Prescription Of Antipsychotic Medication Research Articles

Appropriate prescribing in nursing homes demonstration project (APDP) study protocol: pragmatic, cluster-randomized trial and mixed methods process evaluation of an Ontario policy-maker initiative to improve appropriate prescribing of antipsychotics.

BackgroundAntipsychotic medications are routinely prescribed in nursing homes to address the behavioral and psychological symptoms of dementia. Unfortunately, inappropriate prescribing of antipsychotic medications is common and associated with increased morbidity, adverse drug events, and hospitalizations. Multifaceted interventions can achieve a 12–20 % reduction in antipsychotic prescribing levels in nursing homes. Effective interventions have featured educational outreach and ongoing performance feedback.Methods/DesignThis pragmatic, cluster-randomized control trial and embedded process evaluation seeks to determine the effect of adding academic detailing to audit and feedback on prescribing of antipsychotic medications in nursing homes, compared with audit and feedback alone. Nursing homes within pre-determined regions of Ontario, Canada, are eligible if they express an interest in the intervention. The academic detailing intervention will be delivered by registered health professionals following an intensive training program including relevant clinical issues and techniques to support health professional behavior change. Physicians in both groups will have the opportunity to access confidential reports summarizing their prescribing patterns for antipsychotics in comparison to the local and provincial average. Participating homes will be allocated to one of the two arms of the study (active/full intervention versus standard audit and feedback) in two waves, with a 2:1 allocation ratio. Homes will be randomized after stratifying for geography, baseline antipsychotic prescription rates, and size, to ensure a balance of characteristics. The primary outcome is antipsychotic dispensing in nursing homes, measured 6 months after allocation; secondary outcomes include clinical outcomes and healthcare utilization.DiscussionPolicy-makers and the public have taken note that antipsychotics are used in nursing homes in Ontario far more than other jurisdictions. Academic detailing can be an effective technique to address challenges in appropriate prescribing in nursing homes, but effect sizes vary widely. This opportunistic, policy-driven evaluation, embedded within a government-initiated demonstration project, was designed to ensure policy-makers receive the best evidence possible regarding whether and how to scale up the intervention.Trial registrationClinicalTrials.gov NLM Identifier: NCT02604056.

Interventions that support the creation of dementia friendly environments in health care: protocol for a realist review.

BackgroundImproving health-care outcomes for people living with dementia when they are admitted to hospital is a policy priority. Dementia friendly interventions in health care promote inclusion of patients and carers in decision-making and adapt practices and environments to be appropriate to the needs of people with cognitive impairment. While there has been a wealth of activity, the number of studies evaluating interventions is limited, and the majority focuses on reporting staff and organisational outcomes. By focusing on patient and carer outcomes, this review will aim to develop an explanatory account of how and in what circumstances dementia friendly environments in health care work for people living with dementia and with what outcomes.Method/designRealist review is a theory-driven method which seeks to produce explanatory accounts of why interventions work and specifically, what combination of components are most effective in producing particular outcomes. Stakeholder interviews, a review of the literature, and an expert steering group workshop will be used to explore the assumptions behind interventions that are designed to enhance health care for people living with dementia to understand the underlying programme theories. The review will focus on studies that report patient and carer outcomes, including involvement in decision-making, length of stay and referral to long-term care, adverse incidents (e.g. patient distress, delirium falls, nutrition and hydration and infection), antipsychotic medication prescribing, evidence of patient-centred care and patient and carer satisfaction.DiscussionThe review will provide an explanatory model about how dementia friendly interventions in hospital settings improve outcomes for people living with dementia and their family carers and in what circumstances for future testing and evaluation of future dementia friendly initiatives.Systematic review registrationPROSPERO CRD42015017562

Inequalities in physical comorbidity: a longitudinal comparative cohort study of people with severe mental illness in the UK

ObjectivesLittle is known about the prevalence of comorbidity rates in people with severe mental illness (SMI) in UK primary care. We calculated the prevalence of SMI by UK country, English...

