Neuroleptic and anticholinergic drug use in Chinese patients with schizophrenia resident in a state psychiatric hospital in Singapore

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.

Does the degree of smoking effect the severity of tardive dyskinesia? A longitudinal clinical trial

Background

Tardive dyskinesia (TD) is a movement disorder observed after chronic neuroleptic treatment. Smoking is presumed to increase the prevalence of TD. The question of a cause-effect-relationship between smoking and TD, however, remains to be answered. Purpose of this study was to examine the correlation between the degree of smoking and the severity of TD with respect to differences caused by medication.

Method

We examined 60 patients suffering from schizophrenia and TD. We compared a clozapine-treated group with a group treated with typical neuroleptics. Movement disorders were assessed using the Abnormal-Involuntary-Movement-Scale and the technical device digital image processing, providing rater independent information on perioral movements.

Results

We found a strong correlation (.80 < r < .90, always p < .0001) between the degree of smoking and severity of TD. Repeated measurements revealed a positive correlation between changes in cigarette consumption and changes of the severity of TD (p < .0001). Analyses of covariance indicated a significant group-effect with a lower severity of TD in the clozapine-group compared to the typical-neuroleptics-group (p = .010). Interaction-analyses indicated a higher impact of smoking on the severity of TD in the typical-neuroleptics-group compared to the clozapine-group (p = .033).

Conclusion

Concerning a possible cause-effect-relationship between smoking and TD, smoking is more of a general health hazard than neuroleptic exposure in terms of TD.

The prescription patterns of second-generation antipsychotics in schizophrenia outpatient setting

Background Schizophrenia is a chronic disorder that requires long-term treatment to achieve symptom remission and quality of life improvement. Antipsychotic medications are primary treatments for schizophrenia patients. Second-generation antipsychotics (SGAs) have been recognized as first-line drugs in the treatment of schizophrenia. This study aimed at determining the prescription patterns of SGAs in schizophrenia outpatients in the National Mental Hospital in Indonesia. Methods A retrospective study with descriptive analysis was conducted between October and December 2018, exclusive to data of the patients with schizophrenia only. Data were collected from the prescription records of schizophrenia outpatients. This study performed a descriptive analysis of patient characteristics, percentage of SGAs prescribed, regimen doses of SGAs, average number of SGAs prescribed per patient, and pattern of antipsychotics prescribed. Results The most commonly used SGAs were risperidone 55%, followed by clozapine 38%, aripiprazole 3%, quetiapine 3%, and olanzapine 1%. Antipsychotics were generally prescribed in their recommended doses. Almost all SGAs were prescribed as polypharmacy, and the most common combination of SGAs were risperidone and clozapine. Conclusions This study highlighted that risperidone was the major choice for treatment in the outpatient setting. Polypharmacy is the most common pattern prescription of SGAs in the National Mental Hospital in Indonesia. New studies should focus on the analyses of polypharmacy prospectively, and the role of pharmacist in collaboration with other health professionals in the managing of schizophrenia therapy.

Frequency and correlates of anticholinergic use among patients with schizophrenia in Denmark: A Nation-wide pharmacoepidemiological study

Anticholinergic medications are used to treat extrapyramidal adverse effects induced by antipsychotics. Anticholinergics are associated with adverse effects: constipation, dry mouth and worsening of cognitive function. Anticholinergics have potential for abuse and are not recommended for long term-treatment. We aimed to investigate the use of anticholinergics in patients with schizophrenia. The national health registers in Denmark were used to examine: The prevalence of anticholinergics in 1996-2012 using a cross-sectional design; geographic variations in the prescription of anticholinergics in 2012; correlates of treatment with anticholinergics. The proportion of patients using anticholinergics decreased significantly from 11.7% in 1996 to 5.7% in 2012. The prescription pattern varied considerably between national regions in 2012, ranging from 4.0% in the Capital Region to 8.1% in the Northern Denmark Region. Long-term use of anticholinergics was predicted by older age, age at debut of schizophrenia, receiving early retirement pension, typical antipsychotic use, antipsychotic polypharmacy, typical + atypical antipsychotics, antidepressant treatment, high doses of antipsychotics measured in defined-daily-dose, physical comorbidity and psychiatrists` greater caseload. Use of anticholinergics declined during the study period, and showed substantial variation across the regions in 2012. Long-term use was linked to typical antipsychotic use and variables that are associated with greater illness severity.

