Antipsychotic Medication Utilization Trends Among Texas Veterans: 1997–2002

Predictors of antipsychotics switching among ambulatory patients with schizophrenia in Ethiopia: a multicenter hospital-based cross-sectional study

INTRODUCTION

A change of therapy from one to another antipsychotic medication is currently the main challenge of therapy. This study aimed to assess the prevalence of antipsychotic medication switches and determinants among patients with schizophrenia in Northwest Ethiopia.

METHODS

Multi-center hospital-based cross-sectional study was conducted at five Comprehensive Specialized Hospitals found in Northwest Ethiopia from April 30, 2021, to August 30, 2021. Data were extracted from both patients' medical charts and interviews. Data were entered into Epi-data software version 3.5.1 and exported to SPSS version 25.0 for analysis. A multivariable logistic regression model was fitted to identify factors associated with medication regimen switch. The level of significance of the study was kept at a p-value of 0.05 with a 95% confidence interval.

RESULT

A total of 414 patients are involved in the study, and 188 (45.5%) of patients switched antipsychotics within one year. The unavailability of the medication is the commonest reason for switching. Being male [AOR = 2.581, 95% CI (1.463, 4.552)], having relapse [AOR = 2.341,95% CI (1.169,4.687)], history of hospitalization in the past year [AOR = 3.00,95% CI (1.478,5.715)] and taking typical antipsychotics [AOR = 3.340, CI (1.76, 6.00)] had a significant association with antipsychotics switching.

CONCLUSIONS AND RECOMMENDATIONS

There is a high prevalence of antipsychotic switches among schizophrenia patients. Prescribers need to be careful while dosing, selecting, and switching antipsychotics, hence may help reduce discontinuation and unnecessary switch and thus achieve optimal clinical management.

Off-label antipsychotic use patterns among Texas Medicaid adults 2013-2016

Aim: To describe trends in off-label antipsychotic use among Texas Medicaid adults and examine whether demographic and clinical characteristics were associated with off-label use. Methods: Three diagnostic groups (i.e. no diagnosis, on label and off-label) were created based on mental health disorder diagnoses and related antipsychotic prescriptions. Results: During 2013-2016, the prevalence of off-label antipsychotic use decreased from 22.5% to 17.4% and the proportions of no mental health diagnosis remained stable (7.3-9.4%). Patients aged ≥25 years and second-generation antipsychotic users had significantly lower odds of receiving antipsychotics off-label or with no diagnosis. Conclusion: Compared with previous Medicaid database studies, the proportions of off-label antipsychotic use and antipsychotic use with no concurrent psychiatric diagnosis were notably lower.

Prescription patterns of antipsychotics in the management of first episode psychosis at three psychiatric hospitals in Khartoum, 2018: A descriptive cross-sectional study

BACKGROUND

First-Episode Psychosis (FEP) is defined as the first treatment contact with psychiatric service, regardless of the duration of symptoms. This study aims to determine the antipsychotics prescription patterns in FEP patients at three psychiatric hospitals in Khartoum.

METHOD

A descriptive cross-sectional retrospective hospital-based study was conducted at Eltigani Elmahi, Taha Baasher, and Abd Elaal Aledrissi Psychiatric hospitals in Khartoum State, Sudan, during the period March to July 2018. Medical records of patients with FEP were identified and reviewed to look for demographic data, the onset of symptoms, investigations requested, and medications prescribed. Data were recorded and subjected to statistical analysis using the Statistical Package for Social Sciences.

RESULT

Reviewing the medical records of the 98 FEP patients (66 males and 32 females) included in the study showed that the majority of patients (94.8%) were medicated with combinations of psychotropic medications. The most commonly used combination was Haloperidol, Olanzapine, Promethazine, and Benzodiazepines. And only 5.1% of the whole population was treated with an atypical antipsychotic (Olanzapine) as a monotherapy.

CONCLUSION

Based on prescription patterns and requested investigations, there was a wide gap between the actual practice regarding antipsychotics prescriptions for FEP at the three psychiatric hospitals and the evidence-based guidelines in this respect.

Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases

Purpose

Despite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization.

Methods

A descriptive cross-sectional cohort study of Nova Scotia Seniors’ Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Abstract Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated.

Findings

We identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis.

Implications

In each year from 2009 to 2014, 6% of Nova Scotia Seniors’ Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.

Changing Trends in Treatment of Acute Mania: Experience of a Tertiary Centre Over a Decade

We investigated trends over a decade in the prescription of lithium, antiepileptics, and antipsychotic agents at discharge for patients hospitalised for acute mania. We conducted a retrospective review of medical records for 165 inpatients with acute mania who had been hospitalised in Cerrahpaşa Faculty of Medicine, Department of Psychiatry during 2001-2002 and 2011-2012. Among 165 patients, prescription of olanzapine at discharge increased from 3 to 46 % (p < 0.001), while prescription of haloperidol decreased from 55 to 21 % (p < 0.001). Use of other atypical antipsychotics did not change significantly (risperidone decreased from 14 to 11 %, p = 0.5; quetiapine increased from 10 to 16 %, p = 0.2). Use of valproate, carbamazepine, and lithium did not change significantly. Use of electroconvulsive therapy in acute mania decreased by half from 27 to 13 % (p = 0.02). Typical antipsychotics alone or in combination with antiepileptics were the most common treatment regimen at discharge at 2001-2002; while 10 years later, they had been largely replaced by lithium or antiepileptics combined with second generation antipsychotics. Antipsychotic agents remained to be an important component of acute treatment of mania in our practice.

Utilization of Psychopharmacological Treatment Among Patients With Newly Diagnosed Bipolar Disorder From 2001 to 2010

OBJECTIVE

The aim of the study was to examine utilization and patterns of psychopharmacological treatment during a 1-year follow-up period among patients with newly diagnosed bipolar disorder from 2001 to 2010.

METHODS

Patients with newly diagnosed bipolar disorder from 2001 to 2010 were identified from the National Health Insurance Research Database in Taiwan. We assessed prescription records related to 4 kinds of psychopharmacological medication, including antipsychotics (APs), antidepressants, mood stabilizers, and benzodiazepines, as well as health care utilization in a 1-year follow-up period among the study subjects. In addition, logistic regressions were applied to test the trends for utilization of psychopharmacological treatment during the 10-year study period.

RESULTS

A total of 2703 patients newly diagnosed with bipolar disorder were enrolled. The ratio of good adherence, defined as medications possession ratio greater than 0.8, for use of the examined psychopharmacological medication was relatively low during the study period. The use of first-generation APs, selective serotonin reuptake inhibitors, tricyclic antidepressants, lithium, carbamazepine, and benzodiazepines has declined; however, the use of second-generation APs, serotonin and norepinephrine reuptake inhibitors, lamotrigine, and valproate has risen markedly during the 10-year period.

CONCLUSIONS

This study presents patterns of pharmacological treatment in patients with newly diagnosed bipolar disorder in Taiwan for a 10-year study period. It would be of importance to further investigate causes and outcomes for polytherapy and nonadherence to psychotropic medications among patients with bipolar disorder.

The Ascendancy of Second-Generation Antipsychotics as Frontline Antimanic Agents

INTRODUCTION

Knowledge of the factors affecting the adoption of new medications can enhance mental health care and guide quality improvement and policy development. Food and Drug Administration indications for treating bipolar disorder with several second-generation antipsychotics (SGAs) in the 2000s represent an opportunity to identify factors that impact the spread of a then-innovative treatment through a new population.

METHODS

Analysis of Department of Veterans Affairs administrative data identified the population of 170,811 veterans diagnosed with bipolar disorder from 2003 to 2010. We analyzed time trends and predictors of antimanic choice (SGA vs other) among the 40,512 outpatients with bipolar disorder who initiated their first VA outpatient antimanic prescription, using multinomial logistic regression in month-by-month analyses. We conducted classwise analyses and investigated prespecified predictors among specific agents.

