U.S. national trends in the use of antipsychotics during office visits, 1998-2002

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.

Evaluation of Patients with Suspected Gastroparesis

There is substantial overlap between the symptoms of gastroparesis and a variety of alternative disorders. These conditions include rumination syndrome, drug-induced gastric emptying delay, cannabinoid hyperemesis syndrome, and eating disorders, which can be identified based on the history alone. The remaining patients require a diagnostic approach of physical examination, laboratory tests, evaluation with esophagogastroduodenoscopy or contrast radiography, and a test to measure gastric emptying. Symptomatic patients who have normal nutritional status and gastric emptying that is either normal or mildly delayed should be diagnosed with functional dyspepsia, whereas patients with moderate or severe gastric emptying delay are diagnosed with gastroparesis.

Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid

BACKGROUND

Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines.

OBJECTIVES

To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use.

METHODS

Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring.

RESULTS

Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening.

CONCLUSIONS

While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children.

DISCLOSURES

This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.

Prevalence of multiple antipsychotic use and associated adverse effects in Australians with mental illness

AIM

This article analyzes the prevalence of use of concurrent multiple antipsychotics and high dosage treatment in people with mental illness, to assess the burden of antipsychotic drug-related side-effects associated with multiple use, and to identify strategies shown to reduce antipsychotic polypharmacy.

METHODS

Literature reviewed was sourced from MEDLINE, Embase, CINAHL, InformIT, PsycINFO, International Pharmaceutical Abstracts, Cochrane Library database and Joanna Briggs Institute databases to identify Australian studies published between January 2000 and February 2015. Studies that reported prevalence of multiple antipsychotic use or addressed the issue of antipsychotic drug-related side-effects were included. Systematic reviews, randomized controlled trials, and observational pre-post studies of Australian and international interventions aiming to reduce multiple antipsychotic use in mental health settings were also identified.

RESULTS

Nineteen studies reporting prevalence of multiple antipsychotic use were identified. The proportion of patients taking more than one antipsychotic ranged from 5 to 61%. Of the studies assessing dosages used, between one-third and one-half of all patients taking multiple antipsychotics received doses higher than recommended. Data from one national study reported that people taking multiple antipsychotics were more likely to experience at least one side-effect in comparison to consumers taking a single antipsychotic (90 verses 80%).International evidence of direct trials of conversion from treatment regimens involving multiple antipsychotics to those based on monotherapy show that between 50 and 75% of people with serious mental illness could be successfully converted to single-agent treatment, with up to 25% obtaining an improvement in health and the remaining 50% staying well managed.

CONCLUSION

Use of multiple antipsychotics is common among Australian people with mental illness, despite guidelines recommending that only one antipsychotic should be used in most cases. People taking more than one antipsychotic at a time are more likely to experience side-effects, and to receive higher than recommended antipsychotic doses. Direct trials that aimed to reduce multiple antipsychotic use suggest it is possible to effectively reduce therapy in the majority of people without worsening outcomes. Simple educational programmes targeting health professionals have not been found to be effective; however, complex multifaceted programmes and quality improvement programmes have demonstrated effect.

Sudden Cardiac Death: Pharmacotherapy and Proarrhythmic Drugs: A Nationwide Cohort Study in Denmark

OBJECTIVES

This study sought to describe the use of pharmacotherapy in a nationwide cohort of young patients with sudden cardiac death (SCD).

BACKGROUND

Several drugs have been associated with an increased risk of SCD and sudden arrhythmic death syndrome (SADS). It remains unclear how pharmacotherapy may contribute to the overall burden of SCD in the general population.

METHODS

This was a nationwide study that included all deaths that occurred between 2000 and 2009 and between 2007 and 2009 in people age 1 to 35 years and 36 to 49 years, respectively. Two physicians identified all SCDs through review of death certificates. Autopsy reports were collected. Pharmacotherapy prescribed within 90 days before SCD was identified in the Danish Registry of Medicinal Product Statistics.