Antipsychotic Use Pattern in Schizophrenia Outpatients: Correlates of Polypharmacy

Background:

This study investigates the antipsychotic use patterns of patients with schizophrenia and its correlations in their daily drug use patterns.

Methods:

Patients with schizophrenia who have regular records at two different community counselling centres (CCS) were included in the study. Information about their medications and sociodemographic data was recorded through face-to-face interviews and supporting information about their drug use patterns was obtained from their relatives/caregivers/nurse. The Clinical Global Impression Scale (severity of illness) and the General Assessment of Functionality scales were also administered.

Results:

Patients with schizophrenia used 2.0 ± 0.81 antipsychotics daily and 3.52 ± 2.55 pills (1–18). Seventy-one percent of the patients used two or more kinds of psychotropic drugs. The most frequently used antipsychotics were quetiapine, a second generation antipsychotic, and haloperidol, a typical antipsychotic. Clinical severity, regular visits to a CCS and use of depot antipsychotics were independent predictors for polypharmacy.

Conclusion:

The rate of polypharmacy use is high in Turkey. There are multiple risk factors related with polipharmacy. New studies should focus risk factors for preventing polypharmacy.

A randomized, double-blind, comparison of the efficacy and safety of low-dose olanzapine plus low-dose trifluoperazine versus full-dose olanzapine in the acute treatment of schizophrenia

OBJECTIVE

Antipsychotic polypharmacy is common in clinical practice, but not recommended in guidelines for treating schizophrenia patients. This study aimed to compare the efficacy and safety of low-dose olanzapine plus low-dose trifluoperazine (a first-generation antipsychotic [FGA]) to full-dose olanzapine (a second-generation antipsychotic [SGA]) in the treatment of acute schizophrenia.

METHOD

In this 6-week, double-blind, fixed-dose study, patients were randomized to receive 5mg/day of olanzapine plus 5mg/day of trifluoperazine or 10mg/day of olanzapine for 6weeks. Efficacy measures, including the Positive and Negative Syndrome Scale (PANSS) and other scales, safety measures, side effect measures, and quality of life were assessed regularly. Response was defined as at least a 30% reduction in the PANSS total score.

RESULTS

Both groups were similar in: 1) baseline characteristics, 2) score changes in all efficacy measures, safety measures, side effect measures, and quality of life, and 3) response rates at each visit. The polypharmacy group with low-dose olanzapine did not have less weight gain and lower lipid levels than the monotherapy group with full-dose olanzapine.

CONCLUSION

Polypharmacy is as efficacious and safe as, but cheaper than, monotherapy in the acute treatment of schizophrenia. Whether our findings can be generalized to other combinations of an appropriate ratio of one FGA to another SGA dosage, which can achieve favorable clinical responses and side effect profiles, needs further investigation.

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.

Long-acting antipsychotic drugs for the treatment of schizophrenia: use in daily practice from naturalistic observations

BACKGROUND

Current guidelines suggest specific criteria for oral or long-acting injectable antipsychotic drugs (LAIs). This review aims to describe the demographic and clinical characteristics of the ideal profile of the patient with schizophrenia treated with LAIs, through the analysis of nonrandomized studies.

METHODS

A systematic review of nonrandomized studies in English was performed attempting to analyze the factors related to the choice and use of LAIs in daily practice. The contents were outlined using the Cochrane methods for nonrandomized studies and the variables included demographic as well as clinical characteristics. The available literature did not allow any statistical analysis that could be used to identify the ideal profile of patients with schizophrenia to be treated with LAIs.

