The prevalence of antipsychotic polypharmacy in schizophrenic patients discharged from psychiatric units in Poland

Antipsychotic polypharmacy and associated factors among patients with schizophrenia: Multicenter cross-sectional study in Northwest Ethiopia

BACKGROUND

Antipsychotic polypharmacy (APP) remains common despite guideline recommendations to minimize combinations, except after repeated antipsychotic monotherapy trials. This study aimed to assess APP and its associated factors among schizophrenia patients at comprehensive specialized hospitals in Northwest Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 422 schizophrenia patients at selected hospitals in Ethiopia from June to August 2022. The data were collected using a semi-structured questionnaire. Study participants were enrolled using systematic random sampling. Data entry and analysis were done with Epi-data version 4.6.1 and SPSS version 24, respectively. APP was determined by reviewing the number of medications based on relevant evidence. A multivariable logistic regression model was fitted to identify APP factors. Variables with a p-value of < 0.05 at a 95% confidence interval were considered statistically significant.

RESULTS

From a total of 430 approached samples, 422 (98.1% response rate) eligible patients were included in the study. An overall APP prevalence was 22.7% (95% CI: 19-27). Duration of illness (AOR = 2.88; 95% CI: 1.49, 5.59); duration of treatment (AOR = 3.79; 95% CI: 1.05, 13.62); number of admissions (AOR = 4.93; 95% CI: 2.52, 9.64); and substance use (AOR = 2.58; 95% CI: 1.49, 4.47) were significantly associated with APP.

CONCLUSION AND RECOMMENDATION

In this study, APP was recorded in a considerable number of patients. Patients with a longer duration of illness and treatment, frequent admissions, and substance users need critical follow-up to minimize antipsychotic medication use.

Augmentation Therapies as Treatments for Coexisting Somatic Problems in Schizophrenia-A Systematic Review

The aim of this review is to appraise the data from available randomized clinical trials (RCT) regarding the possible combinations of neuroleptic and non-antipsychotic treatment which could enhance antipsychotic therapy efficacy whilst simultaneously addressing somatic symptoms in individuals with schizophrenia. A systematic search of the PubMed database up to February 2022 was conducted. Inclusion criteria: randomized controlled trials using augmentation therapy in chronic schizophrenia in adults, written in English, and only studies with psychometric assessments of schizophrenia were incorporated. Exclusion criteria: non-clinical, first episode of schizophrenia, patients on medication other than antipsychotics augmented, and not adjunctive therapy. Overall, 37 studies of 1931 patients with schizophrenia who received a combination of antipsychotic medication with other drugs were selected. A statistically significant reduction of negative and positive symptoms of schizophrenia, measured with the PANSS scale, when using a combination of antipsychotic treatment along with aspirin, simvastatin, N-acetylcysteine, or pioglitazone was found. A combination of antipsychotic medication with aspirin, simvastatin, N-acetylcysteine, or pioglitazone seems to be effective in the reduction of symptoms of schizophrenia in adults, but long-term studies are required to confirm this effect.

Real-world effectiveness of mood stabilizer use in schizophrenia

OBJECTIVE

Mood stabilizers (MS) are often used as adjunctive medication in patients with schizophrenia. The aim of this study was to investigate the real-world effectiveness of MS use in persons with schizophrenia.

METHODS

The study cohort included all persons treated in inpatient care due to schizophrenia during 1972-2014 in Finland (N = 61,889). Drug purchase data were obtained from the national Prescription register and modeled with the PRE2DUP method. The follow-up period covered the years 1996-2017. Mood stabilizers included carbamazepine, valproic acid, lamotrigine, and lithium. The main outcome was psychosis hospitalization. We utilized within-individual design to compare the risk of outcome between time-periods of MS use and non-use within the same person. Stratified Cox regression analyses were conducted with adjusted hazard ratios (aHR) and 95% confidence intervals (CIs).

RESULTS

Mean age at cohort entry was 46.2 years (SD 16.0) and 50.3% were male. During the follow-up (maximum of 22 years, median 14.8 years, interquartile range 7.5-22.0), 28.1% (N = 17,370) of the study cohort used MS, valproic acid being the most often used one (60.4%, N = 10,483). Risk of psychosis hospitalization was lower during MS use than non-use (aHR 0.88, 95% CI 0.86-0.90). Use of lithium (0.84, 0.81-0.87), valproic acid (0.87, 0.85-0.90), and lamotrigine (0.90, 0.85-0.95) were associated with lower risk of psychosis hospitalization compared with their non-use, whereas carbamazepine use was not.