RESULTS

In classwise analyses, SGAs supplanted lithium, valproate, and carbamazepine/oxcarbazepine as the most commonly initiated antimanics by 2007. Psychosis, but not other indices of severity, predicted SGA initiation. Demographic analyses did not identify substantial disparities in initiation of SGAs. Drug-specific analyses revealed some consideration of medical comorbidities in choosing among specific antimanic agents, although effect sizes were small. Most patients initiating an antimanic had received an antidepressant in the previous year.

DISCUSSION

Second-generation antipsychotics quickly became the frontline antimanic treatment for bipolar disorder, although antidepressants most commonly predated antimanic prescriptions. Second-generation antipsychotics were used for a broad range of patients rather than being restricted to a severely ill subpopulation. The modest association of antimanic choice with relevant medical comorbidities suggests that continued attention to quality prescribing practices is warranted.

Antipsychotic Prescribing Patterns in First-episode Schizophrenia: A Five-year Comparison

OBJECTIVE

Early treatment choice is critical in first-episode schizophrenia-spectrum disorders. The purpose of this study was to describe prescribing trends of antipsychotics use in patients with first-episode schizophrenia in 2005 and 2010, respectively.

METHODS

We reviewed the medical records of newly treated patients with schizophrenia from a university psychiatric hospital in 2005 (n=47) and 2010 (n=52). We defined patients as receiving a high antipsychotic dose if their ratio of prescribed daily dose (PDD) to defined daily dose (DDD) was greater than 1.5.

RESULTS

The rates of high-dose antipsychotic prescription were 61.7% and 53.8% in 2005 and 2010, respectively. The rates of antipsychotic polypharmacy were 34.6% in 2005 and 34.0% in 2010. The most common first-prescribed antipsychotics were (in descending order of prescription frequency) olanzapine, risperidone, aripiprazole, and haloperidol in 2005 and risperidone, quetiapine, paliperidone, and olanzapine in 2010. High-dose antipsychotics were significantly associated with antipsychotic polypharmacy (odds ratio=23.97; p<0.01). More individuals were treated with mood stabilizers in 2010 than in 2005 (p=0.003).

CONCLUSION

The practice of prescribing high-dose antipsychotics and associated antipsychotic polypharmacy were common even for initial treatment of first-episode schizophrenia in 2005 and 2010. In 2010, the list of the most common first-prescribed antipsychotics changed, and the use of mood stabilizers increased in non-affective schizophrenia.

Increased Silent Brain Infarction Accompanied With High Prevalence of Diabetes and Dyslipidemia in Psychiatric Inpatients: A Cross-Sectional Study

OBJECTIVE

Patients with schizophrenia have increased risk of atherosclerotic diseases. It is already known that lifestyle-related disorders and the use of antipsychotics are closely related with the progression of atherosclerosis in psychiatric patients. Stroke as well as coronary heart disease play an important role in the cause of death in Asia and Japan. Thus, we studied the prevalence of cerebrovascular disease in psychiatric inpatients in Japan using brain magnetic resonance imaging (MRI).

METHOD

This cross-sectional study was performed from January 2012 to December 2013. Study participants were 152 hospitalized patients (61 men and 91 women) in the Department of Psychiatry at Kohnodai Hospital, National Center for Global Health and Medicine, Ichikawa City, Japan. Mean ages were 50.0 and 57.1 years old for men and women, respectively. The diagnoses (DSM-IV-TR criteria) of participants were schizophrenia (69.1%), mood disorder (18.4%), and other mental disorders (12.5%). We checked physical status, metabolic status of glucose and lipid levels, and brain MRI within 1 week of admission.

RESULTS

The study group showed a significantly high prevalence of diabetes and low high-density lipoprotein (HDL) cholesterolemia in both sexes (n = 61 in men, n = 91 in women, P < .05). In the study group, serum fasting plasma glucose and hemoglobin A1c levels were significantly high (n = 152, P < .05), but serum HDL cholesterol and total cholesterol were significantly low in both sexes (n = 61 in men, n = 90 in women, P < .05), and triglycerides were low in men (n = 61, P < .05). Silent brain infarction was recognized at a higher rate (n = 98, P < .05) compared with healthy controls.