RESULTS

We identified 1,363 SCDs; median age was 38 years (interquartile range: 29 to 45 years), and 72% (n = 975) were men. Autopsy was performed in 55%. Overall, 58% of SCD cases (n = 786) received at least 1 drug within 90 days before death. The most common drugs were analgesic drugs (n = 239; 18%), antihypertensive drugs (n = 234; 17%), and antibiotic drugs (n = 218; 16%). After multivariable adjustment, prescription of "brugadogenic" drugs or >1 QT-prolonging drug was associated with an increased risk of SADS compared with explained SCD (odds ratio: 2.16 [95% confidence interval: 1.12 to 4.17] and 2.91 [95% confidence interval: 1.46 to 5.81], respectively).

CONCLUSIONS

Pharmacotherapy was identified in 58% of the SCD cases. After multivariable adjustment, there was a 2- and 3-fold increased risk of SADS compared with explained SCD in patients receiving brugadogenic drugs or >1 QT-prolonging drug, respectively. Identification of high-risk patients is warranted to lower the burden of SCD.

Antipsychotics and associated risk of out-of-hospital cardiac arrest

Antipsychotic drugs have been associated with sudden cardiac death, but differences in the risk of out-of-hospital cardiac arrest (OHCA) associated with different antipsychotic drug classes are not clear. We identified all OHCAs in Denmark (2001-2010). The risk of OHCA associated with antipsychotic drug use was evaluated by conditional logistic regression analysis in case-time-control models. In total, 2,205 (7.6%) of 28,947 OHCA patients received treatment with an antipsychotic drug at the time of the event. Overall, treatment with any antipsychotic drug was associated with OHCA (odds ratio (OR) = 1.53, 95% confidence interval (CI): 1.23-1.89), as was use with typical antipsychotics (OR = 1.66, CI: 1.27-2.17). By contrast, overall, atypical antipsychotic drug use was not (OR = 1.29, CI: 0.90-1.85). Two individual typical antipsychotic drugs, haloperidol (OR = 2.43, CI: 1.20-4.93) and levomepromazine (OR = 2.05, CI: 1.18-3.56), were associated with OHCA, as was one atypical antipsychotic drug, quetiapine (OR = 3.64, CI: 1.59-8.30).

Changes in the prescription pattern of antipsychotics for schizophrenic outpatients after the implementation of a global budgeting program

BACKGROUND

A hospital-based global budget (GB) program was implemented by the Taiwan Bureau of National Health Insurance (TBNHI) to control the rising costs of medical care. We investigated whether the introduction of the GB program affected prescriptions for second-generation antipsychotics (SGAs) for schizophrenic outpatients in public and private medical and psychiatric centers.

METHODS

The prescription data of schizophrenic outpatients treated between 2001 and 2004 were retrieved from the TBNHI database, which included outpatients who were diagnosed as having schizophrenia during the period from 1996 to 2001. Because the new health insurance policy may have had a lag effect on physicians' decision regarding SGA prescription, we used January 2004 as the timepoint to divide the data, which was 6 months after GB implementation. Thus, data from the 6-month period immediately after the GB implementation were included in the pre-GB period. Second-generation antipsychotics included in the study were clozapine, risperidone, olanzapine, quetiapine, ziprasidone, zotepin, and amisulpride.

RESULTS

After January 2004, the proportion of SGA use in outpatient departments did not show an upward trend, as had been observed in the pre-GB period, which appeared at a staggering pace lasting for 12 months (p = 0.0004). Compared with medical centers, SGA expenditures in the psychiatric centers were less affected in the GB period (p < 0.0001). Compared to the private sector, the SGA expenditures in the public sector were less affected in the GB period (p < 0.019).

CONCLUSION

We concluded that the GB implementation reduced SGA expenditures significantly. The extent of influence varied among hospitals (i.e., public versus private, medical versus psychiatric centers), which was most likely caused by financial factors.

Clozapine: a review of clinical practice guidelines and prescribing trends

BACKGROUND

Clozapine effectiveness in the treatment of refractory schizophrenia has been sustained by published evidence in the last two decades, despite the introduction of safer options.