The Growing Trend of Prescribing Antipsychotics for Young People in Finland, 2000 to 2010

Abstract Background: According to previous reports from many countries (e.g., the United States, Germany, the United Kingdom), the use of antipsychotic drugs has increased among young people. Antipsychotics have also increasingly been prescribed for non-psychotic disorders. Objective The purpose of this study was to estimate the rate at which antipsychotics were prescribed for young people in the age groups of 10 to 14 years, 15 to 19 years, and 20 to 24 years in Finland in the years 2000, 2005, and 2010. Methods This was a nationwide register study using data from the databases of Statistics Finland and the Finnish National Prescription Register. Statistics Finland’s databases provided background information, including the total number of young people and the Finnish National Prescription Register keeps record of all drug orders reimbursed by the Social Insurance Institution of Finland. Results The prescription of antipsychotics grew 6.8-, 4.6-, and 2.6-fold over the study period for these three age groups, respectively. For the youngest age group, use was more common among males than females in all three periods studied. During the course of the study period, the use of antipsychotics became more common among females: in 2010, antipsychotics were more commonly used among females than males in both the 15- to 19-year-old age group and the 20- to 24-year-old age group. The younger the patient, the higher the probability that the indication for medication was a non-psychotic disorder. Conclusions In Finland, the trends involved in the prescription of antipsychotic medications resemble those seen in many Western countries. Therefore, it is important that the safety and effectiveness of these pharmaceuticals be investigated among young people as well.

Further evidence to support weight loss and lifestyle interventions for people taking antipsychotic medications

ABSTRACT FROM: Green CA, Yarborough BJ, Leo MC, et al . The STRIDE weight loss and lifestyle intervention for individuals taking antipsychotic medications: a randomized trial. Am J Psychiatry 2015;172:71–81....

Risk of Fetal Death after Treatment with Antipsychotic Medications during Pregnancy.

BackgroundAntipsychotic medications are increasingly used during pregnancy. Nevertheless, fetal risks are still not fully studied. It is currently unclear whether the antipsychotic treatment might induce a higher risk of fetal death. We aimed to determine if use of antipsychotic medication during pregnancy is associated with an increased risk of spontaneous abortion or stillbirth.MethodsIn a historical cohort study, we identified all clinically recognized pregnancies registered in the nationwide Danish registries from 1997 to 2008 (N = 1,005,319). Exposure was defined as any prescription of antipsychotic medications redeemed by the pregnant women during the exposure window, and recorded in the Danish National Prescription Register. Outcome was defined as any spontaneous abortion or stillbirth recorded in the Danish National Hospital Register and the Danish Medical Birth Register respectively.ResultsWomen exposed to antipsychotic medications during pregnancy had a 34% higher risk of spontaneous abortion (adjusted relative risk = 1.34; 95% confidence interval = 1.22; 1.46) compared to unexposed women, but a similar risk compared to women exposed prior to (but not during) pregnancy (adjusted relative risk = 1.04; 95% confidence interval = 0.93; 1.17). The risk of spontaneous abortion was not increased in exposed pregnancies when compared to unexposed pregnancies in the same women (adjusted hazard ratio = 1.11; 95% CI = 0.94; 1.31). A twofold higher risk of stillbirth was found in women exposed to antipsychotic medications compared with unexposed women (relative risk = 2.27; 95% confidence interval = 1.45; 3.55) and compared with women exposed only prior to pregnancy (relative risk = 2.06; 95% confidence interval = 1.01; 4.19).ConclusionsThe increased risk of spontaneous abortion found in women treated with antipsychotic medications during pregnancy is most likely due to confounding factors. The risk of stillbirth was twofold higher in pregnancies exposed to antipsychotic medication during pregnancy. Treatment with antipsychotic medications during pregnancy requires careful consideration.

Symptom Assessment for a Palliative Care Approach in People With Dementia Admitted to Acute Hospitals: Results From a National Audit.

