Use Of Antipsychotic Polypharmacy Research Articles

Antipsychotic Polypharmacy in Inpatients with Schizophrenia in Asia (2001−2009)

This study aimed to identify trends in the use of antipsychotic polypharmacy (APP) and their demographic and clinical correlates in the treatment of schizophrenia in Asia between 2001 and 2009. A total of 6,761 schizophrenia inpatients in 9 Asian countries and territories were examined; 2,399 in 2001, 2,136 in 2004, and 2,226 in 2009. Patients’ socio-demographic and clinical characteristics and prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure. The proportion of APP prescription decreased from 46.8 % in 2001, to 38.3 % in 2004, and increased to 43.4 % in 2009, with wide intercountry variations at each survey. Multiple logistic regression analysis of the whole sample revealed that patients on APP were younger, had a higher dose of antipsychotics in chlorpromazine equivalents, and more severe positive and negative symptoms. They were also more likely to receive depot and fi rst-generation antipsychotic drugs. The frequency of APP prescription varied between countries and territories, suggesting that a host of clinical and socio-cultural factors played a role in determining APP use in Asia. To resolve the discrepancy between treatment recommendation and clinical practice, regular reviews of prescription patterns are needed.

How Dosing Might Influence the Conclusion in an Antipsychotic Polypharmacy Effectiveness Trial

Back to table of contents Previous article Next article Communications and UpdatesFull AccessHow Dosing Might Influence the Conclusion in an Antipsychotic Polypharmacy Effectiveness TrialLone Baandrup, M.D., Ph.D.Lone BaandrupGlostrup, DenmarkSearch for more papers by this author, M.D., Ph.D.Published Online:1 Oct 2011https://doi.org/10.1176/appi.ajp.2011.11050751AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In the July 2011 issue of the Journal, Susan M. Essock et al. (1) provided valuable information on an important clinical paradox: the widespread use of antipsychotic polypharmacy in the treatment of schizophrenia, despite the lack of evidence to support it. However, the study had an essential limitation that was not addressed in the article: the matter of dosing.The total daily dose of antipsychotic drugs at baseline was comparable between groups, as shown in Table 1 of the article. The total dosage at 6 months follow-up and at treatment discontinuation (for those discontinuing before 6 months) was not reported in the article, but it is highly likely that this dosage was significantly lower in the monotherapy group because one of the prescribed antipsychotics had been discontinued (medication dosing was not constrained by the protocol). If this was the case, there was a bias favoring the polypharmacy group with regard to effectiveness. This is emphasized by the fact that all the study participants had residual symptoms and were candidates for change of medication. Decreasing the total dosage of antipsychotic drugs (as is the most probable scenario in the switch to monotherapy group) in such a study population would a priori be expected to be less effective than continuing the same dosage (as in the stay on polypharmacy group). Thus, future studies should include a mandatory increase in the dosage of the remaining antipsychotic drug when switching from polypharmacy to monotherapy to compensate for the dosage reduction. If possible, the dosage should be reduced at a later point in time, but initially the dosage in the monotherapy group has to equal the dosage in the polypharmacy group. If not, the lack of effectiveness observed in this study might merely reflect the effect of dosage reduction and not the effect of the reduced number of drugs. If the question of dosing is not taken into consideration, the main conclusion of the study (“Discontinuing one of two antipsychotics was followed by treatment discontinuation more often and more quickly than when both antipsychotics were continued”) might be strongly biased in favor of antipsychotic polypharmacy—and might prevent some clinicians from trying to switch their patients from polypharmacy to monotherapy, even though the secondary conclusion of the study (“two-thirds of participants successfully switched, the groups did not differ with respect to symptom control, and switching to monotherapy resulted in weight loss”) strongly supports such effort.Glostrup, DenmarkThe author reports no financial relationships with commercial interests.Accepted for publication in July 2011.Reference1. Essock SM , Schooler NR , Stroup TS , McEvoy JP , Rojas I , Jackson C , Covell NH, The Schizophrenia Trials Network: Effectiveness of switching from antipsychotic polypharmacy to monotherapy. Am J Psychiatry 2011; 168:702–708Link, Google Scholar FiguresReferencesCited byDetailsCited byAntipsychotic Polypharmacy for the Management of Schizophrenia: Evidence and Recommendations1 July 2021 | Drugs, Vol. 81, No. 11Current World LiteratureCurrent Opinion in Psychiatry, Vol. 26, No. 2Antipsychotic Polypharmacy in USA20 December 2012 Volume 168Issue 10 October 2011Pages 1117-1117 Metrics PDF download History Accepted 1 July 2011 Published online 1 October 2011 Published in print 1 October 2011