RESULTS

Eighty publications were selected and reviewed. Prevalence of LAI use ranged from 4.8% to 66%. The only demographic characteristics that were consistently assessed through retrieved studies were age (38.5 years in the 1970's, 35.8 years in the 1980's, 39.3 years in the 1990's, to 39.5 years in the 2000's) and gender (male > female).Efficacy was assessed through the use of various symptom scales and other indirect measurements; safety was assessed through extrapyramidal symptoms and the use of anticholinergic drugs, but these data were inconsistent and impossible to pool. Efficacy and safety results reported in the different studies yielded a good therapeutic profile with a maximum of 74% decrease in hospital admissions and the prevalence of extrapyramidal symptoms with LAIs consistently increased at 6, 12, 18, and 24 months (35.4%, 37.1%, 36.9%, and 41.3%, respectively).

CONCLUSIONS

This analysis of the available literature strongly suggests that further observational studies on patients with schizophrenia treated with LAIs are needed to systematically assess their demographic and clinical characteristics and the relationships between them and patient outcome.Besides the good efficacy and safety profile of LAIs, health care staff must also take into account the importance of establishing a therapeutic alliance with the patient and his/her relatives when selecting the most appropriate treatment. LAIs seem to be a good choice not only because of their good safety and efficacy profile, but also because they improve compliance, a key factor to improving adherence and to establishing a therapeutic alliance between patients with schizophrenia, their relatives, and their health care providers.

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.

Reducing antipsychotic polypharmacy among psychogeriatric and adult patients with chronic schizophrenia

INTRODUCTION

At the Institute of Mental Health/Woodbridge Hospital, 55% of the long-stay patients are on more than two antipsychotics for treatment of chronic schizophrenia. Our aim was to reduce antipsychotic polypharmacy (APP) among chronic schizophrenia inpatients at the long-term wards at the Institute of Mental Health, Singapore from 2006 to 2008.

METHODOLOGY

Using Clinical Practice Improvement Program (CPIP) methodology and using a Plan, Do, Study, Act approach, we surveyed patients, physicians, and nurses for responses regarding reducing the amount of APP for psychiatric patients. The first CPIP (CPIP1) was conducted from August 2006 to January 2007, and focused on psychogeriatric chronic schizophrenia inpatients. This methodology was spread to a second CPIP (CPIP2) from April 2008 to October 2008, which focused on adult chronic schizophrenia inpatients.

RESULTS

Both CPIPs were successful in the reduction of APP within the geriatric and adult long-term patients. For CPIP1, eight patients had their antipsychotics reduced. There was a reduction of an average chlorpromazine-equivalent dose per day from 375 mg per patient to 170 mg. For CPIP2, the average number of antipsychotics was reduced from 2.9 to 2.27 from July 2008 to October 2008. There was a reduction of an average chlorpromazine-equivalent dose per day from 1523 mg per patient to 1246 mg. There was no documented relapse within six months of implementation of both the projects.

CONCLUSION

APP in long-term patients suffering from chronic schizophrenia can be safely reduced with proper clinical titration, aided by guidelines and protocols.

Antipsychotic polypharmacy in schizophrenia: benefits and risks

Antipsychotic polypharmacy refers to the co-prescription of more than one antipsychotic drug for an individual patient. Surveys of prescribing in psychiatric services internationally have identified the relatively frequent and consistent use of combined antipsychotics, usually for people with established schizophrenia, with a prevalence of up to 50% in some clinical settings. A common reason for prescribing more than one antipsychotic is to gain a greater or more rapid therapeutic response than has been achieved with antipsychotic monotherapy. However, the evidence on the risks and benefits for such a strategy is equivocal, and not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry. Combined antipsychotics are a major contributor to high-dose prescribing, associated with an increased adverse effect burden, and of limited value in helping to establish the optimum maintenance regimen for a patient. The relatively widespread use of antipsychotic polypharmacy identified in cross-sectional surveys reflects not only the addition of a second antipsychotic to boost therapeutic response, but also the use of as-required antipsychotic medication (mainly to treat disturbed behaviour), gradual cross-titration while switching from one antipsychotic to another, and augmentation of clozapine with a second antipsychotic where the illness has failed to respond adequately to an optimized trial of clozapine. This review addresses the clinical trial data and other evidence for each of these pharmacological approaches. Also reviewed are examples of systematic, practice-based interventions designed to reduce the prevalence of antipsychotic polypharmacy, most of which have met with only modest success. Guidelines generally agree that if combined antipsychotics are prescribed to treat refractory psychotic illness, this should be after other, evidence-based, pharmacological treatments such as clozapine have been exhausted. Further, their prescription for each patient should be in the context of an individual trial, with monitoring of the clinical response and adverse effects, and appropriate physical health monitoring.

