A pilot study of antipsychotic prescribing decisions for acutely-Ill hospitalized patients

BACKGROUND

Evidence on antipsychotic prescribing decisions is limited. This pilot study quantified factors considered in choosing an antipsychotic and evaluated the influence of metabolic status on treatment decisions.

METHODS

Prescribing decisions by 4 psychiatrists were examined based on 80 adult patients initiated on antipsychotic medication diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder by DSM-IV criteria, who were admitted to an acute inpatient psychiatric program of an urban Veterans Affairs Medical Center. The primary analysis examined the association between antipsychotic treatment choice and predictions of symptom control and metabolic risk. Secondary analyses included comparison of the chosen and next best treatments in predicted symptom control and metabolic risk, the frequency of reasons cited for drug choice, and the association between treatment choice and patients' baseline metabolic parameters. Mean differences and odds-ratios (OR) with 95% confidence intervals were used to compare relationships between treatment choice, ratings of risk and metabolic data.

RESULTS

Antipsychotic choice correlated significantly with ratings of predicted symptom control (OR = .92, p = 0.02) and metabolic risk (OR = .88, p = 0.01). Mean differences between the chosen and next best drugs were significant but small in predicted symptom control (F = 2.81, df = 3, 76; p<0.05) compared with larger differences in anticipated metabolic risk (F = 14.80, df = 3, 76; p = 0.0001). Nevertheless, among 24 identified reasons influencing drug selection, anticipated metabolic risk of chosen antipsychotics was cited less often than efficacy measures. In contrast to psychiatrists' expectations of metabolic risk with selected treatments, we found that patients' actual baseline BMI, fasting glucose, blood pressure, and Framingham risk levels did not necessarily predict antipsychotic treatment choice independent of other factors.

CONCLUSION

In the context of an acute psychiatric hospitalization, pilot data suggest that predictions of symptom control and metabolic risk correlated significantly with antipsychotic choice, but study psychiatrists were willing to assume relative degrees of metabolic risk in favor of effective symptom control. However, prescribing decisions were influenced by numerous patient and treatment factors. These findings support the potential utility of the ATCQ questionnaire in quantifying antipsychotic prescribing decisions. Further validation studies of the ATCQ questionnaire could enhance translation of research findings and application of treatment guidelines.

Why Patients Sign Out Against Medical Advice (AMA): Factors Motivating Patients to Sign Out AMA

A retrospective review of the against medical advice (AMA) discharges revealed that the majority of the patients left AMA for personal reasons, i.e., sickness or death in the family; reconciliation with spouse, girl friend, or family members; financial problems; and legal issues such as a court date. Strategies to reduce AMA discharges and increase patient retention in treatment are suggested.

Nicotine intervention during detoxification and treatment for other substance use

This preliminary study evaluated the efficacy of a brief smoking cessation intervention (30 controls, 34 intervention groups) on a smoke-free inpatient unit for substance use detoxification. Controls received usual care, including the transdermal nicotine patch and referral to an outpatient smoking program. The intervention group additionally received a structured motivational enhancement program. Biochemically confirmed smoking cessation rate and abstinence/reduction of alcohol or other drug use were the main outcome measures taken 6 months after treatment initiation. The smoking cessation intervention did not result in greater participation in formal outpatient smoking cessation treatment and was not associated with either enhanced smoking cessation (6 vs. 0%) or greater smoking reduction at follow-up. Both groups significantly reduced the number of cigarettes smoked per day (cpd) from about 24 at baseline to 10cpd. The groups did not differ on abstinence from nonnicotine addictive substances. Smoking cessation treatment in substance users undergoing detoxification resulted in little or no smoking cessation advantage.

Absence of parkinsonism among patients in long-term neuroleptic therapy who abuse cocaine

The study used the United Parkinson's Disease Scale to compare parkinsonian signs and symptoms among 19 patients in long-term neuroleptic therapy who had a history of cocaine abuse with those among 24 similar patients with no history of cocaine use. There was no significant difference between the two groups' scores. The results suggest that chronic cocaine abuse is not a risk factor for parkinsonism among subjects in long-term neuroleptic therapy.

Unscheduled admissions and AMA discharges from a substance abuse unit

On the inpatient substance abuse service of the Philadelphia Veterans Administration Hospital, we found that patients who were admitted to the hospital "unscheduled" had a disproportionately higher incidence of subsequent AMA (against medical advice) discharge, particularly if they were alcoholic. This finding calls into question the cost-effectiveness of hospitalization as an initial treatment strategy for substance abusers who enter treatment impulsively and points out the need for additional study to determine the most cost-effective treatments for addicts whose primary motivation for treatment may be to obtain relief from precipitating stressors.