CONCLUSIONS

Mood stabilizers were relatively often used as adjunctive treatments in schizophrenia and their use was associated with a 12% decreased risk of psychosis rehospitalization, a marker of relapse in schizophrenia.

Medication Gaps and Antipsychotic Polypharmacy in Previously Hospitalized Schizophrenia Patients: An Electronic Cohort Study in Three Canadian Provinces

BACKGROUND

Real world evidence about antipsychotics focuses on rehospitalization. Modeling the time course of pharmacotherapy would show patients' adherence to medications and physicians' adherence to medication guidelines. We aimed to calculate the cumulative time spent in second generation antipsychotics (SGAs), gaps, antipsychotic polypharmacy, and clozapine in discharged schizophrenia patients.

METHODS

Hospitalization and pharmacy dispensing data from 2008-2018 in Manitoba, Saskatchewan, and British Columbia were linked and an electronic cohort (N = 2,997) was created (mean follow-up: 49 months, SD = 38). Cohort members were required to have a minimum of 6 weeks medicated with aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone.

RESULTS

The multistate model predicted that schizophrenia patients accumulated 44 months in SGA monotherapy, 4 months in polypharmacy, 11 months in medication gaps and 17 days in clozapine over a 5-year period. The majority of transitions were between SGA and medication gap. Accumulated time in medication gaps was seven times as much as in clozapine. Each 10% delay in SGA initiation post-discharge was associated with a 2, 1, and 6% higher risk for polypharmacy (95% CI: 1.01-1.02), gap (95% CI: 1.01-1.01), and clozapine (95% CI: 1.04-1.08), respectively.

INTERPRETATION

Schizophrenia patients accumulated more time unmedicated and in polypharmacy compared to clozapine. Either treatment guidelines for schizophrenia are not followed, or real-world challenges hamper their implementation.

Frequency, reasons, and factors associated with antipsychotic polypharmacy in Schizophrenia: A retrospective chart review in a tertiary hospital in India

The practice of antipsychotic polypharmacy in schizophrenia appears to be common although evidence-based guidelines do not routinely recommend it. The reasons for polypharmacy are however unclear. The objective of the study was to assess the frequency of polypharmacy, reasons for initiation and the factors associated with it. A retrospective chart review of case records of all the patients diagnosed with schizophrenia at the department of psychiatry from January 2011 to December 2018 was done. Frequency of antipsychotic polypharmacy, reasons influencing it and factors associated with polypharmacy were extracted using a proforma. Of 529 patients diagnosed with schizophrenia, 232 patients (43.9 %) were receiving antipsychotic polypharmacy. Common reasons for polypharmacy included the usage of depot along with oral antipsychotic for a prolonged period (37.7 %), augmentation of response with the second antipsychotic (17.7 %) and treatment of a different symptom domain like negative symptoms (9.5 %). In comparison to monopharmacy, antipsychotic polypharmacy was more commonly associated with side effects and extrapyramidal symptoms. Patients on polypharmacy had a higher number of hospitalizations too. As the trend of antipsychotic polypharmacy is on the rise, it is important to assess for reasons influencing polypharmacy to avoid undesirable side effects. The side effect burden of polypharmacy is significantly more than those receiving single antipsychotics. Oral antipsychotics should ideally be discontinued after the depot antipsychotic reaches steady-state levels. Irrational usage of second antipsychotic to augment the response of first antipsychotic agent needs to be avoided.

Association between DRD2 and ANKK1 polymorphisms with the deficit syndrome in schizophrenia

BACKGROUND

The clinical course of schizophrenia varies among patients and is difficult to predict. Some patient populations present persistent negative symptoms, referred to as the deficit syndrome. Compared to relatives of non-deficit schizophrenia patients, family members of this patient population are at an increased risk of developing schizophrenia. Therefore, the aim of this study was to search for genetic underpinnings of the deficit syndrome in schizophrenia.

METHODS

Three SNPs, i.e., rs1799732 and rs6276 located within DRD2, and rs1800497 within ANKK1, were identified in the DNA samples of 198 schizophrenia probands, including 103 patients with deficit (DS) and 95 patients with non-deficit schizophrenia (NDS). Results: No significant differences concerning any of the analyzed polymorphisms were found between DS and NDS patients. However, significant links were observed between family history of schizophrenia and the deficit syndrome, G/G genotype and rs6276 G allele. In a separate analysis, we identified significant differences in frequencies of rs6276 G allele between DS and NDS patients with family history of schizophrenia. No significant associations were found between DRD2 and ANKK1 SNPs and the age of onset or schizophrenia symptom severity.