As the prevalence of dementia increases, more people will need dementia palliative and end-of-life (EOL) care in acute hospitals. Published literature suggests that good quality care is not always provided. To evaluate the prescription of antipsychotics and performance of multidisciplinary assessments relevant to palliative care for people with dementia, including those at EOL, during hospital admission. As part of a national audit of dementia care, 660 case notes were reviewed across 35 acute hospitals. In the entire cohort, many assessments essential to dementia palliative care were not performed. Of the total sample, 76 patients died, were documented to be receiving EOL care, and/or were referred for specialist palliative care. In this cohort, even less symptom assessment was performed (eg, no pain assessment in 27%, no delirium screening in 68%, and no mood or behavioral and psychological symptoms of dementia in 93%). In all, 37% had antipsychotic drugs during their admission and 71% of these received a new prescription in hospital, most commonly for "agitation." This study suggests a picture of poor symptom assessment and possible inappropriate prescription of antipsychotic medication, including at EOL, hindering the planning and delivery of effective dementia palliative care in acute hospitals.

Demographic and clinical factors predicting retention in methadone maintenance: results from an Irish cohort.

Retention in Methadone Maintenance Treatment (MMT) is superior to that of other therapies for opioid addiction, but with international retention rates around 50% after 1year of treatment, there remains a need for improved retention rates. This study aimed to explore the demographic and clinical factors predicting retention in MMT. Face-to-face surveys with MMT patients in a Dublin methadone clinic were conducted. Retention was assessed by the presence and duration of breaks in treatment at any stage. 189 patients participated in the study. 46% (n=87) reported having at least one break in treatment, and the median duration of a break was 3months. Age, current methadone dose and prescription of antipsychotic medication were significant predictors of retention. Patients who were older, single, living in their own home, on a higher dose of methadone, or taking antipsychotic medications had fewer breaks in treatment. Males tended to have significantly longer breaks. Patients reported that the main reasons for breaks were relapse into drug use (21.8%, n=19), incarceration (11.4%, n=10), weary of MMT (13.7%, n=12) or problems at the clinic (10.3%, n=9). Factors enabling regular attendance included wanting to get or stay clean (37.5%, n=51), avoidance of withdrawal symptoms (16.1%, n=22), methadone dependence (13.9%, n=19) and services provided (10.2%, n=14). Patients who were older, single, living in their own home, on a higher dose of methadone, or taking antipsychotic medications had fewer breaks in treatment.

Medication Needs Vary for Terminally Ill Vietnam Era Veterans With and Without a Diagnosis of PTSD.

This retrospective pilot study aims to evaluate the clinical impact of palliative care in the treatment of terminally ill Vietnam Veterans with a history of posttraumatic stress disorder (PTSD) versus those without PTSD, as it pertains to medications for symptom control at the end of life (EOL). Active prescriptions for benzodiazepines, hypnotics, antidepressants, and antipsychotic medications at the EOL were recorded. During EOL care, 28 (72%) participants with PTSD used these medications versus 55 (40%) of the non-PTSD participants (P = .0005). There was significant correlation between a lifetime diagnosis of PTSD with antidepressant use (P = .0002) and hypnotics (P = .0085) during EOL care but not with benzodiazepines or antipsychotics. The higher utilization of certain medication classes among participants with PTSD may indicate that PTSD treatment should continue at the EOL to improve care.

Some states use peer review to reduce overprescribing of antipsychotics to youth

Thirty‐one states have been using prior authorization policies for Medicaid prescribing of antipsychotic medication for children under the age of 7, according to new research. The main purpose of the prior authorizations is to reduce inappropriate prescribing, the researchers found.