Antipsychotic Polypharmacy in Schizophrenia

Antipsychotic polypharmacy refers to the co-prescription of more than one antipsychotic drug for an individual patient. Surveys of prescribing in psychiatric services internationally have identified the relatively frequent and consistent use of combined antipsychotics, usually for people with established schizophrenia, with a prevalence of up to 50% in some clinical settings. A common reason for prescribing more than one antipsychotic is to gain a greater or more rapid therapeutic response than has been achieved with antipsychotic monotherapy. However, the evidence on the risks and benefits for such a strategy is equivocal, and not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry. Combined antipsychotics are a major contributor to high-dose prescribing, associated with an increased adverse effect burden, and of limited value in helping to establish the optimum maintenance regimen for a patient. The relatively widespread use of antipsychotic polypharmacy identified in cross-sectional surveys reflects not only the addition of a second antipsychotic to boost therapeutic response, but also the use of as-required antipsychotic medication (mainly to treat disturbed behaviour), gradual cross-titration while switching from one antipsychotic to another, and augmentation of clozapine with a second antipsychotic where the illness has failed to respond adequately to an optimized trial of clozapine. This review addresses the clinical trial data and other evidence for each of these pharmacological approaches. Also reviewed are examples of systematic, practice-based interventions designed to reduce the prevalence of antipsychotic polypharmacy, most of which have met with only modest success. Guidelines generally agree that if combined antipsychotics are prescribed to treat refractory psychotic illness, this should be after other, evidence-based, pharmacological treatments such as clozapine have been exhausted. Further, their prescription for each patient should be in the context of an individual trial, with monitoring of the clinical response and adverse effects, and appropriate physical health monitoring.

Antipsychotic polypharmacy: A survey study of prescriber attitudes, knowledge and behavior

Objective Although common in psychiatric practice, reasons for antipsychotic polypharmacy (APP) have remained unclear. Methods Single-site, semi-structured interview study of prescribers at a psychiatric teaching hospital inquiring about APP attitudes and behaviors, including frequency, preferred combinations, rationale and concerns. Results Forty-four prescribers reported using APP in 17.0 ± 10.0% of antipsychotic-treated patients. Although clinicians themselves initiated APP in only 23.3 ± 27.0% of cases, they did not attempt conversion to antipsychotic monotherapy in 40.9 ± 37.7%, despite reported successful conversion in 28.0 ± 30.8% of cases. The following reasons justified most APP (0–10): cross-titration (9.2 ± 1.4), failed clozapine trial (8.2 ± 2.2), randomized controlled evidence (8.0 ± 2.0), and clozapine intolerance (7.7 ± 2.6). Prescribers felt “moderately” (5.0 ± 1.9) concerned about APP (0–10), mostly due to chronic side effects (7.6 ± 2.0), lack of evidence (7.1 ± 2.2), non-adherence risk (6.7 ± 2.3) and mortality risk (6.7 ± 3.2), while increased cost (4.9 ± 2.5) and higher total antipsychotic dose (4.2 ± 2.9) ranked lowest. Comparing high with low APP prescribers (> 10% vs. ≤ 10% of patients; mean: 36.1 ± 19.8 vs. 3.4 ± 3.4, p < 0.0001), no differences emerged on 25/26 ratings regarding APP justification and 9/9 ratings regarding concerns. In a multivariate analyses, only attending status (OR = 10.3, p = 0.0043) and endorsing a specific APP preference (OR = 21.4, p = 0.011) predicted APP use > 10% (r 2:0.35, p < 0.0001), yet no uniformly preferred APP strategy emerged. Conclusions High APP prescribers had more clinical experience, less concerns about APP and more likely a preferred APP choice, although no overall preferred strategy emerged. Otherwise, high and low APP prescribers shared attitudes toward APP. Both had inherited most of their APP cases and were reluctant to convert patients to antipsychotic monotherapy.