CONCLUSIONS

The results of our preliminary study fail to provide evidence of associations between DRD2 and ANKK1 polymorphisms with the deficit syndrome or schizophrenia symptom severity, but suggest potential links between rs6276 in DRD2 and the deficit syndrome in patients with hereditary susceptibility to schizophrenia. However, further studies are necessary to confirm this observation.

Hospitalization risk factors in antipsychotic-treated schizophrenia, bipolar I disorder or major depressive disorder

Aim: To examine hospitalization risk factors in antipsychotic-treated patients with schizophrenia, bipolar I disorder (BD-I) or major depressive disorder (MDD). Patients & methods: Using Truven Health MarketScan® Commercial, Medicaid and Medicare Supplemental data (01/01/2012–06/30/2016), logistic regression models were performed to identify risk factors for both psychiatric and all-cause hospitalization in three separate analyses. Results: Significant risk factors included prior hospitalization (schizophrenia: odds ratio [95% CI]: 2.83 [2.50–3.21; psychiatric]; 2.58 [2.31–2.87; all-cause]; BD-I: 2.42 [2.23–2.63]; 2.09 [1.96–2.23]; MDD: 2.81 [2.49–3.16]; 2.21 [2.03–2.40]), previous antipsychotic treatment (schizophrenia: 1.71 [1.52–1.93]; 1.31 [1.18–1.46]; BD-I: 1.33 [1.23–1.44]; 1.22 [1.14–1.30]; MDD: 1.31 (1.11–1.54); 1.17 (1.04–1.32) and substance abuse (schizophrenia: 1.42 [1.27–1.60]; 1.37 [1.23–1.53]; BD-I: 1.72 [1.58–1.86]; 1.61 [1.50–1.72]; MDD: 1.90 [1.68–2.15] and 1.55 [1.41–1.71]). Conclusion: Prior hospitalization, previous antipsychotic treatment and substance abuse were associated with increased hospitalization risk in schizophrenia, BD-I or MDD.

Metformin for Weight Gain Associated with Second-Generation Antipsychotics in Children and Adolescents: A Systematic Review and Meta-Analysis

BACKGROUND

Weight gain is a potentially concerning side effect of second-generation antipsychotics (SGAs). Metformin, a biguanide with antihyperglycemic effects, is used to manage weight gain in adults treated with SGAs.

OBJECTIVE

The objective of this study was to perform the first systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of metformin on weight gain in children and adolescents treated with SGAs.

METHODS

Based on a pre-registered protocol (PROSPERO-CRD42017074839), we searched the PubMed, EMBASE, PsychoINFO, BIOSIS, Science Direct, Cochrane Central, and ClinicalTrials.gov electronic databases through March 2018 (with no restrictions on language, date, or type of publication) for RCTs that assessed the effect of metformin or placebo on body weight in children or adolescents (< 18 years of age) treated with selected SGAs (risperidone, aripiprazole, olanzapine, and clozapine) for any psychiatric disorder. We also contacted relevant drug manufacturers for possible additional pertinent studies/data. A random effects model was used and the quality of the included RCTs was assessed using the Cochrane Risk of Bias tool.

RESULTS

Five RCTs (205 participants in total) were included in the meta-analysis. We found a significant weight decrease in the metformin group compared with placebo after 4, 12, and 16 weeks of treatment {mean difference - 0.98 kg (95% confidence interval [CI] - 1.26, - 0.69); - 1.83 kg (95% CI - 2.47, - 1.18); and - 3.23 kg (95% CI - 5.59, - 0.86), respectively}. A weight decrease at weeks 2 and 8 did not reach statistical significance. The decrease in body mass index (BMI) paralleled that of weight, with a significant effect at weeks 4, 12, and 16. Overall, four studies were rated as unclear, and one study was rated as high, risk of bias.

CONCLUSION

Meta-analytical evidence shows that metformin might decrease weight in children/adolescents treated with SGAs but additional high-quality evidence is needed. Clinicians need to be aware that this use of metformin is currently off-label.

Public health psychopharmacology: a new research discipline comes of age?

Research evidence guiding the identification of pragmatic and effective actions aimed at improving the selection, availability, affordability and rational prescribing of medicines for mental disorders is sparse and inconsistent. In order to boost the development of new research, in this commentary we suggest to organise and classify all the activities in this area under a common theoretical framework and nomenclature, adopting the term 'public health psychopharmacology'. Public health psychopharmacology is proposed as a research discipline, based on contributions from the fields of regulatory science, health services research and implementation science. Implementing the term public health psychopharmacology may offer advantages, as the scientific community would be more focused on common goals and objectives, with, likely, an increasing body of research evidence of practical use.