Gender differences in antipsychotics prescribed to veterans with serious mental illness

ObjectiveTo examine gender differences in prescribing of antipsychotic medications (APMs) according to their liability for weight gain and other metabolic side effects. MethodWe identified 4510 patients with schizophrenia or bipolar disorders receiving usual care in a Veterans Affairs (VA) health care network in the U.S. mid-Atlantic region who initiated treatment with an APM between October 2006 and September 2011. We used multivariable logistic regression to examine gender differences in the likelihood of incident prescription of APMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and selected Veteran demographic, mental health and physical health characteristics. ResultsOverall, 58% of women were prescribed an APM with a low risk of metabolic side effects compared to 45% of men (P<.001). In multivariable analysis, women Veterans were 1.47 times as likely as men to be prescribed a low-metabolic-risk APM (95% confidence interval: 1.26–1.73, P<.001). Several demographic and clinical covariates were also independently related to prescribing of APMs by level of metabolic risk. ConclusionsThe results may suggest that prescribing choices for APMs by VA mental health prescribers and female Veterans reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Antipsychotic medication prescribing in children enrolled in Medicaid.

Although the increase in treatment of children and adolescents with antipsychotic medications has been well documented, much less is known about the factors related to the use of these agents and how closely the treatment follows best practice recommendations. Prescribers of each antipsychotic medication prescription issued for a Medicaid-insured child in Vermont aged <18 years were sent a prior authorization survey that assessed several domains including the clinical indication, other treatments, metabolic monitoring, prescriber specialty, and prescription origin. These variables were combined to categorize prescriptions as following indications approved by the US Food and Drug Administration (FDA) and best practice guidelines. The response rate of the survey was 80%, with 677 surveys from 147 prescribers available for analysis; more than one-half of the respondents were primary care clinicians. Overall, the clinical indication for an antipsychotic prescription followed best practice guidelines 91.7% of the time, with overall best practice guidelines followed at a rate of 50.1%. An FDA indication was followed in 27.2% of cases. Psychiatrists were significantly more likely to follow best practice guidelines than nonpsychiatrists. Antipsychotic medications were typically used only after other pharmacologic and nonpharmacologic treatments were ineffective, although previous treatment with cognitive-behavioral therapy was uncommon (15.5%). Metabolic monitoring that included serial laboratory tests was reported in 57.2% of cases. Current prescribing patterns of antipsychotic medications for children and adolescents follow best practice guidelines approximately one-half of the time, with nonadherence often related to lack of metabolic monitoring.

Antipsychotic prescriptions in Iraq and Afghanistan veterans with posttraumatic stress disorder in Department of Veterans Affairs healthcare, 2007-2012.

Antipsychotic medications have been increasingly prescribed for off-label uses, including treatment of posttraumatic stress disorder (PTSD). Given limited knowledge about their use in returning Iraq and Afghanistan veterans with PTSD, we explored rates of antipsychotic use in this population and correlations with sociodemographic, military service, and psychiatric factors. Iraq and Afghanistan veterans with a PTSD diagnosis based on ICD-9-CM codes enrolled in Veterans Administration care between January 1, 2007, and September 30, 2011, were followed through September 30, 2012. Patients with a comorbid diagnosis of schizophrenia or bipolar disorder were excluded. Poisson regression models evaluated factors associated with prescriptions for antipsychotic versus other psychiatric medications (primary outcome). The mean age of our study population was 29.3 years, and 9.4% were women. Of 186,460 veterans with PTSD diagnoses examined, 19.9% received no psychiatric medications, and the remainder received psychiatric medications that excluded (61.2%) or included (18.9%) antipsychotics. In adjusted models, several factors were independently associated with antipsychotic use, including male sex (adjusted relative risk = 1.25; 95% CI, 1.20-1.30) and enlisted rank (1.44; 95% CI, 1.35-1.53). Increased likelihood of antipsychotic prescribing was associated with suicidal ideation (4.77; 95% CI, 4.59-4.95) and comorbid psychiatric diagnoses including personality disorder (4.27; 95% CI, 4.09-4.46), drug use disorder (3.56; 95% CI, 3.43-3.69), and alcohol use disorder (2.75; 95% CI, 2.65-2.84). A substantial minority of Iraq and Afghanistan veterans diagnosed with PTSD received antipsychotics. Male veterans, those of enlisted rank, and those with suicidal ideation and psychiatric comorbidities were more likely to receive antipsychotics than other types of psychiatric medications. Providers should be cautious about antipsychotic use, given their known metabolic risks and questionable benefits for PTSD.