A brief survey of the current sexual practices of a population admitted for inpatient treatment of drug dependence

We studied a population of high-risk drug users concerning their current sexual practices. They had a pattern of inconsistent or infrequent condom use. Only 11.5% reported always using condoms; 38.2% reported never using them; and 50.3% reported using them sometimes. Experimental educational programs have demonstrated the feasibility of changing sexual behaviors in illicit drug users by using innovative techniques targeted specifically at them. The application of sex and marital therapy techniques to changing high-risk behaviors is not widely discussed in the substance abuse literature. The hypothesis that the application of the techniques of sex and marital therapy in educational programs for drug users will improve outcomes of HIV prevention should be tested.

A randomized double-blind study of neuroelectric therapy in opiate and cocaine detoxification

Prior research on the use of transcranial neuroelectric stimulation suggested that the application of low-amperage, low-frequency alternating current via surface electrodes placed in the mastoid region could relieve the physiological signs and subjective symptoms of withdrawal and craving during opiate detoxification. These effects were reported without gradual tapering of the opiate or the addition of other medications. To test the efficacy of one particular form of neuroelectric therapy (NET), a double-blind, randomized, placebo-controlled study was conducted comparing active NET and placebo NET in the treatment of withdrawal and stabilization of 18 opiate-dependent and 25 cocaine-dependent subjects. Scores on scales for measuring substance withdrawal and craving for each abused substance, as well as the multiple dimensions of mood, were compared for degree of difference across the 10 days of treatment. There was an overall completion rate of 88%, with both cocaine and opiate groups reporting a comfortable detoxification and substantial improvement over the course of a 12-day hospitalization. There was no significant difference between the active or placebo groups, suggesting that placebo was as effective as active NET in reducing drug withdrawal or craving during cocaine and opiate detoxification. However, all placebo patients received 0.2 mA of current, which may have provided a degree of active current. Suggestions are offered for future research.

Methadone and edema

We describe a patient on methadone maintenance who developed distal leg edema after years of treatment. The edema resolved when methadone was discontinued and recurred when it was restarted. This patient is compared to three others reported in the literature who also developed fluid retention shortly after being placed on methadone. We conclude that methadone induced edema can occur not only immediately, but also after years of uncomplicated treatment.

The relationship of cocaine to headache in polysubstance abusers

In a questionnaire survey of inpatient polysubstance abusers it was found that cocaine relieved migraine-type headaches much more often in chronic headache sufferers than in those with only occasional headaches (p less than .05). However, cocaine could also bring on headaches after several hours, both in chronic headache sufferers and in those not subject to headaches. The facts that cocaine may relieve headache immediately, and also may precipitate headaches several hours after use, suggests that the well-known vasoconstrictive actions of cocaine may be responsible. Migraineurs seem more susceptible to some of these effects of cocaine than are people without chronic headaches.

Prolonged presence of metabolite in urine after compulsive cocaine use

The authors studied the pattern of benzoylecgonine excretion in 35 male veterans who had recently used large amounts of cocaine. Following admission to a drug-free environment, the veterans completed a short structured interview and gave daily urine samples for benzoylecgonine analysis. Eleven (31.4%) patients excreted benzoylecgonine at levels of 300 ng/mL or above for 120 hours or longer after admission. Eight (22.9%) patients whose enzyme-multiplied immunoassay test results were negative subsequently tested positive. These findings corroborate recent case reports of prolonged presence of benzoylecgonine in the urine and have important implications for drug treatment programs.

Detoxification with phenobarbital of alprazolam-dependent polysubstance abusers

Alprazolam appears to have an abuse liability among opiate addicts, and detoxification can be prolonged. The authors describe experience with five methadone maintenance patients who were polysubstance abusers and were admitted specifically for detoxification from alprazolam dependence. Phenobarbital in tapering doses adequately suppressed withdrawal symptoms and shortened hospitalization.

Increase in desipramine serum levels associated with methadone treatment

Five men in a methadone treatment program who were also receiving desipramine had significantly higher desipramine serum levels when taking both drugs than when taking the antidepressant alone. Monitoring of desipramine serum levels may be useful with such patients.