DISCUSSION

Current clinical practice guidelines have strongly recommended the use of clozapine in treatment-resistant schizophrenia, but prescribing trends do not appear to have followed such recommendations. Clozapine is still underutilized especially in patients at risk of suicide. It seems that physicians are hesitant in prescribing clozapine due to concerns about serious adverse effects. Recent reports have highlighted the need to inform health professionals about the benefits of treating patients with clozapine and have voiced concerns about the underutilization of clozapine especially in patients at risk of suicide.

SUMMARY

Guidelines and prescribing patterns reported in various countries worldwide are discussed. Suggestions on how to optimize clozapine utilization have been published but more efforts are needed to properly inform and support prescribers' practices.

Changes in physician antipsychotic prescribing preferences, 2002-2007

OBJECTIVE

Physician antipsychotic prescribing behavior may be influenced by comparative effectiveness evidence, regulatory warnings, and formulary and other restrictions on these drugs. This study measured changes in the degree to which physicians are able to customize treatment choices and changes in physician preferences for specific agents after these events.

METHODS

The study used 2002-2007 prescribing data from the IMS Health Xponent database and data on physician characteristics from the American Medical Association for a longitudinal cohort of 7,399 physicians. Descriptive and multivariable regression analyses were conducted of the concentration of prescribing (physician-level Herfindahl index) and preferences for and likelihood of prescribing two first-generation antipsychotics and six second-generation antipsychotics. Analyses adjusted for prescribing volume, specialty, demographic characteristics, practice setting, and education.

RESULTS

Antipsychotic prescribing was highly concentrated at the physician level, with a mean unadjusted Herfindahl index of .33 in 2002 and .29 in 2007. Psychiatrists reduced the concentration of their prescribing more over time than did other physicians. High-volume psychiatrists had a Herfindahl index that was half that of low-volume physicians in other specialties (.18 versus .36), a difference that remained significant (p<.001) after adjustment for physician characteristics. The share of physicians preferring olanzapine dropped from 29.9% in 2002 to 10.3% in 2007 (p<.001) while the share favoring quetiapine increased from 9.4% to 44.5% (p<.001). Few physicians (<5%) preferred a first-generation antipsychotic in 2002 or 2007.

CONCLUSIONS

Preferences for specific antipsychotics changed dramatically during this period. Although physician prescribing remained heavily concentrated, the concentration decreased over time, particularly among psychiatrists.

Controversies in the use of second generation antipsychotics as sleep agent

A growing number of patients present in clinics with complaints of insomnia. Over the past century, great advances have been made in our knowledge of mechanisms of sleep and wakefulness. Understanding sleep neurochemistry has led to better management of different types of insomnias with a variety of non-pharmacological and pharmacological treatments. Unfortunately, the increasing development and availability of second generation antipsychotics (SGA) have prompted their frequent use exclusively for insomnia. However, to date, no large randomized-controlled or placebo-controlled studies have shown the utility of SGAs in the realm of treating insomnia. Many clinicians use SGAs as "off-label" for sleep induction and maintenance, but this practice needs to be readdressed given their potential risks and the current lack of evidence base. This review will highlight the neurochemistry related to sleep, the mechanisms of action by which SGA may have some benefit in treating insomnia, and the risks associated with their utilization.

Pharmacoepidemiology of psychotropic drugs: examples of current research challenges on major public health issues

Background– As a large number of persons are exposed to prescribed psychotropic drugs, their utilisation and impact should be further explored at the population level.Aims– To illustrate the interest of pharmacoepidemiological studies of psychotropic drugs by selected examples of major public health issues.Method– Selective review of the literature. Results – Many questions remain unsolved regarding the behavioural teratogenicity of prenatal exposure to psychotropic drugs, the impact of their increasing use in children, the long-term cognitive consequences of exposure to benzodiazepines, and the risks associated with extension of indications of antipsychotic drugs.Conclusion– Pharmacoepidemiological studies need to be further developed owing to the large number of public health questions raised by the extensive and expanding use of psychotropic drugs.

