Psychopharmacology Practice Research Articles

Impact of a national audit on child and adolescent psychiatrists' prescribing practices.

A look back review of South Kerry Child and Adolescent Mental Health Services (CAMHS) in Ireland, known as the 'Maskey report' (MR), highlighted substandard prescribing practices. The aim of this 'Maskey Impact Study' (MIS) was to explore changes to child and adolescent psychiatrists' prescribing practices following the MR. The study was cross-sectional and mixed method. A study specific questionnaire was distributed electronically to psychiatrists working in CAMHS (n = 160). 102 psychiatrists participated in the study (response rate 63.8%). Perceived improvement in prescribing practices included improved medical record keeping (63.7%), consent documentation (53.9%), medication information provision (41.2%) and physical health monitoring (60.8%). However, 43.1% of psychiatrists reported a reluctance to prescribe medication even when clinically indicated and 50% were more likely to avoid off-label use. Most respondents reported increased stress levels (80.4%) with higher stress being significantly associated with reticence in prescribing (χ2 = 11.746, p < .001) and avoiding off-label use (χ2 = 15.392, p < 0.001). Thematic analysis highlighted increased medication hesitancy, enforced 'meaningless' bureaucracy and medication mistrust among families. Although improvements reported are welcomed, the increased hesitancy of medication use, avoidance of prescribing more than one medication, and avoidance of off-label use, is of concern with potential unintended adverse consequences. Reluctance in prescribing may deprive youth of access to evidence-based treatments and limit exposure of NCHDs to the safe practice of consultant-initiated psychopharmacology. Further research will be important to determine if this impacts clinical care. Continued education in psychopharmacology is essential along with increased public awareness of the evidence for medication, to help restore public confidence and trust in psychopharmacology.

Conducting Psychodynamic Therapy with Children and Youth: Some Thoughts for the Modern Clinician

Clinicians working with children and adolescents must remain dynamic (“zestful, energetic, open to constant change”) while exploring the psychodynamics inherent within the patient-clinician dyad. Cultural climates and trends are constantly changing, and as communications improve in the digital era, the enormity of information makes it difficult to stay up to date. The author shares some opinions and observations he has learnt in his practice of psychopharmacology and psychotherapy with children and teenagers.

What Should Clinicians Know About Palliative Psychopharmacology?

The nature and scope of palliative psychiatry and associated ethical implications are debated in the literature. This article examines conceptual limitations of extant accounts of palliative psychiatry, with a focus on psychopharmacological practice, and suggests that modifiable and unmodifiable psychiatric illnesses exist on a spectrum along which broader or narrower palliative psychiatric care approaches can be outlined. The article also discusses how these approaches intersect with questions about whether and to what extent psychiatric medications have symptom-reducing or disease-modifying effects. The discussion leads to the conclusion that clinicians are ethically obliged to distinguish among and clearly formulate goals of care in a dynamic and ongoing process of shared decision making with patients.

Improving Efficiency and Effectiveness of Psychopharmacology Practice: What Must Be Done and What Shouldn't Be Done

As the science and the data underlying psychopharmacology treatments has become roughly equal to the science underlying medical illness, the level of quality care to achieve psychopharmacology clinical competence in practice has become more difficult for clinicians. This article aims to fill the gap in teaching psychopharmacology and raise the quality level by describing the core tasks for prescribing quality clinical psychopharmacology. We describe reasons why the quality is low, the most common clinical practices that are not being done, and most importantly, delineate the necessary elements for initial and ongoing follow-up visits. The goal is an integrated approach incorporating objective, subjective, and relational factors in psychopharmacology practice. [ Psychiatr Ann . 2023;53(7):294–297.]