No evidence for restrictive care practices in Măori admitted to a New Zealand psychiatric inpatient unit: do specialist cultural teams have a role?

OBJECTIVE

To ascertain the presence, and describe the pattern and extent, of restrictive care practices in the treatment of mental health inpatients in a rural New Zealand unit.

METHODS

Retrospective data was anonymously extracted from patient records at Rotorua Hospital (Rotorua, New Zealand). Data sets were compiled from 300 consecutive patient admissions between January 2000 and December 2001. The demographic and diagnostic characteristics extracted were gender, age, ethnicity (Măori or non-Măori classification only), primary diagnosis, length of hospital stay, seclusion, medication on discharge, dosage of antipsychotic medication if given, referral to psychotherapy, voluntary/involuntary status on admission, and readmission rates.

RESULTS

After controlling for other clinical variables, ethnicity was not associated with specific diagnoses, increased use of seclusion, and involuntary status on admission or higher readmission rates. Măori patients were more likely to receive antipsychotic medication and at higher doses than non-Măori. Măori were less likely to be referred to psychotherapy services and had shorter lengths of stay.

CONCLUSION

There was no evidence of widespread restrictive care practices against Măori, although the disparities in antipsychotic prescription and psychotherapy referral suggest some restrictive care practices do exist. The use of specialist cultural teams in general mental health services may prevent restrictive care practices.

Reducing Polypharmacy Through the Introduction of a Treatment Algorithm: Use of a Treatment Algorithm on the Impact on Polypharmacy

Introduction: Polypharmacy is very common in the psychiatric setting despite the lack of evidence to justify its use. The objective of this study was to review the prescription patterns in a tertiary mental health institute in Asia and evaluate the impact of a treatment algorithm for patients with first-episode psychosis (FEP) on the use of polypharmacy. Materials and Methods: A treatment algorithm was implemented for patients accepted into an Early Psychosis Intervention Programme (EPIP) and the prescription patterns of these patients were compared with a comparator group (pre-EPIP) before the use of the algorithm. The prescribing pattern was established at 2 points: at baseline after the diagnosis was made, and 3 months later. Results: There were 68 subjects in the comparator group and 483 EPIP patients; the latter were on the average younger. None in the comparator group was diagnosed to have an affective psychosis. There was a significant reduction in the rate of antipsychotic polypharmacy, prolonged use of benzodiazepines and anticholinergic medication in EPIP patients. This group also had an increase in the use of second-generation antipsychotics and received lower doses of antipsychotics. Conclusion: The implementation of a treatment algorithm coupled with audit has changed the trend towards polypharmacy among patients with FEP. Key words: Antipsychotics, Drug use review, Psychosis

Antipsychotic polypharmacy in patients with schizophrenia: a multicentre comparative study in East Asia

AIMS

Previous studies of the prescription patterns of psychotropic medications in patients with schizophrenia have highlighted a high rate of antipsychotic polypharmacy, but data in Asia are sparse. This study seeks to examine the prevalence of antipsychotic polypharmacy in patients with schizophrenia and compare the differences between patients receiving one vs. those receiving more than one antipsychotic.

METHODS

Antipsychotic prescription for a sample of 2399 patients with schizophrenia from six countries and territories was evaluated. Daily doses of antipsychotic medications were converted to standard chlorpromazine equivalents (CPZ).