Risk of falls and fractures in older adults using antipsychotic agents: a propensity-matched retrospective cohort study

BACKGROUND

Antipsychotics, especially atypical agents, are widely used in the elderly population to treat behavioural and psychiatric symptoms. Very few studies have compared the risk of falls and fractures among older adults using typical and atypical agents and none of the studies have evaluated differential risk across antipsychotic classes.

OBJECTIVE

To examine the risk of falls and fractures associated with atypical antipsychotic use and typical antipsychotic use in community-dwelling older adults in the US.

METHODS

The study involved a retrospective population-based cohort design matched on propensity scores involving older adults (aged ≥50 years) using atypical or typical antipsychotic agents in the IMS LifeLink™ Health Plan Claims Database. Patients taking atypical antipsychotics were matched with patients taking typical antipsychotics using the Greedy 5 → 1 matching technique. The study evaluated the relative risk of hospitalization/emergency room (ER) visits due to falls/fractures in a 1-year follow-up period, and patients treated with atypical antipsychotics were compared with those treated with typical antipsychotics using the Cox proportional-hazards regression model stratified on matched pairs. The covariates adjusted for in the regression model included duration of therapy and exposure to other psychotropic medications that increase the risk of falls and fractures.

RESULTS

From July 2000 to December 2007, 11 160 (5580 atypical and 5580 typical) users of antipsychotics were obtained after matching on propensity scores. A total of 825 cases of falls/fractures with at least one hospitalization/ER visit following the use of antipsychotic agents were identified. The number of cases with falls/fractures was 450 in atypical antipsychotic users and 375 in typical antipsychotic users. Cox regression model analysis revealed no statistically significant difference between atypical users and typical users with respect to risk of falls/fractures (hazard ratio [HR] 1.01; 95% CI 0.83, 1.22). However, duration of therapy with any antipsychotic medication for >90 days was significantly (HR 1.81; CI 1.35, 2.43) associated with increased risk of falls/fractures compared with <30 days of treatment.

CONCLUSIONS

No statistically significant difference was found between atypical antipsychotic agents and typical antipsychotic agents with regards to the likelihood of falls/fractures in a large cohort of older adults. However, there is a need to be cautious while prescribing atypical and typical antipsychotics in older adults for long periods of time.

Correlates and psychiatric disorders associated with psychotropic drug use in Taiwan

PURPOSE

We used the population-based National Health Insurance database to investigate correlates and psychiatric disorders associated with psychotropic drug use in Taiwan.

METHODS

The National Health Research Institute provided a database of 200,000 random subjects for study. We obtained a random sample of 145,304 subjects aged 18 years or older in 2004. Study subjects who had made at least two psychotropic drug prescriptions during this year were identified. We detected factors associated with psychotropic drug use. In addition, we examined the prevalence of antipsychotic, antidepressant, mood stabilizer, sedative-hypnotic-anxiolytic (SHA) agent, and any psychotropic drug use according to psychiatric disorders.

RESULTS

Higher prevalence of any psychotropic drug use was found in the 25-44, 45-64, and 65 or older age groups, females, aborigine, with a lower premium, with disability, and among those who lived in central region, suburban or rural area. Among those subjects with any major psychiatric disorders, the prevalence of antipsychotic, antidepressant, mood stabilizer, SHA agent, and any psychotropic drug use were 59.3, 49.7, 17.9, 78.6, and 92.0%, respectively. Among those subjects with any minor psychiatric disorders, the prevalence of antipsychotic, antidepressant, mood stabilizer, SHA agent and any psychotropic drug use were 17.5, 41.8, 4.0, 85.5, and 89.4%, respectively.

CONCLUSIONS

Thus, those subjects with any psychiatric disorders had a high percentage of any psychotropic drug use in National Health Insurance program in Taiwan. Future studies should focus on the outcome evaluation and correlates associated with individual psychotropic use.

