Psychotropic drug use in psychiatric inpatients: recent trends and changes over time-data from the AMSP study

A Naturalistic, Non-interventional Investigation of the Clinical and Sociodemographic Characteristics and Prescription Patterns in Patients With Psychotic Disorders at a Tertiary Care Facility in South Asia

OBJECTIVES

 This study aimed to evaluate the trends in the sociodemographic, clinical, and prescription characteristics of patients with psychotic illnesses seen in the outpatient psychiatry department of a tertiary care facility.

METHODS

 Between March 2021 and April 2022, a cross-sectional, prospective, observational, naturalistic, non-interventional study was conducted. A total of two hundred prescriptions were analyzed. To assess the rationality of prescriptions, World Health Organization (WHO) indicators were also computed.

RESULTS

 With a range of 18 to 75 years, the cohort's mean age was 40.26 years, and its average disease duration was 10.75 years. Sixty-seven patients (68.5%) were diagnosed with schizophrenia. Of the 200 prescriptions that were analyzed, 13 antipsychotic prescriptions were written 343 times. Olanzapine was prescribed as an antipsychotic the most frequently (132, 66%), followed by clozapine (75, 37.5%). Haloperidol (41, 20.5%), trifluoperazine (3, 1.5%), loxapine (1, 0.5%), and flupenthixol depot (1, 0.5%) were the most commonly prescribed typical antipsychotics. 91% (181/200) of patients received prescriptions for other drugs in addition to antipsychotics. Trihexyphenidyl (45%), escitalopram (30%), clonazepam (26.5%), sodium valproate (10%), propranolol (10.5%), and modafinil (9.5%) were the most frequently prescribed concurrent medicines. Forty-eight percent (95/200) of prescriptions demonstrated polypharmacy. Among patients, the frequency of antipsychotic prescriptions was 1 in 44% (88/200), 2 in 36.50% (73/200), 3 in 17% (34/200), 4 in 0.5% (1/200), and 5 again in 0.5% (1/200).  Conclusions: On average, the cohort of the current study was young. The commonest diagnosis was mainly schizophrenia. Atypical antipsychotics accounted for the majority of antipsychotic prescriptions in the current study. In this study, a high prevalence of polypharmacy was noted.

[Psychotropic Drugs - Comparison of Application Practice in Forensic and General Psychiatry]

The psychopharmacological application practice in forensic and general psychiatry should be investigated comparatively.The 2014-2019 Pharmaco-Epidemiology and Vigilance (Pharmako-EpiVig) surveys of the Bavarian Institute for Data, Analysis and Quality Assurance (BIDAQ) from forensic psychiatry (n = 4,590) and general psychiatry (n = 5,136) of the Isar-Amper-Klinikum Munich East were evaluated.Mean age and diagnosis distribution of the patient clientele differed, as did substance selection and dosage, which was almost consistently higher in forensic psychiatry. In schizophrenic forensic patients, clozapine was given most frequently. In both specialties, the frequent use of valproate was striking.The results could be interpreted as an indication that forensic patients have more severe and refractory illnesses, and that in clinical practice overall a symptom-related anti-aggressive treatment seems to be significant.

Drug-Induced Liver Injury during Antidepressant Treatment: Results of AMSP, a Drug Surveillance Program

BACKGROUND

Drug-induced liver injury is a common cause of liver damage and the most frequent reason for withdrawal of a drug in the United States. The symptoms of drug-induced liver damage are extremely diverse, with some patients remaining asymptomatic.

METHODS

This observational study is based on data of Arzneimittelsicherheit in der Psychiatrie, a multicenter drug surveillance program in German-speaking countries (Austria, Germany, and Switzerland) recording severe drug reactions in psychiatric inpatients. Of 184234 psychiatric inpatients treated with antidepressants between 1993 and 2011 in 80 psychiatric hospitals, 149 cases of drug-induced liver injury (0.08%) were reported.