Implementation of a clinical practice guideline for schizophrenia in a specialist mental health center: an observational study

Background

In mental health settings, implementation of and adherence to clinical practice guidelines (CPGs) is low. Strategies are needed to overcome barriers and facilitate successful implementation of CPGs into standard care. The goals of this study were to develop a framework for the implementation of a CPG for schizophrenia for hospitalized service users in a mental health care facility, and to monitor adherence to the guideline.

Methods

An eight-step framework was developed based on project management principles: 1) the Appraisal Guideline for Research and Evaluation (AGREE) tool was used to rate and select a CPG; 2) an algorithm was created from the guideline; 3) a gap analysis identified clinical services and processes not conforming with the CPG recommendations; 4) a governance structure was created; 5) a modified Delphi process determined key outcome and process adherence metrics; 6) a project charter was developed; 7) clinical informatics ensured that systems and tools were in place to support the CPG; and 8) therapeutic services were realigned to match the requirements of the CPG within specified fiscal constraints. Percent adherence to the identified process adherence metrics was calculated before (March 2014) and for 12 months after implementation (April 2014-March 2015).

Results

The National Institute of Health and Care Excellence guideline scored highest on AGREE and was used to develop the algorithm. Cognitive behavior therapy for psychosis (CBT-P), art therapy and carer assessments were identified as gaps in care. Clinical global impression – Schizophrenia score was identified as the primary service user outcome variable and antipsychotic polypharmacy, metabolic monitoring, CBT-P referral and supported employment/vocational services referral as the primary process adherence measures. Adherence to guidance for metabolic monitoring (March 2014, 76.7 %; March 2015, 81.6 %), CBT-P referral (March 2014, 6.5 %; March 2015, 11.4 %) and vocational rehabilitation referral (March 2014, 36.6 %; March 2015, 49.1 %) were increased after CPG implementation. There was an initial increase in adherence to antipsychotic monotherapy (March 2014, 53.4 %; November 2014, 62.7 %), which decreased back toward baseline (March 2015, 55.1 %).

Conclusions

The eight-step framework was used to implement a CPG process, though further quality improvements initiatives may be needed to improve adherence.

A Non-Interventional Naturalistic Study of the Prescription Patterns of Antipsychotics in Patients with Schizophrenia from the Spanish Province of Tarragona

Background

The analysis of prescribing patterns in entire catchment areas contributes to global mapping of the use of antipsychotics and may improve treatment outcomes.

Objective

To determine the pattern of long-term antipsychotic prescription in outpatients with schizophrenia in the province of Tarragona (Catalonia-Spain).

Methods

A naturalistic, observational, retrospective, non-interventional study based on the analysis of registries of computerized medical records from an anonymized database of 1,765 patients with schizophrenia treated between 2011 and 2013.

Results

The most used antipsychotic was risperidone, identified in 463 (26.3%) patients, followed by olanzapine in 249 (14.1%), paliperidone in 225 (12.7%), zuclopenthixol in 201 (11.4%), quetiapine in 141 (8%), aripiprazole in 100 (5.7%), and clozapine in 100 (5.7%). Almost 8 out of 10 patients (79.3%) were treated with atypical or second-generation antipsychotics. Long-acting injectable (LAI) formulations were used in 44.8% of patients. Antipsychotics were generally prescribed in their recommended doses, with clozapine, ziprasidone, LAI paliperidone, and LAI risperidone being prescribed at the higher end of their therapeutic ranges. Almost 7 out of 10 patients (69.6%) were on antipsychotic polypharmacy, and 81.4% were on psychiatric medications aside from antipsychotics. Being prescribed quetiapine (OR 14.24, 95% CI 4.94–40.97), LAI (OR 9.99, 95% CI 6.45–15.45), psychiatric co-medications (OR 4.25, 95% CI 2.72–6.64), and paliperidone (OR 3.13, 95% CI 1.23–7.92) were all associated with an increased likelihood of polypharmacy. Being prescribed risperidone (OR 0.54, 95% CI 0.35–0.83) and older age (OR 0.98, 95% CI 0.97–0.99) were related to a low polypharmacy probability.

Conclusions

Polypharmacy is the most common pattern of antipsychotic use in this region of Spain. Use of atypical antipsychotics is extensive. Most patients receive psychiatric co-medications such as anxiolytics or antidepressants. Polypharmacy is associated with the use of quetiapine or paliperidone, use of a LAI, younger age, and psychiatric co-medication.