Long-acting injectable antipsychotics in the treatment of schizophrenia: their role in relapse prevention

IMPORTANCE OF THE FIELD

Antipsychotic medications are the cornerstone of treatment in schizophrenia, and a large body of data confirms the value of ongoing and continuous antipsychotic pharmacotherapy in controlling symptoms and preventing relapse. However, nonadherence with antipsychotic treatment is a significant issue, with estimates as high as 90%.

AREAS COVERED IN THIS REVIEW

This review focuses on long-acting injectable (LAI) antipsychotics and their role in the treatment of schizophrenia. The existing literature, with an emphasis on clinical evidence, is assessed. This includes both reviews and specific trials that examine LAIs and compare them with oral agents, with measures ranging from relapse and rehospitalization to adherence. Both advantages and limitations (e.g., challenges in terms of dose titration and time to steady state) are examined.

WHAT THE READER WILL GAIN

This overview serves as an update for clinicians wishing to understand LAIs better, including the newer second-generation antipsychotics (SGAs) with this formulation available, and their potential role in the long-term treatment of individuals with schizophrenia.

TAKE HOME MESSAGE

Despite identified advantages, LAIs are not used as widely as might be expected. It would seem that clinicians are at least partly responsible for this, influenced by our own misperceptions (e.g., that LAIs are not acceptable to patients) and, perhaps, misinformation (e.g., increased side effect risk). As clinicians, we may well be shortchanging LAIs if we position them as a treatment of last resort for the multi-episode, nonadherent, 'revolving door' patient, especially given recent evidence underscoring their potential benefits in first-episode patients. The search for new and more effective antipsychotics will continue, but we are reminded that suboptimal outcomes may have as much to do with nonadherence as inadequate treatments. Evidence has established that LAI antipsychotics demonstrate distinct benefits in this regard, and we would be remiss if we did not exploit this already available strategy. As well as additional research, we need to rethink how we position these agents in our treatment algorithms if we are to maximize their potential.

Antipsychotic prescribing trends: a review of pharmaco-epidemiological studies

OBJECTIVE

To review findings from pharmaco-epidemiological studies exploring antipsychotic (AP) drugs prescribing trends.

METHOD

We retrieved original studies that explored AP prescribing trends in general population samples since 2000. For each study, we extracted information on sampling method, period, assessment of AP use and corresponding estimates (incidence rates, prevalence rates, pharmacy sales, prescription data) and diagnostic assessment.

RESULTS

Nearly all studies meeting the inclusion criteria (n = 17) showed an increase in AP prescriptions, mainly because of a dramatic rise in second-generation antipsychotics (SGAP) prescriptions. APs are often prescribed for non-psychotic disorders in adults as well as in children and adolescents.

CONCLUSION

Considering the growing number of persons from the general population exposed to APs, population studies assessing the risk/benefit ratio of SGAP use in disorders other than psychosis are necessary, particularly in children and adolescents.

The subjective experience of taking antipsychotic medication: a content analysis of Internet data

OBJECTIVE

We explored the subjective effects associated with olanzapine, risperidone and older antipsychotics.

METHOD

We conducted a content analysis of an Internet database of comments about prescribed medications.

RESULTS

We analysed 223 comments on risperidone, 170 on olanzapine and 46 relating to three older antipsychotics. The predominant subjective effects produced by all drugs consisted of sedation, cognitive impairment and emotional flattening or indifference. Connections appeared between these effects and Parkinsonian-like symptoms with the older drugs, sexual impairment with risperidone and metabolic effects with olanzapine. The experience of akathisia was frequently linked to suicidal thoughts. Some respondents described how the drugs' subjective effects helped to reduce symptoms of mania, psychosis and anxiety.

CONCLUSION

The generalisability of Internet data is uncertain. However, the data suggest that adverse subjective effects play a central role in the experience of taking antipsychotic drugs and may be related to the drugs' desired benefits.