RESULTS

The study revealed that incidence rates of drug-induced liver injury were highest during treatment with mianserine (0.36%), agomelatine (0.33%), and clomipramine (0.23%). The lowest probability of drug-induced liver injury occurred during treatment with selective serotonin reuptake inhibitors ([0.03%), especially escitalopram [0.01%], citalopram [0.02%], and fluoxetine [0.02%]). The most common clinical symptoms were nausea, fatigue, loss of appetite, and abdominal pain. In contrast to previous findings, the dosage at the timepoint when DILI occurred was higher in 7 of 9 substances than the median overall dosage. Regarding liver enzymes, duloxetine and clomipramine were associated with increased glutamat-pyruvat-transaminase and glutamat-oxalat-transaminase values, while mirtazapine hardly increased enzyme values. By contrast, duloxetine performed best in terms of gamma-glutamyl-transferase values, and trimipramine, clomipramine, and venlafaxine performed worst.

CONCLUSIONS

Our findings suggest that selective serotonin reuptake inhibitors are less likely than the other antidepressants, examined in this study, to precipitate drug-induced liver injury, especially in patients with preknown liver dysfunction.

Flupentixol use and adverse reactions in comparison with other common first- and second-generation antipsychotics: data from the AMSP study

This study compares the first-generation antipsychotic (FGA) flupentixol to haloperidol and common second-generation antipsychotics (SGAs) as to drug utilization and severe adverse drug reactions (ADRs) in clinical treatment of schizophrenia inpatients using data from the drug safety program Arzneimittelsicherheit in der Psychiatrie (AMSP). AMSP drug utilization and reported ADR data were analyzed. Type and frequency of severe ADRs attributed to flupentixol were compared with haloperidol, clozapine, olanzapine, quetiapine, risperidone and amisulpride in a total of 56,861 schizophrenia inpatients exposed to these drugs. In spite of increasing prescription of SGAs, flupentixol was consistently used in schizophrenic inpatients (about 5 %) over time. Reporting rates of severe ADR ranged from 0.38 to 1.20 % for the individual antipsychotics (drugs imputed alone); flupentixol ranked lowest. The type of ADR differed considerably; as to severe EPMS, flupentixol (0.27 %), such as risperidone (0.28 %), held an intermediate position between haloperidol/amisulpride (0.55/0.52 %) and olanzapine/quetiapine (<0.1 %). The study is a heuristic approach, not a confirmatory test. Flupentixol has a stable place in the treatment of schizophrenia in spite of the introduction of different SGAs. Comparative ADR profiles suggest an intermediate position between FGAs and SGAs for flupentixol in clinical practice.

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.

Changes in the treatment of acute psychosis in a German public hospital from 1998 to 2004

INTRODUCTION

The aim of our study was to investigate antipsychotic treatment strategies in acute schizophrenic episodes in a German university hospital.

METHODS

Documented pharmacological procedures in the first six weeks of acute episodes of schizophrenia in the years 1998 (n = 108), 2001 (n = 92), and 2004 (n = 94) were analyzed. Inclusion criteria were: admission voluntary and involuntary as inpatient to our acute ward with a diagnosis of F20x according to ICD 10.

RESULTS

Atypical antipsychotics (AAP) were significant more frequently used in the first week of treatment in 2001 and 2004 compared to the year 1998. Switching to AAP occurred significantly earlier in 2001 and 2004 (after 7.6 +/- 7 days in 1998, 3.5 +/- 5 days in 2001 and 2.3 +/- 5 days in 2004; P < 0.002). In all three years prescription of high potent typical antipsychotics decreased during the first six weeks of treatment. Involuntary treatment (P < 0.001) and age (P = 0.001) were significantly correlated to initial prescription of AAP. Involuntary admitted patients received more often a combination of high-potent conventional high potent typical neuroleptics and AAP (48% vs. 24%, P = 0.007).

CONCLUSION

Second generation atypicals are used more frequently according to current guidelines and switching from conventional medications occurs earlier.

Simultaneous prescribing of atypical antipsychotics, conventional antipsychotics and anticholinergics-a European study

Objective

The aim of this study was to investigate to what extent atypical antipsychotics, conventional antipsychotics and anticholinergics are prescribed simultaneously in daily clinical practice in Europe.