CONCLUSIONS

Participants in this study had an increased ratio of silent brain infarction compared with Japanese healthy controls, accompanied with higher ratios of diabetes and low HDL cholesterol.

Patterns of initiation of second generation antipsychotics for bipolar disorder: a month-by-month analysis of provider behavior

BACKGROUND

Several second generation antipsychotics (SGAs) received FDA approval for bipolar disorder in the 2000s. Although efficacious, they have been costly and may cause significant side effects. Little is known about the factors associated with prescribers' decisions to initiate SGA prescriptions for this condition.

METHODS

We gathered administrative data from the Department of Veterans Affairs on 170,713 patients with bipolar disorder between fiscal years 2003-2010. Patients without a prior history of taking SGAs were considered eligible for SGA initiation during the study (n =126,556). Generalized estimating equations identified demographic, clinical, and comorbidity variables associated with initiation of an SGA prescription on a month-by-month basis.

RESULTS

While the number of patients with bipolar disorder using SGAs nearly doubled between 2003 and 2010, analyses controlling for patient characteristics and the rise in the bipolar population revealed a 1.2% annual decline in SGA initiation during this period. Most medical comorbidities were only modestly associated with overall SGA initiation, although significant differences emerged among individual SGAs. Several markers of patient severity predicted SGA initiation, including previous hospitalizations, psychotic features, and a history of other antimanic prescriptions; these severity markers became less firmly linked to SGA initiation over time. Providers in the South were somewhat more likely to initiate SGA treatment.

CONCLUSIONS

The number of veterans with bipolar disorder prescribed SGAs is rising steadily, but this increase appears primarily driven by a corresponding increase in the bipolar population. Month-by-month analyses revealed that higher illness severity predicted SGA initiation, but that this association may be weakening over time.

Trends in pharmacotherapy in patients referred to a bipolar specialty clinic, 2000-2011

OBJECTIVE

To assess mood stabilizer (MS) and second-generation antipsychotic (SGA) prescribing trends in bipolar disorder (BD) outpatients referred to a bipolar disorder specialty clinic over the past 12 years.

METHOD

BD outpatients referred to the Stanford University Bipolar Disorder Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation. Prescription rates for MSs and SGAs were compared during the first (2000-2005) and second (2006-2011) six years.

RESULTS

Among 597 BD patients (mean±SD age 35.4±8.6 years; 58.1% female; 40.7% Type I, 43.6% Type II, and 15.7% Type Not Otherwise Specified; taking 2.6±1.7 prescription psychotropic medications), lamotrigine, quetiapine, and aripiprazole usage more than doubled, from 14.7% to 37.2% (p<0.0001), 7.2% to 19.7% (p<0.0001), and 3.1% to 10.9% (p=0.0003), respectively, while olanzapine and risperidone use decreased by more than half from 15.0% to 6.6% (p=0.0043), and from 8.7% to 3.8% (p=0.039), respectively. SGA use increased from 34.1% to 44.8% (p=0.013), although MS use continued to be more common (in 65.2% for 2006-2011). Use of other individual MSs and SGAs and MSs as a class did not change significantly.

CONCLUSIONS

Over 12 years, in patients referred to a BD specialty clinic, lamotrigine, quetiapine, and aripiprazole use more than doubled, and olanzapine and risperidone use decreased by more than half. Tolerability (for lamotrigine, aripiprazole, olanzapine, and risperidone) more than efficacy (for quetiapine) differences may have driven these findings. Additional studies are needed to explore the relative influences of enhanced tolerability versus efficacy upon prescribing practices in BD patients.

Off-label use of second generation antipsychotics for post-traumatic stress disorder in the Department of Veterans Affairs: time trends and sociodemographic, comorbidity, and regional correlates

PURPOSE

Second generation antipsychotics (SGAs) are widely used for post-traumatic stress disorder (PTSD), although without strong evidence base. With substantial numbers of veterans returning from Iraq/Afghanistan conflicts with PTSD, it is important to characterize the extent of SGA use and identify associated factors.