Sex Differences in Use of Psychotropic Drugs and Drug-Induced Side Effects in Schizophrenia Patients: Findings of the Research on Asia Psychotropic Prescription (REAP) Studies

The aim of this study was to investigate the sex differences in prescribing patterns of psychotropic drugs and drug-induced side effects in schizophrenia patients in Asia using the data of the Research on Asian Psychotropic Prescription Pattern (REAP) surveys. The prescription patterns of 6,441 schizophrenia inpatients in six Asian countries and regions were investigated during the 2001-2009 period. The patients' socio-demographic and clinical characteristics and their prescriptions for psychotropic drugs were recorded using a standardized protocol and data collection procedure. Univariate analyses found the following factors to be significantly associated with the male sex: a younger age, higher doses of antipsychotics, less prominent delusions and hallucinations, more prominent negative symptoms, less likelihood of a prescription for second-generation antipsychotics (SGAs), greater use of antipsychotic polypharmacy, mood stabilizers and depot antipsychotics, more frequent tardive dyskinesia (TD), and less weight gain. In multivariate analyses, fewer prescriptions for SGAs, greater use of mood stabilizers, anticholinergics, antipsychotic polypharmacy and depot antipsychotics, extrapyramidal side effects (EPS) and TD, and less weight gain were independently associated with the male sex. Sex is one of the independent contributors to psychotropic prescription and side effects in Asian schizophrenia patients. Psychopharmacological treatment guidelines for schizophrenia should consider the sexes separately.

Exploring Regional Variation in Antipsychotic Coprescribing Practice

The pharmacologic treatment of schizophrenia is characterized by excessive use of antipsychotic polypharmacy, which reflects a gap between evidence and practice. The aim of the present study was to investigate regional differences in treatment setting characteristics and in physician and nurse attitudes toward antipsychotic polypharmacy and clinical guidelines. Cross-sectional postal questionnaire survey directed to physicians and nurses at 2 pairs of treatment settings in Denmark, characterized by low and high prevalence of antipsychotic polypharmacy, respectively. The questionnaire investigation was conducted during November 2007 to February 2008. Satisfactory response rates were obtained (physicians: 93%; nurses: 87%). The treatment settings with low use of antipsychotic polypharmacy were characterized by raised knowledge/awareness of local antipsychotic treatment guidelines (P = .02 for physicians; P = .01 for nurses). Among physicians, these settings were also characterized by an elevated confidence in these guidelines (P = .01), frequent local educational activities (P < .0001), and increased recent involvement in research (P = .01). Among nurses, a perception of an overwhelming work load (P = .01) and time pressure (P = .003) was significantly more prevalent in treatment settings with high rates of antipsychotic coprescribing, as was the belief in the benefit of antipsychotic polypharmacy augmentation (P = .001). Albeit no causal relationships can be inferred from this cross-sectional observational study, we recommend the furtherance of a treatment environment characterized by easily accessible clinical guidelines, frequent academic activities, and an unruffled atmosphere.

Prescribing antipsychotic drugs for inpatients with schizophrenia in Asia: Comparison of REAP‐2001 and REAP‐2004 studies

