTIVE

The aim of this study was to estimate and compare the prevalence of headaches, nausea or vomiting, agitation, sedation, and sexual dysfunction among patients diagnosed with depression who initiated monotherapy across different classes of antidepressants and to estimate the effect of the type of antidepressant on the likelihood of each of the 5 side effects.

METHODS

A retrospective cohort of patients aged ≥13 who were newly diagnosed with depression and began antidepressant monotherapy was created using LifeLink managed care claims from 1998 to 2008. Antidepressant groups included selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), bupropion, phenylpiperazine, and tetracyclic antidepressants. Prevalence of headache, nausea or vomiting, agitation, sedation, and sexual dysfunction were compared across antidepressant groups. Propensity-adjusted Cox proportional hazards regression was used to estimate the likelihood of each of the 5 side effects for each antidepressant group compared with SSRIs, adjusted for demographic, clinical, and treatment characteristics.

RESULTS

The study cohort included 40,017 patients (3617 adolescents, aged 13-18 years, and 36,400 adults, aged ≥19 years; mean age = 45 years; 67% female) with a new episode of depression who were initiated on antidepressant monotherapy within 30 days of diagnosis (SSRI [66%], bupropion [14%], SNRI [12%], other [8%]). The most common side effects were headache (up to 17/1000 person-months of therapy in adults and adolescents) and nausea (up to 7.2/1000 in adults, 9.3/1000 in adolescents). Relative to adults receiving SSRIs, adults receiving SNRIs had a higher risk of nausea (hazard ratio [HR] = 1.26; 95%CI,1.05-1.51). Adults (HR = 0.78; 95% CI, 0.62-0.96) and adolescents (HR = 0.43; 95% CI, 0.21-0.87) taking bupropion were less likely to experience headaches compared with adults and adolescents, respectively, taking an SSRI. Adolescents receiving a tetracyclic were more likely to experience headaches than adolescents receiving an SSRI (HR = 3.16; 95%CI, 1.13-8.84).

CONCLUSIONS

Prevalence and risk of the 5 side effects varied across types of antidepressants for both adults and adolescents. Results from this study were consistent with prior clinical trials, suggesting that variation in side effect profiles exists in a more generalized managed care population.

Antipsychotic polypharmacy among patients admitted to a geriatric psychiatry unit

OBJECTIVES

This study describes the prevalence of antipsychotic polypharmacy in patients admitted to a geriatric psychiatry unit, compares polypharmacy by psychiatric diagnosis, explores predictors of polypharmacy, and examines changes in antipsychotic polypharmacy from baseline to discharge.

METHODS

A retrospective examination was made of patients admitted to an inpatient geriatric psychiatry ward between 2006 and 2010. All patients with a diagnosis of schizophrenia, bipolar disorder, or dementia prescribed a regularly scheduled antipsychotic for at least 1 month prior to admission were included.

RESULTS

Of the 416 patients meeting selection criteria, nearly 13% were prescribed antipsychotic polypharmacy at the time of admission. Quetiapine was the antipsychotic most commonly involved in polypharmacy. By discharge, the rate of antipsychotic polypharmacy had decreased to 8% (X=4.74, df=1, p=0.03). Patients with a history of a severe mental illness were significantly more likely to have been prescribed antipsychotic polypharmacy compared with those with only a diagnosis of dementia (X=14.67, df=1, p=<0.001). Living situation and psychiatric diagnosis were significant predictors of antipsychotic polypharmacy.

CONCLUSION

Older adults admitted to a geriatric psychiatry ward on a scheduled antipsychotic were commonly prescribed more than one antipsychotic. This was most likely in patients living in a facility (e.g., assisted living, skilled nursing, long-term care) and in those patients with a severe mental illness. A better understanding of the efficacy and safety of antipsychotic polypharmacy in older adults, especially those with dementia, is necessary in order to use these medications rationally.

Trends in adult antipsychotic polypharmacy: progress and challenges in Florida's Medicaid program

We studied trends in antipsychotic polypharmacy over a 4 year period in order to see if a change occurred when a statewide quality improvement program aimed at reducing the practice was implemented. Antipsychotic polypharmacy prevalence rates were calculated for eight 6-month periods for enrollees with schizophrenia and schizoaffective disorder and for those with all other diagnoses. Prevalence increased from 1/2003 to 12/2004 and then declined for 4 successive 6 month periods beginning in the 1/2005-6/05 period when the program began. Piecewise linear regression results for both diagnostic groups confirmed that the change in the likelihood of antipsychotic polypharmacy during the four 6 month periods before program implementation were significantly different than during the four 6 month periods following implementation. While it is impossible to control for the effects of all variables in evaluating the impact of any system wide intervention the data suggest that the program did help to reduce the use of antipsychotic polypharmacy.

Evaluation of a multifaceted intervention to limit excessive antipsychotic co-prescribing in schizophrenia out-patients

OBJECTIVE

To evaluate the effect of a multifaceted educational intervention on the frequency of antipsychotic co-prescribing in adult schizophrenia out-patients.

METHOD

Controlled quasi-experimental study performed in two Danish municipalities matched for baseline prevalence of antipsychotic polypharmacy, socioeconomic status and functional level of patients. The intervention was aimed at psychiatric healthcare providers and consisted of 1 day of didactic lectures, six 3-h educational outreach visits and an electronic reminder during drug prescribing.