Epidemiological trends in psychosis-related Emergency Department visits in the United States, 1992-2001

Mental health visits represented an increasing fraction of all Emergency Department (ED) visits in the U.S. between 1992 and 2001. This study used the National Hospital Ambulatory Medical Care Survey, a 4-staged probability sample of ED visits from geographically diverse hospitals around the U.S., to assess the contribution of all psychosis-related visits to this overall trend. Unlike other mental-health-related ED visits, the rate of psychosis-related visits did not increase. This lack of change is notable in the context of dramatic changes in both healthcare financing and antipsychotic prescribing practices during this period. There was an unexpected decrease in Medicare-funded psychosis-related ED visits at a time of increasing Medicare enrollment overall. An important demographic trend over this decade was the increasing urbanization of psychosis-related ED visits coincident with a relative decrement in such visits within rural areas.

Concomitant antipsychotic prescribing in US outpatient settings

BACKGROUND

Clinicians use concomitant antipsychotic therapy for management of psychotic disorders despite a paucity of evidence for this practice.

OBJECTIVE

To examine national patterns and determinants of concomitant antipsychotic therapy.

METHODS

Concomitant antipsychotic therapy was defined as simultaneous use of 2 or more antipsychotic agents. Prescription data from the 2003-2004 National Ambulatory Medical Care Survey and the outpatient department portion of the 2003-2004 National Hospital Ambulatory Medical Care Survey were used to characterize the prescribing of concomitant antipsychotic therapy and antipsychotic monotherapy (defined as use of a typical or atypical agent). Multiple logistic regression was applied to antipsychotic visits to examine the determinants of concomitant antipsychotic therapy based on patient and provider characteristics.

RESULTS

Overall, concomitant antipsychotic therapy was documented in 9% of the visits involving antipsychotic agents, and monotherapy in 91% of the visits. The use of atypical agents, namely risperidone, olanzapine, and quetiapine, was common in both forms of therapy. Concomitant therapy was frequently used for psychoses and bipolar disorder. Logistic regression revealed that the odds of receiving concomitant antipsychotic therapy were higher for patients younger than 65 years, with greatest odds (odds ratio=6.52) for patients 40 to 64 years old. Having a diagnosis of psychosis quadrupled (odds ratio=4.33) the odds of receiving concomitant antipsychotic therapy. Physicians in metropolitan areas were more likely (odds ratio=2.17) to use concomitant antipsychotic therapy than physicians in non-metropolitan areas.

CONCLUSIONS

Concomitant antipsychotic therapy continues to be prevalent and extensive in outpatient settings. With the use of concomitant antipsychotic therapy as a quality of care measure, there is a need to optimize prescribing of these potent combinations.

Atypical antipsychotic drugs and the risk of sudden cardiac death

BACKGROUND

Users of typical antipsychotic drugs have an increased risk of serious ventricular arrhythmias and sudden cardiac death. However, less is known regarding the cardiac safety of the atypical antipsychotic drugs, which have largely replaced the older agents in clinical practice.

METHODS

We calculated the adjusted incidence of sudden cardiac death among current users of antipsychotic drugs in a retrospective cohort study of Medicaid enrollees in Tennessee. The primary analysis included 44,218 and 46,089 baseline users of single typical and atypical drugs, respectively, and 186,600 matched nonusers of antipsychotic drugs. To assess residual confounding related to factors associated with the use of antipsychotic drugs, we performed a secondary analysis of users of antipsychotic drugs who had no baseline diagnosis of schizophrenia or related psychoses and with whom nonusers were matched according to propensity score (i.e., the predicted probability that they would be users of antipsychotic drugs).