AbstractIntroduction: This international collaborative study aimed to investigate the trend and change in prescription patterns of antipsychotic drugs for inpatient schizophrenia in Asia by comparing two surveys in 2001 and 2004.Methods: Prescription patterns of inpatient schizophrenia in China, Hong Kong, Japan, Korea, Singapore and Taiwan were surveyed in July of 2001 and 2004 using a standardized protocol. Patients' social and clinical characteristics, psychiatric symptoms, course of illness and adverse effects of medications were systematically assessed and recorded. Prescription patterns of antipsychotic drugs were compared and analyzed.Results: Altogether, 4535 patients were surveyed. There were no significant differences in their demographic characteristics between 2001 and 2004. Compared with 2001, a significant increase in the use of second‐generation antipsychotics (SGA) (from 45.5% to 64.7%) with reciprocal decreasing use of first‐generation antipsychotics was found in 2004. The trend was unanimously seen across these Asian countries and among those prescribed with monotherapy or polypharmacy. The proportion using monotherapy significantly increased, from 52.7% in 2001 to 61.1% in 2004. There was a tendency of using a lower dosage of antipsychotic medications and a less concomitant use of anti‐Parkinson drugs.Discussion: The present study showed a trend of increasing use of SGA among Asian countries. Except for Japan and Singapore, a relatively low use of antipsychotic polypharmacy was generally found. The increasing use of SGA and policy changes reduced the mean duration of admission days. With increasing awareness of consumers and continuing education for psychiatrists, the trend is expected to continue.

Antipsychotic polypharmacy in the treatment of children and adolescents in the fee-for-service component of a large state medicaid program

Objectives: The aims of this study were to quantify and describe antipsychotic polypharmacy use among patients aged 6 to 12 years (children) and 13 to 17 years (adolescents) and to identify the characteristics of polypharmacy recipients. Methods: Data from patients enrolled in Florida's Medicaid fee-for-service program and receiving treatment with an antipsychotic were included. Antipsychotic polypharmacy was defined as the receipt of ≥2 antipsychotic medications concurrently for >60 days, with no gaps >15 days in polypharmacy treatment. The prevalence of antipsychotic polypharmacy, durations of treatment episodes, times to antipsychotic polypharmacy after initiation of antipsychotic monotherapy, and rates of antipsychotic combination use were calculated for the period between July 2002 and June 2007. Results: During the 5-year period, 12,764 children and 10,419 adolescents received antipsychotic treatment. The proportions of patients who were male (73% and 63%) and whose race was indicated as “other” (31% and 14%) were significantly greater in children than in adolescents, respectively (both, P < 0.001). Seven percent of the children and 8% of the adolescents were prescribed antipsychotic polypharmacy ( P = 0.001). Mean (SD) durations of polypharmacy episodes were 170.0 (139.0) days in children and 185.5 (175.9) days in adolescents ( P = 0.010). Times to initiation of polyphar-macy were 505.8 (440.5) days in children and 384.9 (424.3) days in adolescents ( P < 0.001). Adolescents (odds ratio [OR] = 1.16; 95% CI, 1.04–1.29) were more likely than children to be polypharmacy recipients, as were those with psychotic disorders (OR = 1.47; 95% CI, 1.20–1.81) compared with those with bipolar I disorder. Patients whose race was indicated as “other” were more likely than patients of white race to receive polypharmacy (OR = 1.18; 95% CI, 1.04–1.34; P < 0.001); other ethnic/racial groups did not differ significantly. The most common specific antipsychotic combinations prescribed in children and adolescents were aripiprazole/quetiapine (23% and 17%, respectively), risperidone/quetiapine (18% and 15%), aripiprazole/ risperidone (17% and 11%), risperidone/olanzapine (5% and 6%), and quetiapine/olanzapine (4% and 7%). Conclusions: The prevalence and duration of Antipsychotic polypharmacy among antipsychotic recipients in this Medicaid fee-for-service population were noteworthy. Research on the risks and benefits of the practice in the pediatric population is needed.

Evaluation of a multifaceted intervention to limit excessive antipsychotic co‐prescribing in schizophrenia out‐patients

To evaluate the effect of a multifaceted educational intervention on the frequency of antipsychotic co-prescribing in adult schizophrenia out-patients. Controlled quasi-experimental study performed in two Danish municipalities matched for baseline prevalence of antipsychotic polypharmacy, socioeconomic status and functional level of patients. The intervention was aimed at psychiatric healthcare providers and consisted of 1 day of didactic lectures, six 3-h educational outreach visits and an electronic reminder during drug prescribing. Between-group use of antipsychotic polypharmacy was compared at baseline (intervention group, N = 232/control group, N = 351) and after 1 year of intervention (intervention group, N = 216/control group, N = 386). The prevalence of antipsychotic polypharmacy at follow-up was not significantly different between treatment settings when adjusting for differences in case-mix (P = 0.07). This multifaceted educational intervention failed to reduce the frequency of antipsychotic co-prescribing, but it suggested that future efforts to improve prescribing practice should address organizational barriers to implementation.