Antipsychotic Medication Prescribing in Children Enrolled in Medicaid

Antipsychotic Medication Prescribing in Children Enrolled in Medicaid

Reducing the rates of prescribing high-dose antipsychotics and polypharmacy on psychiatric inpatient and intensive care units: results of a 6-year quality improvement programme.

There is no conclusive evidence that either high doses or combinations of antipsychotics are more effective than standard doses or monotherapy alone. Nonetheless, prescription of both remains prevalent in the UK. In 2006 the South London and Maudsley NHS Foundation Trust (SLAM) participated in a national survey of prescription of antipsychotic medications, organized by the Prescribing Observatory for Mental Health. Over half of the patients on SLAM inpatient or psychiatric intensive care units were prescribed a high-dose antipsychotic or a combination of antipsychotics. Prescribing high-dose antipsychotics and polypharmacy in SLAM was found to be among the highest in the UK. To assess the impact of a 6-year quality improvement programme aimed at reducing the rates of prescribing high-dose antipsychotics and polypharmacy on SLAM inpatients and psychiatric intensive care units. There was a significant reduction between baseline and final survey in the rates of prescription of both high-dose antipsychotics and polypharmacy on SLAM inpatients and intensive care units (58% versus 10% p < 0.0001 and 57% versus 16%, p < 0.0001 respectively). The proportion of patients at final survey prescribed a high-dose antipsychotic and a combination was substantially lower in SLAM than in the national sample (10% versus 28%, p < 0.0001 and 16% versus 38%, p < 0.0001 respectively). A sustained change in the prescribing culture of an organization can be achieved through a targeted improvement programme.

The effects of prior authorization policies on medicaid-enrolled children's use of antipsychotic medications: evidence from two mid-Atlantic states.

The purpose of this study was to examine the impact of prior authorization policies on the receipt of antipsychotic medication for Medicaid-enrolled children. Using de-identified administrative Medicaid data from two large, neighboring, mid-Atlantic states from November 2007 through June 2011, we identified subjects <18 years of age using antipsychotics, from the broader group of children and adolescents receiving behavioral health services or any psychotropic medication. Prior authorization for antipsychotics was required for children in State A <6 years of age from September 2008, and for children <13 years of age from August 2009. No such prior authorizations existed in State B during that period. Filled prescriptions were identified in the data using national drug codes. Using a triple-difference strategy (using differences among the states, time periods, and differences in antidepressant prescribing rates among states over the same time periods), we examined the effect of the prior authorization policy on the rate at which antipsychotic prescriptions were filled for Medicaid-enrolled children and adolescents. The impact of prior authorization policies on antipsychotic medication use varied by age: Among 6-12 year old children, the impact of the prior authorization policy on antipsychotic medication prescribing was a modest but statistically significant decrease of 0.47% after adjusting for other factors; there was no effect of the prior authorization among children 0-5 years. Prior authorization policies had a modest but statistically significant effect on antipsychotic use in 6-12 year old children, but had no impact in younger children. Future research is needed to understand the utilization and clinical effects of prior authorization and other policies and interventions designed to influence antipsychotic use in children.