METHODS

We determined time trends and patient characteristics associated with the use of SGAs in veterans with PTSD, without comorbid schizophrenia or bipolar disorders, using the Department of Veterans Affairs national administrative data 2003-2010.

RESULTS

Among 732,085 veterans with PTSD, 27.6% received an intentional trial of an SGA in 2003-2010. The annual number treated with SGAs almost doubled (45,268 to 84,197, p < 0.001), while prescribing rates decreased (28.6% to 21.5%, p < 0.001). In multivariate analyses, African Americans (odds ratio (OR) = 1.07, 95%confidence interval (CI) = 1.06-1.09) and Hispanics (OR = 1.13, 95%CI = 1.10-1.17) were more likely to receive SGAs than Whites. Strongest clinical associations were with prior diagnosis of depression (OR = 1.96; 95%CI = 1.94-1.99), substance use disorders (OR = 1.86; 95%CI = 1.84-1.88), and other anxiety disorders (OR = 1.27; 95%CI = 1.26-1.29) (all p - < 0.0001) as well as cardiovascular risk factors. Veterans previously deployed to Iraq/Afghanistan had lower likelihood of SGA receipt. Substantial regional differences were demonstrated (South > Northeast; Midwest and West < Northeast; p < 0.0001); regional administrative units (veterans integrated service networks) contributed minimally to regional differences.

CONCLUSIONS

Post-traumatic stress disorder population growth is driving substantial increases in SGA use. Decreasing rates of the Department of Veterans Affairs prescribing may be due to integrated system-wide mechanisms (e.g., national practice guidelines), although regional variations remain prominent. These analyses provide foundational steps for identifying modifiable provider-level and organization-level determinants of SGA prescription in this growing population.

Epidemiology and treatment of mood disorders in a day hospital setting from 1996 to 2007: an Italian study

BACKGROUND

THE PRESENT STUDY AIMED: to assess prescribing patterns in the treatment of major depression, bipolar disorder type I, cyclothymia, and dysthymia from 1996 to 2007 in a day hospital setting; to evaluate the prevalence of the above-mentioned mood disorders and gender distribution; and to relate familiality, comorbidity, and marital status to each diagnosis.

METHODS

Medical records for 777 day hospital patients with a diagnosis of major depression, bipolar disorder type I, cyclothymia, or dysthymia were grouped into two 6-year periods so as to compare the prescribing patterns of tricyclic antidepressants, selective serotonin reuptake inhibitors, noradrenergic reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, noradrenergic and specific serotonergic antidepressants, first-generation antipsychotics, second-generation antipsychotics, and mood stabilizers. Gender, prevalence, familiality, comorbidity, and marital status were related to each diagnosis.

RESULTS

The most common mood disorder, with a female preponderance, was major depression, regardless of marital status. High percentages of familiality and comorbidity were found for major depression, while a reduction was found in the utilization of tricyclic antidepressants. There was no statistically significant difference in rates of prescription of selective serotonin reuptake inhibitors and noradrenergic reuptake inhibitors, but some irregularities were found upon evaluating each diagnosis (eg, increased utilization of these agents in dysthymia and major depression, respectively). There was an increase in prescriptions for serotonin and norepinephrine reuptake inhibitors, but no marked differences in utilization of noradrenergic and specific serotonergic antidepressants, which remained basically low. There was no significant difference in prescribing of first-generation antipsychotic agents, although a reduction was found. There was a significant increase in utilization of second-generation antipsychotics and mood stabilizers.

CONCLUSION

Our epidemiological findings are consistent with data reported in the literature regarding the high prevalence of major depression among the mood disorders, as well as the impact of familiality and comorbidity. Analysis of prescribing patterns for antidepressants, antipsychotics, and mood stabilizers in the treatment of mood disorders shows a shift from older to newer drugs, and wider use of mood stabilizers.