Trends in Adult Antipsychotic Polypharmacy: Progress and Challenges in Florida’s Medicaid Program

We studied trends in antipsychotic polypharmacy over a 4 year period in order to see if a change occurred when a statewide quality improvement program aimed at reducing the practice was implemented. Antipsychotic polypharmacy prevalence rates were calculated for eight 6-month periods for enrollees with schizophrenia and schizoaffective disorder and for those with all other diagnoses. Prevalence increased from 1/2003 to 12/2004 and then declined for 4 successive 6 month periods beginning in the 1/2005-6/05 period when the program began. Piecewise linear regression results for both diagnostic groups confirmed that the change in the likelihood of antipsychotic polypharmacy during the four 6 month periods before program implementation were significantly different than during the four 6 month periods following implementation. While it is impossible to control for the effects of all variables in evaluating the impact of any system wide intervention the data suggest that the program did help to reduce the use of antipsychotic polypharmacy.

Antipsychotic Polypharmacy in Patients With Schizophrenia in a Brief Hospitalization Unit

Antipsychotic monotherapy is considered the gold standard in pharmacological treatment of schizophrenia and other psychotic disorders. Only 2 of the main clinical guides recommend the use of antipsychotic polypharmacy (AP) for those patients refractory to monotherapy. Nonetheless, there is a large rate of studies, conducted in many different settings, showing that AP is more frequent as would be expected attending experts' recommendations. In this retrospective study, we review all the psychotropic drugs dispensed to inpatients of a brief hospitalization psychiatric unit diagnosed as having schizophrenia or schizoaffective disorder (International Statistical Classification of Diseases, 10th Revision) at time of discharge in the year 2005. These included a total of 209 patients older than 18 years. Of the 209 studied patients, 55.5% were discharged under AP treatment. Inpatients were given a mean of 3.06 psychotropic drugs and a mean of 1.61 antipsychotics at the time of hospital discharge. A total of 33.2% of the studied patients got anticholinergic drugs, and 66.2% were given benzodiazepines. The most prevalent combination of drugs was intramuscular long-acting risperidone plus an atypical antipsychotic. Amisulpride was the most used antipsychotic as adjuvant treatment. Despite different clinical guidelines, AP is a common pharmacological strategy as it is shown in our study and in the reviewed literature. Data in our study indicate that the observed rates of AP cannot exclusively be attributed to the treatment of patients with clozapine-resistant schizophrenia.

When Is Antipsychotic Polypharmacy Supported by Research Evidence? Implications for QI

Concurrent use of multiple standing antipsychotics (antipsychotic polypharmacy) is increasingly common among both inpatients and outpatients. Although this has often been cited as a potential quality-of-care problem, reviews of research evidence on antipsychotic polypharmacy have not distinguished between appropriate versus inappropriate use. A MEDLINE search from 1966 to December 2007 was completed to identify studies comparing changes in symptoms, functioning, and/or side effects between patients treated with multiple antipsychotics and patients treated with a single antipsychotic. The studies were reviewed in two groups on the basis of whether prescribing was concordant with guideline recommendations for multiple-antipsychotic use. A review of the literature, including three randomized controlled trials, found no support for the use of antipsychotic polypharmacy in patients without an established history of treatment resistance to multiple trials of monotherapy. In patients with a history of treatment resistance to multiple monotherapy trials, limited data support antipsychotic polypharmacy, but positive outcomes were primarily found in studies of clozapine augmented with a second-generation antipsychotic. Research evidence is consistent with the goal of avoiding antipsychotic polypharmacy in patients who lack guideline-recommended indications for its use. The Joint Commission is implementing a core measure set for Hospital-Based Inpatient Psychiatric Services. Two of the measures address antipsychotic polypharmacy. The first measure assesses the overall rate. The second measure determines whether clinically appropriate justification has been documented supporting the use of more than one antipsychotic medication.