RESULTS

Current users of typical and of atypical antipsychotic drugs had higher rates of sudden cardiac death than did nonusers of antipsychotic drugs, with adjusted incidence-rate ratios of 1.99 (95% confidence interval [CI], 1.68 to 2.34) and 2.26 (95% CI, 1.88 to 2.72), respectively. The incidence-rate ratio for users of atypical antipsychotic drugs as compared with users of typical antipsychotic drugs was 1.14 (95% CI, 0.93 to 1.39). Former users of antipsychotic drugs had no significantly increased risk (incidence-rate ratio, 1.13; 95% CI, 0.98 to 1.30). For both classes of drugs, the risk for current users increased significantly with an increasing dose. Among users of typical antipsychotic drugs, the incidence-rate ratios increased from 1.31 (95% CI, 0.97 to 1.77) for those taking low doses to 2.42 (95% CI, 1.91 to 3.06) for those taking high doses (P<0.001). Among users of atypical agents, the incidence-rate ratios increased from 1.59 (95% CI, 1 .03 to 2.46) for those taking low doses to 2.86 (95% CI, 2.25 to 3.65) for those taking high doses (P=0.01). The findings were similar in the cohort that was matched for propensity score.

CONCLUSIONS

Current users of typical and of atypical antipsychotic drugs had a similar, dose-related increased risk of sudden cardiac death.

Prevalence, correlates, and disease patterns of antipsychotic use in Taiwan

AIM

The population-based National Health Insurance database was used to investigate the prevalence, correlates, and disease patterns of antipsychotic use in Taiwan.

METHODS

The National Health Research Institutes provided a database of 200,000 random subjects for study. A random sample of 145 304 subjects was obtained, aged > or =18 years in 2004. Study subjects who had been given at least two antipsychotic drug prescriptions during this year were identified. The factors associated with any antipsychotic use were identified. The proportion of antipsychotic use for psychiatric and non-psychiatric disorders was also examined.

RESULTS

The 1-year prevalence of antipsychotic use was 3.5%. Antipsychotic use was found to be more prevalent by age; for women; for individuals with a lower insurance amount; for individuals with disability; and among those subjects who lived in the central or southern area. Among subjects with antipsychotic use, higher proportions of psychiatric disorders were found for schizophrenia, anxiety state, major depressive disorder, neurotic depression, dementia, and bipolar disorder. With respect to medical disorder, higher proportions of antipsychotic use were found for diseases of the digestive system; symptoms, signs, and ill-defined conditions; diseases of the respiratory system, musculoskeletal system and connective tissue, circulatory system, nervous system and sense organs, and genitourinary system.

CONCLUSIONS

Higher proportions of antipsychotic use were found for schizophrenia, depressive disorder, anxiety disorder, dementia, and bipolar disorder. More than 60% of subjects used antipsychotics for non-psychiatric disorders in Taiwan, which deserves further study for the sake of patient safety.

Antipsychotic prescriptions in a university hospital outpatient population in Turkey: a retrospective database analysis, 2005-2006

OBJECTIVE

The aim of this study is to document the sociodemographic and the clinical profile of patients who are on antipsychotic (AP) medication prescribed in outpatient mental health clinic of a university hospital.

METHODS

A retrospective chart review was conducted for all outpatient files between 2005 and 2006 at the Zonguldak Karaelmas University, Medical Faculty Hospital, Department of Psychiatry in Turkey. All patients prescribed AP with regular follow up were recruited for the study. The type of AP and the route of administration were recorded. The diagnosis, age and gender of the patients were also evaluated.

RESULTS

We reviewed 1606 patients' files. APs were prescribed in 27.6% of the patients. Atypical antipsychotics (AAPs) represented 75.1% and typical antipsychotics (TAPs) represented 24.9% of all antipsychotic prescriptions in our study. The main psychiatric diagnoses associated with a TAP prescription were: psychotic disorders (6.5%), major affective disorders (49.5%), anxiety disorders (36.4%), and other psychiatric diseases (7.4%). The main psychiatric diagnoses associated with an AAP prescription were: psychotic disorders (35.1%), major affective disorders (31.1%), anxiety disorders (27.8%), somatoform disorders (2.4%) and other psychiatric diseases (6.4%). Twenty-eight of these patients (6.3%) were prescribed more than one AP, 45 patients were prescribed mood stabilizer (10.2%) and 272 patients were prescribed antidepressant agents (61.2%) in addition to AP.