RESULTS

Antipsychotic polypharmacy was found in 45.7% (n = 1097) of the patients with wide intercountry variations. Polypharmacy was associated with male gender [odds ratio (OR) 1.24, 95% confidence interval (CI) 1.06, 1.46, P < 0.01], advanced age (t = -7.81, d.f. = 2396, P < 0.001), psychiatric hospital setting (OR 1.34, 95% CI 1.11, 1.62) as well as higher daily CPZeq doses (411.47 vs. 983.10 CPZeq day(-1), z = -25.94, P < 0.001), anticholinergic use (OR 3.17, 95% CI 2.65, 3.79, P < 0.001) and less use of an atypical antipsychotic drug (OR 0.83, 95% CI 0.71, 0.98, P < 0.05). On multivariate analysis, country, age and duration of illness were significantly associated with antipsychotic polypharmacy.

CONCLUSION

This study highlighted the wide intercountry variations of antipsychotic polypharmacy which are likely to be influenced by a complex combination of clinical, setting, cultural and personal practice factors, requiring more research.

Prescribing pattern and indicators for performance in a psychiatric practice

AIMS To assess the prescribing pattern and to measure some specific aspects of the behaviour of the prescribers (psychiatrists) before and after educational interventions using core drug use indicators. METHODS In the present randomized retrospective controlled pre-post intervention prescription survey of schizophrenia and depression, 100 prescriptions each for schizophrenia and depression were obtained before and after each intervention. The prescriptions were analyzed for the following prescriber-specific indicators: number of drugs prescribed, prescribing by generic names, prescriptions for essential drugs, antiparkinsonian and benzodiazepines, nature of drugs and number of combinations prescribed. Based on the results of pre-intervention data, two interactional workshops were conducted 1 and 6 months after pre-intervention data collection. The first workshop focused on the results of the prescription audit feedback and reasons thereof. The second workshop focused, in addition, on appropriate management of schizophrenia and depression using consensus treatment guidelines with the aim of evolving a consensus on the treatment in a given hospital setting. RESULTS Before intervention, the essential drugs accounted for 80.95 and 96.91% of the total number of drugs prescribed in depression and schizophrenia, respectively. Prescription for essential drugs improved further significantly in the post intervention period to 95.26% (P<0.04) for depression; whereas, in schizophrenia, prescriptions for essential drugs declined to 80.95%. The average number of drugs prescribed per encounter marginally declined in both schizophrenia (2.46±0.94 to 2.34±0.65) and depression (2.09±0.79 to 2.00±0.65) after the second intervention. The patients receiving two or more drugs from the same group together declined from 12 to 9% in schizophrenia, but increased from 5 to 10% in depression after intervention. Trihexyphenidyl, an antiparkinsonian drug, was co-prescribed (90%) with antipsychotic agents (98%) in schizophrenia; however, use of benzodiazepines declined significantly after intervention to 28% compared to 48% in the pre-intervention period. Also, benzodiazepine use was high (68%) and remained so (70%) after interventions in depression cases. CONCLUSION The present study demonstrates excessive use of antiparkinsonian agents in schizophrenia and benzodiazepines in depression. Monitoring for the use of antiparkinsonian and benzodiazepines can form an important component for measuring specific aspects of prescriber's behaviour, which can be used as an indicator for comparisons at different time intervals and between health facilities.

Clinical characteristics and associated factors in antipsychotic-induced akathisia of Asian patients with schizophrenia

OBJECTIVE

We studied the prevalence of akathisia and its relationship to a number of sociodemographic and clinical factors in a population of Chinese inpatients with Schizophrenia.

METHOD

Six-hundred and forty-five patients were recruited for the study. Akathisia was assessed using the Barnes Akathisia Rating Scale (BARS), dyskinesia by the Abnormal Involuntary Movement Scale (AIMS) and extrapyramidal side effects (EPSE) were assessed by the Simpson-Angus Rating Scale (SARS).

RESULTS

Only 35 (5%) patients were assessed to have akathisia. There was no gender or ethnic difference in the rates of akathisia. However, the majority of the patients (65%) were receiving an anticholinergic agent at the time of the study.

CONCLUSION

Our findings of an overlap between TD and EPSE support the suggestion that there may be a common vulnerability for these movement disorders. The finding of a low rate of akathisia among our Asian patients suggests an inter-ethnic difference in the vulnerability for the development of akathisia. However, comparing our results with the rates reported from other countries may be hampered by the diagnostic and methodological differences across studies.

