Pratiques de prescription des traitements antipsychotiques dans les premières hospitalisations pour épisode psychotique : étude sur une cohorte de patients hospitalisés dans deux hôpitaux girondins

Abstract

The aims of this pharmacoepidemiological study were to describe the antipsychotic medication received during the first admission and over a two-year follow-up in subjects with a first episode of psychosis, and to assess whether the prescriptions in naturalistic conditions were in adequacy with guidelines. All first-admitted patients, less than 50 years old, consecutively hospitalised in 10 acute wards of two psychiatric hospitals serving Bordeaux's catchment area were included over a period of one year, if they presented with at least one overt psychotic symptom during the last month. Information on psychotropic medication received during the first admission was collected in medical records, and that received after the first admission was collected at the end of a two-year follow-up using multiple sources of information. Of the 86 patients included in the cohort, 53 presented with broadly defined schizophrenia and 33 with psychotic mood disorder. All except two subjects were prescribed at least one neuroleptic drug. Antipsychotic drugs (amisulpride, olanzapine, risperidone, clozapine) were the most frequently prescribed drugs during the first admission and over the two-year follow-up. If sedative neuroleptics were excluded, antipsychotic drugs were the first prescribed neuroleptic drugs in a large proportion (80%) of patients. Although few patients were first prescribed a conventional neuroleptic, the proportion of subjects treated with these drugs increased over the next prescriptions, and one out of three patients was prescribed at least one of these drugs during the follow-up. The mean dose of antipsychotic drugs at first discharge was higher than that recommended in first episode patients (amisulpride 616 mg, olanzapine 13 mg, risperidone 7 mg). Coprescription of neuroleptic drugs, found in one third of patients at all times of assessment, was especially due to coprescription of a sedative neuroleptic to a conventional or an antipsychotic one. Nearly half of the patients did not take any psychotropic medication at the end of the follow-up. The main recommendation specifying that the first neuroleptic treatment in subjects with a first episode of psychosis should use antipsychotic drugs instead of conventional neuroleptics was generally respected in this cohort of first-admitted subjects with psychosis. However, conventional neuroleptics were found in first or second rank prescriptions, although they should not be used before at least the third rank. The recommendations that the initial neuroleptic dose should be lower in subjects with a first episode, and that coprescription of neuroleptics should be avoided, were frequently not respected. This study highlights the fact that international guidelines should be better applied in naturalistic conditions, and that clinicians have to be better informed about these recommendations.