CONCLUSIONS

The results reflect the particular use of AAPs in present study population. In line with the published data, the results of this study show that AAPs and TAPs are widely used in those with major affective disorders and psychotic disorders. These findings also underline the widespread off-label use of APs in the treatment of other psychiatric disorders.

Antipsychotic use at adult ambulatory care visits by patients with mental health disorders in the United States, 1996-2003: national estimates and associated factors

OBJECTIVES

This retrospective analysis was conducted to derive national estimates of typical, atypical, and combination (typical-atypical) antipsychotic use and to examine factors associated with their use at adult (age >>-18 years) ambulatory care visits by patients with mental health disorders in the United States.

METHODS

Data on adult visits with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a mental health disorder were extracted from the office-based National Ambulatory Medical Care Survey and the outpatient facilitybased National Hospital Ambulatory Medical Care Survey from 1996 through 2003. The visits were categorized according to whether use of a typical, atypical, or combination antipsychotic was mentioned (either prescribed, supplied, administered, ordered, or continued at the visits). Total weighted visit estimates, weighted visit percentages, and 95% CIs were calculated across the 3 types of visit groups. Bivariate analysis was performed on the association between selected characteristics and the 3 visit groups. Multivariate logistic regression was performed on factors associated with atypical versus typical antipsychotic use.

RESULTS

During the 8-year period, there were an estimated 47.7 million adult ambulatory care visits involving a mental health disorder and mention of an antipsychotic (weighted percent: 0.83%; 95% CI, 0.73-0.93). From 1996/1997 to 2002/2003, visits involving atypical and combination antipsychotics increased by 195% and 149%, respectively, and visits involving typical antipsychotics decreased by 71%. Men, blacks, and those with public insurance made more visits in which combination antipsychotics rather than typical or atypical antipsychotics were mentioned. Relative to typical or combination antipsychotic visits, more atypical antipsychotic visits involved antide-pressants (weighted percent: 61.23% atypical, 37.29% typical, and 38.32% combination). Fewer atypical antipsychotic visits compared with typical or combination antipsychotic visits involved psychotic disorders (weighted percent: 32.94%, 51.23%, and 69.93%, respectively) and medications for extrapyramidal symptoms (weighted percent: 6.69%, 29.95%, and 36.64%). In multivariate analyses controlling for sex, race, diagnosis of schizophrenia, region, diagnosis of anxiety, and recent years, atypical versus typical antipsychotic use was significantly less likely at visits by those aged 41 to 64 years compared with those aged 18 to 40 years (adjusted odds ratio [OR] = 0.63; 95% CI, 0.47-0.84; P = 0.002); significantly less likely at visits by those with public compared with private insurance (Medicare OR = 0.59 [95% CI, 0.40-0.88], P = 0.010; Medicaid OR = 0.44 [95% CI, 0.28-0.69], P < 0.001); and significantly more likely at visits associated with depression compared with those not associated with depression (OR = 1.92; 95% CI, 1.26-2.93; P = 0.003) and those associated with bipolar disorder compared with those not associated with bipolar disorder (OR = 2.10; 95% CI, 1.32-3.36; P = 0.002).

CONCLUSIONS

This retrospective analysis found more atypical than typical or combination antipsychotic use at US ambulatory care visits by adults with mental health disorders other than schizophrenia or psychoses in the period studied. Atypical versus typical antipsychotic use was significantly less likely at visits by adults aged 41 to 64 years and those with public insurance, but significantly more likely at visits by those with depression or bipolar disorder.

Aripiprazole-related tardive dyskinesia

The low prevalence of extrapyramidal symptoms associated with atypical antipsychotics has led to their widespread use during the past decade. Aripiprazole, the newest medication in this class, has been associated with extrapyramidal symptoms (eg, akathisia) and with improvement of tardive dyskinesia (TD), but to date it has not been associated with the development of TD. We report a case of TD associated with the use of aripiprazole 15 mg/day for 18 months for refractory depression. Symptoms of TD resolved within several weeks of discontinuation of aripiprazole.