The pharmacological treatment of schizophrenia in Chinese patients: a comparison of prescription patterns between 1996 and 1999

AIMS

In 1996 a Hong Kong-wide survey of pharmacological treatment for schizophrenic inpatients identified a few idiosyncratic prescription patterns that were not consistent with international standards. In the context of continuous quality assurance, the survey was repeated in 1999 to monitor trends in the pharmacotherapy of schizophrenia and to identify changes in prescribing practices. It was expected that the widespread introduction of novel antipsychotic drugs coupled with continuing medical education would favourably alter prescribing habits.

METHODS

A representative random sample of 1202 schizophrenic patients from all inpatient settings in Hong Kong was surveyed. Basic socio-demographic data and a list of all psychotropic medication taken on census day were collected.

RESULTS

Significant improvement was noted in several aspects of pharmacotherapy in 1999 as compared with 1996. The total daily dosage of antipsychotic drugs decreased from 716 +/- 627 to 561 +/- 482 mg day-1 chlorpromazine equivalent (CPZeq) (Mann-Whitney U-test; Z = -3.906, P = 0.000; 95% confidence interval [CI] = 70.0, 240.2 mg day-1 CPZeq), for acute patients and from 923 +/- 809 to 675 +/- 545 mg day-1 CPZeq (Mann-Whitney U-test; Z=-5.036, P = 0.000; 95% CI = 175.57, 321.63 mg day-1 CPZeq) for chronic patients. The percentage of patients coprescribed antipsychotics and an antiparkinson drug significantly decreased from 67.8% to 61.8% (chi2 = 5.558, P = 0.018) in the chronic schizophrenia group. The percentage of patients taking atypical antipsychotic medication increased significantly from 5.5% to 19.2% (chi2 = 27.14, P = 0.000) in the acute and 3.4% to 12.3% (chi2 = 27.76, P = 0.000) in the chronic group.

CONCLUSIONS

Repeated surveys of prescribing practices proved to be a useful tool to demonstrate trends in the pharmacological treatment of schizophrenia. Our findings suggest that the widespread use of atypical antipsychotic drugs contributed to a more rational pharmacotherapy for schizophrenia.

Tardive dyskinesia and impaired glucose tolerance

The authors examined the role of impaired glucose metabolism in the pathophysiology of tardive dyskinesia in schizophrenic patients with and without persistent TD. Glucose tolerance and insulin levels were determined in 86 patients with persistent tardive dyskinesia and in 108 patients without tardive dyskinesia. Dyskinesias were assessed by the abnormal involuntary movement scale (AIMS) and extrapyramidal symptoms by the Simpson--Angus rating scale (SARS). Fasting blood glucose levels were significantly lower while the first and second hour glucose levels did not reveal any differences in patients with tardive dyskinesia compared with those without tardive dyskinesia. Insulin levels did not differ in these two groups. Our cross-sectional epidemiological study does not suggest hyperglycemia to be a risk factor for tardive dyskinesia. However, prospective long-term studies with multiple assessment points are needed to clarify the role of glucose metabolism in the development of tardive dyskinesia.

Tardive dyskinesia among Chinese and Malay patients with schizophrenia

The prevalence of tardive dyskinesia (TD) was studied with the Abnormal Involuntary Movements Scale in Chinese and Malay patients with schizophrenia who were hospitalized in a Singapore state psychiatric institute. We also studied the relationship of neuroleptic-induced extrapyramidal side effects to TD. By using established criteria, the rates of TD were 40.6% for Chinese and 29.0% for Malays, higher than previously reported for Chinese subjects. Older age and lower current neuroleptic dose were significantly associated with TD. Multivariate analysis, after controlling for other salient risk variables, did not show a significant difference in TD prevalence rates between the two races. We conclude that suggested differences in interethnic rates of TD among Chinese, Malays, and Westerners are unlikely to exist and that any variation in prevalence is more likely to be determined by differences in duration of exposure and dose levels of neuroleptic drugs.