RESULTS

Between-group use of antipsychotic polypharmacy was compared at baseline (intervention group, N = 232/control group, N = 351) and after 1 year of intervention (intervention group, N = 216/control group, N = 386). The prevalence of antipsychotic polypharmacy at follow-up was not significantly different between treatment settings when adjusting for differences in case-mix (P = 0.07).

CONCLUSION

This multifaceted educational intervention failed to reduce the frequency of antipsychotic co-prescribing, but it suggested that future efforts to improve prescribing practice should address organizational barriers to implementation.

Utilization of herbal and nutritional compounds among older adults with bipolar disorder and with major depression

OBJECTIVES

Herbal and nutritional compounds (HNC) are widely used among geriatric populations with depression, however little data exists on HNC use in older populations with bipolar disorder. The goal of this study was to evaluate orally- ingested HNC use in individuals with bipolar disorder and with major depression.

METHODS

This was a cross-sectional analysis of self-reported factual knowledge of HNC, individual perspective on efficacy and safety of HNC, patterns of HNC use, and discussion of HNC with health care providers in 50 older adults with bipolar disorder and 50 older adults with major depression.

RESULTS

In this sample, approximately 30% of older individuals with depression or bipolar disorder used orally- ingested HNC. Over 40% of older adults believed that HNC is FDA-regulated and 14-20% preferred to take HNC compared to physician-prescribed psychotropic medications. Use of HNC was more common among older adults with bipolar disorder (44%) compared to older adults with major depression (16%, p = 0.003). The majority of older adults with mood disorders (64%) had not discussed use of HNC with their treating physicians.

CONCLUSION

Orally ingested HNC was used by nearly one in three older adults with mood disorders, and was more common among those with bipolar disorder compared to those with major depression. Most individuals did not discuss HNC use with their physicians. Clinicians need to assess for HNC use, particularly with respect to potential drug-drug interactions.

The prescribing pattern of a new antipsychotic: a descriptive study of aripiprazole for psychiatric in-patients

In June 2004, aripiprazole was marketed as a second-generation antipsychotic with an entire new mechanism of action. The objective of this descriptive study is to examine the day-to-day prescriptions of aripiprazole to an unselected population of psychiatric in-patients. From 1 February to 1 May 2006, present and former in-patients treated with aripiprazole were identified. Prescriptions of aripiprazole and psychoactive comedication were collected retrospectively from the patient records. Seventy-one patients, mainly schizophrenic, received aripiprazole 2.5 to 55 mg/day for median 350 days. The median average exposure was 18.9 mg/day (range 2.5-45 mg/day) and exceeded 15 and 30 mg/day in 63% and 4.2% of the patients, respectively. Generally, aripiprazole was either added to the existing antipsychotic treatment or replaced other antipsychotics; only 17% of the patients were treatment-naïve. In 25% aripiprazole, monotherapy was commenced whereas aripiprazole-antipsychotic combinations were initially prescribed in 75%. Overall, 85% of the patients received periods of antipsychotic polypharmacy and aripiprazole was combined with 17 different antipsychotics. Each patient received median three (range 0-8) psychoactive drugs parallel with aripiprazole. This study demonstrates reality in psychopharmacology and quote aripiprazole as example. In day-to-day practice, aripiprazole is used as part of highly individualized regimens comprising polypharmacy and excessive dosing. Although theoretically appropriate for some patients, this approach also implies conducting unblinded and uncontrolled mini-experiments. Sparse evidence supports this practice and effectiveness studies of aripiprazole that takes into account the true complexity of clinical prescribing are urgently needed.

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

BACKGROUND AND OBJECTIVES

The pharmacotherapy of psychosis often differs between countries and with respect to treatment guidelines. Little is known about the treatment of first episode psychosis in countries of the former Soviet Union. The objective of the study was to analyse and describe the pharmacotherapy of first episode psychosis in Estonia.

METHODS

Case notes for consecutive patients with schizophrenia, schizotypal or delusional disorders admitted to the psychiatry clinics of the North Estonia Regional Hospital (NERH) and Tartu University Hospital (TUH) between September 2005 and September 2006 were retrospectively reviewed by a trained researcher. Treatment regimens were assessed according to prescribed doses, the incidence of antipsychotic polypharmacy and prescribing of conventional vs. atypical agents.

RESULTS

There were 234 patients admitted to the NERH and TUH, 142 of which were included in the final analyses (mean age 30.3 years for males, 40.4 years for females). Patients were most frequently treated with risperidone (n = 94), olanzapine (n = 43), chlorpromazine (n = 31), haloperidol (n = 21) and quetiapine (n = 24). Fourteen patients received concurrent treatment with two or more antipsychotics for three or more treatment days. Nine patients received antipsychotics in doses exceeding the maximum recommended doses in the British National Formulary.

CONCLUSIONS

The pharmacotherapy of first episode psychosis in Estonia was largely consistent with Estonian and international guidelines, however, the use of conventional antipsychotics and antipsychotic polypharmacy remained common. Estonian treatment guidelines may need to be revised to reflect the best available research evidence.