Subtypes of antipsychotics and suicidal behavior in bipolar disorder

OBJECTIVE

Antipsychotics are commonly used in bipolar disorder, with newer (SGA) agents increasingly replacing FGA antipsychotics, particularly in bipolar depression. There are few data on differences between FGA and SGA antipsychotics in terms of their relationship to suicidal behavior in bipolar disorder.

METHOD

This was a retrospective chart review of 161 bipolar veterans treated naturalistically with antipsychotics at a university-affiliated VA hospital and clinics for up to 8 years. Charts were reviewed to determine monthly antipsychotic use and occurrence of suicidal behavior: completed suicide, attempted suicide or hospitalization to prevent suicide. Suicidal behavior events were compared across patients during treatment with individual antipsychotics and FGAs or SGAs as a class.

RESULTS

Non-lethal suicide events were more common during FGA than SGA monotherapy (9 events/110 months of exposure vs. 6 events/381 months of exposure; χ(2)=9.65, p=0.002). Suicide event rates did not differ between FGAs and SGAs when used in conjunction with mood stabilizers. Event rates were lower with lithium than anticonvulsants when used in conjunction with antipsychotics. No differences were found between olanzapine, risperidone and quetiapine.

LIMITATIONS

The retrospective chart review methodology may have led to confounding by indication and diagnostic inaccuracy. No completed suicides occurred. Study participants were primarily male veterans. Results may not be generalizable to SGAs marketed since 2003.

CONCLUSIONS

FGA antipsychotic monotherapy may be associated with higher suicidal behavior risk than SGA antipsychotic monotherapy. Antipsychotics used in conjunction with mood stabilizers, particularly lithium, are associated with lower rates, independent of antipsychotic subtype.

Antipsychotic polypharmacy in a regional health service: a population-based study

BACKGROUND

To analyse the extent and profile of outpatient regular dispensation of antipsychotics, both in combination and monotherapy, in the Barcelona Health Region (Spain), focusing on the use of clozapine and long-acting injections (LAI).

METHODS

Antipsychotic drugs dispensed for people older than 18 and processed by the Catalan Health Service during 2007 were retrospectively reviewed. First and second generation antipsychotic drugs (FGA and SGA) from the Anatomical Therapeutic Chemical classification (ATC) code N05A (except lithium) were included. A patient selection algorithm was designed to identify prescriptions regularly dispensed. Variables included were age, gender, antipsychotic type, route of administration and number of packages dispensed.

RESULTS

A total of 117,811 patients were given any antipsychotic, of whom 71,004 regularly received such drugs. Among the latter, 9,855 (13.9%) corresponded to an antipsychotic combination, 47,386 (66.7%) to monotherapy and 13,763 (19.4%) to unspecified combinations. Of the patients given antipsychotics in association, 58% were men. Olanzapine (37.1%) and oral risperidone (36.4%) were the most common dispensations. Analysis of the patients dispensed two antipsychotics (57.8%) revealed 198 different combinations, the most frequent being the association of FGA and SGA (62.0%). Clozapine was dispensed to 2.3% of patients. Of those who were receiving antipsychotics in combination, 6.6% were given clozapine, being clozapine plus amisulpride the most frequent association (22.8%). A total of 3.800 patients (5.4%) were given LAI antipsychotics, and 2.662 of these (70.1%) were in combination. Risperidone was the most widely used LAI.

CONCLUSIONS

The scant evidence available regarding the efficacy of combining different antipsychotics contrasts with the high number and variety of combinations prescribed to outpatients, as well as with the limited use of clozapine.

Trends in treatment of newly treated schizophrenia-spectrum disorder patients in Taiwan from 1999 to 2006

PURPOSE

This study aimed to examine trends in the first-year pharmacological treatment of newly treated schizophrenia patients in Taiwan between 1999 and 2006.

METHOD

We collected data from the National Health Insurance Research Database of all newly treated patients with a diagnosis of schizophrenia-spectrum disorder (ICD-9 295.x). We analyzed all prescription records after diagnosis of schizophrenia and described the patterns of antipsychotics use, other concomitant psychotropic agents use, and mental health system utilization. We tested for trend using multivariate logistic regression and Spearman's partial correlation rank test.