Clinical and social correlates with the use of depot antipsychotic drugs in outpatients with schizophrenia in China

To date, no study has investigated the use of depot antipsychotic medication (DA) in Chinese outpatients with schizophrenia. This study explored the frequency and sociodemographic and clinical correlates of DA in schizophrenia outpatients in both Hong Kong (HK) and Beijing (BJ), China. 505 clinically stable outpatients with schizophrenia were randomly selected and interviewed in HK and BJ using standardized assessment instruments. Their basic sociodemographic and clinical data and psychotropic drug prescriptions were collected at the time of a diagnostic interview. 117 (23.2%) patients were prescribed DA, 36.1 and 10% of the HK and BJ samples, respectively. Prescription of DA was associated with a history of suicide, less use of clozapine, more frequent antipsychotic polypharmacy (APP), more frequent admissions, and study site (HK vs. BJ). In multiple logistic regression analysis, study site, less frequent prescription of clozapine, history of suicide, and more frequent use of APP remained significantly associated with DA. There was wide variation in the frequency of DA prescribing between HK and BJ even though the ethnic and clinical characteristics of the two samples were nearly identical. This suggests that sociocultural and economic factors, as well as traditions in psychiatric training and practice all played a role in determining the use of DA.

Adjunctive Versus Monotherapeutic Treatment for Schizophrenia: Addressing Antipsychotic Side Effects

Back to table of contents Previous article Next article Letters to the EditorFull AccessAdjunctive Versus Monotherapeutic Treatment for Schizophrenia: Addressing Antipsychotic Side EffectsMONICA HAZRA B.Sc. Phm, R.Ph.DAVID C. MAMO M.D., M.Sc.GARY REMINGTON M.D., Ph.D., F.R.C.P.C.,MONICA HAZRA B.Sc. Phm, R.Ph.Search for more papers by this authorDAVID C. MAMO M.D., M.Sc.Search for more papers by this authorGARY REMINGTON M.D., Ph.D., F.R.C.P.C.Search for more papers by this author,Published Online:1 Mar 2008https://doi.org/10.1176/appi.ajp.2007.07111738AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To The Editor: In the article by Joo-Cheol Shim, M.D., Ph.D., et al., published in the September 2007 issue of the Journal, aripiprazole was added to haloperidol to evaluate the beneficial effects on haloperidol-induced hyperprolactinemia. The authors pointed out that switching is “not always possible in clinical practice, especially if the patient has responded well to the antipsychotic that produced the hyperprolactinemia” ( 1 , p. 1404). The addition of aripiprazole significantly decreased prolactin levels and improved negative symptoms, sleep, and extrapyramidal side effects. The authors attributed these effects to aripiprazole’s unique mechanism(s) of action (2) . We do not take issue with the scientific merit of this study but are concerned with the clinical implications, specifically the apparent promotion and justification of the adjunctive use of aripiprazole. Well-controlled clinical studies have not supported the use of antipsychotic polypharmacy, and this practice has been associated with increased adverse effects (3 , 4) , premature death (5) , and unnecessary economic demands (6) . Good clinical practice argues for the fewest medications possible and, in the case of treatment with antipsychotics, advocates for the adjunctive use of antipsychotics as a last resort (7) . As a class, the newer antipsychotics have afforded us advantages in decreasing extrapyramidal symptoms, lowering prolactin levels, and reducing the risk of tardive dyskinesia (2 , 7 , 8) . Furthermore, contrary to what is stated in the article by Dr. Joo-Cheol Shim et al., switching antipsychotic drugs, including a switch from haloperidol to aripiprazole, has previously been shown to be safe and effective (9) . Toronto, Ontario, CanadaDr. Remington has received research funding from NARSAD, the Stanley Medical Research Institute, Novartis, and Merck (Germany). Drs. Hazra and Mamo report no competing interests.This letter (doi: 10.1176/appi.ajp.2007.07111738) was accepted for publication in November 2007.