Method

A pharmaco-epidemiological study was carried out in which hospital pharmacists from 45 hospitals in Belgium, Denmark, France, Germany, The Netherlands and Scotland participated. Prescription data for 2,725 patients (mainly inpatients) who had been using an atypical antipsychotic for more than 6 weeks were analysed.

Main outcome measure

The frequencies of simultaneous prescription of atypical antipsychotics with other antipsychotics and/or anticholinergics.

Results

In this sample of patients with an atypical antipsychotic 42.1% was prescribed another antipsychotic (24.1% if low-potent antipsychotics were not included in the analysis) and 30.1% was prescribed an anticholinergic. In total 47.1% of patients were prescribed an atypical antipsychotic without any other antipsychotic or anticholinergic.

Conclusion

It is common practice to prescribe a combination of atypical antipsychotics and conventional antipsychotics and/or anticholinergics. This suggests that monotherapy involving an atypical antipsychotic is not considered to be an adequate treatment for a substantial number of patients in clinical practice.

Decision models in the evaluation of psychotropic drugs : useful tool or useless toy?

A current contribution in the European Journal of Health Economics employs a decision model to compare health care costs of olanzapine and risperidone treatment for schizophrenia. The model suggests that a treatment strategy of first-line olanzapine is cost-saving over a 1-year period, with additional clinical benefits in the form of avoided relapses in the long-term. From a clinical perspective this finding is indubitably relevant, but can physicians and policy makers believe it? The study is presented in a balanced way, assumptions are based on data extracted from clinical trials published in major psychiatric journals, and the theoretical underpinnings of the model are reasonable. Despite these positive aspects, we believe that the methodology used in this study-the decision model approach-is an unsuitable and potentially misleading tool for evaluating psychotropic drugs. In this commentary, taking the olanzapine vs. risperidone model as an example, arguments are provided to support this statement.

Psychotropic drug prescription in a psychiatric university hospital in Germany

A retrospective survey on drug prescription over a 5-year period (1998 to 2003) in 1,540 inpatients in a psychiatric university hospital in Germany was carried out. The aim was to establish a basis for a monitoring of prescription habits and for pharmacoeconomic considerations. It was established that there was only a slight increase in polyvalent drug use between 1998 and 2003. The results are presented in more detail in relation to the diagnosis of organic mental disorders, drug abuse disorders, schizophrenia, mood disorders and personality disorders. Newer atypical antipsychotics, SSRIs and mood stabilizers were increased across diagnoses while lithium and clozapine were prescribed less frequently. The rare occurrence of monotherapy in general might reflect a common trend in psychiatry fostering polydrug use. Studies of this type are biased by the fact that local habits of prescription do not allow generalisation of the findings. Such surveys should be carried out more frequently and simultaneously in different centers. Critical comparisons could help to optimize treatment.

Psychotropic medication utilization in a child and adolescent mental health service

OBJECTIVES

This study aimed to identify rates and correlates of psychotropic drug utilization in children and adolescents in inpatient and outpatient settings.

METHODS

A retrospective chart review examined 122 inpatient and 126 outpatient charts from a metropolitan child and youth mental health service in Brisbane, Australia.

RESULTS

Inpatients received more psychotropic medication than outpatients (71% vs. 25%; p < 0.01). Patients receiving medication were older, had longer hospital admissions, and more complex presentations, including history of abuse or suicide attempts and more diagnoses (all p < 0.01). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently used drug class (44% inpatients; 14% outpatients), primarily indicated for mood disorders (31%). SSRIs and newer antidepressants (ADs) were used more frequently in patients with a high suicide risk (p < 0.01). Atypical antipsychotics (APs) were also used (inpatients 23%; outpatients 3%), primarily for behavioral disturbances. Half of those receiving medication (51%) received polypharmacy (>1 concurrent drug), with up to four drugs used at one time. Rates of polypharmacy were highest among patients receiving antipsychotics.

CONCLUSIONS

Use of psychotropic medication is frequent in this population. Future research should initially focus on inpatients and intensive treatment settings and examine both safety and efficacy of interventions for depression in young people, atypical antipsychotics for behavioral disturbances, and polypharmacy.