RESULTS

A total of 2895 newly treated patients with schizophrenia were enrolled. The percentage of prescriptions of second-generation antipsychotics (SGAs) was found to have increased significantly, from 27.5% in 1999 to 76.9% in 2006. The ratio of good antipsychotics adherence (medication possession ratio >0.8) also increased, from 23.2% in 1998 to 38.9% in 2006. Corresponding to this, the percentage of usage of first-generation antipsychotic drugs, anticholinergic agents, and long-term combination therapy declined. However, the prescription of antidepressants and mood stabilizers and the hospitalization rate increased. No change was noted in the number of psychiatric visits.

CONCLUSION

In the first-year treatment of newly treated schizophrenic patients between 1999 and 2006, we found pharmacological treatment had changed in terms of types of antipsychotics, adherence, and the use of other concomitant psychotropic agents, with the introduction of SGAs. The benefits and costs of the changes with a trend toward an increasing prescription of SGAs warrant further investigation.

The impact of atypical antipsychotic use on obstructive sleep apnea: a pilot study and literature review

BACKGROUND

Limited evidence links atypical antipsychotics (AAs) use to sleep related respiratory dysfunction and greater severity of obstructive sleep apnea (OSA). The present paper reviews the published evidence and examines the impact of AA use on the presence and severity of OSA among subjects with clinically suspected OSA after adjusting for several confounds.

METHODS

Archives of the University of Iowa Sleep Laboratory from 2005 to 2009 were searched for patients using AAs at the time of diagnostic polysomnogram (PSG). PSG data of the 84 AA users with heterogeneous psychiatric disorders (of these 20 diagnosed only with depression) were subsequently compared to PSG data of two randomly selected, non-AA user groups from the same patient pool: (i) 200 subjects with a depressive disorder as the only psychiatric diagnosis, and (ii) 331 mentally healthy controls. PSG data were analyzed adjusting for known demographic, medical, and psychiatric risk factors for OSA.

RESULTS

Prevalence and severity of OSA did not differ significantly across three groups. Sex, age, body mass index (BMI), and neck circumference (NC) independently predicted OSA. Odds ratio for OSA in the subset of AA users carrying the diagnosis of depression (n=20) compared with subjects without mental illness was 4.53 (p<.05). By contrast, AA users without depression or those with multiple psychiatric diagnoses including depression did not show a statistically significantly elevated OSA risk.

CONCLUSIONS

AA use in subjects with depression appears to increase the risk of OSA after controlling for known predisposing factors.

Modeling chronic olanzapine exposure using osmotic minipumps: pharmacological limitations

Animal models can face unique challenges in mirroring what occurs in humans. This is the case for antipsychotics in rodents, where these drugs are metabolized much more rapidly. One strategy to address this issue has been the use of osmotic minipumps to ensure continuous antipsychotic exposure over prolonged intervals, which is routinely the case when these same drugs are administered to humans. More recently, it has been identified that with olanzapine this approach may be compromised by oxidative degradation, a process that can be observed within days. Further, in vivo evidence has reported progressive decreases in plasma levels over a 1-month interval. To address this issue in vitro, osmotic minipumps (n=4), with olanzapine at a concentration resulting in a dose of 7.5mg/kg/day in vivo, were placed in saline-filled Falcon tubes and immersed in a water bath. Olanzapine concentrations were assessed in the minipumps as well as the surrounding water bath at baseline, 1h, and days 1, 7, 14, 21, and 28. Minipump results indicated a monophasic exponential decay and a half-life of 14.8 days (95% CI=13.1-17.1 days). Results from the water bath demonstrated a linear increase in olanzapine up to and including day 21, followed thereafter by a decrease to day 28. It is concluded that administration of olanzapine via osmotic minipump is viable in animal models to mirror what occurs in humans, although the interval should be confined to 2 weeks. As well, strategies in dissolving olanzapine to diminish oxidation are discussed.