A Short History of the Field of Psychopharmacology and Its Effects on Psychopharmacology Practice

This article presents an overview of the history of psychopharmacology. We speculate on its future development as it bears on psychiatric practice. To do this, we first describe chronologically a history of the reactions to and treatments of the “mentally ill” over time, followed by a short history of groundbreaking developments and advances in clinical medicine. We then examine treatment practices and models of drug development from the past, which provide the foundation for the development of modern psychopharmacology practice. [ Psychiatr Ann . 2023;53(7):305–309.]

Treatment of Agitation in Individuals With Bipolar Disorder or Schizophrenia: Lessons Learned for Clinical Psychiatry and Psychiatric Drug Development.

Six lessons can be learned from the pivotal registration trials for sublingual dexmedetomidine (SLD) for the treatment of agitation in individuals with bipolar disorder or schizophrenia: (1) Knowing the function of a well-defined circuit in the brain, such as the locus coeruleus (LC), facilitates the development of central nervous system drugs. (2) Agitation can be conceptualized both clinically and physiologically. From both perspectives, agitation can present and escalate along a spectrum from mild, characterized as mainly hyperaroused (possibly only a subjective experience with no observable manifestations in its mildest form), to moderate to severe. In the severe state, the patient poses a potential danger to self and others. The level of agitation a patient is experiencing can determine the most appropriate treatment. Behavioral techniques may be sufficient for the mild state. As agitation progresses beyond mild severity, medication intervention becomes needed. SLD can be effective when agitation is moderate or even more severe. At this stage, patients can recognize and be distressed by their symptoms and participate in treatment. When agitation has escalated to such a severe state that patients can no longer participate in treatment, then intramuscular or intravenous medication may be needed. In quite severe cases, physical restraint as well as medication may be required. The Positive and Negative Syndrome Scale-Excited Component (PANSS-EC or PEC), a subscale of the PANSS, is a helpful instrument to assess where an individual is along the agitation spectrum. The PEC has been used in studies of pharmacological treatments for agitation, and it is accepted by the US Food and Drug Administration as the primary rating instrument in pivotal efficacy studies of treatments for agitation. (3) Where the patient is on the agitation spectrum is a function of the activity of the LC, which can be one factor in determining the SLD dose that will optimize the patient's clinical outcome. Clinical outcome is optimized when complete resolution of agitation is rapidly achieved, and adverse effects either do not occur or are not clinically meaningful. The adverse effects of greatest interest with SLD are decreases in resting systolic and diastolic blood pressures, reductions in these blood pressures under orthostatic stress, and lower resting heart rate. (4) To ensure safety, the subjects in 2 healthy volunteer studies were not administered doses equivalent to those used to treat agitated patients. The highest dose which a healthy volunteer tolerated in those studies was 40µg. Agitated patients were treated with 120 and 180µg doses. Thus the difference in doses was 3- to 4.5-fold. Agitated patients could also receive 2 additional half doses with an interval of 2 hours between the first and second administrations. For context, there are other examples of situations in which the dose of a drug that is well tolerated by healthy volunteers is lower than the dose that is well tolerated by patients. For example, it has long been accepted that patients with an acute relapse of schizophrenia can tolerate and need higher doses of D2 antagonists for efficacy than healthy volunteers can tolerate who will generally experience substantial sedation if given what is a clinically effective dose in such patients. (5) Agitation is a state phenomenon that may not recur when it is effectively treated, so that the treatment effect can persist for 24 hours despite the plasma half-life of the drug being 2 to 3 hours. (6) Given the established function of the LC, the fact that the dose response and the time curve of the effect are virtually identical in agitated individuals with bipolar disorder or schizophrenia supports the conclusion that the drug is not treating the syndromic diagnoses of bipolar disorder and schizophrenia but rather the state of being agitated because of overactivity of the LC. These 6 lessons are consistent with the discussions in numerous earlier columns in this series and are critical for both the practice of clinical psychopharmacology and psychiatric drug development.

Symptomatic versus disease-modifying effects of psychiatric drugs.