Clinical and social determinants of psychotropic drug prescription for schizophrenia outpatients in China

To date, few studies have investigated prescription patterns of psychotropic drugs in Chinese patients with schizophrenia in general and outpatients in particular. This study examined the role that socio-demographic and clinical factors play in determining psychotropic drug prescriptions for schizophrenia outpatients in China. Two hundred and fifty-five and 250 clinically stable outpatients with schizophrenia were randomly selected and interviewed in Hong Kong (HK) and Beijing (BJ) respectively, using standardized assessment instruments. Prescriptions of psychotropic drugs for all 505 subjects were collected at the time of the assessment. The relationship between antipsychotic drug prescription patterns and a host of socio-demographic and clinical variables was analyzed and compared between the two study sites. Prescription patterns were quite different for the two ethnically homogenous and clinically very similar samples. In multiple logistic regression analyses, the use of depot antipsychotics (DA) and site (HK vs BJ) both significantly predicted antipsychotic polypharmacy (APP), while symptoms of anxiety, use of clozapine and APP and site predicted use of DA. Age, number of hospitalizations, site, and use of DA predicted use of clozapine. No significant differences were found between the quality of life domains of patients with respect to APP, DA, and clozapine. A complex web of economic and clinical factors and health policies plays an important role in determining psychotropic drug prescription practices for Chinese outpatients with schizophrenia.

Analyse du profil socio-démographique et clinique de patients schizophrènes en fonction du traitement neuroleptique reçu

Data concerning the characteristics of patients with schizophrenia and their treatment in day hospitals are scarce. Guidelines for clinical practice are, however, regularly published. Recommendations from the 1994 Consensus Conference underline the necessity of antipsychotic monotherapy in the long term treatment of schizophrenia. In the US the Schizophrenia Patient Outcome Research Team (PORT) published in 1999 treatment recommendations concerning the use of antipsychotics in the acute phase and in maintenance. For maintenance, the recommended dose should be between 300 and 600 mg/day (CPZ equivalents) (recommendation n 4). The aim of this study is to establish the socio-demographic and clinical profile of patients according to the dose of antipsychotic medication prescribed. The study also examines the use of antipsychotic polypharmacy. of the study. For this study, 116 patients treated in 12 different day hospital units were recruited. Inclusion criteria were: a DSM IV diagnosis of schizophrenia, being treated in a day hospital and having received antipsychotic medication for at last 2 months. Instruments were the MINI for a standardized diagnosis of schizophrenia, the CGI and the PANSS. Prescribed doses were transformed in chlorpromazine (CPZ) equivalents, in order to establish comparisons between patients. The population sample was composed of 72 male (61.5%) and 44 female (38.5%) patients. The mean age was 36.4 years old. The mean education level was 11.3 years. A large majority (n=103, 88%) of patients was celibate, 65 patients (55.6%) lived on their own, the others lived with their family (45 patients, 38.5%) or with a spouse (7 patients, 6%). A large majority of patients (75.6%) received some form of state allowance. Only 1.7% were receiving a salary. The mean antipsychotic dose was 660 mg/day and 68% of patients were treated with an atypical antipsychotic (amisulpride, clozapine, olanzapine, risperidone). Thirty-two percent of patients were treated with doses between 600 and 1,000 mg/day and 24% with doses above 1,000 mg/day. When comparing patients according to the dose level they were receiving (<300 mg/day; 300 to 599 mg/day; and 600 to 999 mg/day;>1,000 mg/day), there was no significant difference between groups for socio-demographic variables. Patients treated with doses below 300 mg/day had a better psychosocial profile and were more often treated with loxapine, haloperidol and risperidone. Patients treated with doses above 1,000 mg/day were more often receiving clozapine. There was still a substantial number of patients treated with conventional antipsychotics in the above 1,000 mg/day range. Patients receiving an antipsychotic monotherapy were more often treated with clozapine or olanzapine and presented a higher rate of positive symptoms. These results are discussed in comparison with present guidelines concerning the treatment of patients with schizophrenia.