La trachéotomie : face à l’urgence des troubles physiques, émergence de troubles psychiques

This article presents a clinical case of an adolescent suffering from Duchenne's muscular dystrophy who, while under cortisone treatment, developed for several months a non-dissociative psychotic state with affective disorder after the announcement of the necessity of a tracheotomy. At first refused, this procedure was performed under emergency circumstances after respiratory failure. After several months, the psychotic state disappeared. This article describes the treatment of the psychotic episode by psychotherapy and medication pre- and post-tracheotomy. The authors discuss the principal factors that set off the psychotic episode: the traumatic nature of the announcement of the tracheotomy and its function of recalling previous traumas, adolescence and its transformations and the cortisone therapy. The function of the delusion is analyzed as a solution to a situation of psychic conflict and archaic anxieties, notably feelings of being attacked with corporal transformations generated by the menacing symbolism of the tracheotomy. The article emphasizes the complexity of the treatment of patients suffering from neuromuscular diseases in the case of the prescription of anti-psychotic medications, notably with regard to their secondary respiratory and cardiac effects.

Rising antipsychotic prescriptions for children and youth: cross-sectoral solutions for a multimodal problem

In the past 10 years, off-label prescribing of antipsychotic medications to Canadian children and youth has risen dramatically despite a lack of strong evidence for efficacy and serious adverse effects.[1][1]–[5][2] According to Canadian pharmacoepidemiologic data, antipsychotic medications have

A comparison of psychotropic medication prescribing patterns in East of England prisons and the general population

While the prevalence of mental illness is higher in prisons than in the community, less is known about comparative rates of psychotropic medicine prescribing. This is the first study in a decade to determine the prevalence and patterns of psychotropic medication prescribing in prisons. It is also the first study to comprehensively adjust for age when making comparisons with the general population. Four East of England prisons, housing a total of 2222 men and 341 women were recruited to the study. On census days, clinical records were used to identify and collect data on all prisoners with current, valid prescriptions for hypnotic, anxiolytic, antipsychotic, antimanic, antidepressant and/or stimulant medication, as listed in chapters 4.1 to 4.4 of the British National Formulary. Data on 280,168 patients were obtained for comparison purposes from the Clinical Practice Research Datalink. After adjusting for age, rates of psychotropic prescribing in prison were 5.5 and 5.9 times higher than in community-based men and women, respectively. We also found marked differences in the individual psychotropic drugs prescribed in prison and community settings. Further work is necessary to determine whether psychotropic prescribing patterns in prison reflect an appropriate balance between managing mental illness, physical health risks and medication misuse.

EPA-1395 – Psychopathological predictors of antipsychotic medication use in childhood autism spectrum disorders

Autism Spectrum Disorders (ASDs) affect 1% of children and are associated with lifelong psychosocial impairments. The majority of children with ASD will experience co-occurring psychiatric disorders. In the UK, antipsychotics remain unlicensed for use in ASDs, however 10% of children with ASD receive antipsychotic treatment; the co-occurring disorders being targeted by these medications remains unclear. To examine rates of antipsychotic medication use and identify associated co-occurring disorders among children with ASD receiving psychiatric care. The sample consisted of 2844 children aged 2 to 17 with a NHS clinician recorded ICD-10 diagnoses for ASD between 2008–2013. Clinical variables extracted from their anonymised electronic patient records included disorder severity, medication use, co-occurring ICD-10 diagnoses, family characteristics, demographics and antipsychotic use. Of the 2844 children (79% male), the majority (57%) had co-occurring psychiatric diagnoses. 313 (11%) received antipsychotic medication. The proportion of children aged 13 to 17 years and 6 to 12 years prescribed antipsychotics was 19% and 7% respectively. After controlling for socio-demographic factors, disorder severity, specialist treatment, inpatient duration, risk of self harm, violence to others, self injurious behaviour, maltreatment history, parental mental illness, caregiver anxiety, and neighbourhood deprivation, multivariate regression analysis revealed only hyperactivity disorders (O.R 1.94, 95%C.I. 1.32–2.86), psychotic disorders (O.R 5.12 95% C.I. 2.6–10.1), mood disorders (O.R 2.02, 95%C.I. 1.04–3.92) and intellectual disability (O.R 2.89 95% C.I. 1.89–4.71) were associated with anti-psychotic use. The prescription of antipsychotic medications in this UK ASD clinical sample is strongly associated with specific co-occurring psychiatric disorders and intellectual disability.