Drugs can be divided into two major categories, symptomatic and disease modifying. This review explores whether and how psychiatric drugs fall into one or the other of those categories, and the implications of those results for clinical practice and research in psychopharmacology. Narrative review. Most psychiatric drugs have only short-term effects of improving active symptoms. They do not show long-term benefits for the underlying disease, such as improving the course of illness and improving mortality. Evidence is provided for this claim in the treatment literature of antidepressants for depressive illness and antipsychotics for schizophrenia. Developing truly beneficial drugs for disease modification also is limited by the poor clinical and biological validity of Diagnostic and Statistical Manual diagnoses as well as the use of invalid falsely positive maintenance efficacy randomized discontinuation trial designs. Current psychopharmacology is limited mostly to symptomatic effects, not transformative treatments for the diseases underlying those symptoms. A change in approach is needed in psychopharmacology practice and research, focusing on long-term disease modification rather than short-term symptom improvement.

Psychiatrists' Cognitive and Affective Biases and the Practice of Psychopharmacology: Why Do Psychiatrists Differ From One Another in How They View and Prescribe Certain Medication Classes?

Cognitive and affective biases impact clinical decision-making in general medicine. This article explores how such biases might specifically affect psychiatrists' attitudes and prescribing patterns regarding two medication classes (stimulants and benzodiazepines) and addresses related issues. To supplement personal observations, selective PubMed narrative literature searches were conducted using relevant title/abstract terms, followed by snowballing for additional pertinent titles. Acknowledging that there are many more types of biases, we describe and use clinical vignettes to illustrate 17 cognitive and affective biases that might influence clinicians' psychopharmacological practices. Factors possibly underlying these biases include temperamental differences and both preprofessional and professional socialization. Mitigating strategies can reduce the potentially detrimental impacts that biases may impose on clinical care. How extensively these biases appear, how they differ among psychiatrists and across classes of medication, and how they might be most effectively addressed to minimize harms deserve further systematic study.

Ministry of the Mushroom

Recently there has been a surge of renewed interest in the psychedelic compound psilocybin. In particular, psilocybin is being studied in clinical settings as a potential breakthrough treatment for depression. Alongside this growing therapeutic interest, there has been a rise in the religious use of psilocybin, as evidenced by the creation of a number of psilocybin mushroom churches in the United States. While the dominant popular discourse surrounding psilocybin is currently clinical, psilocybin churches offer an alternative form of meaning making regarding the psychedelic experience. Specifically, this article argues that psilocybin churches enable their followers to participate in a dynamic social process of “sacred sensemaking,” whereby psilocybin mushrooms are considered to be a sacrament, church members follow a ritual-based psychopharmacological practice, and the psychedelic experience is interpreted in terms of a direct encounter with the divine. Different psilocybin churches have unique approaches, ritual practices and cosmologies, nonetheless this article suggests that they may be united by this common process of sacred sensemaking.

Combining Asian and American pedagogy to improve clinical psychopharmacology practice.

As the world becomes increasingly interconnected, psychiatrists across geographical regions and from various international organizations need to collaborate to promote global health and wellness. A necessary step is for nations of the world to develop combined teaching initiatives and curricula to ensure best practices are shared globally. In no field of medicine is this more pressing than in psychiatry - especially psychopharmacology given the recent advances in the field. This paper highlights the need to work collaboratively in developing teaching curricula in psychopharmacology in order to incorporate pedagogy and content from international partners-here from Asia and America.

Psychotropic Drugs - Comparison of Application Practice in Forensic and General Psychiatry

The psychopharmacological application practice in forensic and general psychiatry should be investigated comparatively.The 2014-2019 Pharmaco-Epidemiology and Vigilance (Pharmako-EpiVig) surveys of the Bavarian Institute for Data, Analysis and Quality Assurance (BIDAQ) from forensic psychiatry (n = 4,590) and general psychiatry (n = 5,136) of the Isar-Amper-Klinikum Munich East were evaluated.Mean age and diagnosis distribution of the patient clientele differed, as did substance selection and dosage, which was almost consistently higher in forensic psychiatry. In schizophrenic forensic patients, clozapine was given most frequently. In both specialties, the frequent use of valproate was striking.The results could be interpreted as an indication that forensic patients have more severe and refractory illnesses, and that in clinical practice overall a symptom-related anti-aggressive treatment seems to be significant.