Best Practices: An Initiative to Curtail the Use of Antipsychotic Polypharmacy in a State Psychiatric Hospital

A performance improvement initiative was undertaken at a state psychiatric hospital to reduce antipsychotic polypharmacy. Data from physicians' order forms were used to document the prescribing practices of 14 psychiatrists in November 2001 and in August 2002. After baseline data were collected, the chief of psychiatry met with each psychiatrist to compare his or her prescribing data with data of anonymous peers. The chief also asked all psychiatrists to decrease antipsychotic polypharmacy by at least 10 percent. Antipsychotic polypharmacy fell significantly--from 42 percent of patients treated with antipsychotics in November 2001 to 31 percent in August 2002. Higher utilizers of polypharmacy at baseline continued to be high utilizers at follow-up. Less antipsychotic polypharmacy was not associated with more use of other psychotropic medications. The findings suggest that initiatives that involve the focused attention of leadership and only a modest investment of effort can result in significant change in prescribing practices in a state hospital.

Prevalence, Trends, and Factors Associated With Antipsychotic Polypharmacy Among Medicaid-Eligible Schizophrenia Patients, 1998–2000

To determine the prevalence, trends, and factors associated with antipsychotic polypharmacy categorized according to type of antipsychotic and duration of use and to contrast usage patterns with published treatment guidelines. A retrospective cohort study was designed, and Medicaid recipients > or = 16 years of age with a schizophrenia diagnosis (ICD-9-CM = 295.xx) between 1998 and 2000 were identified from the California (20% random sample) and Georgia Medicaid claims databases. Use of anti-psychotic polypharmacy was categorized based on duration (long-term polypharmacy was defined as lasting > 2 months), and long-term use was further categorized based on type of antipsychotic combinations (clozapine, conventional, and atypical). The prevalence, mean duration, and frequency of and yearwise trends in antipsychotic polypharmacy were estimated. A stepwise logistic variable selection procedure was used to identify factors associated with long-term antipsychotic polypharmacy. Of a total of 31,435 persons with schizophrenia, the 1998-2000 prevalence of anti-psychotic polypharmacy was 40% (N = 12,549; mean age = 43 years; white, 47%; female, 48%; mean duration of polypharmacy = 149 days), and long-term antipsychotic polypharmacy prevalence was 23% (N = 7222, mean duration = 236 days). The prevalence of atypical antipsychotic poly-pharmacy increased between 1998 and 2000 (p < .0001). Use of newer atypicals such as quetiapine (OR = 18.32) and older conventionals such as chlorpromazine (OR = 28.87) was strongly associated with long-term antipsychotic polypharmacy. Antipsychotic polypharmacy is widely prevalent, is prescribed for long durations, and is an increasing phenomenon among Medicaid-eligible schizophrenia patients, indicating a significant discrepancy with treatment guidelines (which do not advocate the use of any poly-pharmacy except for short-term periods when transitioning patients to new antipsychotics). Further research evaluating the effects of antipsychotic polypharmacy in schizophrenia patients may assist in defining the scope and potential of such use.

Mortality in schizophrenia. Antipsychotic polypharmacy and absence of adjunctive anticholinergics over the course of a 10-year prospective study.

Although increased mortality is one of the most consistent and accepted epidemiological findings in schizophrenia, a high rate of suicide appears unable to account fully for this burden which remains poorly understood. A cohort of 88 in-patients was followed prospectively over a 10-year period and predictors of survival sought among demographic, clinical and treatment variables. Over the decade, 39 of the 88 patients (44%) died, with no instances of suicide. Reduced survival was predicted by increasing age, male gender, edentulousness and time since pre-terminal withdrawal of antipsychotics; additionally, two indices of polypharmacy predicted reduced survival: maximum number of antipsychotics given concurrently (relative risk 2.46, 95% CI 1.10-5.47; P = 0.03) and absence of co-treatment with an anticholinergic (relative risk 3.33, 95% CI 0.99-11.11; P = 0.05). Receiving more than one antipsychotic concurrently was associated with reduced survival, in the face of little or no systematic evidence to justify the widespread use of antipsychotic polypharmacy. Conversely, over-cautious attitudes to the use of adjunctive anticholinergics may require re-evaluation.