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

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.

Antipsychotics prescribing patterns of patients with schizophrenia admitted to korean general hospital psychiatric unit: 2001 to 2008

Objective

Although the standard of treatment for schizophrenia is antipsychotic monotherapy, overall psychotropic polypharmacy including antipsychotic polypharmacy is increasingly practiced by clinicians. However, there are very few studies that assess the prescription patterns of psychotropic drugs for patients with schizophrenia in Korea. The objective of this study is to describe changes in prescription patterns with respect to antipsychotic polypharmacy and overall psychotropic polypharmacy.

Methods

In this retrospective study, we reviewed all psychotropic drugs prescribed at the time of discharge for patients diagnosed as having schizophrenia (DSM-IV criteria) who entered a psychiatric unit of a Korean general hospital from 2001 to 2008. These included a total of 467 patients.

Results

Of the 467 patients in this study, 205 (43.9%) were discharged with antipsychotic monotherapy and the rest, 262 (56.1%), were discharged with a polypharmacy regimen. A total of 9% of the studied patients received more than two antipsychotic drugs. The most frequent combination of antipsychotics was clozapine and aripiprazole, followed by clozapine and amisulpride, and risperidone and olanzapine. The ratio of patients discharged with a polypharmacy regimen including antipsychotic polypharmacy increased from 2001 to 2008. In relation to the mean dose of all antipsychotic drugs at the time of discharge, mean length of hospital stay and mean initial global assessment of functioning scores on admission statistically significant differences were not detected between both monotherapy and polypharmacy groups.

Conclusion

The main finding of this study is that polypharmacy with antipsychotics and other psychotropic medicines increased in our psychiatric unit from 2001 to 2008. The rates of antipsychotic polypharmacy in our study were less than those described in our literature review.

Retrospective case series of aripiprazole augmentation in pervasive developmental disorders

Due to co-morbidities and treatment resistant nature of pervasive developmental disorder (PDD), diverse combinations of regimens have been tried. This retrospective study aimed to explore adjunctive use of aripiprazole in children with PDD. Changes in illness severity were measured by Clinical Global Impression of Severity (CGI-S) and Clinical Global Impression of Improvement (CGI-I) in 14 aripiprazole-treated patients with PDD. Improvement of illness severity was observed after aripiprazole add-on (5.8±0.8 to 4.9±1.0, Z=-2.75, p=0.001). Mean dosage was 7.7 mg/day [standard deviation (SD) 3.3, range 5-15]. A higher mean dosage was observed in group with improvement in symptoms (t=-2.33, df =12, p=0.004). The target symptoms most effectively improved after using aripiprazole were positive psychotic symptoms (mean CGI-I: 2.0±1.4, 3 responders/4 patients, 75% response) followed by aggressive behavior (2.5±1.7, 3/4, 75%), self-injurious behavior (2.0±1.0, 2/3, 67%), stereotypic behavior (2.7±1.2, 2/3, 67%), tic (2.8±1.0, 2/4, 50%), irritability (3.5±2.1, 1/2, 50%), obsessive behavior (2.5±2.1, 1/3, 33%), hyperactivity (3.4±1.6, 3/7, 43%) and mood fluctuation (3, 0/1, no response). Five patients (35%) discontinued aripiprazole due to treatment-emergent adverse effects (akathisia, insomnia, withdrawal). The results of this study suggest that aripiprazole augmentation may be used safely in maladaptive behaviors of some populations of PDD. However, future studies are required to confirm these preliminary findings.