Antipsychotic Polypharmacy and High-Dose Antipsychotics in Involuntary Patients: a Seven-Year Audit of Discharge Prescriptions in an Acute Care Unit.

Antipsychotic polypharmacy (APP) is a psychopharmacological practice in which two or more antipsychotics are prescribed simultaneously. Despitethe absence of evidence to support it, it is highly prevalent in clinical settings. Another recurrent practice strongly associated with APP is the prescription of high-dose antipsychotics (HDAs). Compulsory treatment is a legal means to impose treatment on an individual suffering from mental illness who refuses therapeutic intervention. Compulsory treatment has been associated with APP and HDAs and rates of both have been proposed to represent indicators of the quality of prescribing. We aimed to perform an antipsychotic prescription audit in a vulnerable psychiatric population, at the psychiatry department of a district hospital in Portugal, across 7years. We evaluated APP and HDAs in 403 compulsorily admitted patients by reviewing their files at discharge. We used logistic regression to search for factors associated with APP andHDAs. APP was found in 70.5% of individuals, whereas HDAs were found in 51.4%. After adjustment, APP was significantly associated with male gender (Odds Ratio[OR] = 1.85 [1.04; 3.30] 95% Confidence Interval [CI]), involuntary outpatient treatment (OR = .40 [.18; .82] 95% CI), activation of thehospital social services (OR = 1.91 [1.08; 3.38] 95%CI), prescription of antidepressants (OR = .43 [.22; .82] 95%CI) and long-acting injectables (LAI) (OR = 28.29 [13.13; 60.97] 95%CI). HDAs were associated with male gender (OR = 1.76 [1.06; 2.94] 95%CI), the prescription of LAI (OR = 12.92 [6.93; 24.09] 95%CI) and oral first-generation antipsychotics (OR = 2.90 [1.51; 5.60] 95%CI).

3.66 A SURVEY OF CHILD AND ADOLESCENT PSYCHIATRY TRAINEES’ ATTITUDES TOWARDS PRESCRIBING PSYCHOTROPIC MEDICATIONS

Over the past 2 decades, there has been increasing concern regarding the potential overprescription of psychotropic medications in children and adolescents. As a result, there has been a push for more evidence-based prescribing practices and an emphasis on deprescribing to minimize polypharmacy. The goal of this study was to examine trainees’ attitudes toward the practice of psychopharmacology and to consider areas for curriculum development.

A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check".

A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check".

Surveying Psychiatrists' Psychopharmacology Practices Across Common Clinical Scenarios.

The practice of psychopharmacology has become increasingly complex with the expansion of medication options across psychiatric conditions. The level of variability among psychiatrists in their application of medication treatments has received little attention to date. We surveyed 111 psychiatrists attending one of two annual psychiatry meetings in 2017, asking whether they agreed or disagreed with statements about psychopharmacological approaches to 14 common clinical scenarios. High consistency was found for six scenarios, which generally reflected published treatment guidelines, and in recommending that their patients avoid using marijuana. However, low consistency was found for seven scenarios, particularly for statements addressing the use of benzodiazepines and antipsychotic medications. These statements of low consistency generally reflected contradictions or ambiguity across treatment guidelines. In comparison with male psychiatrists, female psychiatrists' responses revealed greater caution around use of medications with addictive potential. Responses to statements were not associated with psychiatrists' perceived adequacy of psychopharmacology training received during residency. Although psychiatrists have high consistency in some aspects of psychopharmacological practice, significant variability exists in important areas of medication use. The consistency of psychotropic medication prescribing may be improved through conducting practical clinical trials that address the existing evidence gaps and by developing educational materials targeting areas of prescriber disagreement.

Clinically Relevant Complications of Drug-Food Interactions in Psychopharmacology

Although often overlooked, the interaction of psychotropic medications with food or dietary health supplements can be clinically relevant, and in some cases it may be catastrophic. In this review, we highlight clinically significant drug-food interactions in psychiatry, including those related to hypertensive crises with monoamine oxidase inhibitors, absorption of medications (such as levothyroxine, ziprasidone, and lurasidone), coadministration with food, the excretion of lithium and other medications in the setting of dietary changes, and the impact of grapefruit juice, St. John's wort, cruciferous vegetables, charbroiled meats, dietary supplements, and alcohol on drug metabolism. Routine inquiry about dietary habits and use of dietary supplements as well as enhanced anticipation and monitoring for potential drug-food interactions is an integral component of optimal psychopharmacologic practice. [ Psychiatr Ann . 2016;46(8):448–455.]

Catastrophic Complications Related to Psychopharmacologic Practice

Catastrophic Complications Related to Psychopharmacologic Practice

Influence of Age, Gender, and Living Circumstances on Patterns of Attention-Deficit/Hyperactivity Disorder Medication Use in Children and Adolescents With or Without Intellectual Disabilities.

The aim of the study was to determine whether there are differences in psychopharmacological practice for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents dependent on the presence or absence of associated intellectual disability; and if there are, whether the differences are influenced by factors such as age, gender, and living circumstances. A case-control cross-sectional design was used. Each arm of the study had a total of 107 children and adolescents aged 5-18 years. Case participants had diagnoses of having intellectual disability and ADHD; comparison participants had diagnoses of having ADHD, but no intellectual disability. Outcome measurements were (1) concurrent use of medications-single medication event as against concurrent multiple medication events-and (2) type of medication used-stimulants versus nonstimulants. Demographic factors considered were gender, age, and living circumstances. Male-to-female ratio in each group was 90:17. Mean age in the case group was 10.93 years (standard deviation [SD]: 3.39 years) and in the comparison group, 12.34 years (SD: 3.22 years). Seventy percent of the case group lived with their biological families, while 84% of the comparison group did so. In the case group, 7.5% were in residential school placements compared with only 0.9% of the comparison group. There were no statistically significant differences in broad measurements of outcomes between the case and comparison groups. Age appeared to be an important moderating factor for type of medication prescribed. Younger children with intellectual disabilities and ADHD were more likely to be established on nonstimulant medications than those with ADHD and no intellectual disabilities (p = 0.024, odds ratio: 1.8; 95% CI: 1.2-2.7). Being between the ages of 5 and 12 years and having intellectual disability and ADHD are associated with raised likelihood of being prescribed nonstimulant medications for ADHD. This difference is maintained irrespective of gender and living circumstances. Reasons for these differences in prescribing practice require further exploration.

Paradoxes of US Psychopharmacology Practice in 2013

In the opinion of the author, 2013 may someday be seen as an important crossroad in US psychopharmacology practice, but the prescribers of psychopharmacology in 2013 may not be paying attention to its potentially bleak future because pharmaceutical companies are discontinuing the development of new

Cause versus association in observational studies in psychopharmacology.

Hypotheses may be generated (and conclusions drawn) from observational studies in areas where information from randomized controlled trials (RCTs) is unavailable. However, observational studies can only establish that significant associations exist between predictor and outcome variables. Observational studies cannot establish that the associations identified represent cause-and-effect relationships. This article discusses examples of associations that were identified in observational studies and that were subsequently refuted in RCTs. Examples are also provided of associations that have yet to be confirmed or refuted but that are nevertheless influential in psychopharmacologic practice. Explanations are offered about how confounding might explain significant relationships between variables that are not related by cause and effect. As a conclusion of this exercise, clinicians are cautioned against placing too much reliance on the findings of observational research.